Med Surg 1 Mastery Questions - Final Exam

The nurse is caring for a client with severe osteoarthritis. What will the nurse anticipate as the client's priority problem? A. Joint pain B. ADL dependence C. Risk for falls D. Muscle stiffness

A

A client taking newly prescribed gabapentin for persistent neuropathic pain reports dizziness. What is the best nursing response? A. "This is a common side effect of gabapentin and will decrease with use." B. "Stop taking the medication and contact the health care provider." C. "The dizziness is caused by the neuropathic pain, not the medication." D. "The dizziness is likely from another medication, not the gabapentin."

A

A client who is HIV positive and receiving combination antiretroviral therapy tells the nurse she is now pregnant. Which drug does the nurse expect to be suspended during this patient's pregnancy? A. Abacavir B. Darunivir C. Tripanavir D. Raltegravir

A

How do plasma cells provide immune protection? A. They actively secrete immunoglobulins against specific antigens. B. They interact with virgin B lymphocytes at first exposure to an antigen, enhancing B-lymphocyte sensitization. C. They regulate the function of natural killer cells, preventing unnecessary damage or death to normal healthy body cells. D. They are responsible for balancing helper cell activity with regulator T-cell activity, ensuring that an immunologic response can be mounted whenever the body is invaded by pathologic microorganisms but limiting the response when the body receives antigens as drugs or food.

A

How does the corresponding increase in carbon dioxide levels that occurs when arterial pH drops assist in maintaining acid-base balance? A. Carbon dioxide loss through exhalation can raise arterial pH levels. B. Carbon dioxide retention during exhalation can lower arterial pH levels. C. Carbon dioxide is a base that can convert free hydrogen ions into a neutral substance. D. Carbon dioxide is a buffer that can bind free hydrogen ions and form a neutral substance.

A

The nurse hears a patient tell her partner that condoms with spermicide are important to protect themselves from sexually transmitted infections (STIs). What is the appropriate nursing response? A. Teach that spermicide has not been shown to be effective in STI prevention. B. Do nothing because the nurse should not be listening to the client's conversation. C. Educate that spermicide must be used with water-based lubricant to be effective. D. Affirm that spermicide helps to block transfer of sexually transmitted organisms.

A

The nurse is assessing the client's heart sounds. Which instruction will the nurse provide if there is difficulty in hearing heart sounds? A. "Please roll onto your left side." B. "Lay all the way down on your back." C. "Please hold your breath while I use my stethoscope." D. "I will just take your pulse instead."

A

The nurse is teaching a client who has osteopenia about alendronate. Which statement by the client indicates a need for further teaching? A. "I will take this drug at night to prevent nausea." B. "I need a dental checkup before taking the drug." C. "I need to sit up for 30 minutes after taking the drug." D. "I will drink plenty of water after I take the drug."

A

Which communication method is appropriate when the nurse is interacting with a client who is deaf? A. Use pictures and writing B. Speak with enunciated words C. Ask client to read the nurse's lips D. Dialogue with the client's caregivers

A

The nurse is caring for a client who was admitted with a draining diabetic ulcer on the lower extremity. What personal protective equipment will the nurse teach the staff to use? Select all that apply. A. Gown B. Gloves C. Mask D. Foot covers E. Goggles

A, B

Which symptom will the nurse teach the client who just had surgery to correct a retinal detachment to immediately report to the eye care provider? Select all that apply. A. Pain in the affected eye B. Pus in the affected eye C. Decreased visual acuity D. Temperature of 99.0°F E. Pupil that constricts in response to light

A, B, C

A client experiences a seizure that is observed by the nurse. What will the nurse document in the client's medical record? Select all that apply. A. Time that seizure began and ended B. Whether the seizure was preceded by an aura C. What the client does after the seizure D. How long it takes for the client to return to preseizure status E. The drugs that are administered during the seizure

A, B, C, D

A client who was bitten by a spider develops cellulitis of the left lower arm. What assessment findings will the nurse expect when caring for this client? Select all that apply. A. Fever B. Pain C. Redness around the spider bite D. Warmth in the affected arm E. Swelling of the affected arm

A, B, C, D, E

The nurse is admitting a client with a probable diagnosis of meningitis. What signs and symptoms might the nurse expect when assessing this client? Select all that apply. A. Photophobia B. Nystagmus C. Decreased level of consciousness D. Decreased movement, such as hemiparesis E. Disorientation to person, place, and time

