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tion And Correct Answers Verified A+
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AAZnurseAZisAZcaringAZforAZaAZclientAZinAZtheAZemergencyAZdepartmentAZwhoAZcomplainsAZofAZepi
gastricAZpainAZandAZfeelingAZlightheaded.AZTheAZclientAZhasAZaAZbloodAZpressureAZofAZ140/80AZ
mmHgAZwithAZaAZheartAZrateAZofAZ75/minAZwhileAZsupineAZandAZ110/65AZmmHgAZsittingAZwithAZaAZ
heartAZrateAZofAZ100/min.AZWhichAZofAZtheAZfollowingAZtasksAZshouldAZtheAZnurseAZperformAZnext
?AZ-AZcorrectAZanswers-AnticipateAZadministrationAZofAZintravenousAZcrystalloidAZsolution.
AAZnurseAZisAZcaringAZforAZaAZ62-year-
oldAZclientAZwhoAZhasAZbeenAZdiagnosedAZwithAZemphysema.AZTheAZnurseAZunderstandsAZthatA
ZtheAZclientAZisAZatAZhigh-
riskAZforAZpulmonaryAZinfection.AZWhichAZofAZtheAZfollowingAZconditionsAZpredisposesAZtheAZclie
ntAZtoAZinfection?AZ-AZcorrectAZanswers-PoolingAZofAZrespiratoryAZsecretions.
WhichAZofAZtheAZfollowingAZmethodsAZofAZoxygenAZdeliveryAZshouldAZaAZnurseAZuseAZtoAZadmini
sterAZoxygenAZforAZaAZclientAZwithAZaAZdropAZinAZoxygenAZsaturationAZfromAZ96%AZtoAZ88%AZonAZr
oomAZairAZafterAZreceivingAZmorphineAZtoAZrelieveAZpainAZafterAZcolonAZresection?AZ(TheAZclientA
ZisAZrestingAZbutAZremainsAZorientedAZandAZcanAZbeAZeasilyAZarousedAZbyAZverbalAZstimuli.)AZ-
AZcorrectAZanswers-NasalAZcannula
AAZnurseAZisAZcaringAZforAZaAZwomanAZwhoAZhasAZundergoneAZaAZradicalAZmastectomyAZforAZbre
astAZcancer.AZSheAZtellsAZtheAZnurse,AZ"I'mAZworriedAZbecauseAZmyAZspouseAZwon'tAZtouchAZmeA
ZsinceAZmyAZbreastAZwasAZremoved."AZWhichAZofAZtheAZfollowingAZisAZtheAZmostAZappropriateAZr
esponseAZbyAZtheAZnurse?AZ-AZcorrectAZanswers-
"HowAZdoAZyouAZfeelAZaboutAZyourAZmastectomy?"
AAZnurseAZisAZcaringAZforAZaAZclientAZwhoAZtookAZanAZoverdoseAZofAZantidepressantsAZandAZwasAZ
discoveredAZbyAZhisAZspouse.AZWhatAZisAZtheAZbestAZresponseAZbyAZtheAZnurseAZwhenAZtheAZspo
useAZstates,AZ"IfAZIAZhadn'tAZcomeAZhomeAZearlyAZfromAZmyAZbusinessAZtrip,AZmyAZspouseAZmight
AZhaveAZdied.AZI'mAZinAZaAZstateAZofAZshock."?AZ-AZcorrectAZanswers-
"ThisAZisAZaAZveryAZoverwhelmingAZsituationAZforAZyou.AZCanAZyouAZtellAZmeAZwhatAZyouAZareAZfe
elingAZnow?"
WhichAZofAZtheAZfollowingAZpediatricAZclientsAZwouldAZrequireAZpromptAZreportingAZtoAZtheAZauth
oritiesAZbyAZtheAZnurse?AZ-AZcorrectAZanswers-AAZ4-year-
oldAZwhoAZfellAZfromAZaAZswingAZsetAZwithAZ1AZfractureAZofAZtheAZulnaAZandAZ2AZhealedAZfracturesAZ
ofAZtheAZhumerusAZonAZX-ray
AAZnurseAZisAZcaringAZforAZaAZclientAZwhoAZhasAZaAZchestAZtubeAZconnectedAZtoAZaAZclosedAZdrain
ageAZsystemAZandAZneedsAZtoAZbeAZtransportedAZtoAZtheAZx-
rayAZdepartment.AZWhichAZofAZtheAZfollowingAZactionsAZshouldAZtheAZnurseAZtake?AZ-
AZcorrectAZanswers-
KeepAZtheAZdrainageAZsystemAZbelowAZtheAZlevelAZofAZtheAZclient'sAZchestAZatAZallAZtimes.
WhichAZofAZtheAZfollowingAZriskAZfactorsAZareAZpartAZofAZtheAZBradenAZScaleAZforAZPredictingAZPr
essureAZSoreAZRisk?AZ(SelectAZallAZthatAZapply.)AZ-AZcorrectAZanswers-FrictionAZandAZshear
Nutrition
, TheAZriskAZfactorsAZassociatedAZwithAZtheAZBradenAZScaleAZincludeAZsensoryAZperception,AZmo
isture,AZactivity,AZmobility,AZnutrition,AZandAZfrictionAZandAZshear.
