ATI Exam 3/ NCLEX Examination Questions

A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the following findings are expected? Select all that apply. A. Impulse control difficulty B. Left hemiplegia C. Loss of depth perception D. Aphasia E. Lack of situational awareness

A, B, C, E.

A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? Select all that apply. A. Have suction equipment available B. Feed the client thickened liquids C. Place food on the unaffected side of the client's mouth D. Assign an assistive perssonnel to feed the client slowly E. Teach the client to swallow with her neck flexed

A, B, C, E. Prevents aspiration.

Critical care unit is completing an admission assessment of a client who has a GSW to the head. Which of the following assessment findings are inidicative of increased ICP? Select all that apply. A. Headache B. Dilated Pupils C. Tachycardia D. Decorticate posturing E. Hypotension

A, B, D. Headache, Dilated pupils, and decorticate/decerebrate posturing are all findings associated with increased ICP.

A nurse is caring for a client who has global aphasia (both receptive and expressive). Which if the following should the nurse include in the clients plan of care? Select all that apply. A. Speak to the client at a slower rate B. Assist the client to use flash cards with pictures C. Speak to the client in a loud voice D. Complete sentences that the client cannot finish E. Give instructions one step at a time.

A, B, E. Slower rate, alternative forms of communication (pictures), and simple step commands.

A nurse is reviewing a prescription for dexamethasone (Decadron) with a client who has an expanding brain tumor. Which of the following are appropriate statements by the nurse? SATA A. "It's given to reduce swelling of the brain" B. "You will need to monitor for low blood sugar" C. "You may notice weight gain" D. "Tumor growth will be delayed" E. "It can cause you to retain fluids"

A. "It's given to reduce swelling of the brain" C. "You may notice weight gain" E. "It can cause you to retain fluids" rationale: it reduces cerebral edema, hyperglycemia,fluid retention and weight gain are adverse effects, it does not affect tumor growth

A nurse is caring for a client who has Myasthenia Gravis and has developed drooping eyelids. Which of the following actions should the nurse take? SATA A. Apply lubricating eye drops B. Encourage use of sunglasses C. Support head with pillows D. Tape eyes closed at night E. Provide periods of rest during the day

A. Apply lubricating eye drops D. Tape eyes closed at night

A nurse is beginning a physical assessment of a client who was recently diagnosed with MS. Which of the following findings should the nurse expect? SATA A. Area of paresthesia B. Involuntary eye movements C. Alopecia D. Increased Salivation E. Ataxia

A. Area of paresthesia B. Involuntary eye movements E. Ataxia Paresthesia is a finding in a client with MS. Nystagmus is a finding in a client with MS. Ataxia occurs in the client with MS as muscle weakness develops and there is loss of coordination

The nurse is teaching a client about taking a new prescription for pyridostigmine. Which statements by the nurse indicate correct information about this drug? SATA A. Avoid opioids other than sedating drugs when taking this medication B. Report increased mucous secretions and sweating immediately to the primary health provider C. Take the prescribed medication after meals to increase intestinal absorption D. Avoid taking antibiotics, especially neomycin, while on this medication E. Maintain the exact same dose of this medication every day

A. Avoid opioids other than sedating drugs when taking this medication B. Report increased mucous secretions and sweating immediately to the primary health provider D. Avoid taking antibiotics, especially neomycin, while on this medication

A nurse is caring for a client diagnosed with Guillain-Barre syndrome. Which assessment findings require nursing action? SATA A. BP of 80/42 B. Respiratory rate of 24 C. Shallow breathing pattern D. Peripheral oxygen saturation of 85% E. Diminished breath sounds in all lung fields

A. BP of 80/42 C. Shallow breathing pattern D. Peripheral oxygen saturation of 85% E. Diminished breath sounds in all lung fields

A nurse is planning care for a client who has brain cancer and is experiencing headaches. Which of the following adjuvant medications are indicated for this client? A. Dexamethasone B. Methylphenidate C. Hydroxyzine D. Amitriptyline

A. CORRECT: Dexamethasone, a glucocorticoid, decreases inflammation and swelling. It is used to reduce cerebral edema and relieve pressure from the tumor.

