NURS 480 (NH N480) Exam 2 V2 – ATI Assessment | Complete Answered Review Guide | Latest 2026.

West Coast University NURS 480 (NH N480)Exam 2 V2 ) – ATI Assessment | Complete Answered Review Guide | Latest 2026. ### 1. A nurse is preparing to administer digoxin to a client with heart failure. Before administering the medication, the nurse reviews the client’s laboratory results and assessment findings: Heart rate 72 bpm, blood pressure 118/70 mmHg, serum potassium 2.9 mEq/L, and digoxin level 0.8 ng/mL. Which action should the nurse take next? A. Hold the digoxin, notify the healthcare provider, and anticipate potassium replacement. B. Administer the digoxin as prescribed and recheck potassium levels in four hours. C. Administer the digoxin with a potassium-rich snack to help counteract hypokalemia. D. Give half the prescribed dose of digoxin to prevent potential toxicity. ### 2. A nurse is caring for a client in the ICU recovering from heart failure who has been receiving digoxin therapy. The nurse is assessing the client for potential signs of digoxin toxicity. Which of the following findings would indicate adverse effects of digoxin? **(Select all that apply.)** ### 3. The nurse is teaching the client who is scheduled for a coronary angiography. Which of the following statements should the nurse make? A. “You will need to keep the affected leg straight after the procedure.” B. “You should have nothing to eat or drink 2 hours prior to the procedure.” C. “You will be given general anesthesia during the procedure.” D. “You should not have this procedure done if you are allergic to eggs.” ### 4. A nurse is caring for a client who is three days postoperative following coronary artery bypass grafting (CABG) surgery. The client declines to perform coughing and deep breathing because they are concerned about causing pain at their incision site. Which action should the nurse take? A. Teach the client to use a pillow to splint their incisions. B. Allow the client to rest and return in half an hour. C. Document in the client’s record that the client is not adhering to the provider orders. D. Inform the client that they must perform coughing and deep breathing exercises before discharge. ### 5. A nurse is caring for a client who just underwent coronary artery bypass graft surgery. The nurse is completing discharge teaching. Which of the following statements, if made by the client, indicates that the client understands the instructions provided? A. “I will store my nitroglycerin in a dark bottle.” B. “If I experience chest pain, I will push through and continue with the activity to build my stamina.” C. “Since I am now on a heart-healthy diet, I can stop monitoring my blood glucose levels.” D. “I will add salt to my diet since the surgery resolved my concern.” ### 6. A nurse is preparing to perform a 12-lead ECG on a client. Which of the following actions is most important for the nurse to take to ensure accurate results during the procedure? A. Ensure that the client remains still and relaxed throughout the procedure. B. Place the electrodes directly over bony prominences to avoid interference. C. Shave areas with hair where the electrodes will be placed. D. Have the patient sit upright with their legs dangling to promote electrode placement. ### 7. Upon assessment, the client has a weak radial pulse. What would be the priority intervention for this client? A. Amiodarone administration B. Synchronized cardioversion C. Dopamine administration D. Atropine administration ### 8. The client is complaining of shortness of breath and chest pain. Which of the following orders or interventions are expected for this client? A. Administer adenosine as ordered. B. Administer atropine as ordered. C. Defibrillate the client as ordered. D. Administer dobutamine as ordered. ### 9. Which of the following interventions would the nurse expect to be provided to this client? A. Prepare for synchronized cardioversion. B. Prepare for defibrillation. C. Prepare for lidocaine administration. D. Prepare for atropine administration. ### 10. A client with heart failure is in the ICU and has been prescribed a low-sodium diet. Which of the following meals is most appropriate for the nurse to recommend based on the dietary restriction? A. Baked chicken with steamed asparagus and quinoa B. Hot dog with a side of coleslaw and potato chips C. Fried fish with tartar sauce and canned baked beans D. Pizza with extra cheese and a side of pickles ### 11. A nurse is educating a client about the differences between right-sided and left-sided heart failure. Which of the following symptoms is most characteristic of left-sided heart failure? A. Shortness of breath and crackles in the lungs B. Edema in the lower extremities and ascites C. Weight gain and jugular vein distention D. Hepatomegaly and cyanosis ### 12. A nurse is preparing to administer sublingual nitroglycerin to a client experiencing chest pain due to a suspected myocardial infarction (MI). Which of the following findings would require the nurse to withhold the medication