clients cardiac status (PEDS p120) c. Administer antibiotics via intermittent IV bolus for 24 hrs. d. Provide stimulation with children of the same age in the play room 2. A nurse observes a client on the psychiatric unit muttering and standing near a window. The client states, The voices are telling me to jump. Which of the following is an appropriate response by the nurse? a. Do you recognize the voices as belonging to anyone you know? b. I understand the voices are frightening you, but I do not hear any voices. c. That cant be true. The only voices in this room are yours and mine. d. You shouldnt be afraid when you think the voices are telling you to hurt yourself. 3. A nurse is caring for a client who is preparing his advance directives. Which of the following statements by the client indicates an understanding of advance directives? (Select all that apply.) a. I need an attorney to witness my signature on the advance directives. *(nurse witnesses it) b. I have the right to refuse treatment. (Leadership p38) c. My doctor will need to approve my advance directives. (just needs to write a prescription) d. My health care proxy can make medical decisions for me. (Leadership p38) e. I cant change my advance directives once submitted. (yes, you can) 4. A client who is pregnant voices her concern that her 3-year-old son will feel left out once the newborn arrives. Which of the following statements by the nurse is appropriate? a. Offer your son a gift when the baby receives one. (Provide a gift from the infant to give the sibling) cc b. Teach your son to change the babys diapers. (Allow older siblings to help in providing care for the infant) c. Tell your son to kiss the baby. (Maternity p126: Let the sibling be one of the first to see the infant) d. Move your son to a toddler bed when the baby arrives. (do this weeks prior to babys arrival) 5. A nurse is teaching a client who has nephrotic syndrome about dietary management. Which of the following instructions should the nurse include in the teaching? a. Limit total daily sodium intake to 4 to 5 grams cc B. Obtain most calories from complex carbohydrates (for CKD) c. Consume a high-protein diet (High protein, high potassium, low sodium) d. Avoid intake of soy products. 6. A nurse is interviewing an adolescent client who has a history of physical aggression due to anger management issues. Which of the following is an appropriate question by the nurse? a. Did you think about removing yourself from the situation when you became angry? b. Why do you get angry when things dont go your way? c. How do you think others feel when you express anger? D. What are you thinking about when you express anger? (assessing the underlying issue of aggression) 7. A nurse is planning care for a client who has a sealed radiation implant and is to remain in the hospital for 1 week. Which of the following should the nurse include in the plan of care? a. Wear a dosimeter film badge while in the clients room. (Med Surg p583) b. Ensure family members remain at least 3 feet from the client (should be at least 6ft) c. Limit each of the clients visitors to 1 hrs. per day. (should be 30 minutes) d. Remove dirty linens from the room after double bagging. 8. A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take? a. Sit at or below the clients eye level during feedings (Funds p215: Observe for aspiration and pocketing of food in the cheeks or other areas of the mouth) b. Talk with the client during her feeding c. Discourage the client from coughing during feedings (encourage pt. to cough to prevent aspiration) d. Instruct the client to lift her chin when swallowing (tuck chin) 9. A nurse is caring for a preschool child who is dehydrated. Which of the following assessment findings indicates moderate dehydration? a. Bradypnea B. Oliguria (Funds p343) c. Diaphoresis d. Excessive tears 10. A nurse is providing teaching to a parent of a child who has varicella. Which of the following statements should the nurse include in the teaching? a. Your child can return to school after a negative titer result. b. Your child can return to school 24 hours after beginning antibiotics. c. Your child can return to school once the lesions have crusted over. REPEAT 2016 d. Your child can return to school once the fever has subsided. 11. A nurse is providing information for a client who has a new prescription for simvastatin. For which of the following should the nurse instruct the client to monitor and report to the provider? a. Muscle weakness- rhabdomyolysis b. Edema c. Weight loss d. Fever 12. A nurse on a medical-surgical unit is receiving report on four clients. Which of the following clients should the nurse assess first? a. A client who is receiving warfarin and has an INR of 3.3 b. A client who had an NG tube inserted 6 hrs. ago and has abdominal distention c. A client who is 4 hrs. postoperative following a thyroidectomy and reports fullness in the back of the throat (edema can lead to resp. distress) d. A client who has acute kidney injury, a creatinine of 4 mg/dL, and a BUN of 52 mg/dL 13. A nurse is receiving report on four postpartum clients. Which of the following clients should the nurse plan to attend to first? a. A client who reports changing her perineal pad every 2 hrs. b. A client who reports abdominal