N470

The nurse assesses a client with Cushing syndrome. Which clinical manifestations should the nurse expect?

-Hyperglycemia -Hypertension -Truncal Obesity

The nurse is caring for a client with hyperosmolar hyperglycemic syndrome. Which prescription should the nurse implement first?

2L 0.9% sodium chloride IV bolus

A client with advanced kidney disease has serum potassium of 7.1 mEq/L (7.1 mmol/L) and creatinine of 4.5 mg/dL (398 µmol/L). What is the priority prescribed intervention?

Administer IV 50% dextrose and regular insulin

The nurse is caring for a client with asthma who received an albuterol nebulizer treatment 15 minutes ago. The unlicensed assistive personnel notifies the nurse of the client's current vital signs and states, "The client reports feeling shaky." Which action by the nurse is appropriate? Click the exhibit button for more information.

Auscultate the client's lung sounds and continue to monitor

The nurse is caring for a client recently admitted for a head injury following a ground-level fall. Which client data should be reported to the health care provider immediately?

Chronic atrial fibrillation is managed with apixaban 5 mg twice daily

The nurse receives handoff of care report for four clients. Which client should the nurse assess first?

Client scheduled for an appendectomy who has abdominal distension and reports steadily increasing pain

The nurse on the medical-surgical unit receives report on assigned clients. Which client warrants immediate attention?

Client with epigastric pain after endoscopic retrograde cholangiopancreatography

The nurse receives report on the following clients. Which client should the nurse see first?

Client with epilepsy who is having a series of consecutive seizures

The emergency department nurse is caring for a client with diabetes mellitus and suspected pneumonia who is lethargic and confused. Which new prescription should the nurse implement first?

Infuse normal saline 1000ml IV bolus once

The nurse is caring for a client who is scheduled for a bedside percutaneous liver biopsy later today. Which laboratory results are most important for the nurse to check prior to the biopsy?

PT and INR

The nurse assesses a client who sustained injuries in a motor vehicle collision. The client reports pain in the right shoulder and rates the pain as 9 on a scale of 0-10. The nurse notes bleeding facial lacerations, bruising behind the right ear, and bloody drainage from the nose. Which action should the nurse perform next?

Place a sample of nasal drainage on a gauze and assess for a yellow ring

The nurse cares for a client with flash pulmonary edema secondary to acute heart failure. The client is receiving oxygen via nonrebreather mask, and furosemide 40 mg IV push is administered. Which finding best indicates that treatment has been effective?

Respiratory rate decreased from 26/min to 18/min

A client with peripheral arterial disease has just returned from femorotibial bypass surgery. What assessment finding should the nurse report to the health care provider immediately?

Severe, unrelieved aching pain of the affected extremity

The nurse is reinforcing teaching to a client diagnosed with thromboangiitis obliterans (Buerger disease). Which topic is mostimportant for the nurse to discuss?

Stopping use of all tobacco and marijuana products

The nurse is answering client telephone calls at the after-hours call center. A client with a history of hypertension reports having a severe head cold and states, "my heart feels like it is beating really fast." What question is most important for the nurse to ask?

What over-the-counter medications have you taken recently?

The graduate nurse (GN) is caring for a male client who had an uncomplicated myocardial infarction (MI) a week ago. The client expresses concern about resuming sexual activity following the MI. Which statement by the GN requires intervention by the supervising nurse?

You can use your sildenafil for erectile dysfunction as long as it has been a couple hours since you last took nitroglycerin

The clinic nurse is obtaining a health history from an adult client who reports dull, aching, midepigastric pain and loss of appetite for the last 3 weeks. Which of the following findings are concerning to the nurse? Select all that apply.

-Client consumes a high diet in spicy foods -Client reports drinking 3-5 alcoholic beverages per day -Client reports having a high stress level due to job loss -Client takes celecoxib daily for osteoarthritis

The nurse is reinforcing teaching of disease management with a client who has congestive heart failure. Which of the following statements by the client indicate a need for further teaching? Select all that apply.

-I take my diuretic as needed, especially if I have plans to leave the house -I weigh myself at least 3 times a week when I get up in the morning

A client with peripheral arterial disease is visiting the health clinic. The nurse completes a health assessment. Which statement by the client indicates a priority need for follow-up teaching?

I prop my legs up in the recliner and use a heating pad when my feet are cold

A client is admitted to the emergency department following a motorcycle collision. Which finding is most concerning to the nurse? Click the exhibit button for additional information.

