ATI RN VATI COMPREHENSIVE PREDICTOR FORM A EXAM

A client who has a diagnosis of complete placenta previa is admitted to the labor and delivery suite at 36 weeks gestation with contractions 5 min in frequency and 1 min in duration. Which of the following actions should the nurse take? C. Prepare the client for a cesarean section - Prepare the client for a cesarean section A nurse enters a client's room and finds the client lying on the floor in a puddle of water. Which of the following statements should the nurse document in an incident report? D. Client found lying on the floor near the bedside table - Client found lying on the floor near the bedside table A charge nurse on a pediatric unit is making assignments for a float nurse from the medical unit. Which of the following clients is appropriate to assign to the float nurse? A. A 10-year-old client who has pneumonia and is receiving respiratory treatments - A 10-year-old client who has pneumonia and is receiving respiratory treatments A nurse is preparing to administer vancomycin to a client who has an infected wound. The nurse should plan to monitor for which of the following adverse reactions? B. Ototoxicity - Ototoxicity A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect? A. Generalized edema - Generalized edema A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client has two school-age children and a limited support system. Which of the following is the priority nursing action? A. Inform the client of available community resources - Inform the client of available community resources A nurse in an emergency department is assessing a client who has a nasal fracture. Which of the following findings should cause the nurse to suspect a skull fracture? A. Clear fluid drainage from the nares - Clear fluid drainage from the nares A nurse in an urgent care clinic is collecting admission history from a client who is at 16 weeks of gestation and has bacterial vaginosis. The nurse should recognize that which of the following clinical findings are associated with this infection? A. Profuse milky white discharge - Profuse milky white discharge A nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse. Which of the following statements indicates the newly licensed nurse understands the purpose of the technique? B. This technique decreases the risk of subcutaneous infiltration - This technique decreases the risk of subcutaneous infiltration 10. A nurse is caring for a full-term newborn immediately following birth. Which of the following actions should the nurse take first? D. Dry the newborn - Dry the newborn A nurse is planning to provide community education about viral hepatitis. Which of the following should the nurse plan to include in the teaching? D. Clients who have a history of viral hepatitis are unable to donate blood - Clients who have a history of viral hepatitis are unable to donate blood A nurse in a residential mental health facility is planning care for a new client who has obsessive compulsive disorder. Which of the following is appropriate for the nurse to include in the plan of care? B. Gradually decrease the time allowed for ritualistic behavior - Gradually decrease the time allowed for ritualistic behavior A nurse is assessing an adult male who has a BMI of 20. The nurse should identify that the client's BMI falls within which of the following categories? A. Healthy weight - Healthy weight A nurse is caring for a client who is nulliparous and in the first stage of labor. The last internal assessment revealed 100% cervical effacement with 5 cm of dilation. At the end of the last contraction, the nurse observes a large gush of fluid coming out of the client's perineal area. Which of the following is a priority action by the nurse? C. Check the FHR - Check the FHR A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? C. Monitor the client for 1 hr after meals - Monitor the client for 1 hr after meals A nurse is performing a skin assessment on a client who has risk factors for development of skin cancer. The nurse should understand that a suspicious lesion is A. Asymmetric, with variegated coloring - Asymmetric, with variegated coloring A nurse is assessing a client's internal eye structures with an ophthalmoscope. Which of the following actions should the nurse take? C. Dim the lights in the room prior to the examination - Dim the lights in the room prior to the examination A nurse is observing a newly licensed nurse irrigate a client's wound. Which of the following actions should the nurse identify as an indication that the newly licensed nurse understands wound irrigation? D. Irrigates the wound from the top to the bottom - Irrigates the wound from the top to the bottom A nurse is planning care for a child who has increased intracranial pressure with a decrease in level of consciousness. Which of the following interventions should the nurse include in the plan of care? A. Perform active range-of-motion exercises B. Maintain the head at a midline position C. Suction the airway frequently D. Perform neurological checks every 4 hrs - Maintain the head at a midline position A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket. After moving the client to safety, which of the followings is the priority action? B. Close the fire doors on the unit - Close the fire doors on the unit A nurse is talking with an adult child of a client who was involuntarily admitted to an inpatient mental health facility. Which of the following statements should