A nurse is assisting with the care of four clients. Which of the following clients is the priority for
the nurse to see
A client who has chest tubes and an oxygen Sat of 90%
Using the airway, breathing, and circulation approach to client care, the nurse should determine
that the priority finding is the client's oxygen saturation level, which is below the expected
reference range of 95% to 100%. Therefore, the nurse should attend to this client first.
3 multiple choice options
A nurse is collecting data from a client who was admitted with a Glasgow Coma Scale of 3.
Which
of the following findings should the nurse expect?
Nonresponsive Commands
A client who has a GCS of less than 8 has evidence of severe head injury and is in a comatose
state. The GCS is a standardized tool that allows for the evaluation of a client's level of
consciousness. The test is divided into three sections that evaluate eye opening, motor
response, and verbal response. The GCS ranges from a high score of 15 (fully alert) to a low
score of 3 (fully comatose).
3 multiple choice options
A nurse is monitoring a client who has a pneumothorax and a chest tube in place with a closed
chest drainage system connected to low suction. For which of the following findings should the
nurse notify the charge nurse
Persistent bubbling in the water seal chamber
Excessive and persistent bubbling in the water-seal chamber indicates an air leak in the
drainage system. The nurse should notify the charge nurse of this finding.
3 multiple choice options
A nurse is collecting data from a client and auscultates intermittent high-pitched sounds during
inspiration over the lower base of the lungs. The nurse should identify this finding as which of
the following lungs sounds
- Fine crackles
Fine crackles are auscultated in the base of the lungs as air moves through airway secretions.
Fine crackles are intermittent, high-pitched sounds heard more often during inspiration.
3 multiple choice options
,A nurse is collecting data from a client who has coronary artery disease. Which of the following
manifestations should the nurse identify as an indication that the client has angina ( SATA)
- Chest Discomfort Radiated
- Pain lasting less that 15mins
- Pain that is relieved with res
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients
should the nurse plan to see first?
A client who has diabetes mellitus with diaphoretic
When using the urgent vs. nonurgent approach to client care, the nurse should determine that
the priority action is to attend to a client who has diabetes mellitus and is diaphoretic.
Diaphoresis is a manifestation of hypoglycemia and can lead to decreased cerebral function.
The nurse should check the client's blood glucose and administer a fast-acting glucose as
prescribed.
We have an expert-written solution to this problem!
A nurse is collecting data from a client who has tuberculosis and started combination therapy
2months ago. Which of the following diagnostic results indicates that the client is adhering to the
medication regimen.
A negative sputum culture
Tuberculosis is an infectious disease spread through airborne droplets. Sputum cultures are
obtained to both diagnose tuberculosis and to determine whether the medication treatment has
been effective. After the client begins antibiotic treatment for tuberculosis, a sputum culture is
obtained monthly. A negative culture is an indication that the client is no longer infectious and
the medication therapy has been effective.
3 multiple choice options
A nurse is collecting data from a client who has bacterial meningitis. Which of the following
findings should the nurse expect?
- Severe Headache
The nurse should expect a client who has meningitis to have severe and persistent headaches
that worsen with movement of the head.
A nurse is reinforcing with a client who has pernicious anemia. Which of the following
statements by the client indicated an understanding of the teaching
, I will be able to switch to a nasal form of cyanocobalamin when my levels stabilize
A nurse is reinforcing discharge teaching with a client who has COPD and reports episodes of
dyspnea. Which of the following instructions should the nurse include?
Used the pursed lip breathing technique
A client who has COPD should use the pursed-lip breathing technique to prolong exhalation,
which increases positive pressure in the lungs, decreases dyspnea, and promotes air exchange.
A nurse is reinforcing teaching with a client who has varicose veins of the right lower extremity.
Which of the following instructions should the nurse include in the teaching
- Apply elastic support hoes before getting out of bed in the morning
The nurse should instruct the client to apply elastic support hose before placing legs in a
dependent position because blood vessels contain less congested blood after sleeping during
the night. Varicose veins are the result of increased pressure within the vessel wall and valve,
which are incompetent at promoting venous return. It manifests as aching pain and fatigue to
the extremity, and it can cause visible dilation of the veins.
A nurse is preparing to transfer a client from a bed to chair following a total knee arthroplasty.
The client has a prescription for partial weight bearing. Which of the following actions should the
nurse
take?
- Flex at the hip and knees before transferring the client
A nurse is reinforcing teaching with a client who is scheduled for a thoracentesis to remove
pleural fluid. Which of the following information should the nurse include in the teaching?
- You will lean forward on the over bed table for this procedure
A thoracentesis is a therapeutic or diagnostic procedure that involves insertion of a needle into
the pleural space. It can be performed at the client's bedside with the client leaning forward on
pillows and across an overbed table. This position widens the intercostal spaces and makes it
easier to insert the needle into the posterior chest and remove the pleural fluid.
A nurse is reinforcing teaching with a client who is in early stage stages of COPD and wants to
use nicotine chewing gum to help him stop smoking. Which of the following recommendations
should the nurse make?