Muffled heart sounds

A client with chest pain is diagnosed with acute pericarditis by the health care provider. The nurse explains that the pain will improve with which of the following?

Sitting up and leaning forward

The nurse is caring for a client with chronic obstructive pulmonary disease when the client becomes tachypneic and reports significant dyspnea. The client's oxygen saturation is 85% on 2 L/min of oxygen per nasal cannula. Which oxygen delivery device is appropriate for this client?

Venturi Mask

The nurse is providing in-service education for graduate nurses (GNs) about primary open-angle glaucoma (POAG). Which statement by a GN indicates a need for further instruction?

Vision loss caused by glaucoma is reversible if treatment is started early

The nurse is caring for a client with an arteriovenous fistula placed in the left forearm 3 weeks ago. Which of the following actions by the nurse are appropriate?Select all that apply.

-Assesses frequently for a thrill and bruit over the client's fistula -Assists the client with range of motion exercises on the left arm -Instructs the client to avoid sleeping with the left arm under the body -Reminds the client to avoid receiving venipunctures in the left arm

The nurse assesses a client with systemic lupus erythematosus who has been taking high-dose prednisone for several months. Which of the following does the nurse recognize as potential adverse effects of prednisone therapy? Select all that apply.

-Increased glycosylated hemoglobin (HgA1c) level -Pale reddish-purple linear marks on the abdominal skin -Prominent fat pads over the supraclavicular region -Significant weight gain without trying

The nurse cares for a client who has a chest tube placed to evacuate a pneumothorax. The nurse observes continuous bubbling in the chamber of the chest drainage system labelled 'C.' Based on this clinical finding, the nurse understands that which situation is most likely? Click the exhibit button for additional information.

An air leak in the system is present

The nurse is caring for a client 1 hour after femoral cardiac catheterization. During assessment of the groin site, the nurse notes a large hematoma forming. Which action is the priority for the nurse?

Applying firm pressure to the femoral puncture site

A client with chronic hypertension, who is currently prescribed amlodipine and hydrochlorothiazide, is being seen for an annual health checkup. The client's blood pressure is 188/96 mm Hg. Which question should the nurse ask first?

How often are you taking your prescribed medications?

The nurse cares for a mechanically ventilated client who has acute respiratory distress syndrome and was prescribed high-level positive-end expiratory pressure settings. Which new assessment finding is the priority to report to the health care provider?

Tracheal deviation slightly toward the left side

The nurse is obtaining a client's health history during a clinic visit. The nurse identifies which of the following client reported factors as increasing the risk for developing peptic ulcer disease?Select all that apply.

-1 pack-per-day cigarette smoking -Daily consumption of 1-2 beers -Frequent ibuprofen use for arthritic pain -High levels of occupational stress

The nurse is caring for a female client newly diagnosed with epilepsy who has been prescribed phenytoin. Which of the following should the nurse include in client teaching? Select all that apply.

-Avoid drinking alcoholic beverages -Do not abruptly stop taking your phenytoin -Wear an epilepsy medical identification bracelet -You may need to start using a nonhormonal birth control method

The nurse is providing discharge teaching to a client who underwent surgical repair of a retinal detachment. Which of the following instructions by the nurse are appropriate to include in the teaching? Select all that apply.

-Avoid engaging activities that may make you vomit or feel nauseated -If you have any new or worsening eye pain report immediately -Try to limit reading and writing to prevent eye strain -You need to avoid lifting heavy objects or straining

The nurse provides education to a client who has newly diagnosed hypertension and heart failure. Based on the client's clinical data, which of the following statements are appropriate to include in the teaching plan? Select all that apply. Click the exhibit button for additional information.

-Avoid high sodium foods such as canned soups are prepackaged meals -Check your blood pressure when you wake up in the morning before bed -Contact the health care provider if you gain 3-5 lb (1.4-2.3 kg) in a week

A nurse is preparing to discharge a client who received a permanent pacemaker yesterday. Which of the following teaching topics should be included in the discharge plan? Select all that apply.

-Avoid lingering around retail store antitheft detectors -Carry a pacemaker identification card at all times -Measure and record pulse rate faily -Report redness swelling or discharge at incision

The nurse is reviewing information about cataracts with a group of older adults. Which of the following statements by the nurse are appropriate to include in teaching? Select all that apply.

-Cataracts are typically painless -Cataracts can lead to blindness -Cataracts may cause the eye to look cloudy -Surgery is the only curative treatment for cataracts

A nurse is caring for 4 clients. Which client will take priority when planning care for the day?