the nurse make? D. The provider can prescribe restraints if your parent tries to harm others - The provider can prescribe restraints if your parent tries to harm others A nurse is assessing a client who has delirium due to a febrile illness. Which of the following findings should the nurse expect? A. Hallucinations - Hallucinations A nurse is assessing a client who is receiving enteral feedings via a gastrostomy tube. The nurse should identify that which of the following findings indicates fluid overload? D. Bounding pulses - Bounding pulses A nurse is caring for a client following an open colectomy. Which of the following findings places the client at risk for delayed wound healing? B. Hyperemesis - Hyperemesis A nurse is assessing a client who has a complete heart block and is receiving transcutaneous pacing. Which of the following findings indicates to the nurse that the treatment is effective? A. Heart rate greater than 60/min - Heart rate greater than 60/min A nurse is caring for a client who is taking levothyroxine. Which of the following findings should indicate to the nurse that the medication is effective? B. Weight loss - Weight loss A nurse at the family planning clinic triages several client over the phone. Which of the following clients should the nurse instruct to come to the clinic? D. A client who has sharp pain in her shoulder following a laparoscopic tubal ligation yesterday - A client who has sharp pain in her shoulder following a laparoscopic tubal ligation yesterday A home health nurse is reviewing treatment goals with a client who has diabetes mellitus. The nurse should evaluate which of the following laboratory tests to determine effective long-term management of blood glucose levels? B. HbA1c - HbA1c A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions should the nurse take while caring for this client? D. Use a dedicated stethoscope - Use a dedicated stethoscope A nurse is planning care for a client who has a gambling disorder. Which of the following instructions should the nurse provide to the client? A. Participate in a 12-step program - Participate in a 12-step program A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions should the nurse take? B. Tell the client to avoid drinking fluids 1 hr before bedtime - Tell the client to avoid drinking fluids 1 hr before bedtime A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include? D. Place the newborn 45 cm from the light source - Place the newborn 45 cm from the light source A nurse is providing teaching to a client who is at 8-week gestation and experiencing episodes of nausea and vomiting. Which of the following instructions should the nurse include? D. Eat a dry carbohydrate before getting out of bed - Eat a dry carbohydrate before getting out of bed A nurse is teaching a client who is scheduled for placement of a peripherally inserted central catheter line. Which of the following information should the nurse include in the teaching? A. Your PICC line will allow long-term access for antibiotic therapy - Your PICC line will allow long-term access for antibiotic therapy A nurse is planning care for a client who has schizophrenia and is having difficulty expressing their feelings. Which of the following referrals should the nurse make? A. Art therapist - Art therapist A nurse in a mental health clinic is observing clients in the day room. The nurse sits down to talk with an adolescent client who was admitted with clinical depression. After a few minutes of conversation, the adolescent asks the nurse, "Why did you choose to talk to me out of this room full of kids?" Which of the following responses by the nurse is therapeutic? D. You're curious why I am interested in you and not the others? - You're curious why I am interested in you and not the others? An occupational health nurse at a group of health care clinics is planning activities to prevent and control the spread of communicable disease. The nurse should identify that which of the following activities is a secondary level of prevention? B. Tuberculosis screenings - Tuberculosis screenings A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the following findings indicates the client is experiencing an adverse effect of the medication? A. Decreased reflexes - Decreased reflexes A nurse is caring for a client who is postoperative following a bowel surgery and has an NG tube connected to low intermittent suction. Which of the following assessment findings should indicate to the nurse that the NG tube might not be functioning properly? D. Abdominal rigidity - Abdominal rigidity A nurse is caring for a 7-year-old child who has severe dehydration. Which of the following findings should the nurse expect? D. Heart rate 152/min - Heart rate 152/min A client who is having suicidal thoughts tells the nurse, "It just does not seem worth it. Why not end my misery?" Which of the following responses by the nurse is appropriate? D. Do you have to plan to end your life? - Do you have to plan to end your life? A nurse is caring for a client who has schizophrenia. Which of the following findings is the nurse's priority? C. The client reports hearing voices - The client reports hearing voices At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first? B. Indigestion - Indigestion A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following actions by the assistive personnel requires the nurse to intervene? C. Offers oral fluids to the client - Offers oral fluids to the client