A, B, C, D, E

A nursing assistant in a nursing home reports to the nurse that an 87-year-old nursing home client has a 6-inch reddened wound with pus draining from it on his shin where he scratched it open yesterday. After directly assessing the client's wound, what are the most relevant priority actions for the nurse to take? Select all that apply. A. Take a photo of the wound to show the primary health care provider when rounds are made 2 days from now. B. Assess the client for signs and symptoms of systemic infection, including temperature elevation. C. Notify the primary health care provider now and request a prescription for antibiotic therapy. D. Ask the primary health care provider to prescribe a tetanus booster vaccination. E. Immediately obtain a specimen for culture and sensitivity testing. F. Cleanse the wound and apply a dry dressing to it.

A, B, C, F

A client who had the Stretta procedure to treat severe GERD is being discharged. Which client statement requires further nursing teaching? Select all that apply. A. "Dysphagia after this procedure is normal." B. "It's important to stop my proton pump inhibitor." C. "I will not take NSAIDs and aspirin for at least 10 days." D. "I might cough up some blood following this procedure." E. "Today I will drink clear liquids and tomorrow I can eat soft food."

A, B, D

A nurse is caring for a 34-year-old client newly diagnosed with GERD. Which lifestyle change will the nurse suggest? Select all that apply. A. Lose weight if needed. B. Do not eat before bed. C. Elevate the foot of your bed by 6 to 12 inches. D. Avoid pants with a tight waistband or belt. E. Eat fatty foods to minimize ongoing hunger.

A, B, D

What health teaching will the nurse include to promote gastric health for an adult client? Select all that apply. A. "Stop smoking or using tobacco of any form." B. "Do not drink excessive amounts of alcohol." C. "Consume high-fat foods and decrease carbohydrates." D. "Avoid excessive amounts of pickled or smoked food." E. "Avoid taking large amounts of NSAIDs."

A, B, D, E

Which physiological processes directly prevent severe hypoglycemia in a healthy adult without diabetes who is NPO for 12 hours? Select all that apply. A. Gluconeogenesis B. Glycogenesis C. Glycogenolysis D. Ketogenesis E. Lipogenesis F. Lipolysis

A, C

The nurse is completing a preoperative physical assessment for a client who will have surgery this afternoon. Which assessment finding will the nurse report to the operative team? Select all that apply. A. Left arm prosthesis B. Skin turgor <3 seconds C. Blood pressure 160/100 mm Hg D. Presence of chest rigidity E. Has been NPO since midnight F. Expressed concern about surgery payment

A, C, D

Which assessment data do the nurse anticipate when a client presents to the emergency department reporting the sensation of a foreign body in the eye? Select all that apply. A. Pain B. Fever C. Tearing D. Photophobia E. Blurred vision

A, C, D, E

What discharge teaching will the nurse provide to a client who had gastric bypass surgery? Select all that apply. A. Be certain to stay hydrated by drinking water. B. Solid food can be introduced back into the diet in a week. C. Report any back, shoulder, or abdominal pain to the surgeon. D. You are likely to have little urine output for the first few weeks. E. Each of your meals should initially contain about 5 tablespoons of food.

A, C, E

Which teaching will the nurse provide to the client who just underwent a skin biopsy and had sutures placed to close the wound? Select all that apply. A. Use antibiotic ointment as prescribed. B. Return for suture removal in 2 to 3 days. C. Report redness to the health care provider. D. Keep dressing moist so skin does not dry out. E. Use tap water or saline to remove any crusting

A, C, E

The nurse is teaching a class regarding reduction of risk factors for cardiovascular disease. Which teaching statement will the nurse include? Select all that apply. A. "If you tend to get angry easily, then your risk for heart disease is higher." B. "To reduce your overall risk, it is important to keep your BMI greater than 30." C. "Do not eat more calories on a daily basis that you are able to burn." D. "Decreasing the amount that you smoke will decrease your overall cardiovascular risk." E. "Secondhand smoke creates a significant risk to others for cardiovascular disease." F. "Exercise moderately at least 2 days per week for a total of 150 minutes."

A, C, E, F

Which electrolytes are most detrimentally affected by low magnesium levels? Select all that apply. A. Calcium B. Chloride C. Hydrogen D. Potassium E. Sodium F. Sulfate

A, D

The nurse is caring for a client with a sealed radiation implant for the treatment of cancer. Which nursing intervention is appropriate? Select all that apply. A. Place a caution sign on the door of the client's room. B. Wear a dosimeter badge for protection when providing care. C. Allow the client's spouse to stay with the client at least 6 feet away for 4 hours. D. Do not allow children to visit the client for any length of time. E. Keep the door to the client's room closed.

