skills exam idk

Pataasin ang iyong marka sa homework at exams ngayon gamit ang Quizwiz!

A client is ordered to receive oxygen therapy via nasal cannula at 4 L/minute. When providing care to this client, what would the nurse need to keep in mind? Select all that apply.

-The maximum flow rate that can be used is 6 L/minute. -The client must have clear, patent nasal passages. -The oxygen needs to be humidified to prevent drying of the mucosa.

The nurse is caring for a client who was found without food or water for 2 days in the desert. What explanation for the need for fluid does the client have? Select all that apply.

-facilitates cellular metabolism -helps maintain normal body temperature -acts as a solvent for electrolytes

The nurse is teaching a client about proper use of a glucometer. Which teaching will the nurse provide?

Blood glucose levels are obtained 30 minutes before eating, and before bedtime.

The nurse is caring for a client who was admitted with a suspected streptococcal throat infection. Which action should the nurse take first?

Collect the throat culture.

The nurse provides care for the client with chronic obstructive pulmonary disease experiencing hypoxia. Which assessment prompts the nurse to immediately report findings to the health care provider?

Decreased level of consciousness

A nurse is caring for a client with phlebitis. The nurse notices that the client's forearm, which has the tubing, has become red and slightly warm. Which actions should the nurse perform to avoid further complications and provide relief to the client?

Discontinue the IV promptly.

The nurse's morning assessment of a client who has a history of heart failure reveals the presence of 2+ pitting edema in the client's ankles and feet bilaterally. Which action should the nurse take to help alleviate the edema?

Elevate the legs

A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV?

Ensure that the prescribed solution is clear and transparent.

A 24-year-old woman was admitted to the hospital for an exacerbation of symptoms related to her cystic fibrosis. During a nurse's assessment of the client, the nurse notices a bluish color around her lips. What is the client exhibiting in this scenario?

cyanosis

A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of:

electrolytes.

The nurse is providing care to a client who has been experiencing emesis for 24 hours. Which fluid should the nurse anticipate incorporating into the client's plan of care?

hypotonic

Upon analysis of a client's arterial blood gas results, the nurse determines that the concentration of carbon dioxide and hydrogen ions are elevated and the oxygen in the arterial blood is decreased. What respiratory assessment findings would the nurse anticipate to observe in a client with these arterial blood gas results?

increase in rate and depth of respirations

A post-surgical client has been ordered an infusion of normal saline (0.9% NaCl) at 125 mL/hour until such time as the client begins drinking adequately. The infusion of this intravenous fluid will cause:

increased fluid volume with no significant redistribution of body fluids.

An adult client is discharged to home with a prescription for oxygen at 2 L/min. Which method of oxygen delivery should the nurse use in this situation?

nasal cannula

The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy does the nurse identify as out of scope nursing practice?

ordering type of solution, additive, amount of infusion, and duration

For which client should the nurse question an order to be placed in the supine position?

the client with a history of heart failure

A client has undergone a gastroscopy and received conscious sedation and a topical anesthetic to the throat. The client is awake and asking for a drink of water. What would the nurse do before allowing the client to drink?

Assess the client's swallow, gag, and cough reflexes.

A nurse reads the laboratory report and notes that the client has hyponatremia. What physical assessment should be made?

Monitor for GI symptoms.

To determine the quality of oxygenation, the nurse performs the physical assessment, the arterial blood gas test, and pulse oximetry. What is the purpose of the pulse oximetry test?

Monitor the amount of oxygen saturation in the blood.

A nurse monitoring a client's IV infusion auscultates the client's lung sounds and detects crackles in the bases in lungs that were previously clear. What would be the most appropriate intervention in this situation?

Notify the primary care provider immediately for possible fluid overload.

The nurse is caring for a client whose blood type is A negative. Which donor blood type does the nurse confirm as compatible for this client?

O negative

The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. Which action should the nurse take?

Stop the transfusion and notify the health care provider.

The nurse is preparing to access an implanted port when administering intravenous fluids and medications. What best practice should be used when accessing this port?

The system is accessed with a noncoring needle and patency is maintained by periodic flushing.

The nurse is assessing a client's intravenous line and notes small air bubbles within the tubing. What is the priority nursing action?