A nurse is caring for a client who has cancer and is taking morphine and carbamazepine for pain. Which of the following effects should the nurse monitor for when giving the medications together? (Select all that apply.) A. Need for reduced dosage of the opioid B. Reduced adverse effects of the opioid C. Increased analgesic effects D. Enhanced CNS stimulation E. Increased opioid tolerance

A. CORRECT: Dosage of the opioid can be reduced when adjuvant medications are added for pain. B. CORRECT: Adverse effects of the opioid can be reduced when adjuvant medications are added for pain. C. CORRECT: Analgesic effects are increased when adjuvant medications are added for pain.

A nurse is planning care for a client who is to receive tetracaine prior to a bronchoscopy. Which of the following actions should the nurse include in the plan of care? A. Keep the client NPO until pharyngeal response returns. B. Monitor the insertion site for a hematoma. C. Palpate the bladder to detect urinary retention. D. Maintain the client on bed rest for 12 hr following the procedure.

A. CORRECT: Keep the client NPO following the procedure until normal pharyngeal sensation returns (approximately 1 hr), and then monitor the client's first oral intake to ensure aspiration does not occur.

A nurse is caring for a client who is receiving a local anesthetic of lidocaine during the repair of a skin laceration. For which of the following manifestations should the nurse monitor as an adverse reaction to the anesthetic? A. Seizures B. Tachycardia C. Hypertension D. Fever

A. CORRECT: Seizure activity is an adverse effect that can occur as a result of local anesthetic injection.

A nurse is caring for a client who experienced a cervical spine injury 3 months ago. Th nurse should plan to implement which of the following types of bladder management methods? A. Condom catheter B. Intermittent urinary catheterization C. Crede's method D. Indwelling urinary catheter

A. Condom catheter Noninvasive method, because the bladder will empty on its own due to the client having an UPPER MOTOR NEURON injury, which is manifested by a spastic bladder.

A nurse is caring for a client who is having surgery for the removal of an encapsulated acoustic tumor. Which of the following potential complication should the nurse monitor for postoperatively? SATAA. A. Increased ICP B. Hemorrhagic shock C. Hydrocephalus D. Hypoglycemia E. Seizures

A. Increased ICP C. Hydrocephalus E. Seizures rationale: hemorrhagic shock occurs secondary to SIADH and hypoglycemia is not a concern for brain surgery

A nurse is caring for a client who was recently admitted to the ED following a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and has a laceration on his forehead that is bleeding. Which of the following is the priority nursing action at this time? A. Keep neck stabilized B. Insert nasogastric tube C. Monitor pulse and blood pressure frequently D. Establish IV access and start fluid replacement

A. Keep neck stabilized The greatest risk to the client is permanent damage to the spinal cord if a cervical injury does exist.

A nurse is planning care for a client who has a spinal cord injury involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should be the nurse's highest priority? A. Prevention of further damage to the spinal cord B. Prevention of contractors of the lower extremities C. Prevention of skin breakdown of areas that lack sensation D. Prevention of postural hypotension when placing the client in a wheelchair

A. Prevention of further damage to the spinal cord Prevent further damage by administering glucocorticoids, minimizing movement of the client until spine stabilization is accomplished through traction or surgery, and adequate O2 to decrease ischemia of the spinal cord.

A nurse is assessing a client for changes in the level of consciousness using the Glasgow Coma Scale (GCS). The client opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the following GCS scores should the nurse document? A. E2 + V3 + M5 = 10 B. E3 + V4 + M4 = 11 C. E4 + V5 + M6 = 15 D. E2 + V2 + M4 = 8

A. The calculation is incorrect. E2 represents eyes opening secondary to pain, V3 represents verbal response with words spoken inappropriately, and M5 represents motor response to pain with a local reaction. B. CORRECT: The client's score is calculated correctly, indicating moderate head injury. E3 represents opening eyes secondary to voice stimulation, V4 represents verbal conversation that is incoherent and disoriented, and M4 represents motor response as a general withdrawal to pain. C. The client's score is calculated incorrectly. E4 represents eyes opening spontaneously, V5 represents verbal conversation as coherent and oriented, and M6 indicates a client is able to follow commands. D. The client's score is calculated incorrectly. E2 represents eyes opening secondary to pain, V2 represents verbal response by the client making sounds but speaking no words, and M4 is a motor response with a general withdrawal to pain.

