ATI RN Capstone Comprehensive Assessment Proctored Test 2019A (Real Exam)

ATI RN Capstone Comprehensive Assessment Proctored Test 2019A (Real Exam) a nurse is planning care for a client who is receiving heparin to treat a deep vein thrombosis of the left lower leg. which of the following interventions should the nurse include in the plan of care? elevate the affected leg ambulation should be encouraged a nurse is teaching a group of guardians about child safety measures. which of the following statements by a guardian indicates an understanding of the teaching? I should have my child avoid sun exposure between 10 am and 2 pm a home health nurse is providing teaching about infection prevention to a client who has cancer and is receiving chemotherapy. Which of the following statements by the client indicates an understanding of the teaching? I will walk for short distances throughout the day a nurse is providing dietary teaching to the parents of a 6 month old infant. which of the following instructions should the nurse include? Introduce new foods one at a time over 5 to 7 days a charge nurse is planning care for a client who has mechanical restraints in place. which of the following interventions should the nurse include in the plan? Provide a staff member to stay with the client continuously can be physically or using an audiovisual device need to document every 15-30 minutes, a new prescription should be in every 4 hrs for adults, every 3 hrs for 9-17 years and every hour for those younger a community health nurse is assisting with the development of a disaster management plan. the nurse should include which of the following nursing responsibilities in the disaster response stage of the plan? performing a rapid needs assessment a nurse manager is assisting with the orientation of a newly licensed nurse. which of the following actions by the nurse requires the nurse manager to intervene? tells the hospital chaplain a clients diagnosis a nurse is caring for a client who is in labor at 39 weeks of gestation. during the second stage of labor, the nurse observes early deceleration on the monitor tracing. which of the following actions should the nurse take? continue observing the fetal heart rate these are an expected finding a nurse manager is planning to make changes to the current scheduling system on the unit. to facilitate the staff's acceptance of this change, which of the following actions should the nurse manager take first? provide information about scheduling issues to the staff unfreezing stage - increase understanding of why change is needed a nurse is planning teaching about allowable foods for a client who has a history of uric acid based urinary calculi formation. which of the following foods should the nurse include in the teaching? oranges can eat citrus fruits no chicken, no organ meats like liver, no red wine (avoiding purine) a charge nurse is teaching a newly licensed nurse how to identify true labor. which of the following should the nurse include in the teaching? the cervix transitions to an anterior position contractions will be felt in the lower abdomen and back, intensity increases with ambulation, cervix shortens and thins a nurse on a medical surgical unit is caring for a client prior to a surgical procedure. which of the following findings should indicate to the nurse that the client has the ability to sign the informed consent? the client is able to accurately describe the upcoming procedure a charge nurse assigns a newly licensed nurse to care for a client who has a chest tube. The nurse expresses concern about having limited experience with monitoring chest tube drainage. which of the following actions should the charge nurse take first to provide teaching about chest tubes? ask the nurse about their knowledge of the procedure a nurse is teaching a client who has a new prescription for estradiol. for which of the following adverse effects of this medication should the nurse instruct the client to monitor and report to the provider? headaches - can be indicative of a thromboembolic stroke a nurse is preparing to administer diazepam 0.3mg/kg IV bolus to a toddler who weighs 22 lb and is experiencing a grand maul seizure. availabale is diazepam solution for injection 5mg/mL. how many mL should the nurse administer? 0 0.6 mL a nurse is caring for a client who is 12 hours postoperative, is receiving PCA for pain control, and requires a blood pressure check in 10 min. which of the following staff members should the nurse assign to collect the information? An assistive personnel (AP) who is assisting a client to return to bed a nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm^3. which of the following interventions should the nurse include in the plan? withhold administering the varicella vaccine to the child - it is a live vaccine and should not be given a nurse is providing teaching about improving nutrition for a client who has multiple sclerosis. which of the following instructions should the nurse include? select all A speech pathologist will be performing a swallowing study for you you should rest before eating meal thicken your beverage before drinking a nurse is assessing a client who has schizophrenia and is