Exam 1 questions
A nurse administers topical gentamicin sulfate (Garamycin) to a clients burn injury. Which laboratory value should the nurse monitor while the client is prescribed this therapy? a. Creatinine b. Red blood cells c. Sodium d. Magnesium
A (its nephrotoxic)
A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the nursing student? (Select all that apply.) a. Bringing the client warm blankets b. Giving the client hot tea to drink c. Massaging the clients painful legs d. Reorienting the client as needed e. Sitting with the client for reassurance
A, D, E,
A client is on intravenous heparin to treat a pulmonary embolism. The clients most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate? a. Decrease the heparin rate. b. Increase the heparin rate. c. No change to the heparin rate. d. Stop heparin; start warfarin (Coumadin).
B
A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred? a. Hemoglobin: 14.2 g/dL b. Platelet count: 82,000/L c. Red blood cell count: 4.8/mm3 d. White blood cell count: 8.7/mm3
B
A nurse assesses a client who has encephalitis. Which manifestations should the nurse recognize as signs of increased intracranial pressure (ICP), a complication of encephalitis? (Select all that apply.) a. Photophobia b. Dilated pupils c. Headache d. Widened pulse pressure e. Bradycardia
B D E
A nurse is dismissing a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management? (Select all that apply.) a. Does not want to purchase a thermometer b. Is allergic to acetaminophen (Tylenol) c. Laughing, says Strenuous? Whats that? d. Lives alone and is new in town with no friends e. Plans to have a beer and go to bed once home
B D E
A nurse assesses a client who is experiencing an absence seizure. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Intermittent rigidity b. Lip smacking c. Sudden loss of muscle tone d. Brief jerking of the extremities e. Picking at clothing f. Patting of the hand on the leg
B E F
A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive perspective of his or her appearance? a. I will allow my spouse to change my dressings. b. I want to have surgical reconstruction. c. I will bathe and dress before breakfast. d. I have secured the pressure dressings as ordered.
C
A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The client asks, Why am I taking this medication? How should the nurse respond? a. Tagamet stimulates intestinal movement so you can eat more. b. It improves fluid retention, which helps prevent hypovolemic shock. c. It helps prevent stomach ulcers, which are common after burns. d. Tagamet protects the kidney from damage caused by dehydration.
C
A client in the intensive care unit is scheduled for a lumbar puncture (LP) today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. What action by the nurse is best? a. Ensure that informed consent is on the chart. b. Document these findings in the clients record. c. Give the prescribed preprocedure sedation. d. Notify the provider of the findings immediately.
D
A nurse reviews the following data in the chart of a client with burn injuries: Admission Notes Wound Assessment 36-year-old female with bilateral leg burns NKDA Health history of asthma and seasonal allergies Bilateral leg burns present with a white and leather-like appearance. No blisters or bleeding present. Client rates pain 2/10 on a scale of 0-10. Based on the data provided, how should the nurse categorize this clients injuries? a. Partial-thickness deep b. Partial-thickness superficial c. Full thickness d. Superficial
C (all others are painful, full thickness is not)
A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.) a. Allow visitors at the clients bedside. b. Ensure the client can communicate if awake. c. Keep the television tuned to a favorite channel. d. Provide back and hand massages when turning. e. Turn the client every 2 hours or more.
a, b, d, e
A 70-kg adult with chronic renal failure is on a 40-g protein diet. The client has a reduced glomerular filtration rate and is not undergoing dialysis. Which result would give the nurse the most concern? a. Albumin level of 2.5 g/dL b. Phosphorus level of 5 mg/dL c. Sodium level of 135 mmol/L d. Potassium level of 5.5 mmol/L
A
A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best? a. Assess for other manifestations of hypoxia. b. Change the sensor on the pulse oximeter. c. Obtain a new oximeter from central supply. d. Tell the client to take slow, deep breaths.
A
A client has a brain abscess and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying the client does not have a seizure disorder. What response by the nurse is best? a. Increased pressure from the abscess can cause seizures. b. Preventing febrile seizures with an abscess is important. c. Seizures always occur in clients with brain abscesses. d. This drug is used to sedate the client with an abscess.
A
A client has a serum potassium level of 6.5 mmol/L, a serum creatinine level of 2 mg/dL, and a urine output of 350 mL/day. What is the best action by the nurse? a. Place the client on a cardiac monitor immediately. b. Teach the client to limit high-potassium foods. c. Continue to monitor the clients intake and output. d. Ask to have the laboratory redraw the blood specimen.
A
A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg, and respiratory irregularities. What action by the nurse takes priority? a. Call the provider or Rapid Response Team. b. Increase the rate of the IV fluid administration. c. Notify respiratory therapy for a breathing treatment. d. Prepare to give IV pain medication.
A
A client has been brought to the emergency department after being shot multiple times. What action should the nurse perform first? a. Apply personal protective equipment. b. Notify local law enforcement officials. c. Obtain universal donor blood. d. Prepare the client for emergency surgery.
A
A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority? a. Alteplase (Activase) b. Enoxaparin (Lovenox) c. Unfractionated heparin d. Warfarin sodium (Coumadin)
A
A client in shock is apprehensive and slightly confused. What action by the nurse is best? a. Offer to remain with the client for awhile. b. Prepare to administer antianxiety medication. c. Raise all four siderails on the clients bed. d. Tell the client everything possible is being done.
