ms III

A nurse is reviewing postoperative instructions with a client following cataract surgery. Which of the following client statements indicates an understanding of the instructions? 1. "I should call my doctor if my vision gets worse." 2. "I will take aspirin for eye discomfort." 3. "I can blow my nose to clear out any drainage." 4. "I can lift objects up to 20 pounds."

1. "I should call my doctor if my vision gets worse."

A nurse is providing discharge teaching for a client who has GERD. Which of the following statements by the client indicates an understanding of the teaching? 1. "I will decrease the amount of carbonated beverages I drink." 2. "I will avoid drinking liquids for 30 minutes after taking a chewable antacid tablet." 3. "I will eat a snack before going to bed." 4. "I will lie down for at least 30 minutes after eating each meal."

1. "I will decrease the amount of carbonated beverages I drink."

A nurse is developing a teaching plan for a client who has Ménière's disease. Which of the following instructions should the nurse include? 1. "Move your head slowly to decrease vertigo." 2. "Apply warm packs to the affected ear during acute attacks." 3. "Increase your intake of foods and fluids high in salt." 4. "Take corticosteroids during acute attacks."

1. "Move your head slowly to decrease vertigo."

A nurse is caring for a client who had a below-the-knee amputation for gangrene of the right foot. The client reports sensations of burning and crushing pain in the toes of the right foot. Which of the following statements should the nurse make? 1. "This type of pain usually decreases over time as the limb becomes less sensitive." 2. "Try to look at the surgical wound as a reminder the limb is gone." 3. "Use a cold compress intermittently to decrease these pain sensations." 4. "Grief over the lost limb can sometimes cause denial that the limb is really gone."

1. "This type of pain usually decreases over time as the limb becomes less sensitive."

A nurse in an emergency department is assessing a client who reports sudden, severe eye pain with blurry vision. The provider determines that the client has primary angle-closure glaucoma. Which of the following medications should the nurse expect to administer? 1. Osmotic diuretics via IV bolus 2. Mydriatic ophthalmic drops 3. Corticosteroid ophthalmic drops 4. Epinephrine via IV bolus

1. Osmotic diuretics via IV bolus

A nurse is assessing a client who has a head injury following a motor-vehicle crash. The nurse should identify that which of the following findings indicates increasing intracranial pressure? 1. Restlessness 2. Dizziness 3. Hypotension 4. Fever

1. Restlessness

A nurse is caring for a client who is 4 hr postoperative following a laparoscopic cholecystectomy. Which of the following findings should the nurse expect? 1. Right shoulder pain 2. Urine output 20 mL/hr 3. Temperature 38.4° C (101.1° F) 4. Oxygen saturation 92%

1. Right shoulder pain

A nurse in an emergency department is caring for a client who suddenly lost consciousness and fell while at home. The provider determines that the client had an embolic stroke. Which of the following medications should the nurse expect to administer? 1. Tissue plasminogen activator 2. Recombinant factor VIII 3. Nitroglycerin 4. Lidocaine

1. Tissue plasminogen activator

A nurse is assessing a client who is 48 hr postoperative following open reduction and internal fixation of a fractured tibia. Which the following findings should the nurse report to the provider? 1. Toes cold to the touch 2. Serous drainage from the pin sites 3. Blanching of the toenail beds with pressure 4. Pink tissue around the fixator insertion sites

1. Toes cold to the touch

A nurse is caring for a client who has celiac disease. Which of the following foods should the nurse remove from the client's meal tray? 1. Wheat toast 2. Tapioca pudding 3. Hard-boiled egg 4. Mashed potatoes

1. Wheat toast

A nurse is caring for a client who has a pelvic fracture. The client reports sudden shortness of breath, stabbing chest pain, and feelings of doom. The nurse should identify that the client is experiencing which of the following complications? 1. Pneumonia 2. Pulmonary embolus 3. Tension pneumothorax 4. Tuberculosis

2. Pulmonary embolus

A nurse is caring for a client who is 3 days postoperative following a right total hip arthroplasty. While transferring to a chair, the client cries out in pain. The nurse should assess the client for which of the following manifestations of dislocation of the hip prosthesis? 1. Bulging in the area over the surgical incision 2. Shortening of the right leg 3. Sensation of warmth over the surgical incision 4. Pallor following elevation of the right leg

2. Shortening of the right leg

A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy (EGD). The nurse should identify that this procedure is used to do which of the following? 1. To visualize polyps in the colon 2. To detect an ulceration in the stomach 3. To identify an obstruction in the biliary tract 4. To determine the presence of free air in the abdomen

2. To detect an ulceration in the stomach

A nurse is assessing a client who has rheumatoid arthritis. Which of the following findings should the nurse expect? 1. Unilateral joint involvement 2. Ulnar deviation 3. Fractures of the spine 4. Decreased sedimentation rate

2. Ulnar deviation

A nurse is providing teaching to the family of a client who has a new diagnosis of amyotrophic lateral sclerosis (ALS). The nurse should include in the teaching that which of the following findings is an early manifestation of ALS? 1. Sensory dysfunction 2. Weakness of the distal extremities 3. Decreased vision 4. Altered temperature regulation

2. Weakness of the distal extremities

A nurse is teaching a client how to prepare for a colonoscopy. Which of the following instructions should the nurse include in the teaching? 1. "Refrain from eating or drinking for 2 hr prior to the procedure." 2. "Stop taking aspirin the day before the procedure." 3. "Drink clear liquids for 24 hr prior to the procedure, and then take nothing by mouth for 6 hr before the procedure." 4 "Drink the oral liquid preparation for bowel cleansing slowly the night before the procedure."

3. "Drink clear liquids for 24 hr prior to the procedure, and then take nothing by mouth for 6 hr before the procedure."

A nurse is caring for a client who is postoperative following shoulder surgery. The client has a prescription to keep the affected arm adducted. Which of the following instructions should the nurse provide the client? 1. "Keep your arm bent at the elbow." 2. "Use a pillow to prop your shoulder up close to your ear." 3. "Hold your arm against the side of your body." 4. "Position your arm with the shoulder at a 90-degree angle.

3. "Hold your arm against the side of your body."

A nurse is teaching a client who has Parkinson's disease and is prescribed carbidopa-levodopa. Which of the following client statements indicates an understanding of the teaching? 1. "I should expect an increase in my blood pressure while taking this medication." 2. "I should take this medication 2 hours after meals to increase absorption." 3. "I should expect that this medication can cause me to be drowsy." 4. "I should expect this medication to be effective within 48 hours."

3. "I should expect that this medication can cause me to be drowsy."

A nurse in a clinic is providing teaching to an adolescent client who has recurrent external otitis. Which of the following instructions should the nurse include in the teaching? 1. Dry the ear canal with a cotton swab after swimming. 2. Apply an ice pack to the ear to relieve pain. 3. Instill a diluted alcohol solution into the ear after swimming. 4. Irrigate the ear with cool tap water to clean.

3. Instill a diluted alcohol solution into the ear after swimming.

A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect? 1. Hypoactive deep-tendon reflexes 2. Ascending paralysis 3. Intention tremors 4. Increased lacrimation

3. Intention tremors

After a Closed Head Injury which assessment is a priority for neurologic status?? 1. Vital Signs 2. Body Posture 3. Level of consciousness 4. Examination of Pupils

3. Level of consciousness

A nurse is assessing a client who has a high-thoracic spinal cord injury. The nurse should identify which of the following findings as a manifestation of autonomic dysreflexia? 1. Flushing of the lower extremities 2. Hypotension 3. Tachycardia 4. Report of a headache

4. Report of a headache

A nurse is planning to teach a client who has epilepsy and a new prescription for phenytoin. Which of the following instructions should the nurse plan to include? 1. Rinse with antiseptic mouthwash instead of using dental floss. 2. Use an over-the-counter antihistamine if a rash develops. 3. Slowly taper the medication after 6 consecutive months without seizure activity. 4. Take medications at a consistent time each day to maintain therapeutic blood levels.

4. Take medications at a consistent time each day to maintain therapeutic blood levels.

A nurse is reviewing the medical history of a client who is scheduled for a magnetic resonance imaging (MRI) examination of the cervical vertebra. The nurse should alert the provider to which of the following information in the client's history that is a contraindication to the procedure? 1. The client has a new tattoo. 2. The client is unable to sit upright. 3. The client has a history of peripheral vascular disease. 4. The client has a pacemaker.

4. The client has a pacemaker.

A nurse is assessing a client who has a duodenal ulcer. Which of the following findings should the nurse expect? 1. The client states that the pain is in the upper epigastrium. 2. The client is malnourished. 3. The client states that ingesting food intensifies the pain. 4. The client reports that pain occurs during the night.

4. The client reports that pain occurs during the night.

A nurse is assessing a client who has cirrhosis. Which of the following findings is the priority for the nurse to report to the provider? 1. Spider angiomas 2. Peripheral edema 3. Bloody stools 4. Jaundice

3. Bloody stools

A nurse is providing discharge instructions for a client who is postoperative following inner maxillary fixation with wiring. Which of the following information should the nurse include? 1. Cut the wiring if emesis occurs. 2. Consume three meals daily as part of a low-protein diet. 3. Swab the mouth with hydrogen peroxide if wiring produces oral irritation. 4. Resume a soft diet in 3 to 5 days.

1. Cut the wiring if emesis occurs.

A nurse is assessing a client who is postoperative following a gastrectomy. The nurse should identify which of the following findings as an indication of abdominal distension? 1. Hiccups 2. Hypertension 3. Bradycardia 4. Chest pain

1. Hiccups

A nurse is planning care for a client who has a closed traumatic brain injury from a fall and is receiving mechanical ventilation. Which of the following interventions is the nurse's priority? 1. Maintain a PaCO of approximately 35 mm Hg. 2. Provide small doses of fentanyl via IV bolus for pain management. 3. Measure body temperature every 1 to 2 hr. 4. Reposition the client every 2 hr

1. Maintain a PaCO of approximately 35 mm Hg.

A nurse is providing teaching to a client who has a new diagnosis of migraine headaches about interventions to reduce pain at the onset of a migraine. Which of the following instructions should the nurse include in the teaching? 1. "Place a warm compress on your forehead." 2. "Darken the lights." 3. "Light a scented candle." 4. "Drink a caffeinated beverage."

2. "Darken the lights."

A nurse is caring for a client who has a history of status epilepticus and requires seizure precautions. Which of the following actions should the nurse take? 1. Assess hourly for a spike in blood pressure. 2. Keep the client on bed rest. 3. Keep a padded tongue blade at the bedside. 4. Establish IV access.

4. Establish IV access.

A nurse is teaching parents about Otitis Media, Which of the following manifestations will the nurse include on teaching? 1. A high-pitched sound heard in the ear 2. Intermittent rapid eye movement 3. Itching on the external canal 4. Feeling of fullness in the ear

4. Feeling of fullness in the ear

A nurse is reviewing the laboratory values of a client who has colorectal cancer. Which of the following findings should the nurse expect? 1. Negative fecal occult blood test 2. Decreased serum carcinoembryonic antigen (CEA) level 3. Hematocrit 43% 4. Hemoglobin 9.1 g/dL

4. Hemoglobin 9.1 g/dL

What is the meaning of an Aura in a patient who suffers from seizures???? 1. An aura is a sensory warning that a seizure is imminent 2. An aura is a severe seizure 3. An aura is sleepiness after the seizure 4. An aura is a period of loss of consciousness.

1. An aura is a sensory warning that a seizure is imminent

A nurse is developing a plan of care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse include in the plan? 1. Measure the client's abdominal girth daily. 2. Check mental status once daily. 3. Provide a daily intake of 4 g of sodium for the client. 4. Assess the client's breath sounds every 12 hr

1. Measure the client's abdominal girth daily.

Which of the following is a sign of increased intracranial pressure?? 1. Widening of the Pulse Pressure 2. Tachycardia 3. Periorbital Edema 4. Decreased Urinary Output

1. Widening of the Pulse Pressure

A nurse is teaching a client who has multiple sclerosis and has a new prescription for glatiramer acetate. Which of the following statements indicates that the client understands the teaching? 1. "I will ask my partner to give the injection in the same spot each time." 2. "I will avoid going to the store when it is crowded." 3. "I will see relief of my symptoms in about 1 week." 4. "I will exercise rigorously while taking this medication."

2. "I will avoid going to the store when it is crowded."

A nurse is providing discharge teaching for a client who has chronic hepatitis C. Which of the following statements by the client indicates an understanding of the teaching? 1. "I will avoid alcohol until I'm no longer contagious." 2. "I will avoid medications that contain acetaminophen." 3. "I will decrease my intake of calories." 4. "I can donate blood once when I am in remission."

2. "I will avoid medications that contain acetaminophen."

A nurse is teaching a client who has osteoporosis and has a new prescription for alendronate. Which of the following information should the nurse include in the teaching? 1. "Take this medication with 8 ounces of milk." 2. "Remain upright for 30 minutes after taking this medication." 3. "Wait 1 hour after taking other medications to take alendronate." 4. "Take vitamin C to promote absorption of this medication."

2. "Remain upright for 30 minutes after taking this medication."

A nurse is caring for a client who has colorectal cancer and is receiving chemotherapy. The client asks the nurse why blood is being drawn for a carcinoembryonic antigen (CEA) level. Which of the following responses should the nurse make? 1. "The CEA determines the current stage of your colon cancer." 2. "The CEA determines the efficacy of your chemotherapy." 3. "The CEA determines if the neutrophil count is below the expected reference range." 4. "The CEA determines if you are experiencing occult bleeding from the gastrointestinal tract."

2. "The CEA determines the efficacy of your chemotherapy."

A nurse is assessing a client who has peritonitis. Which of the following findings should the nurse expect? 1. Bloody diarrhea 2. Board-like abdomen 3. Periumbilical cyanosis 4. Increased bowel sounds

2. Board-like abdomen

A nurse is caring for a client who is in balanced suspension skeletal traction and reports intermittent muscle spasms. Which of the following actions should the nurse take first? 1. Reposition the client. 2. Check the position of the weights and ropes. 3. Administer a muscle relaxant. 4. Provide distraction.

2. Check the position of the weights and ropes.

A nurse is assessing a client who is unconscious and has a rhythmical breathing pattern of rapid deep respirations, followed by rapid shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations? 1. Orthopnea 2. Cheyne-Stokes 3. Paradoxical 4. Kussmaul

2. Cheyne-Stokes

A nurse is providing dietary teaching for a client who is postoperative following a gastrectomy. Which of the following foods should the nurse encourage the client to include in their diet to reduce the risk for dumping syndrome? 1. Ice cream 2. Eggs 3. Grape juice 4. Honey

2. Eggs

A nurse is reviewing the laboratory results of a lumbar puncture (LP) for a client who has manifestations of bacterial meningitis. Which of the following findings should the nurse expect? 1. Elevated glucose 2. Elevated protein 3. Presence of RBCs 4. Presence of D-dimer

2. Elevated protein

A nurse is providing teaching for a client who has cirrhosis and a new prescription for lactulose. The nurse should include which of the following instructions in the teaching? 1. Notify the provider if bloating occurs. 2. Expect to have two to three soft stools per day. 3. Restrict carbohydrates in the diet. 4. Limit oral fluid intake to 1,000 mL per day of clear liquids.

2. Expect to have two to three soft stools per day.

A nurse in the emergency department is assessing a client who was in a motor-vehicle crash 2 days ago and sustained fractures to his tibia, ulna, and several ribs. The client is now disoriented to time and place, has a SaO of 87%, and the nurse notes generalized petechiae on the client's skin. Which of the following complications should the nurse suspect? 1. Hypovolemic shock 2. Fat embolism syndrome 3. Thrombophlebitis 4. Avascular bone necrosis

2. Fat embolism syndrome

A nurse is providing discharge instructions after cataract surgery. Which of the following statements by the client indicates understanding of the instructions???? 1. I will sleep on the affected site 2. I will avoid bending over 3. I will avoid coffee 4. I will take aspirin for pain

2. I will avoid bending over

A nurse is reviewing the laboratory results of a client who has acute pancreatitis. Which of the following findings should the nurse expect? 1. Blood glucose 110 mg/dL 2. Increased amylase 3. WBC count 9,000/mm3 4. Decreased bilirubin

2. Increased amylase

A nurse is caring for a client immediately following application of a plaster cast. The nurse should monitor for and report which of the following findings as an indication of compartment syndrome? 1. Sensation of heat on the surface of the cast 2. Paresthesias of the extremity 3. Pruritus of the extremity 4. Musty odor noted from cast materials

2. Paresthesias of the extremity

A nurse is caring for a client who has a percutaneous endoscopic gastrostomy (PEG) tube and is receiving intermittent feedings. Prior to initiating the feeding, which of the following actions should the nurse take first? 1. Flush the tube with water. 2. Place the client in semi-Fowler's position. 3. Cleanse the skin around the tube site. 4. Aspirate the tube for residual contents

2. Place the client in semi-Fowler's position.

A nurse is providing discharge teaching to the family of a client who has a new diagnosis of a seizure disorder. The nurse should instruct the client's family to take which of the following actions first in the event of a seizure? 1. Reorient the client. 2. Protect the client's head. 3. Loosen constrictive clothing. 4. Turn the client on his side.

2. Protect the client's head.

A nurse is providing dietary teaching for a client who has a new diagnosis of celiac disease. Which of the following statements by the client indicates an understanding of the teaching? 1. "I can return to my regular diet when I am free of symptoms." 2. "I will need to avoid taking vitamin supplements while on this diet." 3. "I will eat beans to ensure I get enough fiber in my diet." 4. "I need to avoid drinking liquids with my meals while on this diet."

3. "I will eat beans to ensure I get enough fiber in my diet."

A nurse is caring for a client who has viral meningitis. Which of the following actions should the nurse take? 1. Assess the client's neurologic status every 8 hr. 2. Initiate droplet precautions. 3. Check capillary refill at least every 4 hr. 4. Place the client in a well-lit environment

3. Check capillary refill at least every 4 hr.

A nurse is providing discharge teaching for a client following an ileostomy. The nurse should instruct the client to report which of the following findings to the provider? 1. Intolerance to high-fiber foods 2. Liquid ileostomy output 3. Dark purple stoma 4. Sensation of burning during bowel elimination

3. Dark purple stoma

A nurse is planning care for a client following a lumbar puncture. Which of the following actions should the nurse plan to take? 1. Apply a pressure dressing to the site for 8 hr. 2. Restrict the client's fluid intake for 24 hr. 3. Ensure that the client lies flat for up to 12 hr. 4. Inform the client that neck stiffness is an expected outcome of the procedure.

3. Ensure that the client lies flat for up to 12 hr.

A nurse is caring for a client who has a retinal detachment. Which of the following findings should the nurse expect? 1. Photophobia 2. Complete vision loss 3. Flashes of bright light 4. Cloudiness of the lens

3. Flashes of bright light

A nurse is providing dietary teaching to a client who has diverticulitis about preventing acute attacks. Which of the following foods should the nurse recommend? 1. Foods high in vitamin C 2. Foods low in fat 3. Foods high in fiber 4. Foods low in calories

3. Foods high in fiber

A nurse is admitting a client who has acute pancreatitis. Which of the following actions should the nurse take first? 1. Insert a nasogastric tube for the client. 2. Administer ceftazidime to the client. 3. Identify the client's current level of pain. 4. Instruct the client to remain NPO.

3. Identify the client's current level of pain.

A nurse is assessing a client who had a right hemispheric stroke. Which of the following neurologic deficits should the nurse expect? 1. Aphasia 2. Right-sided neglect 3. Impulsive behavior 4. Inability to read

3. Impulsive behavior

A nurse is caring for a client who has advancing amyotrophic lateral sclerosis. Which of the following interventions is the nurse's priority? 1. Provide frequent rest periods throughout the day. 2. Administer pain medication on a regular schedule. 3. Monitor pulse oximetry findings. 4. Administer baclofen for spasticity.

3. Monitor pulse oximetry findings.

A nurse is caring for a client who is 72 hr postoperative following an above-the-knee amputation and reports phantom limb pain. Which of the following actions should the nurse take? 1. Remind the client that the surgery removed the limb. 2. Change the dressing on the client's residual limb. 3. Request a prescription for gabapentin for the client. 4. Elevate the client's residual limb above heart level.

3. Request a prescription for gabapentin for the client.

A nurse is assessing a client who was admitted with a bowel obstruction. The client reports severe abdominal pain. Which of the following findings should indicate to the nurse that a possible bowel perforation has occurred? 1. Elevated blood pressure 2. Bowel sounds increased in frequency and pitch 3. Rigid abdomen 4. Emesis of undigested food

3. Rigid abdomen

A nurse is assessing a client who has a new diagnosis of acute angle-closure glaucoma. The nurse should anticipate the client to report which of the following manifestations? 1. Multiple floaters 2. Flashes of light in front of the eye 3. Severe eye pain 4. Double vision

3. Severe eye pain

A nurse is providing discharge teaching for a client who has a new colostomy and is concerned about flatus and odor. Which of the following foods should the nurse recommend to the client? 1. Eggs 2. Fish 3. Yogurt 4. Broccoli

3. Yogurt

A nurse is discussing the difference between rheumatoid arthritis (RA) and osteoarthritis with a newly licensed nurse. Which of the following information should the nurse include about osteoarthritis? 1. "Osteoarthritis is caused by autoimmune processes." 2. "Osteoarthritis leads to a decreased erythrocyte sedimentation rate." 3. "Osteoarthritis affects other organ systems." 4. "Osteoarthritis can impair a joint on a single side of the body."

4. "Osteoarthritis can impair a joint on a single side of the body."

A nurse is teaching a client and her family about the diagnosis and treatment of Alzheimer's disease. Which of the following statements should the nurse identify as an indication that the family understands the teaching? 1. "There is a test for Alzheimer's disease that can establish a reliable diagnosis." 2. "The goal of medication therapy is to reverse the degenerative changes that can occur in brain tissue." 3. "Early manifestations of Alzheimer's disease include mild tremors and muscular rigidity." 4. "The medications that treat Alzheimer's disease can help delay cognitive changes."

4. "The medications that treat Alzheimer's disease can help delay cognitive changes."

A nurse is discussing the plan of care with a client who has osteomyelitis of an open wound on his heel. Which of the following information should nurse include? 1. "You will need to apply a cold pack to the site three times a day." 2. "Your provider might ask you to walk frequently to increase circulation to the area." 3. "You will need to limit consumption of high-protein foods." 4. "Your provider might prescribe a central catheter line for long-term antibiotic therapy."

4. "Your provider might prescribe a central catheter line for long-term antibiotic therapy."