Tighten the roller clamp to stop the infusion.

The nurse is caring for a client who will be recieving multiple antibiotics. When chosing a site for intravenous insertion, which guideline will the nurse follow?

Use distal parts of larger veins where accessible.

The nurse is preparing to administer fluid replacement to a client. Which action should the nurse take first?

Verify the prescription for type of solution and amount of infusion.

A nurse is studying a client's chart and sees that the client's pH is currently at a 7. What condition is the client experiencing?

acidosis

Which is not a primary intracellular electrolyte?

chloride

A client is scheduled for a laboratory test. When explaining the test to the client, which would the nurse most likely include as being involved?

collection of a body fluid specimen

The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which assessment finding is consistent with hypoxia?

confusion

Within 15 minutes after the start of a blood transfusion, the client complains of chills and headache. During frequent vital signs, the nurse begins to see an elevation in the temperature. What condition is the client experiencing?

febrile reaction

Pulse oximetry gives what type of information about the client?

percentage of hemoglobin carrying oxygen

A nurse is conducting a focused respiratory assessment of a 21-year-old client who has been admitted to the hospital with a pneumothorax (collapsed lung). The nurse is aware that this client's diagnosis affects multiple aspects of the respiratory function, including external respiration. In what anatomical location does the external respiration take place?

the alveoli

When caring for older adults with respiratory ailments, why is it imperative that the nurse carefully assess a client who demonstrates restlessness or confusion?

to differentiate signs of inadequate oxygenation from early signs of delirium

An older adult client was recently placed on home oxygen. The client's caregiver reports that the client now refuses to leave the house. What teaching will the nurse provide the caregiver? Select all that apply.

-"Continued socialization with others is important." -"Discuss with the client switching to a portable oxygen device." -"Invite friends and family to the client's house."

A client using home oxygen asks the nurse about changing to an oxygen concentrator. What is the appropriate nursing response? Select all that apply.

-"It collects and concentrates oxygen from room air." -"It eliminates the need for a central reservoir of piped oxygen." -"You may notice an increase in your electric bill." -"It costs less than oxygen supplied in portable tanks."

The nurse is caring for a client with severe edema. Which intervention will the nurse choose to restore fluid balance? Select all that apply.

-Ask provider to order a low-salt diet. -Administer furosemide as ordered. -Reduce infusing fluid volume as ordered. -Treat the underlying condition that contributes to increased fluid volume.

A client with emphysema has aPaCO2 is 80 mm Hg on an arterial blood gas report. Which action(s) will the nurse take? Select all that apply.

-Monitor arterial blood gasses -Auscultate lung sounds -Monitor oxygen saturation -Provide breathing treatments and medications as prescribed -Elevate head of bed

The client has a sodium level of 131 mEq/L and has been placed on fluid restrictions of 1,000 mL per day. What interventions would the nurse include in the plan of care to assist the client in adhering to the fluid restriction? Select all that apply.

-Offer the client fluids in small containers. -Provide a moisturizer for the lips and mouth. -Remove the water pitcher from the client's bedside.

Which of the following are the purposes for collecting specimens? Select all that apply.

-Screen for health problems. -Diagnose health problems. -Direct the plan of care.

A nurse is teaching a client and family about a partial rebreather mask. What would the nurse explain as limitations of the device? Select all that apply.

-requires a minimum of 6 L/min -creates a risk for suffocation -requires monitoring to verify that reservoir bag remains inflated at all times

The nurse is caring for a client who is experiencing an acute exacerbation of asthma. The nurse will explain to the client that after receiving the nebulized albuterol, the client can expect to experience which potential side effect(s) of this medication? Select all that apply.

-tachycardia -nausea -lightheadedness -sore throat -nervousness

A client is reporting slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The client's SaO2 is 90% on pulse oximetry. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed:

6 L/minute.

A nurse has taken a throat culture from a client. The nurse will refrigerate the specimen if it will take longer than how many minutes to deliver it to the laboratory? Record your answer using a whole number.

60

A client is to undergo a test that requires fasting prior to it. How many hours should the nurse advise the client to withhold food for before the test? Record your answer using a whole number.

8

A client who utilizes a portable oxygen device reports planning to attend an upcoming bonfire on the beach. What is the appropriate nursing response?

