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Complete A+ Guide - Nightingale d d d d d
1. An older adult client with a long history of chronic obstructive
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d pulmonary dis- ease (COPD) is admitted with progressive shortness of
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d breath and a persistent cough. She is anxious and is complaining of a
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d dry mouth. Which intervention should the nurse implement?
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A. Administer a prescribed sedative d d d
B. Assist client to an upright position
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C. Encourage client to drink water d d d d
D. Apply a high flow venturi mask: B. Assist client to an upright position
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2. A client with multiple sclerosis (MS) is admitted to the medical unit,
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The client reports fatigue, muscle weakness, and diplopia. Which action
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should the nurse implement to reduce the clients risk for falls? SATA
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A. Provide assistance to bedside commode d d d d
B. Provide frequent rest periods. d d d
C. Offer to assist with warm baths in the morning
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D. Monitor pulse ox during activities d d d d
E. Teach to patch one eye while walking: A. Provide assistance to bedside commode\
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,C. Schedule frequent rest periods.
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E. Teach to patch one eye while walking
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3. A client arrives to the ED following a motor vehicle collision, The
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d nurse observes the client experiencing increasing dyspnea and notes
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d absent breath sounds on the left side, which procedure should the
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d nurse prepare for the client?
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A. Bronchoscopy
B. Chest tube insertion d d
C. Endotracheal intubation d
D. Pulmonary function test: B. Chest tube insertion
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4. Following a transurethral resection of the prostate (TURP) a client
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d is dis- charged from the hospital with an indwelling urinary
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d catheter, Which instruc- tion is most important for the nurse to
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d include in the discharge teaching plan?
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A. Eliminate all spicy foods from your diet d d d d d d
B. Drink 3 liters of water each day
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,C. Clamp the catheter when taking a shower
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D. Avoid driving a car for 2 weeks: B. Drink 3 liters of water each day
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5. An adult woman with Graves disease is admitted with severe
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dehydration and malnutrition, She is currently restless and refusing to
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eat. Which action is most important for the nurse to implement?
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A. Teach client relaxation techniques
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B. Determine the clients food preferences d d d d
C. Maintain a patent Intravenous site d d d d
D. Keep room temperature cool: C. Maintain a paten intravenous site
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6. A client tells the clinic nurse about experiencing burning on
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d urination, and assessment reveals that the client had sexual
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d intercourse four days ago with a person who was a casual
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d acquaintance, Which action should the nurse imple- ment? d d d d d d d
A. Obtain a specimen of urethral drainage for culture
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B. Observe the perineal area for a chancre like lesion
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C. Identify all sexual partners in the last four days.
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D. Assess for perineal itching erythema and excoriation: A. Obtain a specimen
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, d of urethral drainage for culture
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7. The nurse is caring for a client admitted to the hospital with a
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d tentative diagnosis of bacterial meningitis, which diagnostic
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d procedure should the nurse prepare the client for? d d d d d d d
A. Lumbar puncture d
B. Skull radiography d
C. MRI
D. CT: A Lumbar puncture
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8. An older adult client with long term type 2 DM is seen in the clinic for
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d a routine health assessment, which assessment would the nurse
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d complete to determine if a patient with type 2 DM is experiencing long
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d term complications? SATA
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A. Sensation in feet and legs d d d d
B. Skin condition of lower extremities
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C. Visual acuity d
D Serum creatinine and blood urea nitrogen (BUN)
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