54-year-old client 1 day postoperative total thyroidectomy reporting dysphagia

The nurse is caring for a client with chronic obstructive pulmonary disease who has a continuous pulse oximeter that is alarming frequently. What action should the nurse take first?

Observe the client's respiratory rate and effort and auscultate the lungs

The nurse responds to a call for help from another staff member. Upon entering the client's room, the nurse observes an unlicensed assistive personnel (UAP) performing chest compressions on an unconscious adult client while another nurse is calling for the emergency response team. What action by the arriving nurse is the priority?

Obtain the defibrillator and apply the pads to the client's chest

A graduate nurse (GN) is caring for four postoperative clients. Which action by the GN requires intervention by the precepting nurse?

Places a client in high fowler position immediately following femoral artery cardiac catheterization

A nurse is preparing to ambulate a client for the first time following coronary artery bypass surgery. The automatic blood pressure monitor reads 90/60 mm Hg with a heart rate of 62/min. What action should the nurse take next?

Assess the client for light headedness, chest pain and cool extremities

The home health nurse is visiting a client discharged 2 days ago after a coronary artery bypass graft. The client reports fatigue and palpitations, and the nurse connects the client to a portable heart monitor. The nurse recognizes the displayed rhythm as which type? Click on the exhibit button for additional information

Atrial Fibrillation

A nurse on a telemetry unit notes the following rhythm on the central monitor at the nurse's station. What action by the nurse is most important at this time? Click the exhibit button for additional information.

Check the client's mentation and hemodynamic status

The nurse receives handoff of care report on four clients. Which client should the nurse see first?

Client with pericarditis whose blood pressure has decreased from 122/70 mm hg over the past hour

A client returns to the unit after receiving hemodialysis for the first time. The client vomits once, reports headache, and appears restless and disoriented. What is the priority intervention?

Contact the health care provider

A post-anesthesia recovery nurse is reviewing a client's telemetry following surgery. The client is sleeping but oriented when roused, does not report pain or discomfort, and has a blood pressure of 110/60 mm Hg. Which action by the nurse is appropriate at this time? Click on the exhibit button for additional information.

Continue to monitor client

The nurse is caring for a client with type 2 diabetes mellitus who reports feeling lightheaded and shaky. The client's finger-stick blood glucose level is 58 mg/dL (3.2 mmol/L). Which action should the nurse take next?

Give the client a spoonful of honey or jelly

A client is receiving an infusion of total parenteral nutrition (TPN) with 20% dextrose through a central line at 75 mL/hr. The nurse responds to the client's IV pump alarm, which indicates that the bag is empty. The new bag is not expected to arrive from the pharmacy for an hour. What is the most appropriate nursing action?

Hang 10% dextrose in water until the new bag arrives then resume TPN at 75 mL/hr

The nurse provides discharge teaching for a client with hypoparathyroidism. Which client statement indicates a need for further teaching?

I should eat foods with added phosphorus such as cured meats

The nurse is reinforcing teaching about self-care management for a client who had an ileostomy with abdominal stoma created 4 days ago. Which statement by the client indicates a need for additional instruction?

I will change the adhesive barrier and ostomy pouch daily to prevent skin irritation.

The nurse is providing discharge teaching to a client with chronic pancreatitis who is newly prescribed pancrelipase. Which client statement indicates a need for further teaching?

I will have to reduce my alcohol intake to one flass of wine per day

The preoperative nurse is reviewing laboratory data for a client with cholecystitis and a history of atrial fibrillation who is scheduled for an open cholecystectomy. Which result is essential for the nurse to report to the health care provider? Click the exhibit button for additional information.

INR 4.1

The nurse is caring for a client who experienced an anterior wall myocardial infarction 24 hours ago. The nurse recognizes the rhythm on the cardiac monitor as which rhythm?

Ventricular Tachycardia

The clinic nurse receives a call from a client with hyperthyroidism who was prescribed propylthiouracil 4 days ago. The client states, "I think I need a higher dose of this medicine. It does not seem to work for me." Which response by the nurse is appropriate at this time?

You may not see or notice any improvement until 7-14 days after starting the medication

The nurse is caring for a client with coronary artery disease who reports new chest pain. One dose of sublingual nitroglycerin 0.4 mg was given at 0800. After reassessing the client at 0805, what action by the nurse is best? Click on the exhibit button for additional information.