- Do not eat or drink anything 15min before or after chewing the gum
the nurse to see
A client who has chest tubes and an oxygen Sat of 90%
Using the airway, breathing, and circulation approach to client care, the nurse should determine
that the priority finding is the client's oxygen saturation level, which is below the expected
reference range of 95% to 100%. Therefore, the nurse should attend to this client first.
3 multiple choice options
A nurse is collecting data from a client who was admitted with a Glasgow Coma Scale of 3.
Which
of the following findings should the nurse expect?
Nonresponsive Commands
A client who has a GCS of less than 8 has evidence of severe head injury and is in a comatose
state. The GCS is a standardized tool that allows for the evaluation of a client's level of
consciousness. The test is divided into three sections that evaluate eye opening, motor
response, and verbal response. The GCS ranges from a high score of 15 (fully alert) to a low
score of 3 (fully comatose).
3 multiple choice options
A nurse is monitoring a client who has a pneumothorax and a chest tube in place with a closed
chest drainage system connected to low suction. For which of the following findings should the
nurse notify the charge nurse
Persistent bubbling in the water seal chamber
Excessive and persistent bubbling in the water-seal chamber indicates an air leak in the
drainage system. The nurse should notify the charge nurse of this finding.
3 multiple choice options
A nurse is collecting data from a client and auscultates intermittent high-pitched sounds during
inspiration over the lower base of the lungs. The nurse should identify this finding as which of
the following lungs sounds
- Fine crackles
Fine crackles are auscultated in the base of the lungs as air moves through airway secretions.
Fine crackles are intermittent, high-pitched sounds heard more often during inspiration.
3 multiple choice options
,A nurse is collecting data from a client who has coronary artery disease. Which of the following
manifestations should the nurse identify as an indication that the client has angina ( SATA)
- Chest Discomfort Radiated
- Pain lasting less that 15mins
- Pain that is relieved with res
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients
should the nurse plan to see first?
A client who has diabetes mellitus with diaphoretic
When using the urgent vs. nonurgent approach to client care, the nurse should determine that
the priority action is to attend to a client who has diabetes mellitus and is diaphoretic.
Diaphoresis is a manifestation of hypoglycemia and can lead to decreased cerebral function.
The nurse should check the client's blood glucose and administer a fast-acting glucose as
prescribed.
We have an expert-written solution to this problem!
A nurse is collecting data from a client who has tuberculosis and started combination therapy
2months ago. Which of the following diagnostic results indicates that the client is adhering to the
medication regimen.
A negative sputum culture
Tuberculosis is an infectious disease spread through airborne droplets. Sputum cultures are
obtained to both diagnose tuberculosis and to determine whether the medication treatment has
been effective. After the client begins antibiotic treatment for tuberculosis, a sputum culture is
obtained monthly. A negative culture is an indication that the client is no longer infectious and
the medication therapy has been effective.
3 multiple choice options
A nurse is collecting data from a client who has bacterial meningitis. Which of the following
findings should the nurse expect?
- Severe Headache
The nurse should expect a client who has meningitis to have severe and persistent headaches
that worsen with movement of the head.
A nurse is reinforcing with a client who has pernicious anemia. Which of the following
statements by the client indicated an understanding of the teaching
, I will be able to switch to a nasal form of cyanocobalamin when my levels stabilize
A nurse is reinforcing discharge teaching with a client who has COPD and reports episodes of
dyspnea. Which of the following instructions should the nurse include?
Used the pursed lip breathing technique
A client who has COPD should use the pursed-lip breathing technique to prolong exhalation,
which increases positive pressure in the lungs, decreases dyspnea, and promotes air exchange.
A nurse is reinforcing teaching with a client who has varicose veins of the right lower extremity.
Which of the following instructions should the nurse include in the teaching
- Apply elastic support hoes before getting out of bed in the morning
The nurse should instruct the client to apply elastic support hose before placing legs in a
dependent position because blood vessels contain less congested blood after sleeping during
the night. Varicose veins are the result of increased pressure within the vessel wall and valve,
which are incompetent at promoting venous return. It manifests as aching pain and fatigue to
the extremity, and it can cause visible dilation of the veins.
A nurse is preparing to transfer a client from a bed to chair following a total knee arthroplasty.
The client has a prescription for partial weight bearing. Which of the following actions should the
nurse
take?
- Flex at the hip and knees before transferring the client
A nurse is reinforcing teaching with a client who is scheduled for a thoracentesis to remove
pleural fluid. Which of the following information should the nurse include in the teaching?
- You will lean forward on the over bed table for this procedure
A thoracentesis is a therapeutic or diagnostic procedure that involves insertion of a needle into
the pleural space. It can be performed at the client's bedside with the client leaning forward on
pillows and across an overbed table. This position widens the intercostal spaces and makes it
easier to insert the needle into the posterior chest and remove the pleural fluid.
A nurse is reinforcing teaching with a client who is in early stage stages of COPD and wants to
use nicotine chewing gum to help him stop smoking. Which of the following recommendations
should the nurse make?
- Do not eat or drink anything 15min before or after chewing the gum