A, D, E

The nurse is teaching a client who has been prescribed an oral chemotherapy agent. What teaching will the nurse include? A. "Oral chemotherapy drugs are not as toxic as IV chemotherapy." B. "Do not crush, split, break, or chew the oral chemotherapy drug." C. "You may dispose of unused oral chemotherapy drugs in the trash." D. "Oral chemotherapy drugs are not absorbed through the skin."

B

A client has been receiving the same dose of an intravenous opioid for 2 days to manage postsurgical pain. The client reports that the drug is no longer controlling the pain. What does the nurse suspect? A. There is likely a history of addiction. B. Tolerance to the opioid is developing. C. Physical dependence is developing. D. The client is opioid naïve.

B

A client is diagnosed with C. difficile infection. What nursing action is the priority for the client? A. Provide meticulous skin care. B. Place the client on Contact Precautions. C. Give the client an antipyretic medication. D. Encourage the client to drink extra fluids.

B

A client is receiving an intravenous infusion of 100 mEq (mmol) of potassium chloride in 1000 mL of normal saline. How many mEq (mmol) of potassium per hour does the nurse calculate the client will receive if the IV is infused at a rate of 150 mL/hour? A. 12 mEq (mmol) B. 15 mEq (mmol) C. 18 mEq (mmol) D. 20 mEq (mmol)

B

A client with a history of BPH calls the telehealth nurse reporting the sudden onset of testicular pain after moving heavy furniture. What is the appropriate nursing response? A. "Taking ibuprofen may help alleviate the pain." B. "Please go to your closest emergency department right away." C. "This is a common reaction when performing labor; the pain will go away." D. "Your BPH is probably giving you difficulty because you were moving furniture."

B

A client with chemotherapy-induced neutropenia is prescribed filgrastim. The client states, "The bones in my legs are aching so bad." What is the appropriate nursing response? A. "The pain in your legs is likely from the cancer." B. "Bone pain is a side effect of filgrastim that improves with time." C. "Increasing activity will help with the bone pain." D. "Have you had any fever or nausea?"

B

A public health nurse is assessing community clients for oral health disorders. Which client is identified at highest risk? A. 23-year-old with three dental fillings B. 34-year-old with schizophrenia C. 55-year-old with stable angina D. 62-year-old with irritable bowel syndrome

B

How does a mutation in a suppressor gene, such as BRCA1, increase the risk for cancer development? A. Converting a proto-oncogene into an oncogene B. Removing the control over proto-oncogene expression C. Reducing the amount of cyclins produced by the oncogenes D. Inhibiting the recognition of abnormal cells through immunosurveillance

B

The nurse is caring for a 33-year-old female client who has been intimate with women and men. What teaching will the nurse provide regarding the Gardisil 9 vaccine? A. "Patients older than 26 cannot receive an HPV vaccine." B. "You will need three doses of the vaccine instead of two." C. "I will give you a single dose and you will be protected from future HPV." D. "HPV vaccines must be administered to people who have never had intercourse."

B

The nurse is caring for a postoperative patient who has asked for pain medicine an hour before it is due. What is the priority nursing response? A. "You cannot have more pain medicine until an hour from now." B. "Can you describe the pain you are having, and rate it on a 1-to-10 scale?" C. "I can help you begin a pain diary so we can see trends when your pain worsens." D. "Let's try some relaxation exercises to help address the discomfort you are feeling."

B

The nurse is assessing a client who has late-stage rheumatoid arthritis. Which assessment findings would the nurse expect for this client? Select all that apply. A. Joint inflammation B. Severe weight loss C. Bony nodules D. Joint deformities E. SjÖgren syndrome

B, D, E

The nurse is teaching a client with erectile dysfunction about taking sildenafil to achieve an erection. Which client statement demonstrates an understanding of this drug? A. "I can have sex up to 8 hours after taking the drug." B. "I might get a headache or stuffy nose when this drug is used." C. "Taking this with a drink or two of alcohol will enhance my performance." D. "If one pill doesn't work, it is acceptable for me to quickly take another pill."