"When using portable oxygen, you should avoid any fire."

A client with a nonhealing pressure injury has been prescribed hyperbaric oxygen therapy (HBOT). The client tells the nurse, "This kind of treatment doesn't make any sense to me." What is the appropriate nursing response?

"Wounds heal because HBOT helps to regenerate new tissue quickly."

The nurse is preparing the client for a Papanicolaou (Pap) test. The client asks the nurse, "What will this test tell me?" What responses by the nurse are correct? Select all that apply.

-"This test will screen for abnormal cervical cells." -"This test will help determine the status of reproductive hormone activity." -"This test will detect normal or infectious microorganisms in the vagina or uterus."

A client is undergoing a diagnostic test. While the procedure is going on, the nurse notices that the client is becoming emotional. What measures would the nurse employ? Select all that apply.

-Ask if the client is in pain or cold. -Implement comfort measures as needed. -Hold the client's hand. -Report the situation to the examiner.

The nurse is preparing a client to undergo an endoscopy. What is the appropriate nursing responsibility(ies)? Select all that apply.

-preparing the examination room -obtaining equipment and supplies for the procedure -ensuring the client has an identification bracelet present -reporting any incorrect test preparations promptly before the procedure

A nurse is teaching a client about total parenteral nutrition. What should the nurse teach the client regarding the substances within total parenteral nutrition? Select all that apply.

-proteins -carbohydrates -fats -vitamins -minerals

Which procedures are commonly done with the client in the Sims' position? Select all that apply.

-vaginal examination -rectal temperature assessment -suppository insertion -enema administration

The nurse is providing education to a client who has been recently diagnosed with type 2 diabetes. The nurse confirms teaching is effective when the client indicates they will check their blood glucose how long before a scheduled meal?

30

When measuring a client's intake and output, the nurse notes that the client has lost 1 lb in fluid over the last 2 days. What is the equivalent, in milliliters, of the client's fluid loss? Record your answer using a whole number.

475

Which fluid should be administered slowly to prevent circulatory overload?

5% NaCl

The nurse works at an agency that automatically places certain clients on intake and output (I&O). For which client will the nurse document all I&O?

55-year-old with congestive heart failure on furosemide

A nurse measures a client's 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse also do with the information?

Compare the total intake and output of fluids for the 24 hours.

The client has had an intravenous pyelogram for the detection of kidney stones. What should the nurse encourage the client to do after the test to promote urinary excretion?

Drink large amounts of fluids.

The nurse is working with a colleague and observes the colleague changing the bag of a client's IV solution as pictured above. What is the nurse's most appropriate response?

Encourage the colleague to hang the bag on the IV pole before spiking it.

Which teaching about the humidifier is important for the nurse to provide to a client using oxygen?

It decreases dry mucous membranes via delivering small water droplets.

A hospital client has illuminated the call light and told the nurse, "I can't quite seem to catch my breath." The client appears to be in no visible distress. What is the first intervention that the nurse should perform?

Raise the head of the client's bed and put the client in the high Fowler position.

While preparing the room for a bedside procedure, which action would be most appropriate for the nurse to take?

Remove any unnecessary furniture.

The nurse is caring for a client with shortness of breath who is receiving oxygen at 4 L/minute. Which assessment finding will demonstrate that oxygen therapy is effective?

SpO2 96%

The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. What is the priority nursing action?

Stop the transfusion.

A pregnant client visits a health care facility for her scheduled checkup before her delivery date. The physician needs to check the client's reproductive organs for any kind of irritation or discomfort. The physician asks the nurse to help the client into the lithotomy position. Which statement describes the lithotomy position?

The client should be in a reclining position with the feet in stirrups.

A woman had a left mastectomy with axillary node dissection due to cancer. How would this affect placement of an intravenous line?

The left arm should not be used.

A client has had an upper endoscopy with conscious sedation and topical anesthesia spray. What should the nurse do to prevent aspiration after the procedure is finished?

Withhold food or fluids for at least 2 hours after the procedure or until return of the gag reflex.

The nurse would expect to recommend an oxygen tent for which client?

a child who will not leave a facemask or cannula in place

Accurate fluid volume assessment has been ordered for a client who has been acutely ill since the time of admission to the hospital. The nurse can best monitor this client's fluid balance by:

accurately measuring and recording the client's intake and output.

