268. A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at bedtime. What action should
is nurse take?
Administer is medication as prescribed of a glass of water
269. Which client should is nurse assess frequently because of is risk for overflow incontinence? A client
To is confused and frequently forgets to go to is bathroom
270. While monitoring a client during a seizure, which interventions should is nurse implement? (Select all
that apply)
a) Move obstacle away from client
b) Monitor physical movements
c) Observe for a patent airway
d) Record is duration of is seizure
271. A male client of a long history of alcoholism is admitted because of mild confusion and fine motor
tremors. He reports that he quit drinking alcohol and stopped smoking cigarettes one month ago after his bro
isr died of lung cancer. Which intervention is most important for is nurses to include in is client’s plan ofcare?
a) Determine client’s level current blood alcohol level.
b) Observe for changes in level of consciousness.
c) Involve is client’s family in healthcare decisions.
d) Provide grief counseling for client and his family.
Rationale: Based on is client’s history of drinking, he may be exhibiting sing of hepatic involvement and
encephalopathy. Changes in is client’s level of consciousness should be monitored to determine if he able to
maintain consciousness, so neurological assessment has is highest priority.
272. An older adult female admitted to is intensive care unit (ICU) of a possible stroke is intubated of
ventilator setting of tidal volume 600, PlO2 40%, and respiratory rate of 12 breaths/minute. is arterial blood
gas (ABG) results after intubation are PH 7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To normalize is
client’s ABG finding, which action is required?
a) Report is results to is healthcare provider.
b) Increase ventilator rate.
c) Administer a dose of sodium carbonate.
d) Decrease is flow rate of oxygen.
Rationale: This client is experience respiratory acidosis. Increasing is ventilator rate depletes CO2 a, which
returns is PH toward normal. Report findings is important but only after increasing ventilator rate.
273. is mo isr of is 12- month-old of cystic fibrosis reports that her child is experiencing increasing
congestion despite is use of chest physical israpy (CPT) twice a day, and has also experiences a loss of
appetite. What instruction should is nurse provide?
a) Perform CPT after meals to increase appetite and improve food intake.
b) CPT should be performed more frequently, but at least an hour before meals.
c) Stop using CPT during is daytime until is child has regained an appetite.
is nurse take?
Administer is medication as prescribed of a glass of water
269. Which client should is nurse assess frequently because of is risk for overflow incontinence? A client
To is confused and frequently forgets to go to is bathroom
270. While monitoring a client during a seizure, which interventions should is nurse implement? (Select all
that apply)
a) Move obstacle away from client
b) Monitor physical movements
c) Observe for a patent airway
d) Record is duration of is seizure
271. A male client of a long history of alcoholism is admitted because of mild confusion and fine motor
tremors. He reports that he quit drinking alcohol and stopped smoking cigarettes one month ago after his bro
isr died of lung cancer. Which intervention is most important for is nurses to include in is client’s plan ofcare?
a) Determine client’s level current blood alcohol level.
b) Observe for changes in level of consciousness.
c) Involve is client’s family in healthcare decisions.
d) Provide grief counseling for client and his family.
Rationale: Based on is client’s history of drinking, he may be exhibiting sing of hepatic involvement and
encephalopathy. Changes in is client’s level of consciousness should be monitored to determine if he able to
maintain consciousness, so neurological assessment has is highest priority.
272. An older adult female admitted to is intensive care unit (ICU) of a possible stroke is intubated of
ventilator setting of tidal volume 600, PlO2 40%, and respiratory rate of 12 breaths/minute. is arterial blood
gas (ABG) results after intubation are PH 7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To normalize is
client’s ABG finding, which action is required?
a) Report is results to is healthcare provider.
b) Increase ventilator rate.
c) Administer a dose of sodium carbonate.
d) Decrease is flow rate of oxygen.
Rationale: This client is experience respiratory acidosis. Increasing is ventilator rate depletes CO2 a, which
returns is PH toward normal. Report findings is important but only after increasing ventilator rate.
273. is mo isr of is 12- month-old of cystic fibrosis reports that her child is experiencing increasing
congestion despite is use of chest physical israpy (CPT) twice a day, and has also experiences a loss of
appetite. What instruction should is nurse provide?
a) Perform CPT after meals to increase appetite and improve food intake.
b) CPT should be performed more frequently, but at least an hour before meals.
c) Stop using CPT during is daytime until is child has regained an appetite.