pain during breastfeeding c. A client who has a urine output of 250 mL in 6 hrs. d. A client who has hyporeflexia while receiving magnesium sulfate REPEAT 14. A nurse is providing nutritional teaching regarding appropriate food choices to a client who has a new diagnosis of uric acid calculi. Which of the following should the nurse include in the teaching? a. Roast beef b. Chicken breast c. Low-fat yogurt (avoid purine foods [organ meats & shellfish] & poultry) d. Tuna fish 15. A nurse in the emergency department is caring for a client who has a full-thickness burn of the thorax and upper torso. After securing the clients airway, which of the following is the nurses priority intervention? a. Preventing infection b. Offering emotional support c. Providing pain management d. Initiating IV fluid resuscitation – REPEAT 16. A nurse is caring for a client who will undergo a procedure. The client states she does not want the provider to discuss the results with her partner. Which of the following is an appropriate response for the nurse to make? REPEAT a. The provider will be tactful when talking to your partner. b. You have the right to decide who receives information. c. Is there a reason you dont want your partner to know about your procedure? d. Your partner can be a great source of support for you at this time. 17. A nurse is providing teaching about dietary recommendations to the parents of a school-age child who has acute kidney injury. Which of the following recommendations should the nurse include in the teaching? a. Provide low-calcium foods b. Provide high-phosphorus foods c. Provide low-potassium foods d. Provide high-sodium foods 18. A nurse is planning care for a school-age child who is 4 hrs. postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care? REPEAT a. Apply a warm compress to the operative site every 4 hrs. b. Offer small amounts of clear liquids 6 hrs. following surgery c. Give cromolyn nebulized solution every 8 hrs. d. Administer analgesics on a scheduled basis for the first 24 hrs. 19. A nurse is assessing a client who is 8 hrs. postpartum and has been unable to void. Which of the following actions should the nurse take first? a. Pour warm water over the clients perineum b. Offer the client a Sitz-bath c. Insert a sterile catheter d. Administer an analgesic 20. A nurse is providing nutritional teaching for an older adult client who has seizure disorder and a new prescription for phenytoin. Which of the following statements by the nurse is appropriate? a. Limit foods that contain folic acid while taking this medication. b. You should expect a change in the color of your stool while taking this medication. c. Increase your intake of vitamin D while taking this medication. – phenytoin complication (bone pain and weakness) d. Plan to take this medication with antacids. 21. A nurse is assessing a client who sustained fractures to both legs in a motor-vehicle crash. Which of the following findings indicates the client is experiencing a fat embolism? b. Decreased pedal pulses c. Pain unrelieved by opioid analgesics d. Crepitus at the knee joint 22. A nurse is teaching a client who is at 41 weeks of gestation about a nonstress test. Which of the following information should the nurse include in the teaching? b. You should massage one of your nipples to stimulate contractions of your uterus. c. You will need blood work before and after the test. d. You should avoid eating or drinking for 4 hrs. before the test. 23. A home health nurse is assessing a client who has amyotrophic lateral sclerosis (ALS) and has had recent weight loss. Which of the following is the priority admission data for the nurse to obtain? a. Changes in appetite b. Daily fluid intake d. Prescribed medications 24. A nurse is providing discharge teaching for a client who has myelosuppression following chemotherapy treatment. Which of the following statements should the nurse include in the teaching? a. Eat a diet rich in fresh fruits and vegetables. c. Children may visit as long as theyve recently received a live influenza vaccination. d. Check your temperature weekly. BONE MARROW SUPPRESSION- IMMUNOCOMPROMISED. AVOID 25. A nurse is caring for a client who has undergone a modified radical mastectomy. The client has a closed-suction drain. Which of the following actions should the nurse take? REPEAT a. Maintain the client in supine position for the first 24 hrs. b. Secure the drain to the bedding d. Position the affected extremity below the level of the clients heart 26. A nurse is providing discharge instructions to a client who is 1-day postoperative vertical banded gastroplasty for morbid obesity. Which of the following statements demonstrates an understanding for the dietary teaching? b. I will be limited to pureed foods for the next 6 months. (weeks) c. I should eat three meals per day. d. Vomiting is common and I will have to learn to live with it. SERVE TO RESTRICT AND DECREASE FOOD INTAKE HELPS TO PROMOTE WT LOSS 27. A home health nurse is visiting a client whose partner states that she is overwhelmed by caring for him. When suggesting respite care, which of the following explanations should the nurse provide? a. Respite care offers financial resources to help care for your husband. b. Respite care includes volunteers who will perform household tasks. c. Respite care provides clinicians to work with you in caring for your husband. 