Funds Final Exam Test Bank Q's

a. Atelactasis

This is assessing a client who is two days post operative and auscultates bilateral breath sounds, but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications? a. Atelectasis b. Pneumonia c. Pulmonary embolism d. Arterial thrombus

b. viral infection

Nurse is assessing a client who is experiencing chronic stress. Which of the following findings should the nurse expect? a. Hypotension b. Viral infection c. Increased energy d. Increased cognitive awareness

b. "I am hoping this will limit my discomfort."

Nurse is caring for a client who has cancer and is receiving palliative care. Which of the following statements by the client indicates they understand this type of treatment? a. "I am thinking of getting a second opinion." b. "I am hoping this will limit my discomfort." c. "This treatment should help me live a little longer." d. "This is not working and I plan to stop treatment."

(Idk this one) but I'm guessing: b. Each client's expression of pain may be different and individualized. c. Patient-controlled analgesia (PCA) offers a constant level of opioids within therapeutic range. d. Pain level and pain tolerance can be assessed using a scale from 0 to 10. e. The client will express the feeling of pain both verbally and nonverbally.

Nurse is planning care for client who is postoperative period which of the following statements about pain management should the nurse consider when implementing client care? (select all that apply) a. Use of analgesics will eventually lead to addiction. b. Each client's expression of pain may be different and individualized. c. Patient-controlled analgesia (PCA) offers a constant level of opioids within therapeutic range. d. Pain level and pain tolerance can be assessed using a scale from 0 to 10. e. The client will express the feeling of pain both verbally and nonverbally.

d. Determine if the client uses hearing aids

A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse? a. Speak using his usual tone of voice b. Stand directly in front of the client c. Rephrase statements the client does not hear d. Determine if the client uses hearing aids

c. Explore the client's feelings about dietary modifications.

A nurse is caring for a client who has a new diagnosis of type one diabetes mellitus. To focus on affective learning with this client which of the following intervention should the nurse use? a. Ask the client to perform a return demonstration of insulin injection. b. Review the action of insulin therapy. c. Explore the client's feelings about dietary modifications. d. Have the client practice blood-glucose monitoring using a glucometer.

b. Serosanguineous drainage at this time is a manifestation of possible dehiscence.

A nurse is changing the dressing of a client who is one week postoperative following abdominal surgery and notes the presence of serosanguineous drainage. The nurse should recognize that this is an indication of which of the following circumstances? a. Serosanguineous drainage at this time is expected after abdominal surgery. b. Serosanguineous drainage at this time is a manifestation of possible dehiscence. c. Serosanguineous drainage at this time is a manifestation of hemorrhage. d. Serosanguineous drainage at this time is a manifestation of infection.

a. Pain

A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as they need to postpone the session? a. Pain b. Hearing loss c. The client's culture d. Motor impairment

b. Recent long flight e. Immobility

A nurse is giving a presentation about preventing deep vein thrombosis. Which of the following should the nurse include as a risk factor for this disorder? a. BMI of 20 b. Recent long flight c. Hypertension d. High calcium intake e. Immobility

a. Are signs of impending death

1. A nurse assesses a hospice client. The assessment reveals BP 74/40, urine output 30 cc over three hours, poor skin turgor and skin cool to touch, respiratory 8 and irregular, and dysphasia. The nurse recognizes these combined assessment findings a. Are signs of impending death b. Are signs of airway obstruction. c. Are signs the patient may require resuscitation soon. d. Are signs of the need to increase oral fluids to improve hydration.

a. The date of the incident d. The time the client was to receive the medication e. The client's vital signs