and notify the healthcare provider? A. The client reports taking tadalafil for benign prostatic hyperplasia 6 hours ago. B. The client reports taking aspirin 30 minutes ago. C. Blood pressure is 130/80 mmHg. D. The client complains of a 5/10 headache. ### 13. What is the nurse’s priority action? A. Begin chest compressions. B. Notify the provider. C. Administer epinephrine per protocol. D. Defibrillate the client. ### 14. A 62-year-old client with a history of coronary artery disease presents to the emergency department. The client is presently hooked to a monitor with the ECG reading provided. Upon assessment, the client appears to be reading quietly and sitting comfortably in bed with no signs of distress or shortness of breath. What is the most appropriate action by the nurse? A. Continue monitoring the client. B. Administer atropine as ordered by the provider. C. Perform a cardiac thump. D. Prepare for cardioversion. ### 15. A nurse is caring for two clients with different types of arrhythmias. One client is undergoing cardioversion, and the other is being treated with defibrillation. Which of the following statements accurately differentiates cardioversion from defibrillation? A. Cardioversion delivers a synchronized shock to the heart, timed with the R wave of the QRS complex. In contrast, defibrillation delivers an unsynchronized shock to the heart at any point in the cardiac cycle. B. Cardioversion is used for ventricular fibrillation, while defibrillation is used for atrial fibrillation. C. Cardioversion is done with a higher energy level than defibrillation to reset the heart’s rhythm. D. Defibrillation is always synchronized with the QRS complex, while cardioversion is not. ### 16. A nurse is caring for a client in the ICU who is undergoing hemodynamic monitoring. The client’s central venous pressure (CVP) is 1 mmHg and the mean arterial pressure (MAP) is 50 mmHg. Which of the following interventions should the nurse prioritize? A. Administer 0.9% NaCl bolus as ordered to increase preload. B. Administer a vasoconstrictor as ordered to increase systemic vascular resistance. C. Administer furosemide (Lasix) to reduce preload. D. Decrease the rate of IV fluids to prevent fluid overload. ### 17. A nurse is reviewing the results of a troponin test for a client suspected of having a myocardial infarction (MI). Which of the following statements about troponin testing is most accurate? A. Troponin increases in the presence of damage to cardiac muscles. B. Troponin levels provide the location of the myocardial infarction. C. Troponin levels provide information regarding the valvular functions of the heart. D. Troponin provides information on which chambers of the heart are affected. ### 18. A client with crushing sternal chest pain was given morphine. Which of the following statements reflects the rationale for using morphine for this client? A. Morphine reduces the client’s pain perception. B. Morphine reduces the workload of the heart. C. Morphine lowers the client’s anxiety levels. D. Morphine relieves the client’s shortness of breath. ### 19. A nurse is preparing to use an invasive arterial line to monitor a client’s blood pressure. The nurse is preparing the pressure transducer for use and must ensure it is properly zeroed before beginning monitoring. Where should the nurse position the transducer for accurate readings? A. At the level of the client’s fourth intercostal space, mid-axillary line. B. At the level of the client’s bed. C. At the level of the client’s right shoulder. D. At the level of the client’s femoral artery. ### 20. A nurse is educating a client with coronary artery disease. Which of the following statements should the nurse include to explain how changes in the coronary arteries contribute to symptoms? A. Coronary artery disease affects the client when the diameter of the arteries becomes narrowed, causing a reduction of blood supply to cardiac muscles. B. Symptoms arise when the coronary arteries dilate, increasing blood flow and pressure. C. Weakened coronary arteries and heart function result in poor circulation, leading to angina. D. With age, coronary arteries become more elastic and stretch, limiting oxygen delivery to the heart. ### 21. A client arrives at the emergency department with crushing chest pain that started 2 hours ago. The ECG shows ST-segment elevation in leads V2–V4. The provider prescribes alteplase (tPA). What is an appropriate intervention by the nurse with this medication? A. Notify the provider if the client develops petechiae or black tarry stools. B. Administer alteplase within 90 minutes of arrival to the hospital. C. Apply loose dressings over wounds. D. Start a second IV after administering the medication. ### 22. A nurse in the ICU is preparing discharge teaching for a client with angina. A nitroglycerin transdermal patch is ordered for long-term prophylaxis. Which of the following needs to be included in the instructions for this client? A. “Remove the old patch, wash the skin with soap and water, and dry thoroughly before