B

The primary health care provider prescribes bismuth subsalicylate for a client as part of treating H. pylori infection. What health teaching will the nurse include for the client about this drug? A. "Do not crush this drug before taking." B. "The drug may cause your tongue and stool to turn black." C. "Take the drug at night only." D. "The drug may cause you to have diarrhea."

B

Which assessment data is most relevant for the nurse to obtain from a client who has a serum potassium level of 2.9 mEq/L? A. Asking about the use of sugar substitutes B. Determining what drugs are taken daily C. Measuring the client's response to Chvostek testing D. Asking about a history of kidney disease

B

Which part of the HIV infection process is disrupted by the antiretroviral drug class of entry inhibitors? A. Activating the viral enzyme "integrase" within the infected host's cells B. Binding of the virus to the CD4+ receptor and either of the two co-receptors C. Clipping the newly generated viral proteins into smaller functional pieces D. Fusing of the newly created viral particle with the infected cell's membrane

B

Which specific information will the nurse teach to the client with systemic lupus erythematosus newly prescribed belimumab therapy? A. Avoid injecting it in a site near a cutaneous lesion. B. The drug can only be given by a health care professional. C. Do not chew, crush, or split the tablet containing this drug. D. The drug must be taken at bedtime because it causes extreme drowsiness.

B

Which statement made by the client on the way to the catheterization laboratory requires an immediate action by the nurse? A. "My allergies are bothering me, so I took some Benadryl last night before bed." B. "I was nervous last night, but I still remembered to take my warfarin." C. "I sure am hungry. I haven't had anything to eat since I went to bed last night." D. "I don't know what I will do if they find a blockage in my heart."

B

While making rounds the nurse finds a client with type 1 diabetes mellitus pale, sweaty, and slightly confused; the client can swallow. The client's blood glucose level check is 48 mg/dL (2.7 mmol/L). What is the nurse's best first action to prevent harm? A. Call the pharmacy and order a STAT does of glucagon. B. Immediately give the client 30 g of glucose orally. C. Start an IV and administer a small amount of a concentrated dextrose solution. D. Recheck the blood glucose level and call the Rapid Response Team.

B

Which health promotion activity(ies) will the nurse recommend to prevent harm in a client with type 2 diabetes? Select all that apply. A. "Avoid all dietary carbohydrate and fat." B. "Have your eyes and vision assessed by an ophthalmologist every year." C. "Reduce your intake of animal fat and increase your intake of plant sterols." D. "Be sure to take your antidiabetes drug right before you engage in any type of exercise." E. "Keep your feet warm in cold weather by using either a hot water bottle or a heating pad." F. "Avoid foot damage from shoe-rubbing by going barefoot or wearing flip-flops when you are at home."

B, C

Which intervention will the nurse delegate to assistive personnel (AP) for a client who has poor personal hygiene? Select all that apply. A. Obtain a social history. B. Assist the client with bathing. C. Help the client with brushing of teeth. D. Tell the client that he or she smells bad. E. Consult social services to assess the client's living conditions. F. Teach client and family members how to help with personal hygiene. G. Notify the health care provider of suspected drug or alcohol addiction. H. Assess for cognitive function or physical limitations that can interfere with grooming.

B, C

Which adverse drug effects will the nurse assess for in a hospitalized client who is prescribed an anticholinergic drug to manage incontinence? (Select all that apply.) A. Insomnia B. Blurred vision C. Constipation D. Dry mouth E. Loss of sphincter control F. Increased sweating G. Worsening mental function

B, C, D, G

Which statement(s) regarding type I hypersensitivity reactions is/are true? Select all that apply. A. Antihistamines are of minimal benefit because the reactions are mediated by IgE rather than histamine. B. The response is characterized by the five cardinal symptoms of inflammation. C. Type I responses are usually directed against non-self but the response is excessive. D. Susceptibility for developing a type I hypersensitivity response follows an X-linked recessive pattern of inheritance. E. This type of hypersensitivity reaction is most strongly associated with systemic lupus erythematosus. F. Responses always occur within minutes of exposure to the allergen. G. The second phase of the reaction with accumulation of excess bradykinin is responsible for development of angioedema.