1. A nurse find that a client did not receive a scheduled dose of furosemide (lasix). Which of the following should the nurse include in the incident/variance report? (select all that apply) a. The date of the incident b. The name of the provider who prescribed the medication c. The potential adverse effects of the medication d. The time the client was to receive the medication e. The client's vital signs

d. Necrotic Subcutaneous tissue

1. A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings in a manifestation of a stage 3 pressure ulcer? a. Exposed bone b. Blood filled blisters c. Partial-thickness skin loss. d. Necrotic subcutaneous tissue

a. Breathing ranging from very deep to very shallow with periods of apnea

1. A nurse is assessing the respiratory pattern of an older adult client who is receiving end of life care. Which of the following assessment findings should the nurse identify as Cheyne-strokes respirations? a. Breathing ranging from very deep to very shallow with periods of apnea b. Shallow to normal breaths alternating with periods of apnea c. Rapid respirations that are unusually deep and regular d. An inability to breathe without dyspnea unless sitting upright

c. respiratory acidosis

1. A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 in a PaCO2 of 50 mm per HG. The nurse should identify the client is experiencing which type of acid base imbalances> a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

a. Yogurt

A nurse is teaching a client about foods that are included on a clear liquid diet. Which of the following food choices made by the client indicates the need for further teaching? a. Yogurt b. Popsicle c. Gelatin Broth

b. Take the medication with food.

1. A nurse is teaching a client who has a new prescription for ibuprofen to treat hip pain. Which of the following instruction should the nurse include in the teaching? a. Expect ringing in your ears. b. Take the medication with food. c. Store the medication in the refrigerator. d. Monitor for weight loss.

c. Decompress the stomach

1. A nurse is teaching a client who has a prescription of a nasogastric tube (NG) to treat a pyloric obstruction. Which of the following rationales for the use to the nasogastric tube should the nurse include in the teaching? a. Determine the pH of the gastric secretions b. Supply nutrients via tube feedings c. Decompress the stomach d. Administer medications

b. Removing the abdominal dressing

1. A nurse is working with an assistive personnel while caring for a surgical client who is one day postoperative. Which task should the nurse take responsibility for completing? a. Measuring vital signs b. Removing the abdominal dressing c. Helping the client into the shower d. Ambulating the client in the hallway

a. Complete a neurological check

1. A nurse on the medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes 100/min, Respiratory rate 24 per minute, BP 132/76MM HG, and temperature 36.8°C (98.2F). Which of the following actions should the nurse perform? a. Complete a neurological check. b. Administer the prescribed PRN antihypertensive medication. c. Increase the client's fluid intake. d. Hold the client's evening dose of digoxin.

d. Serosanguineous

1. Nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following? a. Serous b. Purulent c. Sanguineous d. Serosanguineous

d. 42 units

1. Nurse is caring for a client who has diabetes and a new prescription for 14 units of regular insulin and 28 units of NPH insulin subcutaneously at breakfast daily. What is the total number of units of insulin that the nurse should prepare in the insulin syringe? a. 14 units b. 28 units c. 32 units d. 42 units

c. The surgical dressing

1. Nurse is caring for a client who just returned from the PACU with an IV fluid infusion and an NG tube in place following abdominal surgery which of the following data is a priority for the nurse to assess? a. The coping ability of the client b. The client's bowel sounds 24-28 c. The surgical dressing d. The patency of the NG tube

a. Discontinue suction when assessing for peristalsis b. Irrigate the NG tube with 0.9% sodium chloride irrigation solution. c. Place sequential compression devices on the bilateral lower extremities. d. Reposition the client from side to side every 2 hr.

1. Nurse is caring for an older adult client who has had surgery for an intestinal obstruction and has an NG tube to wall suction. Which of the following intervention should the nurse include in the clients post operative plan of care? (select all that apply) a. Discontinue suction when assessing for peristalsis b. Irrigate the NG tube with 0.9% sodium chloride irrigation solution. c. Place sequential compression devices on the bilateral lower extremities. d. Reposition the client from side to side every 2 hr. e. Encourage the use of an incentive spirometer every 2 hr while the client is awake.

d. The client is 71 years old

1. Nurse is reviewing the medical record for a client who has a healthcare associated infection. The nurse should identify which of the following findings as a risk factor for acquiring an HAI? a. The client had an appendectomy 6 months ago. b. The client has bipolar disorder. c. The client is a male. d. The client is 71 years old.

d. Have short teaching sessions.