applying the new patch.” B. “If you are experiencing hypotension, you can cut the patch to reduce the dose.” C. “Apply the patch on consistent hairy areas.” D. “Remove the patch during the day. Ensure that you are medication-free for 5–6 hours per day.” ### 23. A nurse is providing dietary education to an ICU client with hypercholesterolemia who has been prescribed atorvastatin. Which client statement indicates the need for further teaching? A. “The best time to take this medication is during the day.” B. “I will eat more fiber-rich foods like oats and beans to help lower my cholesterol.” C. “I should avoid grapefruit juice while taking this medication.” D. “I will include fats like salmon and avocados in my diet.” ### 24. A client presents to the unit with low back pain, hypertension, and a pulsating abdominal mass. While awaiting surgery, which nursing intervention is the highest priority? A. Monitor blood pressure and administer antihypertensive medications as prescribed. B. Encourage ambulation to promote circulation and prevent blood pooling. C. Perform frequent abdominal palpation to assess for changes. D. Provide a high-fiber diet to prevent straining during bowel movements. ### 25. You are the charge nurse in a busy telemetry unit. The following four clients arrive at the same time. Which client should be seen first? A. A 68-year-old client with six successive premature ventricular contractions on an EKG rhythm strip who became unresponsive. B. A 75-year-old female with a peripheral pulse of 68 and an apical pulse of 121 with complaints of palpitations. C. An 18-year-old female client with a heart rate of 110 beats per minute after breaking up with her significant other. D. A 54-year-old male client with chest pain that becomes worse with breathing and when leaning forward. ### 26. A client is recovering after undergoing a coronary angiogram. The nurse notices that the client is becoming increasingly anxious and begins to complain of itching, a rash on the chest, difficulty breathing, and swelling around the eyes. Which complication or reaction should the nurse identify? A. Anaphylactic reaction B. Catheter tip migration to the atria C. Myocardial infarction D. Pericarditis ### 27. A client is recovering after undergoing a coronary angiography with contrast dye. After the procedure, the nurse notes swelling of the tongue and lips. Which of the following interventions should the nurse prioritize? A. Administer epinephrine IM as prescribed. B. Administer cetirizine PO as prescribed. C. Administer prednisone 40 mg PO. D. Administer hydrocortisone via IV. ### 28. Which of the following arrhythmias would warrant an external pacemaker? A. Third-degree AV block B. Sinus tachycardia C. Asymptomatic sinus bradycardia D. Premature ventricular contractions ### 29. A client with a history of coronary artery disease is scheduled for a cardiac catheterization. During the pre-procedure assessment, the nurse discovers that the client has a known allergy to iodine-based contrast dye. Which action should the nurse take first? A. Notify the provider and the team. Document the allergy in the client’s chart. B. Administer diphenhydramine HCl 50 mg IV 1 hour before the procedure. C. Administer prednisone 13 hours, 7 hours, and 1 hour before the procedure. D. Administer methylprednisolone 30 mg 12 hours and 2 hours before the procedure. ### 30. A client presents to the emergency department with chest discomfort. Which statement by the client is most concerning for an acute myocardial infarction rather than angina? A. “The pain is squeezing and spreads to my jaw. I took my nitroglycerin and it did not help with the pain.” B. “The pain occurs after I eat and then goes away after a short while.” C. “The pain occurs when I smoke and then disappears after.” D. “The pain occurs when I exercise but if I rest, it goes away.” ### 31. A 62-year-old male is admitted to the hospital following a myocardial infarction. The nurse notes the patient is experiencing symptoms of pulmonary congestion, including bilateral crackles in the lungs and dyspnea on exertion. Which of the following medical diagnoses is most likely associated with these findings? A. Congestive heart failure B. Ischemic mitral regurgitation C. Ventricular septal wall rupture D. Dressler syndrome ### 32. A 72-year-old male with a history of coronary artery disease is diagnosed with an acute myocardial infarction. The client is unable to undergo cardiac catheterization. Which of the following treatments would the patient most likely receive? A. Thrombolytic therapy B. Coronary artery bypass grafting (CABG) C. Percutaneous transluminal angioplasty (PTA) D. Stent placement ### 33. A 65-year-old male client who has recently experienced a myocardial infarction is prescribed an ACE inhibitor. Which of the following is the primary reason for continuing this medication long-term in post-MI patients? A. This medication reduces the strain on the heart, improving long-term survival. B. To reduce the risk of thromboembolism. C. To enhance the action of other