HESI MEDSURGE BRAND NEW QUESTIONS WITH NGN STYLE 55 Q&A V

10. A client returns to the unit following a craniotomy for removal of a brain tumor and is obtunded but arouses to painful stimuli. Which assessment is most important for the nurse to obtain? A. Drainage or dressing. B. Last administration of analgesia C. Body temperature D. Serial Blood pressure and pulse ANSWERE: B 11. A male client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA) which resulted in paralysis of his right arm. When the nurse enters the room, he is struggling to put on a shirt, and he curses at the nurse. What is the best first response by the nurse? A. “We will give you a class on dressing tomorrow.” B. “The unit has a policy against staff harassment.” C. “Dressing must be a frustrating experience for you.” D. “It is important to dress the right arm first.” ANSWERE: C 12. An older client who is agitated, dyspneic, orthopneic, and using accessory muscles to breathe is admitted for further treatment. Initial assessment includes a heart rate 124 beats/min and irregular, respirations 36b breaths/minute, blood pressure 168/100 mmHg, wheezes, and crackles in all lung fields. An hour after the administration of furosemide 50 mg IV, which assessment should the nurse obtain to determine the clients resp9ne to treatment? (Select all that apply). A. skin elasticity B. Pain scale C. Lung sounds D. Urinary output E. Oxygen saturation ANSWERES: C, E