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A nurse is collecting data on four clients. Which of the following is the highest
priority finding by the nurse?
Diarrhea
A nurse in a rehabilitation facility has received report on four clients. Which of the
following should the nurse evaluate first?
A client who had abdominal surgery 10 days ago and reports feeling his incision pop
A nurses caring for an older adult client who recently experienced the death of
her partner. Which of the following is the priority need of the client?
Creating meaningful social relationships
A nurse is preparing to administer oral medication to a client who has unilateral
weakness following a cerebrovascular accident (CVA). Which of the following
should be the priority action of the nurse?
Have the client position the head with the chin down while swallowing
A nurse is conducting therapeutic medication monitoring on four clients. Which
of the findings should be immediately reported to the provider?
Digoxin 3.0ng/mL
A nurses caring for a client who has a urinary track infection. The client is
disoriented and found wandering on another unit. Which of the following actions
should the nurse take first?
Move the client to room near the nurses station
A nurse is reinforcing discharge teaching to a new mother regarding sudden
infant death syndrome (SIDS). Which of the following is the highest priority to
include in the instructions?
Place the infant in a supine position when sleeping
A nurse is caring for a client who has a serum potassium level of 3.1 mEq/L.
Which of the following actions should the nurse take first?
Obtain an ECG
A nurse is caring for a client who is having difficulty breathing. Which of the
following actions should the nurse take first?
Place the client in the orthopneic position
A nurse is collecting data on four clients. Which of the following findings is the
most urgent?
Warmth and pain in the calf
A nurse in an urgent care clinic is caring for a client who has bronchitis with thick
pulmonary secretions. The client's oxygen saturation level is 90% on room air.
Which of the following actions should the nurse take first?
Assist client to cough effectively
A nurse in a long-term care facility is assisting with the admission of several
clients. To prevent falls in hospitalized clients, which of the following actions
should the nurse take first?
Determine the mobility status of each patient