taking chlorpromazine. which of the following findings is the priority for the nurse to report to the provider? temperature 39.4 (102.9) a client is receiving lorazepam IV for panic attacks and develops a respiratory rate of 6/min and a blood pressure of 90/44 mm Hg. Which of the following medications should the nurse anticipate administering? flumazenil a nurse is caring for an older adult client in the PACU following general anesthesia. which of the following findings should the nurse report to the provider? audible stridor a nurse is preparing a sterile field in order to insert an indwelling urinary catheter for a male client. which of the following techniques should the nurse use to maintain surgical aseptic technique? set the catheter tray on the overbed table at waist height a nurse is planning care for a client who has a deficit with cranial nerve II. which of the following actions should the nurse plan to take? clear objects from the clients walking area a nurse is providing discharge instructions to a client following a total hip arthroplasty. which of the following instructions should the nurse include? install a raised toilet seat at home a nurse is assessing a client who is receiving a blood transfusion. which of the following findings should indicate to the nurse that the client is having a hemolytic transfusion reaction? low back pain other signs include hypotension, tachycardia a nurse is caring for a child who is experiencing a tonic clinic seizure. which of the following actions should the nurse take? place the child in a side lying position a nurse is administering medications to a client who has a percutaneous gastrostomy tube for enteral feedings. which of the following actions should the nurse take to prevent clogging of the tube? flush the client's gastrostomy tube with 30 mL of water before administering the medication a nurse is assessing a client who has macular degeneration. which of the following findings should the nurse expect? decreased central vision a nurse is assessing a client who has schizophrenia. the nurse should identify the following alteration in speech as which of the following? clang association - uses words based on their sound rather than their meaning (this one had a lot of b words) a nurse in a clinic receives a call form a guardian whose child has varicella. the guardian asks when the child can return to school. which of the following responses should the nurse make? when the crusts have formed on every lesion a nurse is providing discharge instructions to a client who has a new prescription for warfarin. which of the following client statements should the nurse identify as an indication that the client understands the teaching? I should report a change in the color of my stools - red, black, tarry, etc. a nurse is assessing a school age child who has cystic fibrosis. which of the following findings is the priority for the nurse to report to the provider? hemoptysis 275 mL/24 hr when caring for a child, a nurse plans to use nonpharmacological interventions to enhance the effectiveness of pain medication. which of the following strategies incorporates visualization techniques to help decrease the child's discomfort? blowing bubbles with liquid soap to blow the hurt away an assistive personnel and a nurse are turning a client onto the right side. which of the following actions by the AP requires the nurse to intervene? Places a pillow under the client's right arm the AP should place a pillow under the client's left arm to prevent internal rotation of the left shoulder a nurse on a mental health unit is caring for a client who tells the nurse that she does not want to receive a scheduled dose of lorazepam IM. which of the following actions should the nurse take? document the client's refusal of the medication a nurse is caring for four clients., which of the following clients should the nurse assign to an assistive personnel to assist with meals a client who has Alzheimer's disease and is demonstrating aphasia a mental health nurse is conducting the first of several meetings with a client whose partner recently died. the nurse should perform which of the following actions to establish trust during the orientation phase of the nurse client relationship establish the termination date of therapy a nurse is caring for a client who is at 28 weeks of gestation. the client asks the nurse to explain what causes her to have constipation. which of the following responses should the nurse make? the enlarged uterus compresses the intestines and causes constipation a nurse manager is reviewing unit records and discovers that client falls occur most frequently during the hours of 0540 and 0730. Which of the following actions should the nurse take when conducting a root cause analysis investigate environmental factors that might be contributing to client injury during these hours a nurse is caring for a client who is immediately postoperative following a total vaginal hysterectomy. which of the following actions should the nurse take first? measure the clients vital signs (every 15 minutes until stable) a charge nurse is planning an educational session for staff nurses about working with parents whose terminally ill