Administer a second dose of 0.4 mg of nitroglycerin sublingually

In the intensive care unit, the nurse cares for a client who develops diabetes insipidus (DI) 2 days after pituitary adenoma removal via hypophysectomy. Which intervention should the nurse implement?

Administer desmopressin

A 62-year-old client is scheduled for open abdominal aneurysm repair. What key assessment should be made by the nurse preoperatively?

Assess character and quality of peripheral pulses

The clinic nurse is assessing a client who reports leg pain with activity that disappears with rest but is now occurring more frequently. What is the nurse's priority action?

Assess for presence and quality of distal leg pulses bilaterally

The nurse admits a client diagnosed with acute diverticulitis who has fever, left lower quadrant pain, abdominal distension, and vomiting. Which new prescription from the health care provider should the nurse clarify?

Give soap suds enema once, now

The nurse receives new prescriptions for a group of clients. Which prescription should the nurse complete first?

Give sublingual nitroglycerin to a client with coronary artery disease who reports dull chest pain

The nurse is caring for a client with a traumatic brain injury following a motor vehicle collision. The client is completely unresponsive to verbal or physical stimulus and does not open the eyes. Which prescription should the nurse clarify with the health care provider?

Infuse 0.45% sodium chloride at a rate of 100 ml/hr

A client on the telemetry unit is found in cardiac arrest with pulseless electrical activity. What action should the nurse take?

Initiate cardiopulmonary resuscitation

A nurse is caring for a client with hypercapnia caused by chronic obstructive pulmonary disease. Which nursing action will help to reduce serum carbon dioxide levels?

Instruct the client on pursed lip breathing

A 65-year-old client with end-stage renal disease comes to the emergency department after missing 5 hemodialysis sessions. Serum potassium level is 7.5 mEq/L (7.5 mmol/L) and ECG shows tall, peaked T waves. Which prescription will immediately protect the client from experiencing dysrhythmias associated with hyperkalemia?

Intravenous calcium gluconate

The nurse is admitting a client with addisonian crisis. Which of following interventions are appropriate to include in the client's plan of care? Select all that apply.

-Administer IV hydrocortisone as prescribed -Assess heart rate and blood pressure frequently -Obtain blood samples for serum electrolyte levels -Perform capillary glucose testing as prescribed

The nurse cares for a client admitted with respiratory distress. Which actions by the nurse are appropriate? Click the exhibit button for additional information.Select all that apply.

-Administer prescribed IV antibiotics -Assist the client to fowler position -Initiate supplemental oxygen as prescribed -Obtain specimen for sputum culture

The nurse assesses a client for the development of peritonitis following a perforated gastric ulcer. Which of the following assessments support development of this complication? Select all that apply.

-Apical pulse of 138/min -rebound tenderness with guarding -rigid abdomen on palpation -worsening diffuse abdominal pain

The clinic nurse is reinforcing instructions to a client with type 1 diabetes mellitus about sick-day management. Which of the following instructions should the nurse include? Select all that apply.

-Check your blood sugar at least every four hours -Check your urine for ketones if your blood sugar is higher than 240 mg/dl (13.3 mmol/L) -Increase the amount of water you drink throughout the day -Notify your health care provider if you have persistent nausea and vomiting

The nurse is preparing to reinforce teaching regarding a newly prescribed medication for a client with a hearing impairment. Which of the following actions by the nurse are appropriate? Select all that apply.

-Determine the client's preferred method of communication -Encourage the client to repeat back instructions -Sit directly in front of the client while speaking

The nurse is caring for a client with advanced amyotrophic lateral sclerosis. Which of the following assessment findings should the nurse anticipate? Select all that apply.

-Difficulty speaking -Muscle wasting -Respiratory Distress

The nurse in the endocrinology clinic is collecting a client's health history. Which of the following questions should the nurse include when assessing for clinical manifestations of hypothyroidism? Select all that apply

-Do you have difficulty keeping warm in cooler temperatures? -Has the frequency of your bowl movements slowed? -Have you noticed your hair thinning or falling out recently?

The clinic nurse is educating a client with pneumonia about ways to improve secretion clearance. Which of the following instructions should the nurse provide to help the client clear the respiratory secretions? Select all that apply.

-Drink at least 2000-3000 mL of water each day -Make sure you are getting up and walking frequently -Say the word 'huff' when coughing to move more secretions -Try to use your incentive spirometer hourly, if possible

The nurse cares for a client who had an abdominal aortic aneurysm repair 6 hours ago. Which assessment findings would indicate possible graft leakage and require a report to the primary care provider? Select all that apply.