A nurse is reviewing the medical history of a client who is taking a garlic supplement. The nurse should identify that which of the following findings is a contraindication for taking this supplement? C. The client takes aspirin daily - The client takes aspirin daily A nurse in a mental health facility is interviewing a newly admitted client. Which of the following actions should the nurse take when conducting the interview? D. Lean in slightly when speaking to the client - Lean in slightly when speaking to the client A nurse on a medical unit has just received change-of-shift report. Which of the following clients should the nurse assess first? A. A 68-year-old client who had a myocardial infarction 2 days ago and reports chest pain on a scale of 0 to 10 - A 68-year-old client who had a myocardial infarction 2 days ago and reports chest pain on a scale of 0 to 10 A nurse is assessing a client prior to performing a blood draw. The nurse should identify that an allergy to which of the following food can indicate that the client has an allergy to latex? C. Avocados - Avocados A nurse is planning discharge teaching for a client who is scheduled to receive intravenous infusions at home. Which of the following instructions should the nurse plan to include? D. Place the infusion pump cord against the baseboards - Place the infusion pump cord against the baseboards A nurse is preparing to witness a client's signature on an informed consent for a total knee arthroplasty. Which of the following client statements indicates the nurse should contact the surgeon? D. I am thankful there are no serious complications from this type of surgery - I am thankful there are no serious complications from this type of surgery A nurse plans to ambulate a client on the third day after cardiac surgery. Which of the following interventions should the nurse take so that the client will best tolerate ambulation? B. Premedicate the client with the prescribed analgesic - Premedicate the client with the prescribed analgesic A nurse is planning the discharge of an infant who has tetralogy of Fallot. The nurse anticipates the need for which of the following equipment? D. Pulse oximeter - Pulse oximeter A nurse is admitting a client who has antisocial personality disorder. Which of the following client behaviors should the nurse identify as consistent with this disorder? C. Uses others for personal gain - Uses others for personal gain A nurse is teaching the parent of a school-age child who has scabies about the application of permethrin 5% cream. The nurse should include which of the following as a potential adverse effect of the medication? A. Burning - Burning A nurse is teaching a client who has a new prescription for digoxin. Which of the following statements should the nurse include in the teaching? A. "Notify your provider if you experience muscle weakness." - "Notify your provider if you experience muscle weakness." A nurse is planning teaching for a client who is at 10 weeks of gestation and has a history of urinary tract infections. Which of the following information should the nurse plan to include in the teaching about UTI prevention? C. Empty the bladder before and after intercourse - Empty the bladder before and after intercourse A nurse is providing discharge teaching to a client who is postpartum and plans to breastfeed. Which of the following should the nurse recommend the client increase in their diet during lactation? D. Calcium - Calcium A nurse is caring for a client who has been taking propranolol. Which of the following findings indicates a need to withhold the medication? A. Pulse 54/min - Pulse 54/min A nurse is providing teaching about preventing mastitis to a client who is postpartum and breastfeeding her newborn. Which of the following instructions should the nurse include? D. "Try to have your baby empty your breasts with each feeding - "Try to have your baby empty your breasts with each feeding A nurse is caring for a client who is receiving total parenteral nutrition. Which of the following findings requires immediate intervention by the nurse? D. Weight increase of 2 kg in the past 24 hours - Weight increase of 2 kg in the past 24 hours A nurse is caring for a client who reports chest pain. Which of the following findings indicates myocardial damage? B. Troponin I 1.8 ng/mL - Troponin I 1.8 ng/mL A nurse is assessing a client who has a fentanyl patch in place for chronic pain. Which of the following findings should the nurse report to the provider? A. No bowel movement for 3 days - No bowel movement for 3 days A nurse is providing teaching to a client who has osteoporosis and a new prescription for alendronate. Which of the following statements by the client indicates an understanding of the teaching? C. "I will take this medication with 8 ounces of water." - "I will take this medication with 8 ounces of water." A nurse is caring for a client who experienced a stroke and has dysphagia. Which of the following findings should indicate to the nurse the client is at risk for aspiration? C. The client pockets food on one side of his mouth - The client pockets food on one side of his mouth A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an assistive personnel? C. A client who had a stroke 2 days ago and needs help toileting - A client who had a stroke 2 days ago and needs help toileting A nurse is caring for a client who is receiving continuous enteral feedings and reports diarrhea. Which of the following actions