RN Concept-Based Assessment Level 2 Online Practice B

A nurse is caring for a client who has pneumonia. Which of the following actions is the priority for the nurse to take? -Monitor intake and output -Provide teaching about antibiotic therapy -Administer the influenza vaccine -Observe the client perform incentive spirometry - Answer- Observe the client perform incentive spirometry When using the airway, breathing, and circulation framework, the priority action the nurse should take is to observe the client perform incentive spirometry. Incentive spirometry improves gas exchange and oxygenation and stimulates coughing, which assists in clearing secretions. A nurse is assessing a client who has hyperthyroidism and has been taking methimazole for 6 months. Which of the following findings indicates a therapeutic response to the medication -The client's skin is warm and moist -The client reports sleeping longer during the night -The client is experiencing increased bowel movements -The client's weight is 1.4 kg (3.1 lb) less than baseline - Answer- The client reports sleeping longer during the night The nurse should recognize that insomnia is a manifestation of hyperthyroidism. The client's ability to sleep longer during the night indicates a therapeutic response to the medication. A nurse is planning discharge teaching for the guardian of a child who had a cardiac catheterization. Which of the following instructions should the nurse include? -Monitor the site daily for drainage -Leave the pressure dressing on the 48 hr -Administer aspirin if the child reports pain -Resume tub baths in 24hr - Answer- Monitor the site daily for drainage