1. Preparing to teach a client who has a low literacy level. Which of the following methods should the nurse plan to include? a. Emphasize four important points at each session. b. Use a passive voice to explain the information. c. Refer to the client in the third person during the session. d. Have short teaching sessions.

d. Demonstrate how fill insulin syringe and give insulin injection

1. The nurse is caring for a new diabetic client who is being taught how to administer insulin. The nurse knows that the patient care objective have been met when the patient is able to? a. Verbalize the method of insulin administration and how insulin works b. Teach back what precautions are to take when taking insulin c. State the value and importance self insulin injection for diabetics d. Demonstrate how fill insulin syringe and give insulin injection

a. Assist the client to cough and deep breathe every hour. b. Administer PRN analgesics as needed. d. Give the client a back massage. e. Teach the client relaxation techniques.

1. The nurse is planning care for a client who is four hours postoperative. Which of the following actions should the nurse include in the plan of care? (select all that apply) a. Assist the client to cough and deep breathe every hour. b. Administer PRN analgesics as needed. c. Encourage the client to turn every 4 hr. d. Give the client a back massage. e. Teach the client relaxation techniques.

c. Call the prescribing physician and inform her of the client's serum potassium level results.

1. What is caring for a client who has a prescription for potassium chloride (KCL) 20 mEq PO daily. The nurse reviews the clients most recent laboratory results and find the clients potassium level is 5.2 mEq/L. Which of the following actions should the nurse take? a. Give the ordered KCL as prescribed. b. Omit the KCL dose and document it was not given. c. Call the prescribing physician and inform her of the client's serum potassium level results. d. Call the lab to verify the client's results.

c. Decrease the IV flow rate

A 70-year-old client is admitted to the PACU with an intravenous solution of 0.9% NaCl which is running at 125cc per hour. The nurse detects new onset of crackles in the lung bases and distended neck veins. What is the nurses priority action? a. Notify the healthcare provider b. Immediately document findings in the medical record c. Decrease the IV flow rate d. Discontinue the IV

d. "I don't eat shellfish because it gives me hives."

A Nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements by the client should the nurse report to the provider? a. "I drink at least 2 quarts of fluid every day." b. "The last time I voided it was painful and red-tinged." c. "My period ended 2 days ago." d. "I don't eat shellfish because it gives me hives."

a. Decreased gastric motility b. Decreased skin elasticity c. Increased pain threshold

A Nurse is caring for an older adult client. The nurse she recognized the client is at risk for which of the following physiological changes? (select all that apply) a. Decreased gastric motility b. Decreased skin elasticity c. Increased pain threshold d. Increased metabolic rate e. Increased cardiac output

b. Ten years

A Nurse is teaching a group of middle adult client about early detection of colorectal cancer. The nurse should include the American Cancer Society recommendation that men and women beginning at age 50 who are at average risk should have a fecal occult blood test and a colonoscopy at which of the following intervals? a. Five years b. Ten years c. One year d. Two years

b. "Laxative helps eliminate the barium."

A client who is scheduled for a barium swallow asked the nurse why a laxative is necessary following the procedure. Which of the following responses should the nurse make? a. "Laxative will prevent the absorption of magnesium" b. "Laxative helps eliminate the barium" c. "Laxative is the protocol at this facility" d. "The laxative makes the barium turn brown"

a. Provide skin care with a moisture barrier cream. b. Administer artificial tears PRN. d. Perform mouth care every hour. e. Administer oxygen 2 L/min via nasal cannula.

A hospice nurse is reviewing the prescriptions for a client who is receiving palliative care. Which of the following prescriptions should the nurse expect? (select all that apply) a. Provide skin care with a moisture barrier cream. b. Administer artificial tears PRN. c. Obtain vital signs every 2 hr. d. Perform mouth care every hour. e. Administer oxygen 2 L/min via nasal cannula.

c. Yellow-green drainage on the surgical incision

A nurse Is assessing a client who is 48 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider? a. Blood pressure 102/66 mm Hg b. Straw-colored urine from an indwelling urinary catheter c. Yellow-green drainage on the surgical incision d. Respiratory rate 18/min

a. Increase ambulation

A nurse Is planning care for a client who is postoperative and at risk for paralytic ileus. Which of the following interventions should the nurse plan to take to promote peristalsis? a. Increase ambulation. b. Decrease fluid intake. c. Increase protein intake. d. Offer the client the bedpan every 2 hr.