B, C, G

In preparing a client with head and neck cancer (pharyngeal) for radiation therapy, which side effects does the nurse teach the client to expect? Select all that apply. A. Scalp and eyebrow alopecia B. Taste sensation loss or changes C. Bloody and purulent sinus drainage D. Increased risk for skin breakdown E. Moderate weight gain F. Increased risk for cavities G. Gastroesophageal reflux H. A persistent blue tinge to the skin and mucous membranes around the mouth

B, D, F

A client shows the nurse two pictures of the same lesion, taken 1 month apart. Which assessment finding requires nursing intervention? A. The light pink color of the lesion is the same in both photographs. B. The lesion has almost disappeared by the time of the second photograph. C. The lesion borders have expanded and are shaped differently in the second picture. D. The lesion's well-approximated margins and size look no different in either photograph.

C

A client with severe angioedema and tongue swelling from a drug allergy has stridor and an oxygen saturation of 60%. For which type of respiratory support does the nurse prepare? A. Nasal CPAP B. Tracheotomy C. Cricothyroidotomy D. Endotracheal intubation

C

An older adult client receiving an infusion of 5% dextrose in 0.9% normal saline at 150 mL/hour has developed shortness of breath with a decrease in oxygen saturation to 86%. What is the priority nursing intervention? A. Notify the health care provider B. Place the client on oxygen C. Sit the client upright in bed D. Assess the client's lung sounds

C

The handgrasp strength of a client with metabolic acidosis has diminished since the previous assessment 1 hour ago. What is the nurse's best first action? A. Measure the client's pulse and blood pressure B. Apply humidified oxygen by nasal cannula C. Assess the client's oxygen saturation D. Notify the Rapid Response Team

C

The white blood cell count with differential of a client undergoing preadmission testing before surgery indicates a total count of 5000 cells per cubic millimeter (mm3) of blood. Which of the follow differential counts or percentages does the nurse report to the surgeon to prevent harm? A. Eosinophils 300/mm3 B. Monocytes 600/mm3 C. Segmented neutrophils 2000/mm3 D. Lymphocytes 2100/mm3

C

Which action will the nurse perform first for a client in anaphylaxis to prevent harm? A. Applying oxygen by nonrebreather mask B. Administering IV diphenhydramine C. Injecting epinephrine D. Initiating IV access

C

Which client statement regarding treatment of a skin infection requires intervention by the nurse? A. "I am not going to share my clothes with anyone else." B. "Because I am over 60, I am going to get the shingles vaccine." C. "It is important to keep my skin very moist, so I will use lotion." D. "If I get a fever or chills, I will contact my primary health care provider."

C

Which precaution is a priority for the nurse to teach a client prescribed pramlintide to prevent harm? A. Only take this drug once weekly. B. Do not drink alcohol when taking this drug. C. Do not mix in the same syringe with insulin. D. Report any genital itching to your primary health care provider.

C

Which statements made by a 62-year-old client alert the nurse to the possibility that he may be at increased genetic risk for cancer development? Select all that apply. A. An older aunt died from a brain tumor while she had breast cancer. B. He had two benign colon polyps removed during his most recent routine colonoscopy. C. His sister died from cancer of the appendix. D. His brother is being treated for breast cancer. E. His 32-year-old daughter has been recently diagnosed with cervical cancer. F. One person in each of the previous three generations of his family died from lung cancer.

C, D

When teaching a community group of older adults, what information will the nurse include regarding normal hearing changes associated with aging? Select all that apply. A. Hair in the ear thins and falls out B. Hearing acuity changes in all older adults C. Cerumen dries and becomes impacted more easily D. The ability to hear low-frequency pitches diminishes first E. Sounds such as f, s, sh, and pa may be more difficult to discern

C, E

A 28-year-old female client states, "I don't know why I get cystitis every year. I don't drink much at work so that I can avoid using the public toilet." Which teaching by the nurse is most likely to reduce her risk for cystitis? Select all that apply. A. Reinforce her choice to avoid using a public toilet. B. Teach her to shower immediately after having sexual intercourse. C. Suggest that she drink at least 2 to 3 L of fluid throughout the day. D. Urge her to change her method of birth control from oral contraceptives to a barrier method. E. Instruct her to always wipe her perineum from front to back after each toilet use. F. Reinforce that she should complete the entire course of antibiotics as prescribed. G. Instruct her to empty her bladder immediately before intercourse.

C, E, F, G

When preparing to administer a prescribed subcutaneous dose of NPH insulin from an open vial taken from a medication drawer to a client with diabetes, the nurse notes the solution is cloudy. What action will the nurse perform to ensure client safety? A. Warm the vial in a bowl of warm water until it reaches normal body temperature. B. Return the vial to the pharmacy and open a fresh vial of NPH insulin. C. Roll the vial between the hands until the insulin is clear. D. Check the expiration date and draw up the insulin dose.