cardiac medications like beta-blockers. D. To decrease the chances of developing high blood pressure. ### 34. A nurse is preparing to administer amoxicillin 350 mg PO. Available is amoxicillin 250 mg/5 mL. How many mL should the nurse administer? Round to the nearest whole number. ### 35. A nurse is preparing to administer potassium chloride 20 mEq suspension PO daily. The amount available is potassium chloride suspension 10 mEq/mL. How many mL should the nurse administer? ### 36. A nurse is preparing to administer vancomycin 15 mg/kg/day divided equally every 12 hr. The client weighs 198 lb. How many mg should the nurse administer with each dose? ### 37. Daily weights are being recorded for a client with chronic heart failure. The weight one week ago was 95 kg. This morning it is 100 kg. The nurse understands that this corresponds to a: A. Fluid retention of 5 L B. Fluid retention of 4 L C. Fluid retention of 3 L D. Fluid retention of 2 L ### 38. A client in the emergency department develops sinus bradycardia at a rate of 52 beats per minute with dizziness and shortness of breath. Which action should the nurse take first? A. Administer atropine 0.5 mg IV push. B. Give the scheduled dose of diltiazem (Cardizem). C. Have the patient perform the Valsalva maneuver. D. Administer digoxin as ordered. ### 39. Identify the arrhythmia from the ECG strip. A. Sinus bradycardia B. Sinus tachycardia C. Ventricular fibrillation D. Ventricular tachycardia ### 40. Interpret the ECG provided. A. Normal sinus rhythm B. Sinus bradycardia C. Sinus tachycardia D. Atrial flutter ### 41. Interpret the following ECG. A. Mobitz type 2 B. Normal sinus rhythm C. Sinus bradycardia D. Sinus tachycardia ### 42. A patient presents to the clinic with a complaint of drooping of his right eyelid that has progressively worsened over the past three months. The nurse notes mild ptosis of the right eye. The client denies pain but reports occasional double vision. Which of the following conditions should the nurse suspect as a possible cause? A. Myasthenia gravis B. Conjunctivitis C. Retinal detachment D. Cataracts ### 43. A client who has had a stroke is experiencing aphasia. It has been one week since the stroke, and the client is beginning to show functional improvement by demonstrating the ability to follow verbal directions. Which rehabilitation interventions should now be included in the client’s care plan? A. Encourage the client to communicate using gestures and pictures. B. Provide only written instructions to reinforce learning. C. Avoid verbal communication to prevent client frustration. D. Allow the client to remain passive to avoid stress. ### 44. Which of the following is the most common presenting symptom of a transient ischemic attack (TIA)? A. Brief episode of unilateral weakness or numbness B. Blurred vision or transient vision loss C. Difficulty speaking or understanding speech for 3 months D. Gradual onset of memory loss and confusion ### 45. A nurse is caring for a client diagnosed with a hemorrhagic stroke. The client’s blood pressure is 198/110 mmHg, Glasgow Coma Scale score is 10, and they exhibit right-sided hemiparesis with slurred speech. Which intervention should the nurse implement first? A. Keep the client’s head of the bed elevated at 30 degrees. B. Administer intravenous alteplase (tPA) to dissolve the clot. C. Encourage the client to cough and deep breathe frequently. D. Administer intravenous fluids rapidly to maintain blood pressure. ### 46. The nurse is performing a cranial nerve assessment on a client with a suspected neurological disorder. The client reports facial asymmetry and difficulty closing one eye. Which of the following assessment techniques would best evaluate the function of Cranial Nerve VII? A. Assess the client’s ability to smile, raise eyebrows, and puff out their cheeks symmetrically. B. Ask the client to clench their teeth and palpate the masseter muscle for strength. C. Perform the Weber and Rinne tests to evaluate air and bone conduction of sound. D. Have the client stick out their tongue and assess for midline deviation. ### 47. A nurse is caring for a client who suddenly experiences a tonic-clonic seizure. Which action should the nurse take first? A. Turn the client to the side and protect the head. B. Restrain the client to prevent injury. C. Insert a tongue blade to prevent aspiration. D. Attempt to hold the client’s extremities to reduce movement. ### 48. A nurse is assessing a client suspected of having bacterial meningitis. Which finding would be most concerning and require immediate intervention? A. Sudden onset of confusion and decreasing level of consciousness B. Fever, severe headache, and photophobia C. Positive Brudzinski’s and Kernig’s signs D. Nuchal rigidity and muscle aches ### 49. A client is diagnosed with bacterial meningitis. Which nursing intervention is the priority? A. Start IV antibiotics as soon as possible. B. Administer acetaminophen for fever and headache. C. Perform a lumbar puncture to confirm the diagnosis. D. Place the client in a