28. A nurse is collecting a specimen for urinalysis and culture from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take during collection? a. Obtain the urinalysis specimen before the culture specimen. b. Collect 2 mL or urine for each specimen. c. Drain the specimen from the drainage bag. 29. A nurse is caring for four clients. Which of the following clients should the nurse care for first? b. A client who has a burn requiring a sterile dressing change c. A client who received a chemotherapy treatment and reports nausea d. A client who had an appendectomy 2 days ago and has diminished bowel sounds 30. A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu. The nurse should recognize which of the following findings as a potential contraindication to using lavender? a. The client has a history of alcohol use disorder b. The client has a history of asthma c. The client takes Vitamin C daily 31. A nurse is providing discharge teaching to a client following a total hip arthroplasty. Which of the following statements by the client indicates an understanding of the teaching? b. I dont need to use a walker when walking around my house. c. I will stay in bed for 3 days after returning home before starting leg exercises. d. I will bend over at my hips to tie my shoes. bend at your knees 32. A nurse is assessing a client who is experiencing a pulmonary embolism. Which of the following manifestations should the nurse expect? a. Hypertension c. Bradycardia d. Frothy sputum 33. A nurse is performing a neurological examination on a client as part of a complete physical assessment. The nurse determines that cranial nerve XI is intact when the client performs which of the following actions? b. Frowns symmetrically c. Sticks his tongue out d. Identifies a sour taste cra 34. A nurse is preparing to administer lactated Ringers 500 mL IV to infuse over 4 hrs. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if applicable. Do not use a trailing zero.) ! 31 gtt/min 4×60= 240mins 500/240 = 2.08 x 15 gtt = 31.25 or 31 35. A nurse is teaching an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching? a. HbA1c level greater than 8% c. Blood glucose level less than 60 mg/dL before breakfast d. Blood glucose level greater than 200 mg/dL at bedtime 36. A nurse is caring for a client who develops a lower left leg deep-vein thrombosis following surgery. Which of the following actions should the nurse take? b. Check for the presence of a Homans sign c. Form a 5 cm (2 in) cuff at the top of the ant embolism stocking d. Massage the left lower extremity 37. A nurse working in an acute care mental health facility is assessing a client who has schizophrenia. Which of the following findings should the nurse expect? a. Euphoric mood b. All-or-nothing thinking c. Hypochondriasis 38. A nurse is developing a nutritional care plan for a client who has COPD with severe dyspnea. To promote intake, which of the following instructions is appropriate to include in the plan of care? a. Administer a bronchodilator after meals b. Ambulate the client before each meal c. Offer the client three large meals each day 39. A nurse is caring for four clients who are scheduled for surgery the same day. Which of the following laboratory values indicates the need for intervention before surgery? a. WBC 9,800/mm3 b. Creatinine 0.9 mg/dL < 1.0 is normal c. Fasting blood glucose 108 mg/dL 40. A nurse in a long-term care facility is managing the care of an older adult client who has difficulty swallowing and occasional choking during meals. The nurse should initiate a referral to which of the following members of the interprofessional care team? a. Social worker b. Respiratory therapist d. Occupational therapist 41. A nurse in an oncology clinic receives a call from the partner of a client who has pancreatic cancer. The partner tells the nurse that she is able to manage the clients physical care, but she doesnt want to leave him home alone while she travels for work. Which of the following referrals should the nurse make? b. Respite care c. Skilled nursing facility d. Restorative care 42. A nurse is caring for a client who has deep-vein thrombosis of the left lower extremity. Which of the following actions should the nurse take? (Click on the Exhibit button below for additional client information. There are three tabs that contain separate categories of data.) a. Massage the affected extremity every 4 hrs. b. Administer acetaminophen d. Position the client with the affected extremity lower than the heart 43. A nurse preceptor is working with a newly licensed nurse to care for a client who has vancomycin-resistant enterococci (VRE). Which of the following actions by the newly licensed nurse requires the nurse preceptor to intervene? b. Cleaning her hands with alcohol-based antiseptic after delivering a meal to the client c. Instructing the client to dispose of soiled facial tissues in the wastebasket in his room d. Wiping a clients over bed table with hydrogen peroxide following a dressing change 44. A nurse in a health clinic is developing written material to teach adult clients how to manage their blood pressure. Which of the following strategies should the