Glasgow Coma Scale of 3 - CORRECT ANSWER-Expect nonresponsive to commands Angina Manifestations - CORRECT ANSWER-Chest discomfort radiated, pain 15mins, relieved with rest Diabetes Mellitus Client - CORRECT ANSWER-Plan to see diaphoretic client

Glasgow Coma Scale of 3 - CORRECT ANSWER-Expect nonresponsive to commands Angina Manifestations - CORRECT ANSWER-Chest discomfort radiated, pain 15mins, relieved with rest Diabetes Mellitus Client - CORRECT ANSWER-Plan to see diaphoretic client first Testicular Self-Examination - CORRECT ANSWER-Instruct to examine after a warm shower Tuberculosis Combination Therapy - CORRECT ANSWER-Adherence indicated by negative sputum culture Bacterial Meningitis - CORRECT ANSWER-Expect severe headache Pernicious Anemia Teaching - CORRECT ANSWER-Client understanding: switch to nasal cyanocobalamin Right-Sided Hemiparesis ADLs - CORRECT ANSWER-Include combing hair with unaffected arm COPD Discharge Teaching - CORRECT ANSWER-Include pursed lip breathing technique Varicose Veins Instruction - CORRECT ANSWER-Teach to apply elastic support hose in the morning Total Knee Arthroplasty Transfer - CORRECT ANSWER-Flex at hip and knees before transferring Thoracentesis Teaching - CORRECT ANSWER-Lean forward on over bed table for procedure Alzheimer's Sleep Promotion - CORRECT ANSWER-Provide light snack of cheese and crackers at bedtime Nicotine Chewing Gum Use - CORRECT ANSWER-Recommend no eating/drinking 15min around gum use Diabetes Foot Care - CORRECT ANSWER-Prop feet up while watching TV Neurogenic Bladder Interventions - CORRECT ANSWER-Include stroking inner thigh in plan for bladder control Systemic Lupus Erythematosus - CORRECT ANSWER-Expect joint pain in the client GERD Dietary Teaching - CORRECT ANSWER-Instruct to avoid peppermint Enteral Feedings with Medications - CORRECT ANSWER-Flush tube with water before and after each medication Oxygen Concentrator Safety - CORRECT ANSWER-Include maintaining electrical backup system Hypoglycemia Management - CORRECT ANSWER-Have client drink a glass of milk for glucose 50mg/dL Hypertension Dietary Selections - CORRECT ANSWER-Instruct to avoid pretzels for sodium intake Pheochromocytoma Findings - CORRECT ANSWER-Expect hypertension in the client Gastric Lavage Teaching - CORRECT ANSWER-Inform about semi-upright position during the procedure Right-Sided Heart Failure Findings - CORRECT ANSWER-Expect peripheral edema, hepatomegaly, abdominal distension Neutropenia Care - CORRECT ANSWER-Include bathing with antimicrobial soap, daily temperature checks, and avoiding gardening Alzheimer's Home Care - CORRECT ANSWER-Include labeling kitchen cabinets and drawers for caregiver Low Sodium Level - CORRECT ANSWER-Nurse is collecting data from a client with sodium level of 128mEq/L Mental Confusion - CORRECT ANSWER-Expected finding in a client Clopidogrel - CORRECT ANSWER-Medication preventing clot formation post-stroke Yogurt - CORRECT ANSWER-Recommended solid food for client after severe diarrhea 3oz canned salmon - CORRECT ANSWER-Food with high calcium for client with hypocalcemia Macular degeneration - CORRECT ANSWER-Visual impairment cause requiring glare management Closed irrigation - CORRECT ANSWER-Procedure for indwelling urinary catheter post-surgery Persistent bubbling - CORRECT ANSWER-Sign requiring notification in a client with pneumothorax Assistive personnel (AP) - CORRECT ANSWER-Task delegation for documenting client output Tinnitus - CORRECT ANSWER-Adverse effect of furosemide in heart failure client Pain radiating to right shoulder - CORRECT ANSWER-Expected manifestation in