should the nurse take? A. Discard opened cans of formula after 24 hrs - Discard opened cans of formula after 24 hrs A nurse is caring for an adolescent who is receiving treatment for heart failure. Based on the client's chart findings, which of the following actions should the nurse plan to take? B. Withhold digoxin - Withhold digoxin A nurse is reviewing the employee health program for new employees. Which of the following diagnostic assessments should the nurse recommend for all new employees to screen for the presence of tuberculosis? D. Mantoux test - Mantoux test A nurse is providing teaching about car seat safety to the parent of a term newborn. Which of the following statements by the parent indicates an understanding of the teaching? A. "I should place a rolled blanket along each side of my baby's head in the car seat." - "I should place a rolled blanket along each side of my baby's head in the car seat." A nurse in the labor and delivery unit is reviewing medications for a group of clients. Which of the following medications places the fetus at risk for teratogenic effects? B. Phenytoin for seizure disorder - Phenytoin for seizure disorder An emergency department nurse triages a group of school children injured in a school bus crash. Which of the following children should the nurse have the provider evaluate first? C. A child who reports diplopia and nausea and was unconscious at the scene but is now awake - A child who reports diplopia and nausea and was unconscious at the scene but is now awake A nurse is caring for a client who is receiving total parental nutrition. For which of the following findings should the nurse monitor as a potential complication of TPN? D. Electrolyte imbalance - Electrolyte imbalance A nurse is analyzing the laboratory data on a client who has dehydration. Which finding should the nurse anticipate in a client who has fluid volume deficit? C. Elevated blood urea nitrogen - Elevated blood urea nitrogen A nurse is performing high-frequency chest compressions using a mechanical chest compression device for a child who has cystic fibrosis. Which of the following findings indicates the treatment has been effective? C. The child has increased sputum production - The child has increased sputum production A nurse in an inpatient mental health facility is caring for a client who has major depressive disorder and refuses to take her medication. Which of the following actions should the nurse take first? B. Identify the reason for the client's refusal - Identify the reason for the client's refusal A nurse is providing discharge teaching about disease prevention to a client who has active tuberculosis. Which of the following should the nurse include? A. Educating the client how to cover nose and mouth with tissues when coughing - Educating the client how to cover nose and mouth with tissues when coughing A nurse is caring for a client following a possible exposure to anthrax. Which of the following actions should the nurse take? D. Begin prophylactic treatment with ciprofloxacin - Begin prophylactic treatment with ciprofloxacin A nurse is caring for a client who has a newly implanted sealed internal radiation device to treat cervical cancer. Which of the following is an appropriate action for the nurse to take? B. Keep a 3-foot distance from the radiation implant - Keep a 3-foot distance from the radiation implant A nurse is admitting a client to the medical-surgical unit. Which of the following actions should the nurse take first? B. Observe the client's level of mobility - Observe the client's level of mobility A nurse is assessing a client in the PACU. Which of the following findings indicates decreased cardiac output? A. Oliguria - Oliguria A nurse in a newborn nursery is performing assessments on four neonates that are all less than 24 hr old. The nurse should plan to notify the provider of which of the following findings? D. Pinna below the outer canthus of the eye - Pinna below the outer canthus of the eye A nurse is providing teaching to the guardian of a school-age child who has a new prescription for ferrous sulfate capsules PO. Which of the following instructions should the nurse include in the teaching? C. Administer the medication with a glass of orange juice - Administer the medication with a glass of orange juice A nurse at a public health clinic is caring for a group of clients. Which of the following should the nurse identify as a reportable diagnosis to the CDC? B. Hepatitis A - Hepatitis A A nurse is giving change of shift report about a client who is 36 hr postoperative to another nurse. Which of the following should the nurse include? D. Pain relieved by position change - Pain relieved by position change A charge nurse is evaluating the time management skills of a newly licensed nurse. Which of the following actions should the charge nurse identify as an effective time management skill? B. Completes activities for one client before moving to the next client - Completes activities for one client before moving to the next client A nurse is caring for a client who has a prescription for atorvastatin. Which of the following client conditions is a contraindication to this medication? A. Hepatitis C - Hepatitis C A nurse delegates tasks to a licensed practical nurse and an assistive personnel. When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN? D. Measure the amount of gastric drainage every 2 hr - Measure the amount of gastric drainage every 2 hr A nurse is assessing