nurse use in creating the material? a. Create material using a 12-point font size b. Type information in capital letters c. Use words with one or two syllables 45. A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take? b. Place the client in a side-lying position prior to assessing the fetal heart rate c. Perform Leopold maneuvers prior to auscultating the fetal heart rate d. Measure the fundal height to determine the placement of the ultrasound stethoscope 46. A nurse in a mental health facility received change-of-shift report on four clients. Which of the following clients should the nurse plan to assess first? b. A client who received a PRN dose of haloperidol 2 hrs. ago for increased anxiety c. A newly admitted client who has a history of 4.5 (10 lbs.) weight loss in the past 2 months d. A client who will be receiving his first ECT treatment today 47. A nurse is admitting a client who has a history of atrial fibrillation. The nurse should recognize that atrial fibrillation places the client at risk for which of the following? b. Cardiac tamponade c. Hemothorax d. Widened pulse pressure 48. A nurse is teaching a client who is trying to conceive. Which of the following should the nurse instruct the client to increase in her diet to prevent a neural tube defect? a. Iron b. Calcium d. Zinc 49. A nurse is caring for a client who is not ambulatory. Which of the following interventions is appropriate to prevent contracture? a. Place a towel roll under the clients neck b. Align a trochanter wedge between the clients legs c. Apply an orthotic to the clients foot- REPEAT d. Position a pillow under the clients knees 50. A nurse is caring for a client who has a thoracic spine injury. Which of the following actions is appropriate for the nurse to take when turning the client? b. Instruct the client to keep his arms at his side when altering positions c. Place a pillow under the clients knees when changing positions d. Use a sheet when repositioning the client onto his side 51. A nurse is teaching a client about a variety of stress management techniques. Which of the following instructions by the nurse is appropriate? b. Imagine a situation that has been stimulating for you when practicing guided imagery. c. Talk to someone who you admire as the first step in using mindfulness techniques to relax. d. Breathe in through your mouth and out through your nose when using deep breathing exercises. 52. A nurse is caring for a client who is incontinent and has a stage II pressure ulcer on her coccyx. Which of the following interventions should the nurse implement? a. Reposition the client every 3 hrs. b. Use two facility personnel to slide the client up in bed d. Apply lotion to the skin every 4 hrs. 53. A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the following clients should the nurse see first? b. A client who has pregestational diabetes mellitus and an HbA1c of 6.2% c. A client who is at 28 weeks of gestation and reports leukorrhea d. A client who is at 36 weeks of gestation with a biophysical profile score of 8 54. A nurse is preparing to obtain a blood sample from a client who has a central venous catheter. Which of the following actions should the nurse take? (Select all that apply) d. Aspirate the blood sample with large bore needle e. Apply a tourniquet above the catheter insertion site 55. A nurse is caring for a client who is receiving intravenous antibiotics every 6 hr. Which of the following responses by the client is the priority for the nurse to evaluate? a. I dont understand why I am getting this antibiotic. b. My arm burns each time that medication is running. d. This medication bag is still full. 56. A nurse is caring for a client who has schizoaffective disorder and tells the nurse, Im the prince of peace and my enemies are coming to take me to another world. Which of the following responses should the nurse make? a. Why do you think people will come for you? b. Lets take a walk around the unit together. c. The staff and I will protect you from them. 57. A nurse is caring for a client following a stroke. The client has right-sided weakness and facial drooping. Which of the following nursing actions is the priority? a. Perform range-of-motion exercises to the clients extremities b. Place the clients right hand in a supination position d. Change the clients position every 2 hrs. 58. A charge nurse is providing information to a group of nurses on the unit about risk factor for hypoglycemia in newborns. Which of the following risk factors should the charge nurse include in the information? (Select all that apply) a. Anemia b. Infection c. Maternal diabetes d. Prematurity e. Polycythemia 59. A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first? a. A client who has a fracture and is in balance suspension traction b. A client who uses a wheelchair and is confused c. A client who is bedridden and wears a hearing aid d. A client who is ambulatory and receiving oxygen 60. A nurse is providing discharge instructions for a client who has a new prescription for clopidogrel following a cardiac catheterization. Which of the following instructions should the nurse include? a. Your stools will become black and tarry b. Take NSAIDs for pain every 6 hours d. Take medication twice daily with acetaminophen. 