b. Dispose the dressing in a Biohazardous waste container

A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material? a. Discard the dressing in the bedside trash receptacle b. Dispose the dressing in a Biohazardous waste container c. Enclose the dressing in a single clear plastic bag and discard in the bedside trash receptacle d. Double bag the dressing in clear bags and label it biohazard'

a. Mask

A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of personal protective equipment should the nurse remove last? a. Mask b. Gloves c. Gown d. Goggles

b. Denial

A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. When he arrives for his first dialysis treatment, he tells the nurse, "I decided to come today, but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again". The nurse should identify that this client is demonstrating which of the following Kubler-Ross stages of grieving? a. Bargaining b. Denial c. Depression d. Anger

c. Movement of the ET tube into the right main bronchus

A nurse in the PACU and is assessing a client who has an endotracheal tube placed and observes the absence of left-sided chest wall expansion upon respirations. Which of the following complications should the nurse suspect? a. Blockage of the ET tube by the client's tongue b. Passage of the ET tube into the esophagus c. Movement of the ET tube into the right main bronchus d. Infection of the vocal cords

125 mL/hr 500 mL/4 hr = X mL/hr X = 125 mL/hr

A nurse is Preparing to administer 40 mEq of potassium chloride and 45% sodium chloride 500 mL IV to infuse 10 mEq per hour. The nurse should set the IV pump to deliver how many milliliters per hour?

D. Airborne

A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client? a. Contact b. Droplet c. Protective d. Airborne

c. Cover the area with saline-soaked sterile dressings.

A nurse is assessing a client one day post operative following abdominal surgery. Suddenly the client reports a pulling sensation and pain in his surgical incision. Which of the following actions should the nurse take? a. Have the client lie flat in bed. b. Use sterile gauze to place gentle pressure on the exposed organs. c. Cover the area with saline-soaked sterile dressings. d. Apply an abdominal binder.

c. Paralytic ileus

A nurse is assessing a client who is 3 days postoperative following surgery and notes the absence of bowel sounds, abdominal distention, and the client passing no flatus. Which of the following conditions should the nurse suspect? a. Ulcerative colitis b. Cholesystitis c. Paralytic ileus d. Would dehiscence

a. Cover the wound with a sterile saline soaked dressing

A nurse is assessing a client who is post operative and find the clients abdominall incision has eviscerated. Which of the following actions should the nurse take? a. Cover the wound with a sterile saline-soaked dressing. b. Place the client in high-Fowler's position. c. Auscultate all quadrants of the abdomen for bowel sounds. d. Gently reinsert the protruding tissue.

a. Fatigue

A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect? a. Fatigue b. Hypertension c. Bradycardia Diarrhea

1,370 mL. Explanation: Client voids: 400 mL + 350 mL = 750 mL urine output this shift Chest drainage: To calculate the chest output for the current shift, the nurse should determine the difference between the previous drainage level mark and the current drainage level mark. 175 mL - 155 mL = 20 mL drainage this shift NG tube: 575 mL output this shift Jackson-Pratt drain: 25 mL output this shift

A nurse is calculating the output of a client at the end of the shift. The nurse notes the following: client voided 400 mL at 1100 and 350 mL at 1430. The closed chest drainage system was previously marked at 155 mL and is now at 175 mL. The NG tube has 575 mL in drainage container, and 25 mL is empties out of the Jackson-Pratt drainage tube. How many mL should the nurse record in the medical record as the client's output.

c. "I just can't believe that this dialysis is going to ruin my whole life"

A nurse is caring for a client who has a new diagnosis of chronic kidney disease. Which of the following statements should the nurse identify as an indication of anticipatory grieving? a. "I know that I will get a kidney transplant. I am a good candidate" b. "I can now eat whatever I want. The dialysis will remove it from my system" c. "I just can't believe that this dialysis is going to ruin my whole life" d. "I know that kidney disease runs in my family but I can prevent it"

a. Transparent Dressing

A nurse is caring for a client who has a stage one pressure ulcer. Which of the following dressings should the nurse plan to apply? a. Transparent dressing b. Wet to dry gauze dressing c. Hydrogel dressing d. Alginate dressing

c. "The doctor says I only have a few months to live, but I know he was exaggerating to get me to take my medication"

