A 16-year-old client reports to the B C EF
clinic with their caregiver. The client's
caregiver informs the nurse that the
client has "not been themselves lately."
Select the 4 findings that require
follow-up.
A. Attends school regularly
B. Caregiver reporting client acting
differently than usual
C. Witnessing their family's death
D. Heart rate 99/min
E. Smoking marijuana to clear their
mind
F. Client experiences nightmares
G. Client experiences nightmares
H. Startles easy during thunderstorm
,174. A nurse is caring for a client who
requires nasotracheal suctioning.
Identify
the sequence the nurse should follow
to perform suctioning. (Move the
steps into
the box on the right, placing them in
the order of performance. Use all the
steps.)
A. Rinse the catheter to remove
secretions.
B. Don sterile gloves.
C. Apply suction while rotating the
catheter.
D. Insert the catheter during the
client's inspiration.
E. Turn on the suction and set the
pressure.
,:A nurse is caring for a client who is D. The client's systolic blood pressure decreases by 25 mm Hg.
taking antihypertensive medication
and is moving from a supine to a
sitting position.
Which of the following findings should
indicate to the nurse that the client is
experiencing orthostatic
hypotension?
A. The client's heart rate increases by
10/min.
B. The client's diastolic blood pressure
increases by 10 mm Hg.
C. The client reports heart
palpitations.
D. The client's systolic blood pressure
decreases by 25 mm Hg.
, A. Position the ultrasound A. Position the ultrasound stethoscope above the symphysis pubis to a
stethoscope above the symphysis the fetal
pubis to assess the fetal heart rate.
heart rate.
B. Measure the fundal height to
determine the placement of the
ultrasound
stethoscope.
C. Place the client in a side-lying
position prior to assessing the fetal
heart rate.
D. Perform Leopold maneuvers prior
to auscultating the fetal heart rate.
clinic with their caregiver. The client's
caregiver informs the nurse that the
client has "not been themselves lately."
Select the 4 findings that require
follow-up.
A. Attends school regularly
B. Caregiver reporting client acting
differently than usual
C. Witnessing their family's death
D. Heart rate 99/min
E. Smoking marijuana to clear their
mind
F. Client experiences nightmares
G. Client experiences nightmares
H. Startles easy during thunderstorm
,174. A nurse is caring for a client who
requires nasotracheal suctioning.
Identify
the sequence the nurse should follow
to perform suctioning. (Move the
steps into
the box on the right, placing them in
the order of performance. Use all the
steps.)
A. Rinse the catheter to remove
secretions.
B. Don sterile gloves.
C. Apply suction while rotating the
catheter.
D. Insert the catheter during the
client's inspiration.
E. Turn on the suction and set the
pressure.
,:A nurse is caring for a client who is D. The client's systolic blood pressure decreases by 25 mm Hg.
taking antihypertensive medication
and is moving from a supine to a
sitting position.
Which of the following findings should
indicate to the nurse that the client is
experiencing orthostatic
hypotension?
A. The client's heart rate increases by
10/min.
B. The client's diastolic blood pressure
increases by 10 mm Hg.
C. The client reports heart
palpitations.
D. The client's systolic blood pressure
decreases by 25 mm Hg.
, A. Position the ultrasound A. Position the ultrasound stethoscope above the symphysis pubis to a
stethoscope above the symphysis the fetal
pubis to assess the fetal heart rate.
heart rate.
B. Measure the fundal height to
determine the placement of the
ultrasound
stethoscope.
C. Place the client in a side-lying
position prior to assessing the fetal
heart rate.
D. Perform Leopold maneuvers prior
to auscultating the fetal heart rate.