61. A nurse is an outpatient mental health facility is providing teaching to a group of adolescents. Which of the following statements by a client indicates an understanding of the teaching? a. I will limit my alcohol use to one drink daily while taking disulfiram. b. I will avoid foods containing tyramine while taking fluoxetine. c. I will take my lithium on an empty stomach. d. I will take the sustained-release methylphenidate every morning. 62. A nurse is planning care for a client who has stage II Parkinsons disease. Which of the following actions should the nurse include in the plan of care? a. Offer clear liquids with in between meals b. Offer high-calorie nutrition supplements c. Encourage the client to concentrate on looking at his feet while walking d. Encourage the client to participate in small muscle dexterity activities 63. A nurse is obtaining a medical history from a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should report which of the following conditions is a contraindication to the use of metformin? b. Gluten intolerance c. Seizure disorder d. Polycystic ovary syndrome 64. A nurse is preparing to catheterize a toddler for a urine culture. Which of the following is an appropriate action for the nurse to take? a. Obtain a 12 F catheter b. Apply EMLA cream prior to the procedure c. Discard the first 10 mL of urine d. Don sterile gloves prior to the procedure- REPEAT 65. A charge nurse is teaching a newly licensed nurse about clients designating a healthcare proxy in situations that require a durable power of attorney for health care (DPAHC). Which of the following information should the charge nurse include? a. The proxy should make healthcare decisions for the client regardless of the clients ability to do so. b. The proxy can make treatment decisions if the client is under anesthesia. c. The proxy can make financial decisions if the need arises. d. The proxy should manage legal issues for the client. 66. A nurse is providing teaching to a client who is receiving misoprostol for induction of labor. Which of the following statements hould the nurse include in the teaching? a. You will have oxytocin initiated within 3 hours of administration of the medication. b. You will have intermittent fetal monitoring while you receive the medication. c. You will lie on your side for 30 minutes after the medication is inserted. d. You will have a urinary catheter inserted prior to the placement of the medication. 67. A nurse is assessing a client who is at 24 weeks of gestation during a routine prenatal exam. Which of the following findings hould the nurse report to the provider? a. Bleeding gums b. White vaginal discharge c. Fundal height of 26 cm d. Periorbital edema 68. A nurse is caring for a client who has lung cancer and has a sealed radiation implant. Which of the following actions should the nurse take? (Select all that apply) b. Limit visitors to 30 minutes per day c. Wear a lead apron when providing care d. Place the client in a semi-private room " private e. Instruct visitors who are pregnant to remain 3 feet from the client " 6 feet 69. A nurse is planning care for a child who has increased intracranial pressure with a decrease in level of consciousness. Which of the ollowing interventions should the nurse include in the plan of care? a. Perform neurological checks every 4 hrs. b. Perform active range-of-motion exercises d. Suction the airway frequently 70. A charge nurse is orienting a newly licensed nurse to the telemetry unit. Which of the following should the charge nurse identify as he purpose of telemetry monitoring? a. To measure cardiac perfusion b. To identify valve insufficiency c. To measure cardiac output d. To identify dysrhythmias 71. At her first prenatal visit a client asks the nurse when she will most likely deliver. If her last menstrual period began on March 31, when is the estimated date of delivery (EDD)? a. December 24 b. January 7 - 3 month + 7 days c. December 31 d. January 3 72. A charge nurse is preparing to lead negotiations among nursing staff due to a conflict about overtime requirements. Which of the following strategies should the charge nurse use to promote effective negotiation? a. Focus on how the conflict occurred b. Attempt to understand both sides of the issue c. Identify solutions prior to negotiation d. Personalize the conflict 73. A public health nurse is managing four projects for the community. Which of the following activities should the nurse identify as a primary prevention strategy? a. Providing crisis intervention through a mobile counseling unit b. Conducting mental health screenings at the local community center d. Referring individuals who have mental health disorders to day treatment programs 74. A nurse is caring for an infant who is in contact isolation and received a blood transfusion. Which of the following actions is appropriate for the nurse to take to provide cost-effective care? a. Return unopened equipment to the supply center b. Stock the room with a 2-day supply of disposable diapers c. Bring in formula as needed d. Leave the unused infusion pump in the room until discharge 75. A nurse in a providers office is caring for a client who asks about using acupuncture to manage his osteoarthritis pain. The nurse should identify which of the