a client who has a long arm cast. For which of the following findings should the nurse monitor when assessing for acute compartment syndrome A. Edema - Edema A nurse is caring for a client who has opioid use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect? A. Hyperreflexia - Hyperreflexia A nurse is caring for a client who is at high risk for developing diabetes insipidus following a severe head injury. Which assessment finding indicates to the nurse that the client is developing DI? B. Urine output of 250 mL/hr - Urine output of 250 mL/hr A nurse is planning to perform wound irrigation for a client who has an open secondary wound. When creating a sterile field, which of the following actions should the nurse take? B. Hold the bottle of sterile solution with the palm over the label while pouring - Hold the bottle of sterile solution with the palm over the label while pouring A nurse is caring for a client who is in labor and receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. Which of the following should the nurse expect? A. Head compression - Head compression A nurse is caring for a client who is requesting treatment for a gambling disorder. Which of the following medications should the nurse expect the provider to prescribe? C. Sertraline - Sertraline A charge nurse overhears two assistive personnel in the unit lobby discussing the HIV status of a client. Which of the following response is the priority for the nurse to make? C. Please stop this discussion - Please stop this discussion A nurse is planning care for a client who is prescribed a cane for ambulation. Which of the following actions should the nurse include in the plan of care? A. Remind the client to place the cane on the unaffected side - Remind the client to place the cane on the unaffected side A nurse is planning care for a client who has a sealed radiation implant and is to remain in the hospital for 1 week. Which of the following should the nurse include in the plan of care? C. Wear a dosimeter film badge while in the client's room - Wear a dosimeter film badge while in the client's room A nurse is assessing a client who was brought to the emergency department by his adult child. The client has visible contusions on all four extremities. Which of the following actions should the nurse take? A. Report the incident to Adult Protective Services - Report the incident to Adult Protective Services A home health nurse is assessing a client who reports a headache and appears confused and drowsy. The client has a kerosene space heater in use. Which of the following actions should the nurse take first? A. Take the client outdoors - Take the client outdoors A nurse is assessing a client who is postoperative following abdominal surgery. The client states, "I feel like my incision ripped open." The nurse notes dehiscence of the incision. Which of the following actions should the nurse take? B. Place the client in a low-Fowler's position - Place the client in a low-Fowler's position A nurse is caring for a client who reports the use of chondroitin and glucosamine. The health benefit of this supplement combination is to do which of the following? D. Improve joint functioning - Improve joint functioning A nurse is caring for a client who has a hearing impairment. When speaking to the client, the nurse should incorporate which of the following communication methods? B. Rephrase sentences the client does not understand - Rephrase sentences the client does not understand During the immediate postoperative period following thoracic surgery, a nurse medicates a client for pain on a schedule. The rationale for this nursing action is which of the following? D. Facilitates deep breathing - Facilitates deep breathing A nurse is providing teaching to the parent of a 6-month-old infant who is teething and having difficulty sleeping. Which of the following instructions should the nurse include? C. Administer acetaminophen drops to your child before bedtime - Administer acetaminophen drops to your child before bedtime A nurse is providing dietary teaching to a client who has an increased cholesterol level. Which of the following foods should the nurse recommend? B. Egg whites - Egg whites A nurse is following protocol for preventing puncture injuries. Which of the following actions should the nurse take? D. Place lancets in a puncture-proof container - Place lancets in a puncture-proof container A home health nurse is teaching a guardian about administering tube feedings to their 3-month- old infant. Which of the following information should the nurse include in the teaching? A. Allow the infant to suck on a pacifier during feedings - Allow the infant to suck on a pacifier during feedings A nurse in the recovery room is assessing a client who has a new chest tube. The nurse finds that the water seal is no longer tidaling. The nurse should identify the finding as resulting from which of the following? B. The tubing may be kinked - The tubing may be kinked A nurse is assessing a client who has pericarditis. Which of the following findings is the priority? C. Paradoxical pulse - Paradoxical pulse A nurse is assessing a client 1 week after a successful bone marrow transplant. The client reports peeling of skin on her hands and feet. The nurse should recognize this desquamation as an indication of which of the following complications? C. Graft-versus-host disease - Graft-versus-host disease A client has just returned to the nursing unit following cardiac