A
A client in the emergency department has several broken ribs. What care measure will best promote comfort? a. Allowing the client to choose the position in bed b. Humidifying the supplemental oxygen c. Offering frequent, small drinks of water d. Providing warmed blankets
A
A client in the intensive care unit is started on continuous venovenous hemofiltration (CVVH). Which finding is the cause of immediate action by the nurse? a. Blood pressure of 76/58 mm Hg b. Sodium level of 138 mEq/L c. Potassium level of 5.5 mEq/L d. Pulse rate of 90 beats/min
A
A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best? a. High glucose is common in shock and needs to be treated. b. Some of the medications we are giving are to raise blood sugar. c. The IV solution has lots of glucose, which raises blood sugar. d. The stress of this illness has made your spouse a diabetic.
A
A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The clients spouse is very frustrated, stating that the clients personality has changed and the situation is intolerable. What action by the nurse is best? a. Explain that personality changes are common following brain injuries. b. Ask the client why he or she is acting out and behaving differently. c. Refer the client and spouse to a head injury support group. d. Tell the spouse this is expected and he or she will have to learn to cope.
A
A client is receiving norepinephrine (Levophed) for shock. What assessment finding best indicates a therapeutic effect from this drug? a. Alert and oriented, answering questions b. Client denial of chest pain or chest pressure c. IV site without redness or swelling d. Urine output of 30 mL/hr for 2 hours
A
A client is taking furosemide (Lasix) 40 mg/day for management of chronic kidney disease (CKD). To detect the positive effect of the medication, what action of the nurse is best? a. Obtain daily weights of the client. b. Auscultate heart and breath sounds. c. Palpate the clients abdomen. d. Assess the clients diet history.
A
A client who had a severe traumatic brain injury is being discharged home, where the spouse will be a full-time caregiver. What statement by the spouse would lead the nurse to provide further education on home care? a. I know I can take care of all these needs by myself. b. I need to seek counseling because I am very angry. c. Hopefully things will improve gradually over time. d. With respite care and support, I think I can do this.
A
A client with chronic kidney disease (CKD) is experiencing nausea, vomiting, visual changes, and anorexia. Which action by the nurse is best? a. Check the clients digoxin (Lanoxin) level. b. Administer an anti-nausea medication c. Ask if the client is able to eat crackers. d. Get a referral to a gastrointestinal provider
A
A male client comes into the emergency department with a serum creatinine of 2.2 mg/dL and a blood urea nitrogen (BUN) of 24 mL/dL. What question should the nurse ask first when taking this clients history? a. Have you been taking any aspirin, ibuprofen, or naproxen recently? b. Do you have anyone in your family with renal failure? c. Have you had a diet that is low in protein recently? d. Has a relative had a kidney transplant lately?
A
A male client with chronic kidney disease (CKD) is refusing to take his medication and has missed two hemodialysis appointments. What is the best initial action for the nurse? a. Discuss what the treatment regimen means to him. b. Refer the client to a mental health nurse practitioner. c. Reschedule the appointments to another date and time. d. Discuss the option of peritoneal dialysis.
A
A marathon runner comes into the clinic and states I have not urinated very much in the last few days. The nurse notes a heart rate of 110 beats/min and a blood pressure of 86/58 mm Hg. Which action by the nurse is the priority? a. Give the client a bottle of water immediately. b. Start an intravenous line for fluids. c. Teach the client to drink 2 to 3 liters of water daily. d. Perform an electrocardiogram.
A
A nurse cares for a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the clients pain? a. Administer the prescribed intravenous morphine sulfate. b. Apply ice to skin around the burn wound for 20 minutes. c. Administer prescribed intramuscular ketorolac (Toradol). d. Decrease tactile stimulation near the burn injuries.
A
A nurse delegates hydrotherapy to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this activity? a. Keep the water temperature constant when showering the client. b. Assess the wound beds during the hydrotherapy treatment. c. Apply a topical enzyme agent after bathing the client. d. Use sterile saline to irrigate and clean the clients wounds.
A
A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate? a. Assess the cause of the agitation. b. Reassure the client that he or she is safe. c. Restrain the clients hands. d. Sedate the client immediately.
A
A nurse is caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first? a. Client with a Glasgow Coma Scale score that was 10 and is now is 8 b. Client with a Glasgow Coma Scale score that was 9 and is now is 12 c. Client with a moderate brain injury who is amnesic for the event d. Client who is requesting pain medication for a headache
A
After teaching a client with a spinal cord injury, the nurse assesses the clients understanding. Which client statement indicates a correct understanding of how to prevent respiratory problems at home? a. Ill use my incentive spirometer every 2 hours while Im awake. b. Ill drink thinned fluids to prevent choking. c. Ill take cough medicine to prevent excessive coughing. d. Ill position myself on my right side so I dont aspirate.
A
An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. Which action should the nurse take first? a. Apply oxygen and continuous pulse oximetry. b. Provide small quantities of ice chips and sips of water. c. Request a prescription for an antitussive medication. d. Ask the respiratory therapist to provide humidified air.
A
The nurse assesses a client who has a severe burn injury. Which statement indicates the client understands the psychosocial impact of a severe burn injury? a. It is normal to feel some depression. b. I will go back to work immediately. c. I will not feel anger about my situation. d. Once I get home, things will be normal.
