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AAnurseAinAaAmedical-surgicalAunitAisAcaringAforAsixAclients.
CompleteAtheAfollowingAsentenceAbyAusingAtheAlistAofAoptions.
TheAfirstAclientAtheAnurseAshouldAassessAisA_____AfollowedAbyA_____.
ClientA1:AClientAisAadmittedAwithAaAnewAdiagnosisAofArheumatoidAarthritis.ClientA2:AClientAh
asAaAhistoryAofAhyperlipidemia.AAtorvastatinA20AmgAPOAadministeredAasAprescribed.ClientA
3:AClientAisA1AdayApostoperative.AReportsApainAasA8AonAaAscaleAofA0AtoA10.AMorphineA5AmgA
subcutaneousAadministeredAasAprescribed.ClientA4:AClientAisAadmittedAwithAaAnewAdiagno
sisAofAheartAfailure.ClientA5:AClientAhasAaAstageA2ApressureAinjuryAonAtheAleftAheel.ClientA6:A
ClientAisAadmittedAwithAaAnewAdiagnosisAofAdiabetesAmellitus.A-
ACORRECTAANSWERSAAACorrectAAnswerA(1):
ClientA3
WhenAusingAtheAairway,Abreathing,AcirculationAapproachAtoAclientAcare,AtheAnurseAshouldA
determineAthatAthisAclientAisAtheApriorityAclientAtoAassess.ATheAclientAhasAanAoxygenAsaturat
ionAthatAisAlessAthanAtheAexpectedAreferenceArange,AwhichAisAanAindicationAofAhypoxia.
CorrectAAnswerA(2):
ClientA4
WhenAusingAtheAairway,Abreathing,AcirculationAapproachAtoAclientAcare,AtheAnurseAshouldA
determineAthatAthisAclientAisAtheAnextApriorityAclientAtoAassess.ATheAclientAhasAaApotassiumA
levelAthatAisAlessAthanAtheAexpectedAreferenceArange,AwhichAplacesAtheAclientAatAriskAforAdy
srhythmias.
InCORRECTAANSWERSA(1):
ClientA1AisAincorrect.ATheAnurseAshouldAassessAthisAclientAbecauseAtheAclient'sAC-
reactiveAproteinAisAgreaterAthanAtheAexpectedAreferenceArange,AwhichAisAanAindicationAofAi
nflammation.AHowever,AthereAisAanotherAclientAtheAnurseAshouldAassessAfirst.
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ClientA2AisAincorrect.ATheAnurseAshouldAassessAthisAclientAbecauseAtheAclient'sAcholesterol
AlevelAisAgreaterAthanAtheAexpectedAreferenceArange,AwhichAplacesAthemAatAriskAforAcorona
ryAheartAdisease.AHowever,AthereAisAanotherAclientAtheAnurseAshouldAassessAfirst.
InCORRECTAANSWERSA(2):
ClientA5AisAincorrect.ATheAnurseAshouldAassessAthisAclientAbecauseAtheirAprealbuminAlevelAi
sAlessAthanAtheAexpectedAreferenceArange,AwhichAplacesAthemAatAriskAforAdelayedAwoundA
healing.AHowever,AthisAclientAisAnotAtheAnextApriorityAclientAtoAassess.
ClientA6AisAincorrect.ATheAnurseAshouldAassessAthisAclientAbecauseAtheirAglycosylatedAhem
oglobinAlevelAisAgreaterAthanAtheAexpectedAreferenceArange,AwhichAindicatesApoorAdiabetic
Acontrol.AHowever,AthisAclientAisAnotAtheAnextApriorityAclientAtoAassess.
AAnurseAisAcaringAforAaAclientAwhoAhasACOPD.
SelectAtheA3AfindingsAthatArequireAfollow-up.
BreathAsounds
BloodApressure
OxygenAsaturation
Temperature
HeartArateA-ACORRECTAANSWERSAAACorrectAAnswer:
BreathASounds
CracklesAareAcausedAbyAmucousAinAtheAairwaysAandAareAaAmanifestationAofApneumonia.AD
ecreasedAbreathAsoundsAindicateAdecreasedAventilationAandArequireAfollow-
upAbyAtheAnurse.
OxygenASaturation
TheAclient'sAoxygenAsaturationAisAbelowAtheAexpectedAreferenceArangeAofA95%AtoA100%,Ai
ndicatingAhypoxia,AandArequiresAfollow-upAbyAtheAnurse.
