Verified Answers//Fully Detailed
A nurse is caring for a client in the emergency department who complains of
epigastric pain and feeling lightheaded. The client has a blood pressure of 140/80
mmHg with a heart rate of 75/min while supine and 110/65 mmHg sitting with a
heart rate of 100/min. Which of the following tasks should the nurse perform
next? - CORRECT ANSWER- Anticipate administration of intravenous crystalloid
solution.
A nurse is caring for a 62-year-old client who has been diagnosed with
emphysema. The nurse understands that the client is at high-risk for pulmonary
infection. Which of the following conditions predisposes the client to infection? -
CORRECT ANSWER- Pooling of respiratory secretions.
Which of the following methods of oxygen delivery should a nurse use to
administer oxygen for a client with a drop in oxygen saturation from 96% to 88%
on room air after receiving morphine to relieve pain after colon resection? (The
client is resting but remains oriented and can be easily aroused by verbal stimuli.)
- CORRECT ANSWER- Nasal cannula
A nurse is caring for a woman who has undergone a radical mastectomy for
breast cancer. She tells the nurse, "I'm worried because my spouse won't touch
me since my breast was removed." Which of the following is the most appropriate
response by the nurse? - CORRECT ANSWER- "How do you feel about your
mastectomy?"
, A nurse is caring for a client who took an overdose of antidepressants and was
discovered by his spouse. What is the best response by the nurse when the
spouse states, "If I hadn't come home early from my business trip, my spouse
might have died. I'm in a state of shock."? - CORRECT ANSWER- "This is a very
overwhelming situation for you. Can you tell me what you are feeling now?"
Which of the following pediatric clients would require prompt reporting to the
authorities by the nurse? - CORRECT ANSWER- A 4-year-old who fell from a swing
set with 1 fracture of the ulna and 2 healed fractures of the humerus on X-ray
A nurse is caring for a client who has a chest tube connected to a closed drainage
system and needs to be transported to the x-ray department. Which of the
following actions should the nurse take? - CORRECT ANSWER- Keep the drainage
system below the level of the client's chest at all times.
Which of the following risk factors are part of the Braden Scale for Predicting
Pressure Sore Risk? (Select all that apply.) - CORRECT ANSWER- Friction and shear
Nutrition
The risk factors associated with the Braden Scale include sensory perception,
moisture, activity, mobility, nutrition, and friction and shear.
A nurse is planning care for a client who has acute respiratory distress syndrome.
Which of the following interventions should the nurse include in the plan? -
CORRECT ANSWER- Place in prone position
Respiratory cards following - CORRECT ANSWER-