A
The nurse gets the hand-off report on four clients. Which client should the nurse assess first? a. Client with a blood pressure change of 128/74 to 110/88 mm Hg b. Client with oxygen saturation unchanged at 94% c. Client with a pulse change of 100 to 88 beats/min d. Client with urine output of 40 mL/hr for the last 2 hours
A
The nurse is teaching a client with chronic kidney disease (CKD) about the sodium restriction needed in the diet to prevent edema and hypertension. Which statement by the client indicates more teaching is needed? a. I am thrilled that I can continue to eat fast food. b. I will cut out bacon with my eggs every morning. c. My cooking style will change by not adding salt. d. I will probably lose weight by cutting out potato chips.
A
A nurse assesses clients on a medical-surgical unit. Which clients should the nurse identify as at risk for secondary seizures? (Select all that apply.) a. A 26-year-old woman with a left temporal brain tumor b. A 38-year-old male client in an alcohol withdrawal program c. A 42-year-old football player with a traumatic brain injury d. A 66-year-old female client with multiple sclerosis e. A 72-year-old man with chronic obstructive pulmonary disease
A B C
A client has a small-bore feeding tube (Dobhoff tube) inserted for continuous enteral feedings while recovering from a traumatic brain injury. What actions should the nurse include in the clients care? (Select all that apply.) a. Assess tube placement per agency policy. b. Keep the head of the bed elevated at least 30 degrees. c. Listen to lung sounds at least every 4 hours. d. Run continuous feedings on a feeding pump. e. Use blue dye to determine proper placement.
A B C D
A nurse plans care for a client with burn injuries. Which interventions should the nurse implement to prevent infection in the client? (Select all that apply.) a. Ask all family members and visitors to perform hand hygiene before touching the client. b. Carefully monitor burn wounds when providing each dressing change. c. Clean equipment with alcohol between uses with each client on the unit. d. Allow family members to only bring the client plants from the hospitals gift shop. e. Use aseptic technique and wear gloves when performing wound care.
A B E
After teaching a client with a spinal cord tumor, the nurse assesses the clients understanding. Which statements by the client indicate a correct understanding of the teaching? (Select all that apply.) a. Even though turning hurts, I will remind you to turn me every 2 hours. b. Radiation therapy can shrink the tumor but also can cause more problems. c. Surgery will be scheduled to remove the tumor and reverse my symptoms. d. I put my affairs in order because this type of cancer is almost always fatal. e. My family is moving my bedroom downstairs for when I am discharged home.
A B E
A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.) a. Heart rate of 34 beats/min b. Blood pressure of 185/65 mm Hg c. Urine output less than 30 mL/hr d. Decreased level of consciousness e. Increased oxygen saturation
A C D
A nurse cares for older clients who have traumatic brain injury. What should the nurse understand about this population? (Select all that apply.) a. Admission can overwhelm the coping mechanisms for older clients. b. Alcohol is typically involved in most traumatic brain injuries for this age group. c. These clients are more susceptible to systemic and wound infections. d. Other medical conditions can complicate treatment for these clients. e. Very few traumatic brain injuries occur in this age group.
A C D
1. A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which assessment data should the nurse obtain to assess the clients coping strategies? (Select all that apply.) a. Spiritual beliefs b. Level of pain c. Family support d. Level of independence e. Annual income f. Previous coping strategies
A C D F
A nursing student studying traumatic brain injuries (TBIs) should recognize which facts about these disorders? (Select all that apply.) a. A client with a moderate trauma may need hospitalization. b. A Glasgow Coma Scale score of 10 indicates a mild brain injury. c. Only open head injuries can cause a severe TBI. d. A client with a Glasgow Coma Scale score of 3 has severe TBI. e. The terms mild TBI and concussion have similar meanings.
A D E
A nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Have suction equipment at the bedside. b. Place a padded tongue blade at the bedside. c. Permit only clear oral fluids. d. Keep bed rails up at all times. e. Maintain the client on strict bedrest. f. Ensure that the client has IV access.
A D F
A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (Select all that apply.) a. Administer analgesics. b. Prevent wound infections. c. Provide fluid replacement. d. Decrease core temperature. e. Initiate physical therapy.
A, B, C
The nurse is caring for five clients on the medical-surgical unit. Which clients would the nurse consider to be at risk for post-renal acute kidney injury (AKI)? (Select all that apply.) a. Man with prostate cancer b. Woman with blood clots in the urinary tract c. Client with ureterolithiasis d. Firefighter with severe burns e. Young woman with lupus
A, B, C
The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.) a. Adherence to proper hand hygiene b. Administering anti-ulcer medication c. Elevating the head of the bed d. Providing oral care per protocol e. Suctioning the client on a regular schedule
A, B, C, D
The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher risk for shock. For what factors would the nurse assess? (Select all that apply.) a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition e. Overhydration
A, B, C, D,
A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.) a. Acknowledge the frightening nature of the illness. b. Delegate a back rub to the unlicensed assistive personnel (UAP). c. Give simple explanations of what is happening. d. Request a prescription for antianxiety medication. e. Stay with the client and speak in a quiet, calm voice.
A, B, C, E
A client is undergoing hemodialysis. The clients blood pressure at the beginning of the procedure was 136/88 mm Hg, and now it is 110/54 mm Hg. What actions should the nurse perform to maintain blood pressure? (Select all that apply.) a. Adjust the rate of extracorporeal blood flow. b. Place the client in the Trendelenburg position. c. Stop the hemodialysis treatment. d. Administer a 250-mL bolus of normal saline. e. Contact the health care provider for orders.
A, B, D
A client is unsure of the decision to undergo peritoneal dialysis (PD) and wishes to discuss the advantages of this treatment with the nurse. Which statements by the nurse are accurate regarding PD? (Select all that apply.) a. You will not need vascular access to perform PD. b. There is less restriction of protein and fluids. c. You will have no risk for infection with PD. d. You have flexible scheduling for the exchanges. e. It takes less time than hemodialysis treatments.
A, B, D
The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.) a. Chest wall stiffness b. Decreased muscle strength c. Inability to cooperate d. Less lung elasticity e. Poor vision and hearing
A, B, D
A nurse cares for a client with burn injuries who is experiencing anxiety and pain. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.) a. Music as a distraction b. Tactile stimulation c. Massage to injury sites d. Cold compresses e. Increasing client control
A, B, E
The nurse is caring for a client with suspected severe sepsis. What does the nurse prepare to do within 3 hours of the client being identified as being at risk? (Select all that apply.) a. Administer antibiotics. b. Draw serum lactate levels. c. Infuse vasopressors. d. Measure central venous pressure. e. Obtain blood cultures.
A, B, E
The student nurse studying shock understands that the common manifestations of this condition are directly related to which problems? (Select all that apply.) a. Anaerobic metabolism b. Hyperglycemia c. Hypotension d. Impaired renal perfusion e. Increased perfusion
A, C
The nurse caring for hospitalized clients includes which actions on their care plans to reduce the possibility of the clients developing shock? (Select all that apply.) a. Assessing and identifying clients at risk b. Monitoring the daily white blood cell count c. Performing proper hand hygiene d. Removing invasive lines as soon as possible e. Using aseptic technique during procedures
A, C ,D ,E
A nurse cares for an older client with burn injuries. Which age-related changes are paired appropriately with their complications from the burn injuries? (Select all that apply.) a. Slower healing time Increased risk for loss of function from contracture formation b. Reduced inflammatory response Deep partial-thickness wound with minimal exposure c. Reduced thoracic compliance Increased risk for atelectasis d. High incidence of cardiac impairments Increased risk for acute kidney injury e. Thinner skin May not exhibit a fever when infection is present
A, C, D
A nurse plans care for a client with burn injuries. Which interventions should the nurse include in this clients plan of care to ensure adequate nutrition? (Select all that apply.) a. Provide at least 5000 kcal/day. b. Start an oral diet on the first day. c. Administer a diet high in protein. d. Collaborate with a registered dietitian. e. Offer frequent high-calorie snacks.
A, C, D, E,
A client is hospitalized in the oliguric phase of acute kidney injury (AKI) and is receiving tube feedings. The nurse is teaching the clients spouse about the kidney-specific formulation for the enteral solution compared to standard formulas. What components should be discussed in the teaching plan? (Select all that apply.) a. Lower sodium b. Higher calcium c. Lower potassium d. Higher phosphorus e. Higher calories
A, C, E
A nurse is caring for a postoperative 70-kg client who had major blood loss during surgery. Which findings by the nurse should prompt immediate action to prevent acute kidney injury? (Select all that apply.) a. Urine output of 100 mL in 4 hours b. Urine output of 500 mL in 12 hours c. Large amount of sediment in the urine d. Amber, odorless urine e. Blood pressure of 90/60 mm Hg
A, C, E
. A nurse assesses a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication? a. Partial pressure of arterial oxygen (PaO2) of 80 mm Hg b. Urine output of 20 mL/hr c. Productive cough with white pulmonary secretions d. Core temperature of 100.6 F (38 C)
B
A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority? a. Apply direct pressure to the bleeding. b. Ensure the client has a patent airway. c. Obtain consent for emergency surgery. d. Start two large-bore IV catheters.
B
A client is admitted with acute kidney injury (AKI) and a urine output of 2000 mL/day. What is the major concern of the nurse regarding this clients care? a. Edema and pain b. Electrolyte and fluid imbalance c. Cardiac and respiratory status d. Mental health status
B
A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The clients sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge? a. All my friends and neighbors are planning a party for me. b. I hope I can get my water turned back on when I get home. c. I am going to have my daughter scoop the cat litter box. d. My grandkids are so excited to have me coming home!
B
A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication? a. Hamburger and French fries b. Large chefs salad and muffin c. No selection; spouse brings pizza d. Tuna salad sandwich and chips
B
A client is having a peritoneal dialysis treatment. The nurse notes an opaque color to the effluent. What is the priority action by the nurse? a. Warm the dialysate solution in a microwave before instillation. b. Take a sample of the effluent and send to the laboratory. c. Flush the tubing with normal saline to maintain patency of the catheter. d. Check the peritoneal catheter for kinking and curling.
B
A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals the client has an alteration in the gene CYP2C19. What action by the nurse is best? a. Instruct the client to eliminate all vitamin K from the diet. b. Prepare preoperative teaching for an inferior vena cava (IVC) filter. c. Refer the client to a chronic illness support group. d. Teach the client to use a soft-bristled toothbrush.
B
A client is recovering from a kidney transplant. The clients urine output was 1500 mL over the last 12-hour period since transplantation. What is the priority assessment by the nurse? a. Checking skin turgor b. Taking blood pressure c. Assessing lung sounds d. Weighing the client
B
A client with a traumatic brain injury is agitated and fighting the ventilator. What drug should the nurse prepare to administer? a.. Carbamazepine (Tegretol) b. Dexmedetomidine (Precedex) c. Diazepam (Valium) d. Mannitol (Osmitrol)
B
A clients mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm Hg. Based on the clients cerebral perfusion pressure, what should the nurse anticipate for this client? a. Impending brain herniation b. Poor prognosis and cognitive function c. Probable complete recovery d. Unable to tell from this information
B
A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority? a. Assess the clients lung sounds. b. Notify the Rapid Response Team. c. Provide reassurance to the client. d. Take a full set of vital signs.
B
A nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How should the nurse document this activity? a. Atonic seizure b. Tonic-clonic seizure c. Myoclonic seizure d. Absence seizure
B
A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication should the nurse prepare to administer? a. Atenolol (Tenormin) b. Lorazepam (Ativan) c. Phenytoin (Dilantin) d. Lisinopril (Prinivil)
B
A nurse cares for a client with burn injuries from a house fire. The client is not consistently oriented and reports a headache. Which action should the nurse take? a. Increase the clients oxygen and obtain blood gases. b. Draw blood for a carboxyhemoglobin level. c. Increase the clients intravenous fluid rate. d. Perform a thorough Mini-Mental State Examination.
B
A nurse is caring for a client after surgery who is restless and apprehensive. The unlicensed assistive personnel (UAP) reports the vital signs and the nurse sees they are only slightly different from previous readings. What action does the nurse delegate next to the UAP? a. Assess the client for pain or discomfort. b. Measure urine output from the catheter. c. Reposition the client to the unaffected side. d. Stay with the client and reassure him or her.
B
A nurse is caring for a client after surgery. The clients respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last assessed 4 hours ago. What action by the nurse is best? a. Ask if the client needs pain medication. b. Assess the clients tissue perfusion further. c. Document the findings in the clients chart. d. Increase the rate of the clients IV infusion.
B
A nurse is caring for a client on the medical stepdown unit. The following data are related to this client: Subjective Information Laboratory Analysis Physical Assessment Shortness of breath for 20 minutes Feels frightened Cant catch my breath pH: 7.12 PaCO2: 28 mm Hg PaO2: 58 mm Hg SaO2: 88% Pulse: 120 beats/min Respiratory rate: 34 breaths/min Blood pressure 158/92 mm Hg Lungs have crackles What action by the nurse is most appropriate? a. Call respiratory therapy for a breathing treatment. b. Facilitate a STAT pulmonary angiography. c. Prepare for immediate endotracheal intubation. d. Prepare to administer intravenous anticoagulants.
B
A nurse is caring for several clients at risk for shock. Which laboratory value requires the nurse to communicate with the health care provider? a. Creatinine: 0.9 mg/dL b. Lactate: 6 mmol/L c. Sodium: 150 mEq/L d. White blood cell count: 11,000/mm3
B
A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority? a. Assessing that the ventilator settings are correct b. Ensuring there is a bag-valve-mask in the room c. Obtaining personal protective equipment d. Planning to suction the client upon arrival to the room
B
A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management? a. Poor visual acuity b. Strict vegetarian c. Refusal to stop smoking d. Wants weight loss surgery
B
A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The clients urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question? a. Increase intravenous fluids by 100 mL/hr. b. Administer furosemide (Lasix) 40 mg IV push. c. Continue to monitor urine output hourly. d. Draw blood for serum electrolytes STAT.
B
A nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. Which action should the nurse take? a. Start fluids via a large-bore catheter. b. Turn the clients head to the side. c. Administer IV push diazepam. d. Prepare to intubate the client.
B
A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock? a. Do not get dehydrated in warm weather. b. Drink fluids on a regular schedule. c. Seek attention for any lacerations. d. Take medications as prescribed.
B
A student is caring for a client who suffered massive blood loss after trauma. How does the student correlate the blood loss with the clients mean arterial pressure (MAP)? a. It causes vasoconstriction and increased MAP. b. Lower blood volume lowers MAP. c. There is no direct correlation to MAP. d. It raises cardiac output and MAP.
B
A student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action by the student requires immediate intervention by the supervising nurse? a. Assessing the clients platelet count b. Choosing an 18-gauge, 2-inch needle c. Not aspirating prior to injection d. Swabbing the injection site with alcohol
B
An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago. Which prescribed medication should the nurse prepare to administer? a. Intrathecal baclofen (Lioresal) b. Methylprednisolone (Medrol) c. Atropine sulfate d. Epinephrine (Adrenalin)
B
The nurse is assessing a client with a diagnosis of pre-renal acute kidney injury (AKI). Which condition would the nurse expect to find in the clients recent history? a. Pyelonephritis b. Myocardial infarction c. Bladder cancer d. Kidney stones
B
The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination? a. Use a disposable blood pressure cuff to avoid sharing with other clients. b. Change gloves between wound care on different parts of the clients body. c. Use the closed method of burn wound management for all wound care. d. Advocate for proper and consistent handwashing by all members of the staff.
B
The nurse is caring for four clients with chronic kidney disease. Which client should the nurse assess first upon initial rounding? a. Woman with a blood pressure of 158/90 mm Hg b. Client with Kussmaul respirations c. Man with skin itching from head to toe d. Client with halitosis and stomatitis
B
The nurse is teaching the main principles of hemodialysis to a client with chronic kidney disease. Which statement by the client indicates a need for further teaching by the nurse? a. My sodium level changes by movement from the blood into the dialysate. b. Dialysis works by movement of wastes from lower to higher concentration. c. Extra fluid can be pulled from the blood by osmosis. d. The dialysate is similar to blood but without any toxins.