When collecting a throat culture, where is the best place the nurse should obtain the specimen from?

around the palatine tonsils

The nurse is developing the plan of care for a client who is recovering from a bronchoscopy. Which action by the nurse would be a priority to prevent aspiration during administration of medication?

checking for a gag reflex

A client comes to the physician's office with a fever and cough. What diagnostic test does the nurse anticipate will reveal if the client has pneumonia?

chest x-ray

Upon evaluation of a client's medical history, the nurse recognizes that which condition may lead to an inadequate supply of oxygen to the tissues of the body?

chronic anemia

The nurse is caring for a client who was in a motor vehicle accident and requires treatment for internal bleeding from the trauma. Which solution does the nurse anticipate infusing?

colloidal

A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status?

daily weights

A student is learning how to administer intravenous fluids, including accessing a vein. What is the most potentially harmful risk posed for the client when accessing the vein?

infection

A nurse is initiating a peripheral venous access IV infusion prescribed for a client preoperative. In what position would the nurse place the client to perform this skill?

low-Fowler

A client who has to undergo endoscopy has been advised to abstain from food and fluids for at least 6 hours before the procedure. What other precaution should the nurse take in order to ensure client safety during the procedure?

monitor the client's vital signs, breathing, and oxygen saturation

A client with dehydration is being administered IV fluids. During rounds, the nurse noticed that the skin immediately surrounding the IV site was reddish in color and showing signs of inflammation. The nurse recognizes that what phenomenon is likely responsible?

phlebitis

A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene?

placing the tourniquet on the upper arm for 2 minutes

A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client?

platelets

The nurse is preparing to hang a nitroglycerin drip in a glass bottle for a client with chest pain. Which tubing selection by the nurse is appropriate?

primary vented tubing

When capping a primary line for intermittent use, a nurse notices local, acute tenderness; redness, warmth, and slight edema of the vein above the insertion site. Which complication has most likely occurred?

thrombus

Based on recent personality changes, a client is suspected of having a brain tumor and will soon undergo magnetic resonance imaging (MRI). What action should the nurse prioritize when preparing this client for this diagnostic procedure?

removing all metal objects from the client and ensuring the client has no internal metal objects

The nurse is assisting a male client into the modified standing position. What procedure will this client most likely be having?

prostate gland examination

A woman aged 58 years is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires:

replacement of fluids for those lost from vomiting and diarrhea.

An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as:

total parenteral nutrition.

The home care nurse is visiting a client who is totally oxygen dependent and using home oxygen. Upon noticing a gas stove in the kitchen, what teaching will the nurse provide?

"An electric stove may be a safer choice for you."

A nurse is caring for an older adult client who was admitted for dehydration. Which instruction will the nurse give to the client's adult child to prevent this situation from happening again to the client?

"Encourage your parent to drink fluids throughout the day."

A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate?

"Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein."

The nurse performs a respiratory assessment on a healthy client. While listening to the client's lungs, the nurse hears them fill with air and then return to a resting position. The nurse deems the findings normal. Which is the best way to document this respiratory assessment and lung sounds?

"Respiratory rate 14, even, regular, and easy; depth with acceptable parameters; lung sounds clear all lobes bilaterally; absence of adventitious lung sounds; absence of spontaneous cough; oxygen saturation 98%."

A client has been admitted to the post-surgical unit after a metatarsal (foot) amputation and has been provided with an incentive spirometer in order to prevent respiratory complications after surgery. What client education should the nurse provide about the correct use of incentive spirometry?

"Sit up as straight as you can when you're performing incentive spirometry."

Which response would the nurse provide to a client concerned about developing chronic bronchitis due to smoking cigarettes, working with printing chemicals, and living near a paper mill?

-"Have you tried to stop smoking? This can reduce your risk?" -"We can refer you to a smoking cessation program to help reduce developing any future pulmonary issues." -"How long have you lived near the paper mill? This can increase you risk for chronic bronchitis and asthma." -"Exposure to printing chemicals increases the risk for allergies which can trigger chronic bronchitis, so wearing a breathing mask may be needed."

