hemispheric stroke. Which of the following neurologic deficits should the nurse expect to find when assessing the client? (Selec t all that apply.) Correct Answer Visual spatial deficits Left hemianopsia One-sided neglect Rationale: Visual spatial deficits is correct. Visual spatial deficits and loss of depth perception occur secondary to a right -hemispheric stroke. Left hemianopsia is correct. Left hemianopsia, or blindness in the left half of the visual field, occurs secondary to a right -hemispheric stroke. One-sided neglect is correct. One -sided neglect, or an unawareness of the affected side, occurs secondary to a right -hemispher ic stroke. A nurse is caring for a client who has viral pneumonia. The client's pulse oximeter readings have fluctuated between 79% and 88% for the last 30 min. Which of the following oxygen delivery systems should the nurse initiate to provide the highes t concentration of oxygen? Correct Answer Nonrebreather mask Rationale: The nurse should initiate a nonrebreather mask to deliver between 80% to 95% oxygen to the client. A client who has an unstable respiratory status should receive oxygen via a nonrebrea ther mask. A nurse is caring for a client who has bilateral pneumonia and an SaO2 of 85%. The client has dyspnea with a productive cough and is using accessory muscles to breathe. Which of the following actions should the nurse take first? Correct Answer Place the client in high -
Fowler's position ATI RN Adult Medical Surgical Rationale: The greatest risk to this client is injury from airway obstruction. Therefore, the priority intervention the nurse should take is to move the client into high -Fowler's position. High -Fowler's position f acilitates lung expansion and improves ventilation and gas exchange. A nurse is planning care for a client who has extensive burn injuries and is immunocompromised. Which of the following precautions should the nurse include in the plan of care to prevent a Pseudomonas aeruginosa infection? Correct Answer Avoid placing plants or flowers in the client's room Rationale: Live plants can harbor P. aeruginosa, and this bacterium can infect burn wounds and cause life -threatening complications. The nurse should e nsure no one brings live plants or flowers into the client's room. An older adult client is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration? Correct Answer Urine specific gravity 1.045 Rationale: A urine specific gravity greater than 1.030 indicates a decrease in urine volume and an increase in osmolarity, which is a manifestation of hypertonic dehydration. A nurse in an emergency department is reviewing the provider's prescriptions for a client who sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the nurse expect? Correct Answer Administer an opioid analgesic to the client Rationale: The n urse should expect a prescription for an opioid analgesic to promote comfort following a rattlesnake bite. A nurse is teaching a young adult client how to perform testicular self-examination. Which of the following instructions should the nurse include? Correct Answer Roll each testicle between the thumb and fingers