B
A nurse cares for a client with a lower motor neuron injury who is experiencing a flaccid bowel elimination pattern. Which actions should the nurse take to assist in relieving this clients constipation? (Select all that apply.) a. Pour warm water over the perineum. b. Provide a diet high in fluids and fiber. c. Administer daily tap water enemas. d. Implement a consistent daily time for elimination. e. Massage the abdomen from left to right. f. Perform manual disimpaction.
B D F
A nurse is giving discharge instructions to a client recently diagnosed with chronic kidney disease (CKD). Which statements made by the client indicate a correct understanding of the teaching? (Select all that apply.) a. I can continue to take antacids to relieve heartburn. b. I need to ask for an antibiotic when scheduling a dental appointment. c. Ill need to check my blood sugar often to prevent hypoglycemia. d. The dose of my pain medication may have to be adjusted. e. I should watch for bleeding when taking my anticoagulants.
B, C, D, E
The nurse is teaching a client with diabetes mellitus how to prevent or delay chronic kidney disease (CKD). Which client statements indicate a lack of understanding of the teaching? (Select all that apply.) a. I need to decrease sodium, cholesterol, and protein in my diet. b. My weight should be maintained at a body mass index of 30. c. Smoking should be stopped as soon as I possibly can. d. I can continue to take an aspirin every 4 to 8 hours for my pain. e. I really only need to drink a couple of glasses of water each day.
B, D, E
A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.) a. Client who had a reaction to contrast dye yesterday b. Client with a new spinal cord injury on a rotating bed c. Middle-aged man with an exacerbation of asthma d. Older client who is 1-day post hip replacement surgery e. Young obese client with a fractured femur
B, D, E,
.A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate? a. Encourage the client to walk 5 minutes each hour. b. Refer the client to smoking cessation classes. c. Teach the client about factor V Leiden testing. d. Tell the client that sometimes no cause for disease is found.
C
A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the clients oxygen saturation has not significantly improved. What response by the nurse is best? a. Breathing so rapidly interferes with oxygenation. b. Maybe the client has respiratory distress syndrome. c. The blood clot interferes with perfusion in the lungs. d. The client needs immediate intubation and mechanical ventilation.
C
A client has a traumatic brain injury and a positive halo sign. The client is in the intensive care unit, sedated and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time? a. Inability to communicate b. Nutritional deficit c. Risk for acquiring an infection d. Risk for skin breakdown
C
A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority? a. Apply oxygen at 100%. b. Assess the respiratory rate. c. Ensure a patent airway. d. Start two large-bore IV lines.
C
A client in shock has been started on dopamine. What assessment finding requires the nurse to communicate with the provider immediately? a. Blood pressure of 98/68 mm Hg b. Pedal pulses 1+/4+ bilaterally c. Report of chest heaviness d. Urine output of 32 mL/hr
C
A client is diagnosed with chronic kidney disease (CKD). What is an ideal goal of treatment set by the nurse in the care plan to reduce the risk of pulmonary edema? a. Maintaining oxygen saturation of 89% b. Minimal crackles and wheezes in lung sounds c. Maintaining a balanced intake and output d. Limited shortness of breath upon exertion
C
A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)? a. Assess the client for sedation needs. b. Get family permission for restraints. c. Provide frequent oral care per protocol. d. Use nonverbal pain assessment tools.
C
A client is placed on fluid restrictions because of chronic kidney disease (CKD). Which assessment finding would alert the nurse that the clients fluid balance is stable at this time? a. Decreased calcium levels b. Increased phosphorus levels c. No adventitious sounds in the lungs d. Increased edema in the legs
C
A nurse assesses a client with a spinal cord injury at level T5. The clients blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first? a. Initiate oxygen via a nasal cannula. b. Place the client in a supine position. c. Palpate the bladder for distention. d. Administer a prescribed beta blocker.
C
A nurse cares for a client who has facial burns. The client asks, Will I ever look the same? How should the nurse respond? a. With reconstructive surgery, you can look the same. b. We can remove the scars with the use of a pressure dressing. c. You will not look exactly the same but cosmetic surgery will help. d. You shouldnt start worrying about your appearance right now.
C
A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first? a. Assess the level of consciousness and pupillary reactions. b. Ascertain the time food or liquid was last consumed. c. Auscultate breath sounds over the trachea and bronchi. d. Measure abdominal girth and auscultate bowel sounds.
C
A nurse cares for a client with a spinal cord injury. With which interdisciplinary team member should the nurse consult to assist the client with activities of daily living? a. Social worker b. Physical therapist c. Occupational therapist d. Case manager
C
A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3, blood glucose level 198 mg/dL, and temperature 96.2 F (35.6 C). What action by the nurse takes priority? a. Document the findings in the clients chart. b. Give the client warmed blankets for comfort. c. Notify the health care provider immediately. d. Prepare to administer insulin per sliding scale.
C
A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority? a. Ensure the client has adequate sedation. b. Find another provider to intubate. c. Interrupt the procedure to give oxygen. d. Monitor the clients oxygen saturation.
C
A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program. The client states, I do not understand the need for rehabilitation; the paralysis will not go away and it will not get better. How should the nurse respond? a. If you dont want to participate in the rehabilitation program, Ill let the provider know. b. Rehabilitation programs have helped many clients with your injury. You should give it a chance. c. The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability. d. When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first.
C
A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately? a. Arterial pH: 7.32 b. Hematocrit: 52% c. Serum potassium: 6.5 mEq/L d. Serum sodium: 131 mEq/L
C
A nurse reviews these laboratory values of a client who returned from kidney transplantation 12 hours ago: Sodium 136 mEq/L Potassium 5 mEq/L Blood urea nitrogen (BUN) 44 mg/dL Serum creatinine 2.5 mg/dL What initial intervention would the nurse anticipate? a. Start hemodialysis immediately. b. Discuss the need for peritoneal dialysis. c. Increase the dose of immunosuppression. d. Return the client to surgery for exploration.
C
A nurse teaches a client being treated for a full-thickness burn. Which statement should the nurse include in this clients discharge teaching? a. You should change the batteries in your smoke detector once a year. b. Join a program that assists burn clients to reintegration into the community. c. I will demonstrate how to change your wound dressing for you and your family. d. Let me tell you about the many options available to you for reconstructive surgery.
C
A nurse uses the rule of nines to assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the clients body that sustained burns? a. 9% b. 18% c. 27% d. 36%
C
A student nurse is caring for a client who will be receiving sodium nitroprusside (Nipride) via IV infusion. What action by the student causes the registered nurse to intervene? a. Assessing the IV site before giving the drug b. Obtaining a programmable (smart) IV pump c. Removing the IV bag from the brown plastic cover d. Taking and recording a baseline set of vital signs
C
After assessing an older adult client with a burn wound, the nurse documents the findings as follows: Vital Signs Laboratory Results Wound Assessment Heart rate: 110 beats/min Blood pressure: 112/68 mm Hg Respiratory rate: 20 breaths/min Oxygen saturation: 94% Pain: 3/10 Red blood cell count: 5,000,000/mm3 White blood cell count: 10,000/mm3 Platelet count: 200,000/mm3 Left chest burn wound, 3 cm 2.5 cm 0.5 cm, wound bed pale, surrounding tissues with edema present Based on the documented data, which action should the nurse take next? a. Assess the clients skin for signs of adequate perfusion. b. Calculate intake and output ratio for the last 24 hours. c. Prepare to obtain blood and wound cultures. d. Place the client in an isolation room.
C
An intubated clients oxygen saturation has dropped to 88%. What action by the nurse takes priority? a. Determine if the tube is kinked. b. Ensure all connections are patent. c. Listen to the clients lung sounds. d. Suction the endotracheal tube.
C
The charge nurse is orienting a float nurse to an assigned client with an arteriovenous (AV) fistula for hemodialysis in her left arm. Which action by the float nurse would be considered unsafe? a. Palpating the access site for a bruit or thrill b. Using the right arm for a blood pressure reading c. Administering intravenous fluids through the AV fistula d. Checking distal pulses in the left arm
C
The charge nurse of the medical-surgical unit is making staff assignments. Which staff member should be assigned to a client with chronic kidney disease who is exhibiting a low-grade fever and a pericardial friction rub? a. Registered nurse who just floated from the surgical unit b. Registered nurse who just floated from the dialysis unit c. Registered nurse who was assigned the same client yesterday d. Licensed practical nurse with 5 years experience on this floor
C
The nurse is taking the vital signs of a client after hemodialysis. Blood pressure is 110/58 mm Hg, pulse 66 beats/min, and temperature is 99.8 F (37.6 C). What is the most appropriate action by the nurse? a. Administer fluid to increase blood pressure. b. Check the white blood cell count. c. Monitor the clients temperature. d. Connect the client to an electrocardiographic (ECG) monitor.
C
The nurse is teaching a client how to increase the flow of dialysate into the peritoneal cavity during dialysis. Which statement by the client demonstrates a correct understanding of the teaching? a. I should leave the drainage bag above the level of my abdomen. b. I could flush the tubing with normal saline if the flow stops. c. I should take a stool softener every morning to avoid constipation. d. My diet should have low fiber in it to prevent any irritation.
C
The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern? a. I get my chimney swept every other year. b. My hot water heater is set at 120 degrees. c. Sometimes I wake up at night and smoke. d. I use a space heater when it gets below zero.
C
A nurse assesses a client who is recovering from the implantation of a vagal nerve stimulation device. For which clinical manifestations should the nurse assess as common complications of this procedure? (Select all that apply.) a. Bleeding b. Infection c. Hoarseness d. Dysphagia e. Seizures
C D
After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the clients understanding. Which client statements indicate a correct understanding of the teaching related to sexual effects of this injury? (Select all that apply.) a. I will explore other ways besides intercourse to please my partner. b. I will not be able to have an erection because of my injury. c. Ejaculation may not be as predictable as before. d. I may urinate with ejaculation but this will not cause infection. e. I should be able to have an erection with stimulation.
C D E
A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the clients hips and sacrum. Which actions should the nurse take? (Select all that apply.) a. Apply a barrier cream to protect the skin from excoriation. b. Perform range-of-motion (ROM) exercises for the hip joint. c. Re-position the client off of the reddened areas. d. Get the client out of bed and into a chair once a day. e. Obtain a low-air-loss mattress to minimize pressure.
C E
When working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.) a. Avoid drinking alcohol. b. Eat more omega-3 fatty acids. c. Exercise on a regular basis. d. Maintain a healthy weight. e. Stop smoking cigarettes.
C, D, E,
A client has a long history of hypertension. Which category of medications would the nurse expect to be ordered to avoid chronic kidney disease (CKD)? a. Antibiotic b. Histamine blocker c. Bronchodilator d. Angiotensin-converting enzyme (ACE) inhibitor
D
A client has just had a central line catheter placed that is specific for hemodialysis. What is the most appropriate action by the nurse? a. Use the catheter for the next laboratory blood draw. b. Monitor the central venous pressure through this line. c. Access the line for the next intravenous medication. d. Place a heparin or heparin/saline dwell after hemodialysis.
