Answers | Latest Version | 2025/2026 |
Correct & Verified
What is the priority action when a client with a chest tube complains of sudden chest pain and
dyspnea?
✔✔Assess for tracheal deviation and notify the provider immediately.
What electrolyte imbalance is most likely in a client with frequent vomiting?
✔✔Hypokalemia.
Which assessment finding indicates early signs of increased intracranial pressure?
✔✔Restlessness and irritability.
What should the nurse do if a postoperative client has a wound dehiscence with visible bowel?
✔✔Cover the wound with sterile saline-soaked gauze and call the provider.
What lab value should be monitored closely in a client taking warfarin?
✔✔INR.
1
,What is the most accurate way to assess fluid volume status in a client with heart failure?
✔✔Daily weight.
What finding indicates the effectiveness of lactulose in a client with hepatic encephalopathy?
✔✔Improved level of consciousness.
What nursing action should be taken for a client with suspected stroke who arrives within 1 hour
of symptom onset?
✔✔Prepare for immediate CT scan of the head.
What intervention helps prevent pressure injuries in an immobile client?
✔✔Reposition the client at least every 2 hours.
What should the nurse do first when a client with a feeding tube begins coughing during feeding?
✔✔Stop the feeding and assess tube placement.
What lab value is expected in a client with chronic kidney disease?
2
, ✔✔Elevated serum creatinine.
What should a nurse monitor in a client receiving TPN?
✔✔Blood glucose levels.
What is the appropriate nursing action when a client with DKA has serum potassium of 2.8
mEq/L?
✔✔Hold insulin and notify the provider.
What is a priority intervention for a client with epistaxis who is receiving anticoagulant therapy?
✔✔Apply direct pressure and notify the provider.
What nursing instruction is important for a client post-cataract surgery?
✔✔Avoid bending or lifting heavy objects.
What is a sign of digoxin toxicity in an older adult?
✔✔Visual disturbances such as yellow halos.
3