A client is having difficulty breathing. During assessment of the client, which findings would the nurse expect to see? Select all that apply.

-lack of energy -rapid, shallow breathing -nasal flaring

The nurse is caring for a client with severe edema who has crackles in the lungs. Which nursing intervention is the priority for this client?

Administer furosemide as ordered.

The daughter of a client who is being treated for pneumonia has told the nurse that her father had his blood checked for its oxygen level during a previous bout with pneumonia. What disadvantage of arterial blood gas measurement should the client's nurse be aware of?

The procedure is invasive and painful.

A student has joined the marching band at high school. The band begins practicing outside during hot summer weather. Which health promotion information will the school nurse teach the students?

The student should drink large amounts of water on practice days.

The nurse is caring for a client admitted with chronic obstructive pulmonary disease. During shift assessment, the nurse finds that the client is experiencing a change in respiratory and mental status. The most accurate measurement of the concentration of oxygen in the client's blood is:

an arterial blood gas study.

After administering barium as a contrast medium to a client, the nurse explains the side effects to the client. Which of the following is a common side effect of barium ingestion?

constipation

A client with an infection on the genitalia visits a health care facility. In order to inspect the infection, the nurse assists the client into a reclining position with knees bent. What type of position has the nurse placed the client in for inspection?

dorsal recumbent position

During oxygen administration to the client, which pieces of equipment would enable the nurse to regulate the amount of oxygen delivered?

flow meter

The nurse needs to place a client in the Sims' position for an enema. Which action by the nurse is correct?

having client turn to the left side and bend right knee towards the chest

A severely malnourished client has been admitted to a health care facility. The nurse is preparing to administer total parenteral nutrition (TPN) to the client. The nurse should administer the TPN solution in a:

peripheral vein with its tip terminating in the superior vena cava.

Who is responsible for ensuring that clients have sufficient information to give informed consent?

physicians

A client is scheduled for a diagnostic test with contrast medium. For what allergy should the nurse be sure to question the client?

seafood or other foods containing iodine

The nurse is assisting the physician with a paracentesis. The nurse would place the client in which position?

sitting

A 55-year-old obese man reports excessive daytime sleepiness, morning headaches, and sore throat. His wife states that he snores a lot. Which disease is this client most likely suffering from?

sleep apnea

The nurse is caring for a client who has a percutaneous tracheostomy (PCT) following a skydiving accident. Which oxygen delivery device will the nurse select?

tracheostomy collar

A client with chronic obstructive pulmonary disease who uses supplemental oxygen via mask requires oral suctioning. Which action(s) demonstrates the components of appropriate oral suctioning technique by the nurse? Select all that apply.

-Allowing client to rest for 30 to 60 seconds in between suctionings -Removing the client's oxygen and inserting the yankauer catheter into client's mouth -Replacing oxygen on client and clearing out suction catheter by placing yankauer in the basin of water -Running the catheter along the client's gum line to the pharynx in a circular motion while keeping yankauer moving

A nurse has specific responsibilities before a client undergoes a diagnostic test. Place the sequence of conducting these duties in the correct order, from first to last.

-Determine whether the client understands the test's purpose and the activities involved. -Assist with obtaining the client's consent. -Prepare the client. -Obtain the equipment and supplies. -Ready the examination area.

A nurse is caring for an older adult client who is to be discharged from the health care facility. The client has been prescribed an oxygen concentrator at home to continue oxygen therapy. What instructions would the nurse tell the client regarding the use of the oxygen concentrator in the home? Select all that apply.

-Do not smoke or use oxygen where open flames, such as a gas stove, are in use. -The oxygen concentrator needs to be used in a grounded electrical plug. -The oxygen concentrator is portable and cost-effective.

The nurse is caring for a client with emphysema. When teaching the client pursed-lip breathing, the nurse will include which instruction(s)? Select all that apply.

-Inhale slowly through the nose for a count of three. -Shape the lips as if you were about the blow a whistle. -Over time, begin to increase the length of the exhale. -Exhale slowly through pursed lips. -Ensure that the exhale lasts twice as long as the inhale.

A nurse has to assist with obtaining a throat culture. Place the steps of this procedure in the correct sequence from first to last.