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Temperature
TheAclient'sAtemperatureAisAgreaterAthanAtheAexpectedAreferenceArange,AindicatingAanAinfe
ction,AandArequiresAfollow-upAbyAtheAnurse.
IncorrectAAnswer:
BloodApressureAisAincorrect.ATheAclient'sAbloodApressureAisAwithinAtheAexpectedAreferenceA
rangeAandAdoesAnotArequireAfollow-upAbyAtheAnurse.
HeartArateAisAincorrect.ATheAclient'sAheartArateAisAwithinAtheAexpectedAreferenceArangeAofA6
0AtoA100/minAandAdoesAnotArequireAfollow-upAbyAtheAnurse.
AAnurseAinAtheAemergencyAdepartmentA(ED)AisAcaringAforAaAclientAwhoAreportsAabdominalA
pain.A
BasedAonAtheAclient'sAclinicalAfindings,AwhichAofAtheAfollowingAactionsAshouldAtheAnurseAtak
e?ASelectAallAthatAapply.
AssistAtheAclientAtoAaAleftAside-lyingApositionAwithAtheArightAkneeAflexed.
PrepareAtheAclientAforAaAchestAx-ray.
AdministerAaAcleansingAenema.
AuscultateAtheAclient'sAbowelAsounds.
PerformAaAmanualAdigitalAexaminationAofAtheAclient'sArectum.
AdministerAoxycodoneAextended-releaseAtablets.
PrepareAtheAclientAforANGAtubeAplacement.A-ACORRECTAANSWERSAAACorrectAAnswer:
AssistAtheAclientAtoAaAleftAside-lyingApositionAwithAtheArightAkneeAflexedA
TheAnurseAshouldAplaceAtheAclientAinAaAleftAside-
lyingApositionAwithAtheArightAkneeAflexedApriorAtoAadministeringAanAenema.ABecauseAtheApr
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oviderAprescribedAaAcleansingAenemaAforAtheAclient,AtheAnurseAshouldAprepareAtheAclientAf
orAtheAprocedure.
AdministerAaAcleansingAenemaA
TheAnurseAshouldAadministerAaAcleansingAenemaAforAtheAclientAasAaAresultAofAtheAprovider'
sAprescription.AAAcleansingAenemaAisAintendedAtoAassistAwithAbowelAeliminationAandAremo
veAanyAimpactedAfecalAmatterAindicatedAbyAtheAabdominalAx-ray.
AuscultateAtheAclient'sAbowelAsoundsA
TheAnurseAshouldAauscultateAtheAclient'sAbowelAsoundsAtoAdetermineAtheAstatusAofAtheAclie
nt'sAperistalsis.AThisAisAaAnecessaryApartAofAdeterminingAtheApresenceAofAbowelAsounds,Aw
hichAareAanAindicationAofAtheAstatusAofAtheAclient'sAgastrointestinalAtract.
PerformAaAmanualAdigitalAexaminationAofAtheAclient'sArectum
TheAnurseAshouldAperformAaAmanualAdigitalAexaminationAofAtheAclient'sArectumAtoAdetermi
neAifAimpactedAstoolAisApresent.AThisAisAaApartAofAtheAnecessaryAevaluationAofAtheAstatusAof
AtheAclient'sAgastrointestinalAtract.
IncorrectAAnswer:
PrepareAtheAclientAforAaAchestAx-rayAisAincorrect.AAAchestAx-
rayAisAtypicallyAperformedAforAaAclientAwhoAhasAanAimpairmentAofAtheAupperAthoraxAorAlung
s,AnotAtheAabdomen.ATheAclientAhasAalreadyAreceivedAanAabdominalAx-
ray;Atherefore,AaAchestAx-rayAisAnotAnecessary.
PrepareAtheAclientAforANGAtubeAplacementAisAincorrect.ATheAnurseAshouldAnotAprepareAtheA
clientAforAplacementAofAanANGAtubeAbecauseAthereAisAnoAindicationAorAprescriptionAtoAdoAs
o.APlacementAofAanANGAtubeAisArequiredAwhenAthereAisAanAobstructionAofAtheAgastrointesti
nalAtractAandAperistalsisAisAabsent.
AAnurseAisAcaringAforAaAclientAwhoAasksAaboutAtheApurposeAofAadvanceAdirectives.AWhichAo
fAtheAfollowingAstatementsAshouldAtheAnurseAmake?