supine position to prevent spinal cord compression. ### 50. The nurse is preparing a client for a lumbar puncture to assess cerebrospinal fluid for suspected meningitis. Which of the following nursing actions is most important before the procedure? A. Assess for signs of increased intracranial pressure before positioning the client. B. Instruct the client to empty their bladder before the procedure. C. Place the client in a high-Fowler’s position before the procedure. D. Position the client in a side-lying fetal position with the knees drawn up and chin tucked. ### 51. A nurse is reviewing cerebrospinal fluid analysis results from a client who underwent a lumbar puncture. Which finding would indicate a possible bacterial meningitis infection? A. Decreased glucose level in the CSF B. No white blood cells present in CSF C. Elevated glucose level in the CSF D. Presence of red blood cells in the CSF ### 52. A client with a severe traumatic brain injury and refractory increased intracranial pressure is receiving high-dose barbiturate therapy. What is the primary therapeutic goal of administering barbiturates in this client? A. To induce deep sedation, reducing metabolic demand and cerebral oxygen consumption. B. To suppress seizure activity and prevent secondary brain injury due to post-traumatic epilepsy. C. To enhance cerebral perfusion pressure by promoting systemic vasodilation and blood flow to the brain. D. To stabilize autonomic dysfunction and prevent hemodynamic fluctuations associated with traumatic brain injury. ### 53. A nurse is caring for a client with a suspected neurological infection. The client presents with a fever of 102.4°F (39.1°C), photophobia, severe headache, and a positive Kernig’s sign. Based on these findings, which condition is the most likely diagnosis, and what is the nurse’s priority intervention? A. Bacterial meningitis; initiate droplet precautions and administer IV antibiotics immediately. B. Encephalitis; obtain a lumbar puncture to confirm viral infection before starting treatment. C. Subarachnoid hemorrhage; administer antihypertensive medication to reduce risk of rebleeding. D. Brain abscess; prepare the client for urgent CT scan with contrast to determine lesion location. ### 54. A nurse is caring for a client who sustained a T6 spinal cord injury three days ago. The client suddenly reports a severe headache, blurred vision, and nausea, and the nurse observes flushed skin and a blood pressure of 190/110 mmHg. What is the priority nursing action? A. Assess the client for possible bladder distention or bowel impaction. B. Lower the head of the bed to improve circulation. C. Administer IV antihypertensive medication immediately. D. Encourage the client to take deep breaths and remain calm. ### 55. A client is admitted to the emergency department after a diving accident and is suspected of having a cervical spinal cord injury at C5. Which intervention should the nurse perform first? A. Apply a cervical collar and maintain spinal immobilization. B. Assess deep tendon reflexes and muscle strength. C. Insert an indwelling urinary catheter to prevent retention. D. Administer IV corticosteroids to reduce spinal inflammation. ### 56. A nurse is monitoring a client with a severe head injury for early signs of increased intracranial pressure. Which finding would the nurse expect first? A. Restlessness, confusion, and difficulty following commands B. Widening pulse pressure and bradycardia C. Unilateral pupil dilation and sluggish reactivity to light D. Irregular, shallow respirations ### 57. A nurse is performing triage in the emergency department after a mass casualty incident. Which client should be seen first? A. A 45-year-old with an open femur fracture, absent distal pulses, and pale, cool skin B. A 32-year-old with a head laceration and a Glasgow Coma Scale score of 2 C. A 60-year-old with superficial burns on both arms and stable vital signs D. A 25-year-old with minor abrasions and no significant complaints ### 58. A nurse is caring for a client with a severe traumatic brain injury and increased intracranial pressure. Which medication would the nurse expect the healthcare provider to prescribe to help reduce cerebral edema? A. Mannitol (Osmitrol) B. Morphine sulfate C. Warfarin (Coumadin) D. Atropine sulfate ### 59. The nurse is performing a neurological assessment on a client. Which of the following findings would require immediate follow-up? A. Positive Babinski reflex in an adult B. Bilateral pupil size of 3 mm and reactive to light C. Diminished deep tendon reflexes in older adults D. Reports of occasional dizziness when standing ### 60. A client with a spinal cord injury is receiving continuous epidural morphine for pain control. The provider orders morphine to be infused at a rate of 0.2 mg/kg/hr. The client weighs 75 kg. The pharmacy provides a morphine solution of 5 mg/mL. At what rate in mL/hr should the nurse set the infusion pump? Round to the nearest whole number. ### 61. A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip? A. Pacemaker