-Loosen the cap on the tube in which the swab is located. Tell the client to open the mouth wide, stick out the tongue, and tilt the head back. -Depress the middle of the tongue with a tongue blade in your nondominant hand. -Rub and twist the tip of the swab around the tonsil areas and the back of the throat without touching the lips, teeth, or tongue. -Remove the swab and discard the tongue blade in a lined receptacle. -Spread the secretions on the swab across the glass slide. -Replace the swab securely within the tube, taking care not to touch the outside of the container. Crush the packet in the bottom of the tube.

Which should the nurse teach the family about caring for a client with emphysema at home? Select all that apply.

-Maintain a smoke-free environment. -Watch for increased wheezing or signs of a flare-up. -Take advantage of pulmonary rehabilitation programs. -Follow health care provider's prescription for oxygen administration. -Create a long-term caregiving plan.

Arterial blood gases (ABGs) have been drawn on the client. The nurse reviews the results. -pH is 7.31 -PaO2 92 mm Hg (12.24 kPa) -PaCO2 50 mm Hg (6.65 kPa) -HCO3 28 mEq/L (28 mmol/L)

-Respiratory acidosis -Partial compensation

The nurse is caring for a client at risk for pneumonia after having major abdominal surgery. Which nursing instruction(s) is essential for the use of an incentive spirometer? Select all that apply.

-Splint the abdomen with a pillow to decrease discomfort prior to use. -Instruct the client to exhale normally and then place lips securely around the mouthpiece. -Encourage the client to complete breathing exercises about 5 to 10 times every 1 to 2 hours, if possible. -Assist the client to an upright or semi-Fowler position.

The nurse provides care for a client with chronic bronchitis and a decreasing oxygen saturation. Which factor(s), if assessed, indicate a deteriorating condition? Select all that apply.

-Tachypnea -Tachycardia -Shortness of breath -Wheezing and crackles in lungs

The nurse is assessing an adult client who has presented to the emergency department with general weakness. The nurse reviews the client health record to find there is no history of underlying health conditions. The nurse will begin preparing for the insertion of a peripheral intravenous line if which assessment finding(s) are present? Select all that apply.

-The client reports using laxative substances daily. -The client has been vomiting for several days. -The client has a serum potassium level of 2.0 mEq/l (2.0 mmol/l). -The client has severe iron-deficiency anemia.

A 55-year-old male client with emphysema worked with photography chemicals and smoked cigarettes for 30 years. Which symptom(s) will the nurse expects to find? Select all that apply.

-Wheezing -Chronic cough -Shortness of breath -Loss of appetite

The nursing instructor is teaching a nursing student about diagnostic terms. Which suffix will the nursing instructor teach that means "to puncture"?

-centesis

The nurse is preparing to perform venipuncture. Which items will the nurse plan to gather? Select all that apply.

-clean gloves -tourniquet -antiseptic swabs -transparent dressing -adhesive tape

Which client(s) would be an appropriate candidate for total parenteral nutrition (TPN)? Select all that apply.

-client who has full-thickness (third-degree) burns over 40% of the body -client who had gastric surgery and is unable to eat for a few weeks -client with anorexia nervosa

A client has been admitted with fluid volume excess related to right-sided heart failure. Which assessment data would the nurse expect related to the fluid volume excess? Select all that apply.

-crackles in the lungs -distended neck veins

A nurse is assisting with a rectal examination. The nurse would most likely place the client in which position? Select all that apply.

-dorsal recumbent -Sims' -knee-chest

A nurse is to perform capillary blood glucose testing with a client. Which materials would the nurse gather to perform this procedure? Select all that apply.

-glucometer -control solution -lancet holder

An older adult is having a diagnostic test at 10:00 am and is to have nothing to eat or drink after midnight the night before. How can the nurse determine that the patient is tolerating the fasting state? Select all that apply.

-mental status -urinary output -blood pressure

The nurse is applying a pulse oximeter to a client with bronchitis. Which factor(s) does the nurse communicate to the client that could interfere with accurate pulse oximetry? Select all that apply.

-nail polish -thickness of nails -acrylic nails -peripheral vascular disease

Which breathing technique(s) will the nurse teach to the client who has hypoxemia and hypercarbia? Select all that apply.

-pursed-lip breathing -diaphragmatic breathing


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