D

A client has just come to the floor after undergoing inner maxillary fixation for a mandibular fracture with wiring of the jaws. As the nurse raises the head of the bed, the client starts to vomit a large amount of liquid vomitus. What is the nurse's priority action? A. Administer the prescribed antiemetic by the intravenous or rectal route. B. Immediately notify the surgeon, the anesthesiologist, or the rapid response team. C. Cut the wires holding his jaws together, and carefully remove them from the mouth. D. Reposition the client to the side and suction the mouth with a large-bore catheter.

D

A client is diagnosed with renal colic. What would the nurse do first? A. Prepare the client for lithotripsy. B. Encourage oral intake of fluids. C. Strain the urine and send for urinalysis. D. Administer opioids as prescribed.

D

A client receiving gentamycin intravenously reports that the peripheral IV insertion site has become painful and reddened. What is the priority nursing action? A. Contact the primary health care provider B. Document findings in the electronic health record C. Change the IV site to a new location D. Stop the infusion of the drug

D

A client's cancer is staged as T1, N2, M1 according to the TNM classification system. How does the nurse interpret this report? A. The client has two tumors that are nonresponsive to treatment. B. The client has leukemia confined to the bone marrow. C. The client has a 2-cm tumor with one regional lymph node involved and no distant metastasis. D. The client has a small primary tumor extension into two lymph nodes and one site of distant metastasis.

D

For which hospitalized client does the nurse recommend the ongoing use of a urinary catheter? A. A 35-year-old woman who was admitted with a splenic laceration and femur fracture (closed repair completed) following a car crash B. A 48-year-old man who has established paraplegia and is admitted for pneumonia C. A 61-year-old woman who is admitted following a fall at home and has new-onset dysrhythmia D. A 74-year-old man who has lung cancer with brain metastasis and is being transitioned to hospice

D

The nurse is caring for a client who had an anterior total hip arthroplasty yesterday. For which commonly occurring postoperative complication will the nurse monitor for this client? A. Pneumonia B. Paralytic ileus C. Wound dehiscence D. Venous thromboembolism

D

The nurse is caring for a client who is diagnosed with early-stage Alzheimer's disease who has periods of lucidity. What is the best principle for the nurse to use when communicating with this client? A. Use validation therapy to prevent upsetting the client. B. Encourage pet therapy to help allay the client's anxiety. C. Use aromatherapy and other integrative therapies to relax the client. D. Reorient the client frequently to foster reality.

D

The nurse is caring for four clients who have been recommended to consider bariatric surgery. Which assessment data require immediate nursing intervention? A. BMI of 23 with gastrointestinal reflux B. BMI of 36 with hypertension C. BMI of 40 with type II diabetes D. BMI of 43 with sleep apnea

D

What teaching will the nurse provide to a client who has just been fitted for new hearing aids? A. Turn off the hearing aid when not using it. B. Immerse the ear mold in alcohol to fully clean it. C. Store the hearing aid in a warm, humid bathroom when not in use. D. Avoid using hair spray, makeup, and personal care products around the device.

D

What teaching will the nurse provide when educating about carbon monoxide prevention? A. "Carbon monoxide is only dangerous if accompanied by fire." B. "Black smoke can be seen when carbon monoxide is in the air." C. "Your skin will turn a blue color if you have carbon monoxide poisoning." D. "Put carbon monoxide detectors in your home, because this is an odorless gas."

D

When making rounds, the nurse observes that a cognitively impaired client has a partial airway obstruction from inspissation. What is the nurse's priority action? A. Place the bed in reverse Trendelenburg position and apply humidified oxygen by nasal cannula. B. Check the flow sheet to assess for trends in the client's oxygen saturation patterns. C. Determine which assistive personnel (AP) provided this client's morning care today. D. Immediately provide complete oral care to this client.

D

Which condition or manifestation in the client with a serum sodium level of 149 mEq/L indicates to the nurse that this electrolyte imbalance may be caused by excessive fluid loss? A. The client has calf muscle cramping. B. The serum chloride level is low. C. The urine specific gravity is high. D. The hematocrit is 52%.

D

Which food, drink, or herbal supplement does the nurse teach the client taking tipranavir to avoid? A. Caffeinated beverages B. Grapefruit juice C. Dairy products D. St. John's wort

D