catheterization. In the immediate postprocedure period, which of the following is the priority nursing action? D. Immobilizing the affect extremity - Immobilizing the affect extremity A nurse is providing dietary teaching for a client who has a history of nephrolithiasis. Which of the following is appropriate to include in the teaching? D. Avoid foods that have high levels of oxalates - Avoid foods that have high levels of oxalates A charge nurse is creating assignments for the next shift for several nurses and one of the nurses is pregnant. Which of the following clients should the charge nurse assign to a nurse who is not pregnant? A. A 60 year old client who is recovering from shingles - A 60 year old client who is recovering from shingles A nurse is teaching a newly licensed nurse about informed consent. Which of the following statements should the nurse include in the teaching? (Select all that apply) A. By witnessing the signing of the informed consent form, the nurse is indicating that the client voluntarily gave consent B. A client who signs an informed consent form should understand the treatment plan C. A client who signs an informed consent form should be competent D. The nurse should disclose the purpose of the treatment before the client signs the consent form - - By witnessing the signing of the informed consent form, the nurse is indicating that the client voluntarily gave consent - A client who signs an informed consent form should understand the treatment plan - A client who signs an informed consent form should be competent A nurse is preparing to insert an indwelling catheter for a female client. Identify the sequence of actions the nurse should take - 1. Apply sterile gloves and place cleansing balls in antiseptic solution 2. Attach prefilled syringe to indwelling catheter inflation hub 3. Lubricate the catheter and place fenestrated drape over perineum 4. Cleanse the meatus with the dominant hand in a downward motion 5. Insert the catheter until a flow of urine begins (aalci) A nurse in a substance use unit spends an equal amount of time with each of his assigned clients, even though some of the clients have committed serious crimes. Which of the following ethical principles is the nurse demonstrating? A. Justice - Justice A nurse is assessing a client who has a magnesium level of 4.4 mEq/L. Which of the following findings should the nurse expect? A. Hypotension - Hypotension A nurse is reviewing the medical record of a client who has a new prescription for gentamicin. The nurse should identify that concurrent use with which of the following current medications can increase the client's risk for ototoxicity? C. Furosemide - Furosemide A nurse is preparing to administer 2.5mL of medication intramuscularly to an adult client. Which of the following is the safest site for the nurse to use? A. Ventrogluteal - Ventrogluteal A nurse is performing triage following a natural disaster. Which of the following clients should the nurse identify as the highest priority to receive care? C. A client who has a traumatic arm amputation - A client who has a traumatic arm amputation A nurse is caring for a group of clients. Which of the following clients should the nurse assess first? B. A client who has abdominal pain and is vomiting coffee-ground emesis - A client who has abdominal pain and is vomiting coffee-ground emesis A charge nurse is providing teaching to a newly licensed nurse on how to clean surfaces contaminated with blood. Which of the following agents should the nurse include in the teaching? Chlorine bleach - Chlorine bleach A nurse is planning care for a client who is experiencing acute mania. Which of the following actions should the nurse include in the plan of care? B. Provide high-calorie nutritional supplements - Provide high-calorie nutritional supplements A nurse is reviewing the medical records of four clients. Which of the following prescriptions correct documentation? C. Sucralfate 1 g PO hr ac - Sucralfate 1 g PO hr ac A nurse is performing a dressing change for a client who has a sacral wound using negative pressure wound therapy. Which of the following actions should the nurse take first? A. Determine the client's pain level - Determine the client's pain level A nurse is assessing a client who is gravida 2, para 1. The client is at 41 weeks of gestation and is receiving oxytocin for the augmentation of labor. The nurse should decrease the infusion rate for which of the following findings? D. Contractions occur every 90 seconds - Contractions occur every 90 seconds A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood pressure. The nurse should identify that these findings are potential manifestations of which of the following? B. Opioid intoxication - Opioid intoxication A nurse in a postpartum unit is caring for several clients. After receiving a change of shift report, which of the following clients should the nurse assess first? C. A client who is 3 days postpartum and has not had a bowel movement since prior to admission - A client who is 3 days postpartum and has not had a bowel movement since prior to admission A nurse is precepting a nursing student who brings the following client observations to the nurse's attention. Which of the following clients should the nurse assess first? D. A client who is coughing up pink-tinged sputum following a bronchoscopy and lung biopsy 1 hr ago - A client who is coughing up pink-tinged sputum following a bronchoscopy and lung biopsy 1 hr ago