A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy? A. Headache B. Infection C. Aphasia D. Hypertension

A. The nurse should monitor a client who has increased ICP for a headache, but a headache does not indicate a complication directly related to the ventriculostomy. B. CORRECT: The nurse should monitor a client who has a ventriculostomy for infection, which is a complication. The nurse should use strict asepsis to avoid this life-threatening condition, which can result in meningitis. C. The nurse should monitor a client who has increased ICP for aphasia related to the head injury, but this not a complication directly related to the ventriculostomy. D. The nurse should monitor a client who has increased ICP for hypertension, but this is not a complication directly related to the ventriculostomy.

A nurse is preparing to administer an opioid agonist to a client who has acute pain. for which of the following manifestations should the nurse monitor as an adverse effect of this medication? A. Urinary retention B. Tachypnea C. Hypertension D. Irritating cough

A. Urinary retention

A nurse is completing an assessment of a client who has increased ICP. Which of the following are expected findings? SATA A. Disoriented to time and place B. Restlessness and irritability C. Unequal pupils D. ICP of 15 mm/Hg E. Headache

A.Disoriented to time and place B. Restlessness and irritability C. Unequal pupils E. Headache rationale: ICP of 15 is w/in normal range

A nurse is caring for a client who has a closed-head injury with ICP readings ranging from 16 to 22 mmHg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? Select all that apply. A. Suction the ET tube frequently B. Decrease the noise level in the clients room C. Elevate the client's head on two pillows D. Administer a stool softener E. Keep the client well hydrated

B, D. Decrease the noise level can decrease ICP level. Stool softener decreases the need to bear down during BM's, which can increase ICP.

What is the greatest risk for a patient with dysfunction of cranial nerves IX and X? A. Dehydration B. Aspiration pneumonia C. Constipation D. Weight loss

B. Aspiration pneumonia First back to Physical Assessment = Cranial nerve IX= Glossopharyngeal, X=Vagal Aspiration pneumonia is a serious risk B. Speech pathologist would do a swallow evaluation for this patient

A nurse is providing teaching to a client who is experiencing migraine headaches. Which of the following instructions should the nurse provide? (Select all that apply.) A. Take ergotamine as a prophylaxis to prevent a migraine headache. B. Identify and avoid trigger factors. C. Lie down in a dark quiet room at the onset of a migraine. D. Avoid foods that contain tyramine. E. Avoid exercise that can increase heart rate

B. CORRECT: Identifying and avoiding trigger factors is an important action that can help to prevent some migraines. C. CORRECT: Lying down in a dark, quiet room at the onset of a migraine can prevent the onset of more severe manifestations. D. CORRECT: Foods that contain tyramine can be a trigger for some migraines and should be avoided.

A nurse is planning care for a client who has cancer and is taking a glucocorticoid as an adjuvant medication for pain control. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Monitor for urinary retention. B. Monitor blood glucose. C. Monitor blood potassium level. D. Monitor for gastric bleeding. E. Monitor for respiratory depression.

B. CORRECT: Monitoring blood glucose is important because glucocorticoids raise the glucose level, especially in clients who have diabetes mellitus. C. CORRECT: Monitoring blood potassium level is important because glucocorticoids can cause hypokalemia. D. CORRECT: Monitoring for gastric bleeding is important because glucocorticoids irritate the gastric mucosa and put the client at risk for a peptic ulcer.

A nurse is preparing to administer pamidronate to a client who has bone pain related to cancer. Which of the following precautions should the nurse take when administering pamidronate? A. Inspect the skin for redness and irritation when changing the intradermal patch. B. Assess the IV site for thrombophlebitis frequently during administration. C. Instruct the client to sit upright or stand for 30 min following oral administration. D. Watch for manifestations of anaphylaxis for 20 min after IM administration.

B. CORRECT: Pamidronate is administered by IV infusion. This medication is irritating to veins, and assess

A nurse is providing education to a client who is to undergo an electroencephalogram (EEG) the next day. Which of the following information should the nurse include in the teaching? A. "Do not wash your hair the morning of the procedure." B. "Try to stay awake most of the night prior to the procedure." C. "The procedure will take approximately 15 minutes." D. "You will need to lie flat for 4 hours after the procedure."

B. CORRECT: The nurse should teach the client to remain awake most of the night to provide cranial stress and increase the possibility of abnormal electrical activity.

A nurse is reviewing the medication administration record for a client who is receiving transdermal fentanyl for severe pain. The nurse should identify that which of the following medications can cause an adverse effect when administered concurrently with fentanyl? A. Ampicillin B. Diazepam C. Furosemide D. Prednisone

B. Diazepam Diazepam, a benzodiazepine, is a CNS depressant, which can interact by causing the client to become severely sedated when administered concurrently with an opioid agonist or agonist/antagonist

A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor? A. Hyperglycemia B. Hyponatremia C. Hypervolemia D. Oliguria

B. Hyponatremia Mannitol is a powerful osmotic diuretic. Adverse effects include electrolyte imbalances, such as hyponatremia.

Which statements about stroke prevention indicate a client's understanding of health teaching by the nurse? SATA A. I will take aspirin every day B. I have decided to stop smoking C. I will try to walk at least 30 minutes most days of the week D. I need to cut down a lot on my drinking E. I'm going to decrease salt in my diet

B. I have decided to stop smoking C. I will try to walk at least 30 minutes most days of the week D. I need to cut down a lot on my drinking E. I'm going to decrease salt in my diet

Assessment data for pt. w/traumatic brain injury: Heart rate 104/min., B/P 99/44 mmHg, RR 14/min, SpO2 92%, ICP 15 mmHg. Which of the following interventions would most likely improve the pt.'s cerebral pressure? A. Begin a norepinephrine infusion B. Increase the fraction of inspired oxygen (FIO2) from 40% to 60% C. Administer 250 mL of physiological saline D. Place the patient in Semi fowler position

B. Increase the fraction of inspired oxygen (FIO2) from 40% to 60%

A client returns from the PACU after a surgical removal of a brainstem tumor. In what position should the nurse place the client at this time? A. Turn the patient from see to side to prevent aspiration B. Keep the client flat in bed or up to 10 degrees and reposition from side to side C. Elevate the head of the bed at least 30 degrees at all times D. Keep the client in a sitting position in the bed at all times

B. Keep the client flat in bed or up to 10 degrees and reposition from side to side

A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect? A. Fluctuations in blood pressure B. Loss of cognitive function C. Ineffective cough D. Drooping eyelids

B. Loss of cognitive function

A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? A. Teach the client to scan to the right to see objects on the right side of her body B. Place the bedside table on the right side of the bed C. Orient the client to the food on her plate using the clock method D. Place the wheelchair on the clients left side

B. Place the bedside table on the right side of the bed The client is unable to visualize to the left midline of her body. If its on the right, she will be able to see it at all times.

A nurse is caring for a client who has a spinal cord injury who reports a severe headache and is sweating profusely. VS: BP 220/110 mm Hg, Apical HR 54/min. Which of the following actions should the nurse take first? A. Notify the provider B. Sit the client upright in bed C. Check the urinary catheter for a blockage D. Administer antihypertensive medication

B. Sit the client upright in bed The greatest risk to the client is CVA, secondary to elevated bp caused by autonomic dysreflexia. Raising the HOB can lower the BP due to postural hypotension.

The nurse is caring for a patient treated with alteplase following a stroke. Which assessment finding is the highest priority for the nurse? A. client's BP is 144/90 B. client is having epistaxis C. client ate only half of the last meal D. client continues to be drowsy

B. client is having epistaxis

A nurse is caring for a client who has just undergone a craniotomy for a supratentorial tumor. Which of the following prescriptions should the nurse clarify with the provider? A. dexamethasone B. morphine sulfate C. Ondansetron D. phenytoin

B. morphine sulfate rationale: opioid meds should be questioned due to their ability to decrease level of consciousness especially after brain surgery

How can the nurse best assess a patient's cognition? A.Asking the patient about how he or she was transported to the clinic B.Asking the patient about the meaning of various proverbs C.Asking the patient to count backward from 100 by 7s D.Writing down a simple command and giving it to the patient

B.Asking the patient about the meaning of various proverbs

The most common cause of changes in the older patient's mental state is: A.Electrolyte imbalance B.Insufficient oxygen C.Sedative agents D.Infection

B.Insufficient oxygen

A nurse is caring for a client who has a benign brain tumor. The client asks the nurse if he can expect this same type of tumor to occur in other areas of his body. Which of the following is an appropriate response by the nurse? A. "It can spread to breasts and kidneys" B. "It can develop in your GI tract" C. "It is limited to brain tissue" D. "It probably started in another area of your body and spread to your brain"

C. "It is limited to brain tissue" rationale: benign

What percentage of strokes occur in patients less than 65 years of age? A. 10% B. 15% C. 25% D. 35%

C. 25%

Which symptom is the earliest indicator of increased intracranial pressure? A. Increased pupil size B. Elevated blood pressure C. Agitation and confusion D. Nausea and vomiting