spikes before each QRS complex B. Pacemaker spikes after each QRS complex C. Pacemaker spikes before each P wave D. Pacemaker spikes with each T wave ### 62. A nurse is caring for a hemodynamically unstable client in the ICU who is receiving dobutamine. Which of the following findings indicates that the medication is effective? A. Urine output increases from 10 mL/hr to 45 mL/hr B. Central venous pressure increases from 6 mmHg to 12 mmHg C. Heart rate increases from 80 bpm to 120 bpm D. Systolic blood pressure drops from 110 mmHg to 88 mmHg ### 63. A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first? A. Computed tomography (CT) scan B. Complete blood count (CBC) C. Chest radiograph D. 12-lead electrocardiogram ### 64. After evacuation of an epidural hematoma, a patient’s intracranial pressure is being monitored with an intraventricular catheter. Which information obtained by the nurse requires urgent communication with the healthcare provider? A. Temperature of 101.6°F B. Pulse of 102 beats/min C. Intracranial pressure of 15 mmHg D. Mean arterial pressure of 90 mmHg ### 65. A nurse is caring for a client with a C6 spinal cord injury who is using accessory neck muscles to breathe and reports increasing shortness of breath. Which of the following actions should the nurse take first? A. Assist the client into a high-Fowler’s position. B. Prepare for endotracheal intubation and mechanical ventilation. C. Apply high-flow oxygen via non-rebreather mask. D. Assess lung sounds and obtain a pulse oximetry reading. ### 66. A nurse is caring for a client who has increased intracranial pressure following a closed-head injury. Which of the following actions should the nurse take? A. Use log rolling to reposition the client. B. Instruct the client to cough and deep breathe. C. Place the client in a supine position. D. Place a warming blanket on the client. The remaining items in the report **do not display their individual answer choices**, so I am listing the questions only. ### 67. A nurse is providing discharge teaching to a patient who recently had a permanent pacemaker placed. Which statements, if made by the client, indicate an understanding of the discharge teaching provided? **(Select all that apply.)** ### 68. A client with congestive heart failure is prescribed furosemide to help manage fluid retention. Which of the following dietary choices should the nurse include in health teaching to reduce the possibility of side effects of this medication? ### 69. Identify if the client’s signs and symptoms are consistent with the following medical diagnoses. More than one answer is possible per row. ### 70. A nurse is educating a client about modifiable risk factors for heart disease. Which of the following are modifiable risk factors for cardiovascular disease? **(Select all that apply.)** ### 71. A nurse is taking care of a client who is prescribed lisinopril. Which of the following information needs to be included in the health teaching for this client? **(Select all that apply.)** ### 72. Select the 3 responses that the nurse should perform. ### 73. The nurse is assessing a client who was admitted with an acute ischemic stroke affecting the left cerebral hemisphere. Which findings should the nurse anticipate? **(Select all that apply.)** ### 74. A nurse is assessing a client with suspected Cranial Nerve III (Oculomotor Nerve) dysfunction. Which findings would support this diagnosis? **(Select all that apply.)** ### 75. The nurse suspects Cranial Nerve XII (Hypoglossal Nerve) dysfunction in a client. Which findings support this suspicion? **(Select all that apply.)** ### 76. The nurse is caring for a client who has just experienced a generalized seizure. Which nursing interventions should be included in post-seizure care? **(Select all that apply.)** ### 77. A nurse is providing stroke rehabilitation education for a client who recently had a left-sided ischemic stroke. For each functional impairment below, indicate whether it is more commonly associated with a left-sided stroke, a right-sided stroke, or both types of stroke. ### 78. A nurse is caring for a client who has an intracranial pressure reading of 40 mmHg. Which of the following findings should the nurse identify as a late sign of ICP? **(Select all that apply.)** ### 79. Highlight text that corresponds to the correct Glasgow Coma Scale criteria for this patient. ### 80. Which of the following client findings require the nurse’s immediate attention? ### 81. For each assessment finding, specify if the finding is consistent with myocardial infarction, angina, or cholecystitis. Each finding may support more than one disease process. ### 82. The nurse is initiating the client’s plan of care. Complete the following sentence by using the lists of options. ### 83. Click to highlight the four prescriptions that require immediate follow-up. ### 84. Which of the following prescriptions should the nurse implement? ### 85. The nurse is updating the client’s plan of care. Select the 3 findings that indicate the client’s condition is improving.