AAZnurseAZisAZplanningAZcareAZforAZaAZclientAZwhoAZhasAZacuteAZrespiratoryAZdistressAZsyndrom
e.AZWhichAZofAZtheAZfollowingAZinterventionsAZshouldAZtheAZnurseAZincludeAZinAZtheAZplan?AZ-
AZcorrectAZanswers-PlaceAZinAZproneAZposition
RespiratoryAZcardsAZfollowingAZ-AZcorrectAZanswers-
AAZnurseAZisAZcaringAZforAZaAZpostoperativeAZclientAZwhoAZhasAZaAZchestAZtubeAZconnectedAZtoAZs
uctionAZandAZaAZwaterAZsealAZdrainageAZsystem.AZWhichAZofAZtheAZfollowingAZindicatesAZtoAZtheA
ZnurseAZthatAZtheAZchestAZtubeAZisAZfunctioningAZproperly?AZ-AZcorrectAZanswers-
FluctuationAZofAZtheAZfluidAZlevelAZwithinAZtheAZwaterAZsealAZchamber
nurseAZisAZmonitoringAZaAZclientAZwhoAZhasAZaAZchestAZtubeAZinAZplaceAZconnectedAZtoAZwallAZsu
ctionAZdueAZtoAZrightAZsidedAZpneumothorax.AZTheAZclientAZcomplainsAZofAZchestAZburning.AZWh
ichAZofAZtheAZfollowingAZactionsAZshouldAZtheAZnurseAZtake?AZ-AZcorrectAZanswers-
repositionAZtheAZclient
AAZnurseAZisAZcaringAZforAZaAZclientAZwhoAZhasAZaAZthree-
AZchamberAZclosedAZchestAZtubeAZsystem.AZWhichAZofAZtheAZfollowingAZactionsAZshouldAZtheAZnu
rseAZtakeAZafterAZnoticingAZaAZriseAZinAZtheAZwaterAZsealAZchamberAZwithAZclientAZinspiration?AZ-
AZcorrectAZanswers-continueAZtoAZmonitorAZtheAZclient
AAZnurseAZisAZobservingAZtheAZclosedAZchestAZdrainageAZsystemAZofAZaAZclientAZwhoAZisAZ24AZhrAZ
postAZthoracotomy.AZTheAZnurseAZnotesAZslow,AZsteadyAZbubblingAZinAZtheAZsuctionAZcontrolAZc
hamber.AZWhichAZofAZtheAZfollowingAZactionsAZshouldAZtheAZnurseAZtake?AZ-AZcorrectAZanswers-
ContinueAZtoAZmonitorAZclient'sAZrespiratoryAZstatus
AAZnurseAZisAZassessingAZaAZclientAZwhoAZwillAZundergoAZabdominalAZsurgeryAZinAZ2AZhr.AZTheAZc
lientAZreportsAZbeingAZnervousAZaboutAZtheAZsurgery,AZlastAZhadAZfoodAZandAZfluidsAZatAZ2330AZth
eAZpreviousAZevening,AZandAZsignedAZtheAZsurgicalAZconsentAZ2AZdaysAZago.AZWhichAZofAZtheAZfo
llowingAZisAZanAZappropriateAZnursingAZactionAZregardingAZtheseAZfindings?AZ-
AZcorrectAZanswers-DocumentAZtheAZfindingsAZinAZtheAZclient'sAZmedicalAZrecord.
AAZnurseAZinAZtheAZpost-
anesthesiaAZcareAZunitAZisAZcaringAZforAZaAZclientAZwhoAZisAZpostoperativeAZfollowingAZaAZthorac
otomyAZandAZlobectomy.AZWhichAZofAZtheAZfollowingAZpostoperativeAZassessmentsAZshouldAZt
heAZnurseAZgiveAZhighestAZpriorityAZto?AZ-AZcorrectAZanswers-ArterialAZbloodAZgases.
TheAZeffectivenessAZofAZoxygenationAZisAZmonitoredAZusingAZpulseAZoximetryAZandAZarterialAZ
AZ
bloodAZgases.
AAZnurseAZisAZassessingAZaAZclientAZfollowingAZaAZbronchoscopy.AZWhichAZofAZtheAZfollowingAZfi
ndingsAZshouldAZtheAZnurseAZreportAZtoAZtheAZprovider?AZ-AZcorrectAZanswers-Bronchospasms
BronchospasmsAZcanAZindicateAZtheAZclientAZisAZhavingAZdifficultyAZmaintainingAZaAZpatentAZair
way.
Blood-
tingedAZsputum,AZaAZdry,AZnonproductiveAZcough,AZandAZaAZsoreAZthroatAZareAZexpectedAZfindin
gsAZfollowingAZaAZbronchoscopy.
AAZnurseAZisAZcaringAZforAZaAZclientAZwhoAZisAZscheduledAZforAZaAZthoracentesis.AZPriorAZtoAZtheAZ
procedure,AZwhichAZofAZtheAZfollowingAZactionsAZshouldAZtheAZnurseAZtake?AZ-
AZcorrectAZanswers-PositionAZtheAZclientAZupright,AZleaningAZoverAZtheAZbedsideAZtable.