A nurse is caring for a client who has been diagnosed with end-stage liver cancer. Which of the following responses is an indication the client is in the denial phase of the grief process. a. "The doctor has been so good to me. I know he has tried everything he can. It's just my time" b. "I can't believe the doctor graduated from medical school. He doesn't know a thing about treating cancer" c. "The doctor says I only have a few months to live, but I know he was exaggerating to get me to take my medication" d. Even though I am not hurting now, I don't feel like I have the energy to get out of bed

a. Discuss initiating hospice care with the client and family

A nurse is caring for a client who has metastatic bone cancer. The client states, "I want to go home to die" the family is concerned about meeting the clients care needs at home. Which of the following actions should the nurse take? a. Discuss initiating hospice care with the client and family b. Write a referral to place the client in nursing home c. Talk with the provider about extending the clients hospital stay d. Inform the clients family that they are responsible for providing palliative care

c. Passage of flatus

A nurse is caring for a client who is post operative following abdominal surgery. Which of the following findings should indicate to the nurse at the clients peristalsis is returning? a. Hypoactive bowel sounds in two quadrants b. Request for a cup of tea and some toast c. Passage of flatus d. Abdominal distention

b. The client's self-report of pain severity

A nurse is caring for a client who is postoperative. The nurse should base her pain management intervention primarily on which of the following methods of determining the intensity of the clients pain? a. Vital sign measurement b. The client's self-report of pain severity c. Visual observation for nonverbal signs of pain d. The nature and invasiveness of the surgical procedure

a. Oncology nurse

A nurse is selecting a qualified staff member to double check a blood level with a client ID bracelet prior to infusing a unit of blood. The nurse should identify that which of the following persons is qualified? a. Oncology nurse b. Assistive personnel c. Senior nursing student d. Phlebotomist

b.Explaining the operative procedure, risks, and benefits

A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse's responsibilities? a. Assessing the current health status of the client b. Explaining the operative procedure, risks, and benefits c. Reviewing preoperative laboratory test results d. Ensuring that a signed surgical consent form was completed

c. Provide the client with a diet high in protein.

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following intervention should the nurse use to help maintain the integrity of the clients skin? a. Reposition the client every 3 hr. b. Massage bony prominences to promote circulation. c. Provide the client with a diet high in protein. d. Apply cornstarch to keep the skin dry.

c. Apply skin barrier around the stoma site. d. Educate the client that hematuria is expected following the procedure. e. Monitor hourly urine output.

A nurse is planning postoperative care for a client who is scheduled for an ileal conduit (urinary diversion) procedure. The nurse should include which of the following in the clients plan of care? (select all that apply) a. Notify the provider immediately if mucus is present in the urine. b. Maintain the client on a fluid restriction. c. Apply skin barrier around the stoma site. d. Educate the client that hematuria is expected following the procedure. e. Monitor hourly urine output.

a. Determine what the client knows about the surgery.

A nurse is planning pre-operative care for a client who will undergo surgery. Which of the following is the priority action by the nurse? a. Determine what the client knows about the surgery. b. Identify the client's usual coping mechanisms. c. Review the client's current home environment. d. Discuss if family members will assist with postoperative care.

a. Check the clients medical record for the providers prescription

A nurse is preparing to administer is soapsuds enema to a client who has constipation. As a nurse explained the procedure, the client states, "the doctor didn't tell me I was supposed to receive an enema" which of the following nursing actions is appropriate at this time? a. Check the clients medical record for the providers prescription b. Explain to the client that the providers prescribed the procedure c. Assure the client that enemas are commonly prescribed for constipation d. Inform the charge nurse that the client refused the enema

0.2 mL IV bolus

A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg /mL. How many ML should the nurse administer per dose? (Round the answer to the nearest 10th. Use a leading zero if it applies. Do not use a trailing zero.)

b. "Before the examination, your provider will give you a sedative that will make you sleepy."