D
A client is assessed by the nurse after a hemodialysis session. The nurse notes bleeding from the clients nose and around the intravenous catheter. What action by the nurse is the priority? a. Hold pressure over the clients nose for 10 minutes. b. Take the clients pulse, blood pressure, and temperature. c. Assess for a bruit or thrill over the arteriovenous fistula. d. Prepare protamine sulfate for administration
D
A client is brought to the emergency department after sustaining injuries in a severe car crash. The clients chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action by the nurse is the priority? a. Administer oxygen and reassess. b. Auscultate the clients lung sounds. c. Facilitate a portable chest x-ray. d. Prepare to assist with intubation.
D
A client is on mechanical ventilation and the clients spouse wonders why ranitidine (Zantac) is needed since the client only has lung problems. What response by the nurse is best? a. It will increase the motility of the gastrointestinal tract. b. It will keep the gastrointestinal tract functioning normally. c. It will prepare the gastrointestinal tract for enteral feedings. d. It will prevent ulcers from the stress of mechanical ventilation.
D
A client with acute kidney injury has a blood pressure of 76/55 mm Hg. The health care provider ordered 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client is starting to develop shortness of breath. What is the nurses priority action? a. Calculate the mean arterial pressure (MAP). b. Ask for insertion of a pulmonary artery catheter. c. Take the clients pulse. d. Slow down the normal saline infusion.
D
A client with chronic kidney disease states, I feel chained to the hemodialysis machine. What is the nurses best response to the clients statement? a. That feeling will gradually go away as you get used to the treatment. b. You probably need to see a psychiatrist to see if you are depressed. c. Do you need help from social services to discuss financial aid? d. Tell me more about your feelings regarding hemodialysis treatment.
D
A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action should the nurse take next? a. Administer furosemide (Lasix). b. Perform chest physiotherapy. c. Document and reassess in an hour. d. Place the client in an upright position.
D
A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the wheezing is no longer heard. Which action should the nurse take? a. Document the findings and reassess in 1 hour. b. Loosen any constrictive dressings on the chest. c. Raise the head of the bed to a semi-Fowlers position. d. Gather appropriate equipment and prepare for an emergency airway.
D
A nurse cares for a client who has burn injuries. The clients wife asks, When will his high risk for infection decrease? How should the nurse respond? a. When the antibiotic therapy is complete. b. As soon as his albumin levels return to normal. c. Once we complete the fluid resuscitation process. d. When all of his burn wounds have closed.
D
A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority? a. The client is able to initiate spontaneous breaths. b. The inspired oxygen has adequate humidification. c. The upper peak airway pressure limit alarm is off. d. The upper peak airway pressure limit alarm is on.
D
A nurse is caring for a client who is scheduled for a dose of cefazolin and vitamins at this time. Hemodialysis for this client is also scheduled in 60 minutes. Which action by the nurse is best? a. Administer cefazolin since the level of the antibiotic must be maintained. b. Hold the vitamins but administer the cefazolin. c. Hold the cefazolin but administer the vitamins. d. Hold all medications since both cefazolin and vitamins are dialyzable.
D
A nurse teaches a client with a lower motor neuron lesion who wants to achieve bladder control. Which statement should the nurse include in this clients teaching? a. Stroke the inner aspect of your thigh to initiate voiding. b. Use a clean technique for intermittent catheterization. c. Implement digital anal stimulation when your bladder is full. d. Tighten your abdominal muscles to stimulate urine flow.
D
A student nurse asks for an explanation of refractory hypoxemia. What answer by the nurse instructor is best? a. It is chronic hypoxemia that accompanies restrictive airway disease. b. It is hypoxemia from lung damage due to mechanical ventilation. c. It is hypoxemia that continues even after the client is weaned from oxygen. d. It is hypoxemia that persists even with 100% oxygen administration.
D
After teaching a client newly diagnosed with epilepsy, the nurse assesses the clients understanding. Which statement by the client indicates a need for additional teaching? a. I will wear my medical alert bracelet at all times. b. While taking my epilepsy medications, I will not drink any alcoholic beverages. c. I will tell my doctor about my prescription and over-the-counter medications. d. If I am nauseated, I will not take my epilepsy medication.
D
After teaching a client who is diagnosed with new-onset status epilepticus and prescribed phenytoin (Dilantin), the nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching? a. To prevent complications, I will drink at least 2 liters of water daily. b. This medication will stop me from getting an aura before a seizure. c. I will not drive a motor vehicle while taking this medication. d. Even when my seizures stop, I will continue to take this drug.
D
An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first? a. Assess level of consciousness. b. Obtain vital signs. c. Administer oxygen therapy. d. Evaluate respiratory status.
D
The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first? a. Client with cerebral perfusion pressure of 72 mm Hg b. Client who has a Glasgow Coma Scale score of 12 c. Client with a PaCO2 of 36 mm Hg who is on a ventilator d. Client who has a temperature of 102 F (38.9 C)
D
The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client? a. Administer the prescribed tetanus toxoid vaccine. b. Assess the clients wounds for signs of infection. c. Encourage the client to breathe deeply every hour. d. Wash your hands on entering the clients room.
D
The nurse assesses a clients Glasgow Coma Scale (GCS) score and determines it to be 12 (a 4 in each category). What care should the nurse anticipate for this client? a. Can ambulate independently b. May have trouble swallowing c. Needs frequent re-orientation d. Will need near-total care
c