C. Agitation and confusion

A nurse is providing teaching to a client who has migraine headaches and a new prescription for ergotamine. For which of the following manifestations indicating a possible adverse reaction should the nurse instruct the client to stop taking the medication and notify the provider? (Select all that apply.) A. Nausea B. Visual disturbances C. Positive home pregnancy test D. Numbness and tingling in fingers E. Muscle pain

C. CORRECT: A client who has a positive home pregnancy test should stop taking ergotamine and notify the provider. Ergotamine is classified as Pregnancy Risk Category X and can cause fetal abortion. D. CORRECT: Numbness and tingling in fingers or toes can be a finding in ergotamine toxicity. The medication should be stopped and the provider notified. E. CORRECT: Unexplained muscle pain can be a finding in ergotamine toxicity. The medication should be stopped and the provider notified.

A family member asks the nurse about whether there would be any long-term psychological effects from a client's mild traumatic brain injury. What is the nurse's best response? A. You need to talk with the client's primary health care provider B. Usually any effects last for only a few weeks or months C. Each person's reaction to brain injury is different D. You should expect a change in the client's personality

C. Each person's reaction to brain injury is different

A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding? A. Impulse control difficulty B. Poor judgement C. Inability to recognize familiar objects D. Loss of depth perception

C. Inability to recognize familiar objects. Known as agnosia.

A nurse is caring for a client who has just been admitted following a surgical evacuation of a subdural hematoma. Which of the following is the priority assessment? A. Glasgow Coma Scale B. Cranial Nerve Function C. Oxygen saturation D. Pupillary response

C. Oxygen saturationABC's. Brain tissue can only survive for 3 minutes before permanent damage occurs.

A nurse is planning to administer morphine IV to a client who is postoperative. Which of the following actions should the nurse take? A. monitor for seizures and confusion with repeated doses. B. Protect the client's skin from the severe diarrhea that occurs with morphine. C. Withhold this medication if respiratory rate is less than 12/min. D. Give morphine intermittent via IV bolus over 30 seconds or less.

C. Withhold this medication if respiratory rate is less than 12/min.

The nurse is caring for a client with expressive (Broca's) aphasia. Which nursing intervention is appropriate when communicating with the client? A. refer the client to a speech-language pathologist B. speak loudly to help the client interpret what is being said C. provide pictures to help the client communicate D. ask the client to read messages on a white board

C. provide pictures to help the client communicate

A nurse is caring for a client who has end-stage cancer and is receiving morphine. The client's family member asks why the provider prescribed methylnaltrexone. Which of the following responses should the nurse make? A."The medication will increase your mother's respirations." B."The medication will prevent dependence on the morphine." C."The medication will relieve your mother's constipation." D."The medication works with the morphine to increase pain relief."

C."The medication will relieve your mother's constipation."

The spouse of a patient brought to the ED states that 6 hours ago her husband began having difficulty finding words. The patient has since become progressively worse. He has right hemiparesis. Upon assessing the patient, you note that he is lying flat in a supine position and has been incontinent of urine. What is the priority nursing intervention for this patient at this time? A.Provide perineal care B.Assess for gag reflex C.Elevate the head of bed D.Perform a linen and gown change

C.Elevate the head of bed The airway must be protected=Elevate the head of the bed=C ( and further assess)

A nurse is teaching a client who has multiple sclerosis and a new prescription for baclofen. Which of the following statements should the nurse include in the teaching? A. "This medication will help you with your tremors." B. "This medication will help you with your bladder function." C. "This medication may cause your skin to bruise easily." D. "This medication may cause you to experience weakness."

D. "This medication may cause you to experience weakness."

A nurse is teaching a client who has multiple sclerosis and a new prescription for baclofen. Which of the following statements should the nurse include in the teaching? A. "This medication will help you with your tremors." B. "This medication will help you with your bladder function." C. "This medication may cause your skin to bruise easily." D. "This medication may cause your skin to appear yellow in color."

D. "This medication may cause your skin to appear yellow in color." Med to help with spasms. Adverse effect of this medication is jaundice. Can indicate impaired liver function.