A nurse is providing instructions for a 52 year old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate? a. "Don't worry; most clients dislike the prep more than the procedure itself." b. "Before the examination, your provider will give you a sedative that will make you sleepy." c. "I know you're anxious, but this procedure is recommended for people your age." d. "After you have signed the consent form, we can talk more about this."

b. Bathe the patient c. Place patient in anatomical position d. Remove endotracheal tube

A nurse is providing postmortem care to a hospitalized patient. Nursing interventions include? (select all that apply) a. Prepare the death certificate b. Bathe the patient c. Place patient in anatomical position d. Remove endotracheal tube

b. "I will tie a restraint to the position of the bed that moves when the head of the bed is moved"

A nurse is providing teaching to an assistive personnel (AP) about caring for clients with restraints. Which of the following statements by the AP indicates an understanding of teaching? a. "I will tie restraints in double knots" b. "I will tie a restraint to the position of the bed that moves when the head of the bed is moved" c. "I will ensure that restraints fit tightly against the client" d. "I will put four side rails up if a client is confused"

a. pH below 7.35

A nurse is reviewing the arterial blood gas results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see? a. pH below 7.35 b. HCO3 above 26 mEq/L c. PaO2 below 70 mm Hg d. PaCO2 above 45 mm Hg

a. Urine specific gravity 1.035

A nurse is reviewing the laboratory results of a client who has fluid volume deficit. The nurse would expect which of the following findings? a. Urine specific gravity 1.035 b. Hematocrit 44% c. BUN 19 mg/dL d. Sodium 155 mEq/L

b. "Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds."

A nurse is teaching a new group of assistive personnel about the importance of hand hygiene. Which of the following statement should the nurse include? a. "If you wear gloves, you do not have to wash your hands." b. "Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds." c. "Use an alcohol rub when your hands are visibly soiled." d. "If you don't have an infection, your hands won't infect others."

d. Low Self esteem

A nurse manager is discussing the differences between normal and maladaptive grief with nursing staff. Which of the following findings should the nurse manager identify as being a unique component of the maladaptive grieving process? a. Anorexia b. Sleep disturbances c. Anergia d. Low self-esteem

d. Denial

A nurse manager is preparing to confront a staff nurse who is abusing alcohol. Which of the following defense mechanism should the nurse manager expect the staff nurse to use?' a. Projection b. Rationalization c. Repression d. Denial

a. The shoulder droop b. The facial muscles relax d. The pulse is within the expected range

A nurse provides a back massage as a palliative care measure to a client who is unconscious, grimacing, and restless. Which of the following findings should the nurse identify as indicating a therapeutic response? (select all that apply) a. The shoulder droop b. The facial muscles relax c. The respiratory rate increases d. The pulse is within the expected range e. The client draws his legs up into a fetal position

d. Dysphagia

A nurse working for a home health agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address? a. Swollen gums b. Pruritus c. Urinary hesitancy d. Dysphagia

C. laceration.

A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes it's a full thickness wound with jagged edges and muscle tissue visible. The nurse should document this as which of the following types of wound? a. Abrasion b. Contusion c. Laceration d. Puncture

a. pH less than 7.35

It was given to prescribe narcotic pain med at 0800. At 0900 The nurse finds the patient slept in the chair, hard to arouse, with respirations of six per minute. Arterial blood gases are ordered what would you expect to see in the ABG results? a. pH less than 7.35 b. pH higher than 7.45 c. CO2 of about 35 d. CO2 lower than 45

c. Encourage the use of an incentive spirometer

The nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications? a. Perform range of motion exercises b. Place suction equipment at the bedside c. Encourage the use of an incentive spirometer d. Administer an expectorant

1.Make sure the provider has certified the clients death 2. Verify the clients organ and tissue donation status 3. Remove medical equipment from the clients 4. Cleanse the body while adhering to body-fluid precautions 5. Attach identification tags

This is providing postmortem care for a client. Identify the sequence of steps the nurse should follow.

d. Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation.

a nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client wound has eviscerated. After calling for help, which of the following actions should the nurse take? a. Raise the head of the client's bed 15° to 20°. b. Place the client supine with knees bent. c. Assess the client for manifestations of shock. d. Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation.