C C C C C C C
ns and Answers all Answers 100%Correctly/Verified Answer
C C C C C C
s Brand New RATED A+
C C C C
ACnurseCinCaCmedical-surgicalCunitCisCcaringCforCsixCclients.
CompleteC theC followingC sentenceC byC usingC theC listC ofC options.
TheC firstC clientC theC nurseC shouldC assessC isC followedCbyC .
ClientC1:CClientCisCadmittedCwithCaCnewCdiagnosisCofCrheumatoidCarthritis.ClientC2:CClientChC
asCaChistoryCofChyperlipidemia.CAtorvastatinC20CmgDPOCadministeredCasCprescribed.Client
C3:CClientCisC1CdayCpostoperative.CReportsCpainCasC8ConCaCscaleCofC0 CtoC10.CMorphineC5Cmg Cs
CubcutaneousCadministeredCasCprescribed.Client C4:CClientCisCadmittedCwithCaCnewCdiagnosi
CsCofCheartCfailure.ClientC5:CClientChasCaCstageC2CpressureCinjuryConCtheCleftCheel.ClientC6:CCl
CientCisCadmittedCwithCaCnewCdiagnosisCofCdiabetesCmellitus.C-
CORRECTC ANSWERS CorrectC AnswerC (1):
ClientC3
WhenCusingCtheCairway,Cbreathing,CcirculationCapproachCtoCclientCcare,CtheCnurseCshouldCdCe
termineC thatCthisC clientC isC theC priorityCclientCtoCassess.C TheCclientChasCanC oxygenC saturatiCon
C thatCis C less C thanCtheCexpectedC referenceCrange,C whichC isC anC indication C ofC hypoxia.
CorrectC AnswerC (2):
ClientC4
WhenCusingCtheCairway,Cbreathing,CcirculationCapproachCtoCclientCcare,CtheCnurseCshouldCd
CetermineCthatCthisCclientCisCtheCnextCpriorityCclientCtoCassess.CTheCclientChasCaCpotassiumCl
CevelCthatCisClessCthanCtheCexpectedCreferenceCrange,CwhichCplacesCtheCclientCatCriskCforCdys
Crhythmias.
InCORRECTC ANSWERSC (1):
ClientC1CisCincorrect.CTheCnurseCshouldCassessCthisCclientCbecauseCtheCclient'sCC-
reactiveCproteinCisCgreaterCthanCtheCexpectedCreferenceCrange,CwhichCisCanCindicationCofCinfCl
ammation.CHowever,CthereCisCanotherCclientCtheCnurseCshouldCassessCfirst.
,ClientC2CisCincorrect.CTheCnurseCshouldCassessCthisCclientCbecauseCtheCclient'sCcholesterolC
levelCisCgreaterCthanCtheCexpectedCreferenceCrange,CwhichCplacesCthemCatCriskCforCcoronarC
yCheartCdisease.CHowever,CthereCisCanotherCclientCtheCnurseCshouldCassessCfirst.
InCORRECTC ANSWERSC (2):
ClientC 5C isC incorrect.C TheC nurseC shouldC assessC thisC clientC becauseC theirC prealbuminC levelC iC
sClessCthanCtheCexpectedCreferenceCrange,CwhichCplacesCthemCatCriskCforCdelayedCwoundChCea
ling.CHowever,CthisCclientCisCnotCtheCnextCpriorityCclientCtoCassess.
ClientC6CisCincorrect.CTheCnurseCshouldCassessCthisCclientCbecauseCtheirCglycosylatedChemCogl
obinClevelCisCgreaterCthanCtheCexpectedCreferenceCrange,CwhichCindicatesCpoorCdiabeticCcont
rol.CHowever,CthisCclientCisCnotCtheCnextCpriorityCclientCtoCassess.
AC nurseC isC caringDforC aC clientC whoC hasC COPD.
SelectCtheC 3CfindingsC thatC requireC follow-up.
BreathCsoundsCBl
oodCpressure
OxygenCsaturation
Temperature
C
HeartCrateC-CCORRECTC ANSWERS CorrectCAnswer:
BreathCSounds
CracklesCareCcausedCbyCmucousCinCtheCairwaysCandCareCaCmanifestationCofCpneumonia.CDCecr
easedCbreathCsoundsCindicateCdecreasedCventilationCandCrequireCfollow-
upCbyCtheCnurse.
OxygenCSaturation
,TheCclient'sCoxygenCsaturationCisCbelowCtheCexpectedCreferenceCrangeCofC95%CtoC100%,CindCicati
ngChypoxia,CandCrequiresCfollow-upCbyCtheCnurse.
Temperature
TheCclient'sCtemperatureCisCgreaterCthanCtheCexpectedCreferenceCrange,CindicatingCanCinfecCti
on,CandCrequiresCfollow-upCbyCtheCnurse.
IncorrectC Answer:
BloodCpressureCisCincorrect.CTheCclient'sCbloodCpressureCisCwithinCtheCexpectedCreferenceCrCa
ngeCandCdoesCnotCrequireCfollow-upCbyCtheCnurse.
HeartCrateCisCincorrect.CTheCclient'sCheartCrateCisCwithinCtheCexpectedCreferenceCrangeCofC6
C 0CtoC100/min Cand Cdoes CnotCrequire Cfollow-upCbyCthe Cnurse.
ACnurseCinCtheCemergencyCdepartmentC(ED)CisCcaringCforCaCclientCwhoCreportsCabdominalCpCai
n.
BasedConCtheCclient'sCclinicalCfindings,CwhichCofCtheCfollowingCactionsCshouldCtheCnurseCtaC
ke?CSelectCallCthatCapply.
AssistCtheCclientCtoCaCleftCside-
lyingDpositionCwithCtheCrightCkneeCflexed.CPrepareCtheCclientCforCaCchest
x-ray.
C
AdministerCaCcleansingCenema.
AuscultateC theC client'sC bowelC sounds.
PerformCaCmanualCdigitalCexaminationCofCtheCclient'sCrectum.CAdminist
erCoxycodoneCextended-releaseCtablets.
PrepareCtheCclientCforCNGCtubeCplacement.C-CCORRECTCANSWERS
CorrectCAnswer:
AssistCtheCclientCtoCaCleftCside-lyingDpositionCwithCtheCrightCkneeCflexed
C
, TheC nurseC shouldC placeC theC clientC inC aC leftC side-
lyingCpositionCwithCtheCrightCkneeCflexedCpriorCtoCadministeringCanCenema.CBecauseCtheCprCo
viderCprescribedCaCcleansingCenemaCforCtheCclient,CtheCnurseCshouldCprepareCtheCclientCfC orC
theCprocedure.
AdministerCaCcleansingCenema
TheC nurseC shouldC administerC aC cleansingC enemaC forC theC clientC asC aC resultC ofC theC provider'C
sCprescription.CACcleansingCenemaCisCintendedCtoCassistCwithCbowelCeliminationCandCremoC v
eCanyCimpactedCfecalCmatterCindicatedCbyCtheCabdominalCx-ray.
AuscultateC theC client'sC bowelC sounds
TheCnurseCshouldCauscultateCtheCclient'sCbowelCsoundsCtoCdetermineCtheCstatusCofCtheCcliC en
t'sCperistalsis.CThisCisCaCnecessaryCpartCofCdeterminingCtheCpresenceCofCbowelCsounds,C whichC
areCanCindicationCofCtheCstatusCofCtheCclient'sCgastrointestinalCtract.
PerformC aC manualCdigitalC examinationC ofC theC client'sC rectum
TheCnurseCshouldCperformCaCmanualCdigitalCexaminationCofCtheCclient'sCrectumCtoCdetermiCn
eCifCimpactedCstoolCisCpresent.CThisCisCaCpartCofCtheCnecessaryCevaluationCofCtheCstatusCofCtheC
client'sCgastrointestinalCtract.
IncorrectC Answer:
PrepareC theC clientC forC aC chestC x-rayC isC incorrect.C AC chestC x-
rayCisCtypicallyCperformedCforCaCclientCwhoChasCanCimpairmentCofCtheCupperCthoraxCorClungC
s,C notCtheC abdomen.C TheC clientChasCalreadyC receivedC anC abdominalCx-
ray;Ctherefore,CaCchestCx-rayCisCnotCnecessary.
PrepareCtheCclientCforCNGCtubeCplacementCisCincorrect.CTheCnurseCshouldCnotCprepareCtheCcli
entC forC placementC ofC anC NGC tubeC becauseC thereC isC noC indicationC orC prescriptionC toC doC s
o.CPlacementCofCanCNGCtubeCisCrequiredCwhenCthereCisCanCobstructionCofCtheCgastrointestin
C alCtractCandCperistalsisCisCabsent.