following conditions as a contraindication for receiving this treatment? a. Herpes zoster b. Hypertension c. Obesity d. Hypothyroidism 76. A nurse manager observes two staff nurses reviewing the computer records of a client who is not under their care. Which of the following actions should the nurse manager take first? b. Request the nurses present an in-service on client confidentiality c. Place documentation of the nurses actions in the personnel file d. Advise the nurses to read the facilitys confidentiality policy 77. A nurse is teaching a client who is to start a new prescription for carbidopa-levodopa. Which of the following instructions should the nurse include? a. Monitor for hyperglycemia b. Take with a protein snack c. Change positions slowly - orthostatic hypotension d. Report dark-colored urine 78. A nurse is teaching a group of newly licensed nurses about caring for a client who has a Clostridium difficile infection. Which of the following instructions should the nurse include in the teaching? a. Wipe the stethoscope with alcohol after leaving the clients room b. Place the client in a room with negative airflow c. Wear a gown while providing personal hygiene d. Apply a mask when providing care 79. A nurse is caring for a client who has benign prostatic hyperplasia (BPH). The client asks the nurse about using saw palmetto to relieve the symptoms of BPH. The nurse should instruct the client that which of the following medications interacts adversely with saw palmetto? a. Metoprolol b. Clopidogrel - saw palmetto interacts with antiplatelet/anticoagulant medications c. Ipratropium d. Zolpidem 80. A nurse is assessing a client who has a stage IV pressure ulcer and is undergoing treatment prescribed by a wound care consultant. For which of the following findings should the nurse contact the consultant to revise the plan of care? a. Weight loss of 5% in 10 days " Risk for development of pressure ulcer: Recent weight loss- lost 5% of total body weight or 4.5 kg (10lb) practice ass b. Appearance of pink tissue under eschar c. Hgb 15 g/dL d. Albumin level 4.0 g/dL a. Soy 81. A nurse is providing preoperative teaching to an older adult female client who is scheduled for a laminectomy and uses supplements. Which of the following supplements should the nurse identify as increasing the clients risk for hypotension during surgery? c. Probiotics d. Flaxseed 82. A nurse is planning care for a client who is scheduled to receive a peripherally inserted central catheter in the arm. Which of the following interventions is appropriate for the nurse to include in the plan of care? b. Schedule an MRI post procedure to verify placement c. Administer sedation for the procedure d. Use gauze to secure an arm board to the involved extremity 83. A nurse is assessing a client who has fine hair, exophthalmos, and reports intolerance to heat. Which of the following endocrine disorders is associated with these findings? b. Hyperparathyroidism c. Hypoparathyroidism d. Hypothyroidism 84. A nurse is providing discharge teaching for a client who has a prescription for captopril. Which of the following adverse effects should the nurse instruct the client to report to the provider? a. Alopecia b. Headache d. Hypoglycemia 85. A nurse is receiving report on four clients. Which of the following clients should the nurse assess first? b. A client who has an ilial conduit and mucus in the pouch c. A client who had a transurethral resection of the prostate with red-tinged urine in the bag d. A client who has an arteriovenous fistula that vibrates when palpated 86. A nurse is caring for a group of clients. Which of the following clients should the nurse assess first? a. A client who has heart failure and reports shortness of breath while ambulating b. A client who had an open cholecystectomy and has green drainage from the T-tube c. A client who has benign prostatic hyperplasia and is unable to urinate 87. A nurse is caring for a client who has Crohns disease. Which of the following diagnostic procedures should the nurse plan to teach the client regarding pernicious anemia? b. D-dimer test c. Oral glucose tolerance test d. Thyroid scan 88. A nurse is reviewing the medical record of a client who has tuberculosis and a new prescription for rifampin. The nurse should notify the provider for which of the following findings? a. Irregular heart rate b. Elevated blood glucose level d. Allergy to cephalosporins 89. A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning. (Move the steps into the box on the right, placing them in the selected order of performance) 1) Turn on the suction and set the pressure 2) Don sterile gloves 3) Insert the catheter during the clients inspiration 4) Apply suction while rotating the catheter 5) Rinse the catheter to remove secretions 90. A nurse is admitting a client who is to undergo paracentesis for removal of ascetic fluid. Which of the following actions should the nurse take? a. Ensure the client has a full bladder just prior to the procedure b. Weigh the client before and after the procedure c. Administer a low-volume hypertonic enema the night before the procedure d. Place the client in a side-lying position for the procedure 91. A nurse is caring for a child wh
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