-Ecchymosis of the scrotum -Increased abdominal girth -Report of groin pain

The nurse is caring for a client admitted after experiencing a tonic-clonic seizure. Which of the following nursing actions should be implemented as seizure precautions? Select all that apply.

-Insert and maintain a peripheral IV catheter -Place oxygen tubing and bag valve mask near the bedside -Set up suction equipment at the bedside

The clinic nurse is caring for a client with type 1 diabetes mellitus who is having persistent nausea and vomiting. The client states, "I have been unable to keep food and drinks down for 24 hours." Which client statement indicates a need for further teaching?

I have not taken my insulin because I have been sick and unable to eat

The nurse is reinforcing teaching to minimize dumping syndrome with a client who recently underwent a gastrojejunostomy. Which client statement indicates a need for further education?

I will drink chocolate milk with my breakfast

The nurse is providing care to a client with a posterior pituitary tumor. Based on the findings, which prescription should the nurse anticipate? Click the exhibit button for additional information.

Increase the IV fluid administration rate

The nurse is reinforcing education for a client undergoing an extracorporeal shock wave lithotripsy for renal calculi about what to expect following the procedure. Which statement made by the nurse is appropriate?

It is normal to have bruising on your flank where the procedure was performed

The nurse is caring for a client after a thyroidectomy who reports anxiety and tingling at the fingertips and mouth. Which action by the nurse is appropriate?

Obtain a blood sample for a serum calcium level

The nurse is assessing a client who reports dizziness and confusion. After reviewing the client's clinical data, what prescription should the nurse anticipate?

Obtain and prepare atropine IV push for administration

A female client with liver cirrhosis and chronic anemia is hospitalized for a deep venous thrombosis. The client is receiving a heparin infusion and suddenly develops epistaxis. Which laboratory value would indicate that the heparin infusion needs to be turned off?

Partial thromboplastin time of 110 seconds

The nurse is caring for a client with a history of tonic-clonic seizures. After a seizure lasting 25 seconds, the nurse notes that the client is confused for 20 minutes. The client does not know the current location, does not know the current season, and has a headache. The nurse documents the confusion and headache as which phase of the client's seizure activity?

Postical Phase

A client comes to the emergency department with a "pounding heart beat." The client is diaphoretic and pale and admits to using cocaine approximately one hour ago. The client is connected to a cardiac monitor that shows the rhythm displayed in the exhibit. The nurse recognizes it as which rhythm? Click on the exhibit button for additional information.

Supraventricular Tachycardia

The nurse working in the intensive care unit hears an alarm coming from a client's room. On entering the room, the nurse sees the rhythm displayed in the exhibit on the monitor. The nurse recognizes it as which rhythm? Click on the exhibit button for additional information.

Ventricular Fibrillation

A client admitted with an exacerbation of chronic obstructive pulmonary disease is having a panic attack. The client is tachypneic with audible wheezing and has a capillary oxygen saturation (SpO2) of 87% on 4 L of oxygen via nasal cannula. Which of the following interventions are appropriate? Select all that apply.

-Administer prescribed albuterol PRN -Assist the client into a tripod position -Coach the client to use pursed lip breathing -Remain with the client

The nurse is caring for a client with small cell lung cancer who is becoming increasingly lethargic and confused. After reviewing the client's chart and notifying the health care provider, which of the following interventions are appropriate? Select all that apply.

-Administer prescribed salt tablets -Initiate seizure precautions -Perform frequent neurological assessments

The emergency department nurse is caring for a client with severe altered mental status and a history of type 1 diabetes mellitus. After the client's clinical data are reviewed, which of the following actions by the nurse are appropriate? Select all that apply.

-Administer regular insulin continuous IV infusion -Initiate prescribed 2L normal saline IV Bolus -Monitor blood glucose hourly with bedside glucometer -Place the client on continuous cardiac monitoring

The nurse is assessing a client with an exacerbation of chronic obstructive pulmonary disease who is receiving oxygen via nasal cannula at 2 L/min. The client is dyspneic and using accessory muscles to breathe. Which interventions are appropriate? Select all that apply.

-Administer the prescribed albuterol nebulizer treatment PRN -Assist the client to lean forward in a sitting position -Auscultate the client's breath sounds and document findings -Instruct the client to inhale through the nose and exhale through pursed lips

The nurse is providing staff education about peritoneal dialysis. Which of the following statements should the nurse include in the teaching? Select all that apply.