acute cholecystitis Fruity breath odor - CORRECT ANSWER-Finding in a client with diabetic ketoacidosis Preoperative language barrier - CORRECT ANSWER-Action for a nurse caring for a client with language difference Total hip arthroplasty - CORRECT ANSWER-Pre-procedure actions including allergy check and consent form verification Lisinopril - CORRECT ANSWER-Instruction for hypertension client on reporting persistent cough Peripheral IV site - CORRECT ANSWER-Red, warm, and painful site requiring IV discontinuation Cool skin flap - CORRECT ANSWER-Priority finding in a client with type 1 diabetes post-amputation 12 lead ECG - CORRECT ANSWER-Procedure instruction for a client with angina pectoris Mammograms - CORRECT ANSWER-Frequency understanding for postmenopausal client Skeletal traction - CORRECT ANSWER-Care plan intervention for a client in traction Amenorrhea and insomnia - CORRECT ANSWER-Data to report in a client with these symptoms Isometric exercises - CORRECT ANSWER-Bed rest client instruction for muscle tightening Simvastatin - CORRECT ANSWER-Teaching on adverse effect myalgia for a new prescription STI prevention - CORRECT ANSWER-Effective method for sexually active clients Pertussis isolation - CORRECT ANSWER-Precaution for a client with pertussis EEG - CORRECT ANSWER-Instruction for a client scheduled for an EEG Total knee arthroplasty - CORRECT ANSWER-Action for a client moving from bed to wheelchair post-surgery Cataract surgery - CORRECT ANSWER-Postoperative instruction for a client undergoing surgery Chronic renal failure - CORRECT ANSWER-Teaching on epoetin alfa for reducing transfusion need Priority client - CORRECT ANSWER-Client needing immediate attention among four with chest tubes Furosemide - CORRECT ANSWER-Medication for peripheral edema needing monitoring Muscle Weakness - CORRECT ANSWER-Adverse effect to monitor Supplemental Oxygen - CORRECT ANSWER-Action for client scheduled for bronchoscopy NG Tube Insertion - CORRECT ANSWER-Task RN can delegate to LPN Fine Crackles - CORRECT ANSWER-Intermittent high-pitched lung sounds 2000 IU Vit D - CORRECT ANSWER-Preventive measure for osteoporosis Digoxin - CORRECT ANSWER-Medication to withhold for low potassium Eating from Both Sides - CORRECT ANSWER-Effective management of homonymous hemianopsia Swelling of Extremity - CORRECT ANSWER-Instruction for client on hydrocodone Keep Liquid Glasses Full - CORRECT ANSWER-Intervention for child with dysphagia Check Respirations - CORRECT ANSWER-Immediate action for client with cellulitis Purple Stoma - CORRECT ANSWER-Finding about ileostomy to report Pregabalin - CORRECT ANSWER-Medication for phantom pain post-amputation Surgical Mask - CORRECT ANSWER-Transmission prevention for active tuberculosis Avoid Chocolate - CORRECT ANSWER-Instruction for client with migraines Age-Related Changes - CORRECT ANSWER-Physiological changes in older adults Pneumococcal Immunization - CORRECT ANSWER-Recommendation for older adults Dedicated Equipment - CORRECT ANSWER-Precaution for MRSA-infected wound Warm Eardrops - CORRECT ANSWER-Action for administering eardrops Difficulty Contracting - CORRECT ANSWER-Expected finding with low blood glucose Stop Treatment - CORRECT ANSWER-Response to client refusing CT scan Open Eyes - CORRECT ANSWER-Instruction for Romberg test Eliminate Peanuts - CORRECT ANSWER-Diet change for calcium oxalate stones Atrial Fibrillation - CORRECT ANSWER-Identifying dysrhythmia pattern Neck Hole - CORRECT ANSWER-Understanding of laryngectomy with tracheostomy Slow Enema Flow - CORRECT ANSWER-Action for cramping during tap water enema