A nurse is preparing to administer butorphanol to a client who has a history of substance use disorder. The nurse should identify which of the following information as true regarding butorphanol?A. Butorphanol has a greater risk for abuse than morphine. B. Butorphanol causes a higher incidence of respiratory depression than morphine. C. Butorphanol cannot be reversed with an opioid antagonist. D. Butorphanol can cause abstinence syndrome in opioid‑dependent clients

D. Butorphanol can cause abstinence syndrome in opioid‑dependent clients

A nurse is administering amitriptyline to a client who is experiencing cancer pain. For which of the following adverse effects should the nurse monitor? A. Decreased appetite B. Explosive diarrhea C. Decreased pulse rate D. Orthostatic hypotension

D. CORRECT: Amitriptyline can cause orthostatic hypotension. Assess for this effect and instruct the client to move slowly from lying down or sitting after taking this medication.

A nurse is reviewing the health history of a client who has migraine headaches and is to begin prophylaxis therapy with propranolol. Which of the following findings in the client history should the nurse report to the provider? A. The client had a prior myocardial infarction. B. The client takes warfarin for atrial fibrillation. C. The client takes an SSRI for depression. D. An ECG indicates a first-degree heart block.

D. CORRECT: Propranolol is contraindicated in clients who have a first-degree heart block. Report this finding to the provider.

A 27-year-old male suffered a frontal lobe infarction secondary to a car crash. What is an appropriate nursing intervention for this patient? A.Instructing the patient to use a call light prior to getting out of bed B.Placing all items directly in front of the patient C.Using a picture board to assist with communication D. Enabling the bed alarm safety system

D. Enabling the bed alarm safety system

A nurse is reviewing the health record of a client who has a malignant tumor and notes the client has a positive Romberg's sign. Which of the following actions should the nurse take to assess for this sign? A. stroke the lateral aspect of the sole of the foot B. Ask client to blink eyes C. Observe facial drooping D. Have client stand erect with eyes closed

D. Have client stand erect with eyes closed rationale: Romberg tests for balance

A nurse is caring for a client who experienced a cervical spine injury 24 hours ago. Which of the following types of prescribed meds should the nurse clarify with the provider? A. Glucocorticoids B. Plasma expanders C. H2 antagonists D. Muscle relaxants

D. Muscle relaxants The client will not experience muscle spasms until after the spinal shock has resolved, making muscle relaxants unnecessary at this time.

A nurse is caring for a client who has a C4 spinal cord injury. The nurse should recognize the client is at greatest risk for which of the following complications? A. Neurogenic shock B. Paralytic ileus C. Stress ulcer D. Respiratory compromise

D. Respiratory compromise Maintenance of an airway and provision of ventilatory support as needed is the priority intervention. ABCs.

The nurse is caring for a client with trigeminal neuralgia. Which patient problem is the priority for the nurse? A. facial twitching B. problems with communication C. ptosis and diplopia D. severe facial pain

D. severe facial pain

which nursing interventions decrease the risk for cross-contamination in the client with a severe burn injury? SATA a. place the client in isolation b. encourage multiple visitors to support the client c. ensure that no plants or flowers are in the client's room d. teach family members not to bring fresh fruit and vegetables to the client e. change gloves after cleaning and dressing of one wound and before cleaning and dressing another

a. place the client in isolation c. ensure that no plants or flowers are in the client's room d. teach family members not to bring fresh fruit and vegetables to the client

the nurse is encouraging range of motion exercises to the client who states. "this hurts terribly; I don't want to do this." Identify the appropriate nursing responses. SATA a. you have to do the exercises to get well b. range of motion helps promote mobility c. just visualize a beach to get your mind off of the pain d. let me check when you were last given pain medication e. which techniques for pain management have you used in the past that were helpful? f. the health care provider has ordered these exercises, and it is important that you do them as instructed

b. range of motion helps promote mobility d. let me check when you were last given pain medication e. which techniques for pain management have you used in the past that were helpful?

which assessment finding does the nurse interpret as demonstrating a client's fluid resuscitation adequacy? a. decreased skin turgor b. decreased pulse pressure c. decreased core body temperature d. decreased urine specific gravity

d. decreased urine specific gravity

The client asks about ways to prevent carbon monoxide poisoning. Which teaching will the nurse provide? a. you can see black smoke when carbon monoxide is in the air b. if you are experiencing carbon monoxide poisoning, your skin will begin to turn blue c. the only way to get poisoned from carbon monoxide gas is if you are in the presence of a fire d. it is important to have carbon monoxide detectors in your hone because this is an odorless gas

d. it is important to have carbon monoxide detectors in your hone because this is an odorless gas