children are candidates for donating their organs. which of the following information should the nurse plan to include? the family can have the child in an open casket without fearing that the organ donation might disfigure the child's body a nurse is teaching about total parenteral nutrition TPN and IV lipid emulsions with a client who has an extensive burn injury. Which of the following information should the nurse include? you will receive fingersticks for blood glucose testing a nurse is caring for a client who has a fractured femur and has had a fiberglass leg cylinder cast for 24 hours. which of the following assessment findings should the nurse identify as the priority? the client's heel is reddened and tender (possible pressure injury) a home health nurse is providing teaching to a client who has hepatitis A. which of the following instructions should the nurse include? use hydrogen peroxide to clean kitchen surfaces a nurse is preparing to perform an intermittent urinary catheterization for a client who has unrainy retention. which of the following images indicates the catheter the nurse should use? It's a picture of a catheter that is pink in color with no bulbs or anything just one single tube a community health nurse is preparing a health education program for a local rural community. which of the following actions should the nurse plan to take first? identify health related issues within the community a nurse is caring for a client who has generalized anxiety disorder and is to begin taking alprazolam. which of the following actions should the nurse take? initiate fall precautions for the client (common adverse effects are orthostatic hypotension, dizziness, confusion, and lethargy) a nurse in the delivery room is caring for a newborn immediately after birth. which of the following actions should the nurse take first? dry the newborn a nurse in an acute mental health facility is planning care for a client who has anorexia nervosa. which of the following interventions should the nurse include in the clients plan of care? supervise the client during and after eating everything to do with food should be structured, the client has minimal choices a nurse is talking with the partner of a client who attempted suicide. which of the following statements by the client's partner should the nurse identify as the priority? "my husband doesn't know that I've already moved out of the house and filed for a divorce" (lack of social and emotional support) a nurse is assessing a client who has multiple sclerosis. which of the following manifestations should the nurse expect? nystagmus (involuntary eye movement) abdominal striae is found in cushings disease masklike face is found in parkinsons disease ptosis is found in myasthenia gravis a nurse is interviewing a client who is now without a home due to a natural disaster. after ensuring the client's safety, which of the following actions should the nurse take first determine the client's perception of the personal impact of the crisis a nurse is preparing to administer enoxaparin to a client. Identify the area the nurse should use to administer the injection. Subcutaneous tissue in the periumbilical area a nurse is assessing a client who has skeletal traction for a femur fracture. which of the following findings should the nurse identify as the priority? upper chest petechiae (fat embolism syndrome) a nurse is assessing a client who has sickle cell anemia. the nurse should identify which of the following findings as a manifestation of vaso-occlusive crisis? hematuria also painful swelling of the hand and feet and visual disturbances a nurse is assessing a client who has been taking lithium carbonate for the past month to treat bipolar disorder. which of the following assessment findings should the nurse identify as the priority? confusion (lithium toxicity) hand tremors are an adverse effect of lithium a nurse is providing teaching to a parent of a child who has a permanent tracheostomy tube. Identify the sequence of steps the parent should follow to perform tracheostomy care. Remove the inner cannula remove the soiled dressing clean the stoma with 0.9% sodium chloride irrigation change the tracheostomy collar a nurse in an emergency department is assessing a client who reports taking methylenedioxymethamphetamin MDMA. which of the following findings should the nurse expect diaphoresis increases tactile sensitivity, lowered inhibition, chills, muscle cramping, teeth clenching, and mild hallucinogenic effects a nurse is teaching a client who is to start taking misoprostol and currently is on long term therapy with NSAIDs for arthritis. the nurse should provide the client with which of the following information? complete a serum pregnancy test before taking the medication (can induce uterine contractions) a nurse is caring for a client who has a potassium level of 3 mEq/L. For which of the following manifestations should the nurse monitor? decreased deep tendon reflexes muscle weakness as well a nurse in an emergency department is preparing to discharge a client who has experienced intimate partner violence. which of the following actions should the nurse take first? develop a safety plan with the client a nurse is caring for a client who is at 37 weeks of gestation and is experiencing abruptio placentae. which of the following findings should the nurse expect? persistent uterine contractions board like abdomen, and dark red vaginal bleeding a nurse is caring for a client who is in the manic phase of bipolar disorder. which of the following manifestations should the nurse expect? grandiose delusions a nurse is caring for a client who states, "my boss accused me of stealing yesterday. I was so angry I went to the gym and worked out" the nurse should recognize the client is demonstrating which of the following defense mechanisms? sublimation a nurse is teaching a client about foods high in vitamin A. which of the following foods should the nurse recommend as having the highest amount of vitamin A? 1 medium raw carrot a nurse is teaching the parent of a school aged child about administering ear drops. which of the following responses by the parent indicates an understanding of the teaching? "I should pull the top of the ear upward and back while instilling the medication" a nurse is caring for a client who requires physical therapy following discharge. which of the following actions should the nurse take? Involve the client in selection of a physical therapy provider a nurse is planning care for a client who is receiving hemodialysis via an established arteriovenous (AV) fistula in the right arm. which of the following interventions should the nurse include in the client's plan of care? auscultate the affected extremity for a bruit a nurse is providing teaching to a client about newborn safety. which of the following statements should the nurse include in the teaching? "set your hot water heater temperature at or below 120 degrees Fahrenheit" a nurse is caring for a newborn who has herpes simplex virus HSV. which of the following isolation precautions should the nurse initiate? contact a home health nurse is planning care for an older adult client who has impaired vision. which of the following interventions should the nurse include in the plan of care? mark the edges of stairs for contrast should have vision testing done every year a nurse is initiating discharge planning for a client who had a stroke and is experiencing right sided weakness. which of the following actions should the nurse take first? request a referral for the client to receive physical therapy a nurse is reviewing the laboratory findings of a client who is experiencing chest pain. The nurse should identify that an elevation in which of the following laboratory values indicates cellular injury of myocardial tissue? troponin T a nurse is preparing to administer heparin 5,000 units subcutaneously, available is heparin injection 10,000 units/mL. how many mL should the nurse administer per dose? Round to the nearest tenth. 0.5mL a nurse in an outpatient mental health clinic is working with a client who has post traumatic stress disorder PTSD and asks the nurse to recommend a nonpharmacological therapy to use to provide relief of the manifestations. which of the following complementary therapies should the nurse teach the client to use to help alleviate the distress? guided imagery a nurse manager is preparing a newly licensed nurse's performance appraisal. which of the following methods should the nurse manager use to evaluate the nurse's time management skills? maintain regular notes about the nurse's time management skills a nurse is caring for four clients at the beginning of a shift. after receiving change of shift report, which of the following clients should the nurse attend to first? a client who is confused and has been attempting to get out of bed (risk for injury) a night shift nurse is giving change of shift report to the day sift nurse on a client who is ready for discharge. which of the following information is the priority for the nurse to communicate to the oncoming nurse? the client needs assistance when transferring from the bed to a wheelchair a nurse is assessing a client who has a stage II pressure injury. Which of the following wound characteristics should the nurse expect? partial thickness skin loss a nurse is providing discharge instructions to a client who has a new prescription for amitriptyline to treat depression. the nurse should identify that which of the following client statements indicates an understanding of the teaching? "I should watch for common reactions like dry mouth and constipation" a charge nurse is preparing to administer 0900 medications and is told by the pharmacy staff that the medications are not available. medication availability has been an ongoing problem, and the charge nurse has previously discussed this issue with the pharmacy staff. which of the following actions should the charge nurse take first? inform the nurse manager of the issue a nurse is caring for a client who vomits on a reusable BP cuff. which of the following actions should the nurse take? place the BP cuff in a labeled bag to send it for decontamination chlorine bleach is used for blood a nurse is assessing a newborn who is 2 hours old. which of the following findings should the nurse report to the provider? axillary temperature of 36.2 (97.2) should be 36.5-37.5 a nurse manager is on a planning committee to develop an emergency preparedness plan. The nurse should recommend that which of the following actions take place first when implementing an emergency preparedness plan? notify the incident commander a nurse is preparing to administer 15 units of regular insulin along with 20 units of NPH insulin. which of the following actions should the nurse plan to take? inject 20 units of air into the NPH insulin vial draw the short acting regular insulin into the vial first, which prevents the longer acting insulin from contaminating the short acting insulin a charge nurse overhears two staff nurses in the hallway discussing the nutritional status of a client who has anorexia nervosa. which of the following actions should the charge nurse take? tell the nurses to stop the discussion a nurse is assessing a client who is 2 hours postoperative following cardiac catheterization. which of the following information should the nurse report to the provider? neurologic status - responds to verbal stimuli, speech slurred, hand grasps weak and unequal a nurse is providing client education to a postpartum client who has decided to bottle feed the newborn. which of the following instructions should the nurse include in the teaching to help prevent the discomfort of engorgement? place ice packs on the breasts for 15 min several times per day a case manager is reviewing the medical records of several clients. for which of the following clients should the nurse request an interprofessional care conference? A client who has diabetes mellitus and has had repeated hospitalizations for diabetic ketoacidosis a charge nurse is observing a newly licensed nurse administer enteral feedings via NG tube. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? keeps the head of the bed elevated to 45 degrees for 1 hour after feedings a nurse is assessing a client during the immediate postpartum period. which of the following findings requires immediate intervention by the nurse? boggy uterus a nurse is caring for a newborn whose parent asks why the baby is receiving vitamin K. the nurse should explain to the parent that the newborn should receive vitamin K to prevent which of the following? bleeding a nurse is planning care for a client who has thrombocytopenia. which of the following instructions should the nurse include in the client's plan of care? avoid venipunctures when possible a nurse is assessing a 2 month old infant during a well baby examination. which of the following actions should the nurse take to assess the infants rooting reflex? stroke the infants cheek a nurse is teaching a client who has a new prescription for digoxin about manifestations of toxicity. which of the following findings should the nurse include in the teaching? nausea anorexia, abdominal pain, bradycardia, visual changes a nurse is reviewing the urinalysis report of a client who has acute glomerulonephritis. which of the following findings should the nurse expect? protein a nurse working on a medical surgical unit receives a telephone call requesting the status of a client from an individual who identifies themselves as the client's parent. which of the following actions should the nurse take? ask the caller for verification of their identity a nurse is caring for a client who has end stage alzheimer's disease. the adult child of the client says to the nurse "I don't know why I bother to visit my mother anymore" which of the following responses should the nurse make? it seems like you feel your visits are a waste of time a nurse is assessing a client who has antisocial personality disorder. which of the following manifestations should the nurse expect? lack of remorse a community health nurse is performing triage tagging following a mass casualty incident. on which of the following clients should the nurse place a black tag? a client who has significant head trauma and agonal respirations a nurse is caring for a client who has had nausea and vomiting for the past 2 days. The nurse should identify which of the following findings as an indication the client is experiencing fluid volume deficit? orthostatic hypotension increased BUN A nurse is providing discharge teaching to a new parent about car seat safety. which of the following statements should the nurse include in the teaching? secure the retainer clip at the level of your baby's armpits a nurse is caring for a toddler who has infectious gastroenteritis. which of the following actions should the nurse take? initiate oral rehydration therapy for the toddler chx and beef broth contain a lot of sodium and very few carbs so should not be used a nurse is preparing to insert an indwelling urinary catheter for a client. The nurse should assess the client for which of the following conditions prior to starting the procedure? latex allergy a nurse is caring for an older adult client. which of the following findings should the nurse recognize as a physical change associated with aging? decreased lung expansion a charge nurse observes a staff nurse document a dressing change in a client's chart that was not performed. which of the following actions should the charge nurse take first? gather more information about the staff nurse's actions a nurse is providing discharge teaching to a client following a cataract extraction. which of the following statements by the client indicates an understanding of the teaching? "I will bend at the knees when picking an object up off the floor" a nurse is caring for a client who has methicillin-resistant staphylococcus aureus MRSA in an abdominal wound. which of the following precautions should the nurse implement? contact a nurse is caring for a client who is 4 hr postpartum and has a boggy uterus with heavy lochia. which of the following actions should the nurse take first? massage the uterus to expel clots a home health nurse is assessing a 2 week old newborn who has a birth weight of 3.64 kg (8lb) and is being breastfed. which of the following findings indicates effective breastfeeding. the newborn has six to eight wet diapers per day a nurse is caring for a client who has a closed head injury and is receiving mechanical ventilation. the nurse should expect to administer which of the following medications to reduce intracranial pressure? mannitol it is an osmotic diuretic to reduce intracranial pressure a nurse is teaching a newly admitted client who has heart failure about advance directives. which of the following statements should the nurse make? you should complete advance directives in the event you cannot express your own wishes a nurse is teaching the parents of a preschooler about sleep promotion. the parents report that their child is demonstrating reluctance in going to bed at night and states, "I am not tired". Which of the following statements by the parents indicates an understanding of the teaching? we should read a story together every night before bedtime an RN is planning care for a group of clients and is working with a licenced practical nurse LPN and an assistive personnel AP. which of the following tasks should the RN delegate to the LPN insertion of a nasogastric tube a nurse in an emergency department is admitting a client who has cardiac tamponade. which of the following assessment findings should the nurse expect? pulsus paradoxus a nurse is assessing a client who has delirium. which of the following manifestations should the nurse expect? rapid speech a nurse working in a long term care facility is assessing an adult client. which of the following findings places the client at risk for development of a pressure injury recent weight loss(inadequate nutrition) a nurse is caring for a client who had a recent stroke. prior to transferring the client to the bedside commode, which of the following actions should the nurse take first? assess the client for functional limitations a community health nurse is reviewing the medical records of four newly diagnosed clients. The nurse should identify which of the following clients as having a nationally notifiable infectious condition? an adolescent client who has foodborne botulism a nurse is performing tracheostomy care for a client who is postoperative following a laryngectomy. which of the following actions should the nurse take when suctioning the clients airway? apply suction for 10 seconds a nurse is caring for a client who has an STI that must be reported to the state health department. which of the following actions should the nurse take? explain to the client why this information will be shared a nurse is caring for an adolescent client who has a diagnosis of terminal cancer. when discussing the client's prognosis with the parents, the nurse should recognize which of the following responses by the parents as an example of rationalization? "Maybe this is better for our child because we don't want any suffering through chemotherapy treatments" a nurse is assessing a client who has obstructive sleep apnea. for which of the following complications should the nurse monitor? hypertension a nurse is conducting visual acuity testing using the snellen letter chart for a school age child who has eyeglasses. which of the following instructions should the nurse give to the child? you should keep both eyes open during the testing a nurse is preparing to administer a long acting insulin to a client who has diabetes mellitus. which of the following actions should the nurse plan to take first? check the insulin dose with another licensed nurse a clinic nurse is caring for a client who is in the first trimester of pregnancy. the client reports using acupressure bands on both wrists. which of the following statements by the client indicates that this therapy is having the desired effect? "I have not vomited as much recently" a nurse is caring for a client who has hypertension and is taking captopril. which of the following tasks should the nurse delegate to an assistive personnel? obtain the client's blood pressure before the nurse administers medication a nurse is caring for a client who is receiving total parental nutrition TPN solution by continuous IV infusion at 60 mL/hr. The nurse discovers the infusion pump has stopped working. Which of the following actions should the nurse take while waiting for a new infusion pump? provide dextrose 10% in water solution using manual drip tubing at 60 mL/hr a nurse is performing gastric lavage for a client who has gastrointestinal bleeding and an NG tube in place. which of the following actions should the nurse take? use 0.9% sodium chloride for irrigation of the NG tube a nurse is reviewing the medical record of a client who has schizophrenia and is to start taking clozapine. which of the following findings should the nurse identify as a contraindication for the client to receive clozapine? WBC count 2,800/mm^3 a nurse is performing an admission assessment of a preschooler who is in the acute phase of Kawasaki disease. Which of the following findings should the nurse expect? fever unresponsive to antipyretics a nurse is caring for a group of clients. for which of the following events should the nurse complete an incident report? A client's IV pump delivers an inadequate dose of medication a nurse is caring for a client who has bipolar disorder. the nurse observes that the client is becoming increasingly restless. the client is pacing the unit and speaking rapidly, frequently using profanities and sexual references. which of the following actions should the nurse take first? move the client to a quiet place away from others a nurse is assessing a preschooler who has cystic fibrosis and has been receiving oxygen therapy for the past 36 hr. which of the following findings should the nurse identify is an indication that the client has developed oxygen toxicity? substernal pain increased work of breathing a charge nurse is observing a newly licensed nurse performing a physical assessment on a client. which of the following actions by the nurse indicates that the charge nurse should intervene? the newly licensed nurse writes detailed notes while performing the head to toe assessment a nurse is providing discharge teaching to a client who has colorectal cancer and a new colostomy. the client states, "I'm worried about being discharged because I live alone, and my insurance doesn't cover ostomy supplies" which of the following actions should the nurse take? (select all that apply) refer the client to a community based social worker initiate a consult with a home health care provider give the client information about local support groups a nurse is administering cyclophosphamide orally to a school age child who has neuroblastoma. which of the following actions should the nurse take when administering this medication? maintain hydration with liberal fluid intake a nurse is teaching home wound care to the family of a child who has a large wound. which of the following interventions should the nurse recommend? double bad soiled dressings in plastic bags for disposal a client who is 24 hours postoperative following abdominal surgery refuses to ambulate. which of the following actions should the nurse take first? ask the client to rate their pain level a nurse is providing colostomy care for a client using a two piece pouching system. which of the following actions should the nurse take? place the skin barrier over the stoma and hold it for 30 seconds -opening should be no more than 0.3cm larger than the stoma a nurse is preparing to administer 2 units of fresh frozen plasma to a client. which of the following actions should the nurse plan to take? enter the plasma product number into the clients medical record infuse over 30-60 min immediately after getting it from the blood bank a nurse is assessing a client who is experiencing autonomic dysreflexia. which of the following findings should the nurse expect? facial flushing nasal congestion headache a nurse is teaching a client who has opioid use disorder about methadone. which of the following information should the nurse include in the teaching? "sedation is a common adverse effect of this medication" a nurse is providing teaching to an adolescent following insertion of a tunneled central venous catheter without a pressure sensitive valve. which of the following information should the nurse include in the teaching? "you should keep the catheter clamped when not in use" flush with heparin change dressing every 5-7 days a nurse is reviewing the ABG results of a client who has COPD. The results include a pH of 7.3, PaO2 56 mm Hg, PaCO2 54 mm Hg. HCO3 26 mEq/L, SaO2 87%. Which of the following is the correct interpretation of these values uncompensated respiratory acidosis a nurse is assessing a client who has Raynaud's disease. Which of the following findings should the nurse expect? Blanching of the fingers and toes a nurse is caring for a client who has a terminal illness and requests no lifesaving measures if a cardiac arrest occurs. which of the following statements should the nurse make? "I will provide you with information about medical treatment to include in your living will" A nurse is teaching the parents of a toddler about snacks. Which of the following foods should the nurse recommend? diced steamed carrots a nurse is caring for a toddler who is admitted to the pediatric unit for surgery. which of the following should the nurse include in the toddler's plan of care? encourage the parents to bring toys from home a nurse receives a request from a client to review the information in his medical record. which of the following responses should the nurse give? "There's a protocol for reviewing your medical record and I can initiate