A nurse is providing teaching to a class about transient ischemic attacks (TIAs). Which of the following information should the nurse include in the teaching? 1. A TIA can cause irreversible hemiparesis. 2. A TIA can be the result of cerebral bleeding. 3. A TIA can cause cerebral edema. 4. A TIA can precede an ischemic stroke.

4. A TIA can precede an ischemic stroke.

A nurse is reviewing the laboratory results of a client who has hepatic cirrhosis. Which of the following laboratory findings should the nurse report to the provider? 1. Albumin 4.0 g/dL 2. INR 1.0 3. Direct bilirubin 0.5 mg/dL 4. Ammonia 180 mcg/dL

4. Ammonia 180 mcg/dL

A nurse is assessing a client who is experiencing perforation of a peptic ulcer. Which of the following manifestations should the nurse expect? 1. Increased blood pressure 2. Decreased heart rate 3. Yellowing of the skin 4. Board like abdomen

4. Board like abdomen

A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder. Which of the following assessment findings should the nurse report to the provider? 1. Glasgow Coma Scale score of 15 2. Intracranial pressure reading of 15 mm Hg 3. Ecchymosis at base of skull 4. Clear drainage from nose

4. Clear drainage from nose

A nurse is caring for a client who is 2 days postoperative following a gastric bypass. The nurse notes that bowel sounds are present. Which of the following foods should the nurse provide at the initial feeding? 1. Vanilla pudding 2. Apple juice 3. Diet ginger ale 4. Clear liquids

4. Clear liquids

A nurse is performing a pain assessment for a client who is postoperative. Which of the following findings should the nurse use to determine the severity of the client's pain? 1. Client's vital sign changes 2. Client's report of the type of pain 3. Client's nonverbal communication 4. Client's report of pain on a pain scale

4. Client's report of pain on a pain scale

A nurse is assessing a client immediately following a paracentesis for the treatment of ascites. Which of the following findings indicates the procedure was effective? 1. Presence of a fluid wave 2. Increased heart rate 3. Equal pre- and postprocedure weights 4. Decreased shortness of breath

4. Decreased shortness of breath

A nurse is assessing a client who is quadriplegic following a cervical fracture at vertebral level C5. The client reports a throbbing headache and nausea. The nurse notes facial flushing and a blood pressure of 220/110 mm Hg. Which of the following actions should the nurse take first? 1. Administer hydralazine via IV bolus. 2. Loosen the client's clothing. 3. Empty the client's bladder. 4. Elevate the head of the client's bed.

4. Elevate the head of the client's bed.

A nurse is teaching an assistive personnel (AP) about providing care to a client following a total hip arthroplasty. Which of the following instructions should the nurse include? 1. Avoid applying antiembolism stockings to the affected leg. 2. Have the client lean forward when moving from a sitting to a standing position. 3. Discourage the client from sitting in a wheelchair with the back reclined. 4. Place an abductor pillow between the client's legs when turning the client.

4. Place an abductor pillow between the client's legs when turning the client.

A nurse is caring for a client who is recovering from a stroke and has right-sided homonymous hemianopsia. To help the client adapt to the hemianopsia, the nurse should take which of the following actions? 1. Check the client's cheek on the affected side after meals to be sure no food remains there. 2. Encourage the client to sit upright with their head tilted slightly forward during meals. 3. Provide the client with eating utensils that have large handles. 4. Remind the client to look consciously at both sides of their meal tray.

4. Remind the client to look consciously at both sides of their meal tray.

A nurse is caring for a client who is dehydrated and is receiving continuous tube feeding through a pump at 75 mL/hr. When the nurse assesses the client at 0800, which of the following findings requires intervention by the nurse? 1. A full pitcher of water is sitting on the client's bedside table within the client's reach. 2. The disposable feeding bag is from the previous day at 1000 and contains 200 mL of feeding. 3. The client is lying on the right side with a visible dependent loop in the feeding tube. 4. The head of the bed is elevated 20°.

4. The head of the bed is elevated 20°.