-Allow the dialysate solution to infuse via gravity -Assess the client for any new abdominal pain or tenderness -Notify the health care provider if the dialysis outflow fluid is cloudy -Use a sterile technique when instilling and draining the dialysate

The nurse is caring for a client in the postanesthesia care unit following a gastroduodenostomy. Which of the following nursing interventions are appropriate? Select all that apply.

-Applying bilateral sequential compression devices -Encouraging splinting of the incision with a pillow when coughing -Keeping the client NPO until bowl sounds return

The client arrives at the emergency department with an acute head injury, and the nurse obtains a Glasgow Coma Scale (GCS) score at regular intervals. Which of the following interventions are components of the GCS? Select all that apply.

-Ask the client to state their name and date of birth -Instruct the client to hold up two fingers -Monitor the client for spontaneous eye opening -Pinch a nail bed and look for a response to pain

The nurse is teaching clients how to recognize and respond to signs of a stroke at a community health event. Which of the following statements by the nurse are appropriate?Select all that apply.

-Ask the person to smile to see if one side of the face droops -Check if the person's speech has changed or is slurred -If you see any signs of stroke immediately call 911 -See if one arm drifts down after asking the person to raise both arms

The nurse is planning care for a client returning from a femoral-approach cardiac catheterization with stent placement. Which of the following nursing actions are appropriate to include in the care plan? Select all that apply.

-Assess the client for development of chest pain -Encourage the client to increase oral fluid intake -Monitor pulse and skin color distal to the insertion site -Observe the groin for bleeding or hematoma

The nurse is caring for a client admitted for a seizure disorder. The nurse witnesses the client having a tonic-clonic seizure with increasing salivation. Which actions should the nurse take? Select all that apply.

-Call for help -Prepare for suctioning -Turn the client on the side

A client is admitted to the intensive care unit with diagnoses of a brain tumor complicated by transient diabetes insipidus. Which client data related to this complication should the nurse expect? Select all that apply.

-High serum osmolality -Low urine specific gravity -Reports of excessive thirst

The nurse is caring for a client who had an appendectomy yesterday and is reporting left leg tenderness and warmth. Which of the following additional assessments should the nurse perform before contacting the health care provider? Select all that apply.

-Assessment of bilateral leg skin temperature -Measurement of bilateral calf and thigh circumference -Observation of capillary refill time of the affected extremity -Palpation of bilateral dorsalis pedis and posterior tibial pulses

The nurse is teaching a client newly diagnosed with type 1 diabetes mellitus about hypoglycemia. Which of the following client statements demonstrate an understanding of the teaching? Select all that apply.

-I am going to purchase a medical alert band to wear at all times -I need to teach my family the signs and symptoms of hypoglycemia -I should check my blood glucose level immediately if I become shaky -I will carry a simple form of sugar, like hard candy with me at all times

A nurse is caring for a client who has a recent diagnosis of stable angina and has been prescribed daily atenolol and PRN nitroglycerin. Which of the following statements should the nurse include when providing discharge teaching? Select all that apply.

-Avoid exposure to outside temperature extremes when possible -Call emergency medical services if pain worsens after taking nitroglycerin -Nitroglycerin will cause dangerously low blood pressure if taken with sildenafil -Notify the health care provider if your anginal attacks become more frequent

A client with peripheral arterial disease reports aching extremity pain during activity that improves with rest. Which of the following client actions should the nurse encourage? Select all that apply.

-Begin light physical activity and increase intensity as tolerated -Limit intake of foods high in cholesterol and fat -Refrain from smoking or using tobacco products

The nurse is planning care for a client admitted with trigeminal neuralgia and a recent, unintentional weight loss of 40 lb (18 kg). Which of the following nursing actions should be included in the plan of care? Select all that apply.

-Assess the client for signs of depression and social withdrawal -Encourage use of a soft bristled toothbrush for oral hygiene -Evaluate the client's hydration and nutritional status -Teach the client to choose soft foods and chew on the unaffected side

A nurse is caring for a client who is mechanically ventilated with an endotracheal tube. Which interventions should the nurse carry out to reduce the risk of ventilator-associated pneumonia? Select all that apply.

-Maintain the incline of the head of the bed at 30-45 degrees -Perform oral care frequently and include antiseptic solution at least once per shift -Provide opportunities for mobilization such as range-of-motion exercises -Suction secretions pooling above the endotracheal tube cuff