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A nurse is collecting data from a client who began taking catopril 2 days ago. Which of the
following findings should the nurse report to the provider immediately?
a.) Dizziness.
b.) Joint aches.
c.) Metallic taste.
d.) Lip swelling.
Answer: d. lip
swelling.
A nurse is caring for an older adult client who has heart failure. Which of the following findings
should the nurse report to the provider?
a.) Chest X-ray showing cardiomegaly.
b.) Potassium level 4.5 mEq/L.
c.) Urinary output of 1,000 mL in 12 hr.
d.) PaCO2 55 mmHg.
Answer: d. PaCo2 55
mmHg.
An assistive personnel checks the blood glucose level of a client who has diabetes mellitus &
reports a blood glucose level of 42 mm/dL to a nurse. Which of the following actions should the
nurse take first?
a.) Validate when the client received the last dose a hypoglycemic medication.
b.) Check the client's blood pressure.
c.) Review the client's previous meal intake.
d.) Determine if the client is able to swallow.
Answer: d. Determine if the client is able to
swallow.
A nurse is caring for a client who is at risk for anaphylaxis due to bee stings. When reinforcing
,teaching about the use of automatic epinephrine injection, Which of the following actions is the
priority.
a.) Have a client perform the return demonstration of the equipment.
b.) Instruct the client to store the injector at room temperature.
c.) Inform the client to seek medical attention following administration of the injection.
d.) Review the signs of anaphylaxis with the client.
,Answer: a. Have the client perform the return demonstration of the equipment.
A nurse is reinforcing discharge teaching with a client who has a new permanent pacemaker.
Which of the following statements by the client indicates an understanding of the teaching?
"I should check my heart rate everyday".
A nurse in a long-term care facility is assigning tasks to assistive personnel. Which of the
following tasks should the nurse delegate to the AP?
a.) Taking a phone prescription rom a provider.
b.) Providing postmortem care.
c.) Determining a client's need for PRN pain medication.
d.) Instructing a client about the use of incentive spirometry.
Answer: b. Providing postmortem care.
A nurse is collecting data from an older adult client who has cystitis. Which of the following
findings should the nurse anticipate?
a.) Orange-colored urine.
b.) Referred pain in the right shoulder.
c.) Confusion.
d.) Hypothermia.
Answer: c.
Confusion.
A nurse is performing tracheostomy's care for a client who has a chronic tracheostomy. Which of
the following actions should the nurse take?
a.) Suction the client for 20 seconds with each pass.
b.) Allow space for one finger to be placed under the tube ties.
c.) Apply suction pressure while inserting the catheter into the trachea.
d.) Sanitize around the stoma with povidone iodine.
Answer: b. allow space for one finger to be placed under the tube ties.
A nurse is reinforcing teaching with a client who is scheduled for cardiac cauterization. Which of
the following should the nurse tell the client?
, a.) Numbness in the fingertips.
b.) Feeling of heat.
c.) Urge to urinate.
d.) Pain in the jawline.
Answer: b. Feeling of
heat.