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A nurse in a long-term care facility is caring for a client who has dementia which
of the following actions should the nurse take - ANSWER ✓ Provide finger food at
meal time
A nurse is caring for a client who has multiple like fractures and it's 24 hours
postoperative following placement of skeletal traction which of the following
action should the nurse take - ANSWER ✓ Inspect the pin sites, at least every eight
hours
A nurse is teaching a client about preventing the transmission of HIV which of the
following information should the nurse include - ANSWER ✓ Medication is
available that will reduce the risk for HIV transmission
A nurse is assessing a client who recently had a milecardial in fraction, which of
the following findings indicates of the client might be developing pulmonary
edema, so like all that apply - ANSWER ✓ Excessive somnolence, Pink frothy,
sputum and tachypnea
A nurse is caring for a group of clients in which of the following scenarios is the
nurse acting as a client advocate - ANSWER ✓ The nurse refers a client who has
chronic obstructive pulmonary disease for palliative care services.
- Palliative care is an interdisciplinary approach to client care that works toward
optimizing the quality of life for a client who has a chronic illness. Nurses
advocate for their clients when they promote the health, safety, and rights of the
client, such as providing a referral for needed services to relieve suffering and
promote a client's quality of life.
, A nurse is assessing a client who is undergoing radiation therapy for breast cancer
which of the following findings is an indication to the nurse at the client is
experiencing an adverse effect of the therapy - ANSWER ✓ Skin changes
A nurse is assessing a client who has a new diagnosis of pericarditis, which of the
following findings should the nurse identify as a manifestation of cardiac
tamponade - ANSWER ✓ PARADOXICAL PULSE.
- Cardiac tamponade results from an excess of fluid in the pericardial cavity and
causes a sudden drop in cardiac output. Paradoxical pulse is a systolic blood
pressure of 10 mm Hg or more on expiration and is a manifestation of cardiac
tamponade. The nurse should report manifestations of cardiac tamponade to the
provider immediately.
A nurse is caring for a client who is intubated and receiving mechanical
ventilation for heroin toxicity which of the following assessment is the nurses
priority - ANSWER ✓ ABGs
A nurse is preparing to teaching plan for a client who is starting to receive
hemodialysis for chronic kidney disease, which of the following instruction should
the nurse include in the teaching - ANSWER ✓ Increase your intake of protein to
1-1.5g/ kilogram per day.
A nurse note that a client eyes are protruding slightly from their orbits, which the
following laboratory finding should the nurse expect - ANSWER ✓ Increased T4
levels
A nurse is caring for a client immediately following intervention with an
endotracheal tube. Which of the following methods should the nurse identify as the
most reliable for verifying placement of the ET tube - ANSWER ✓ Check for end
tidal carbon dioxide levels or CHEST X RAY
A nurse is teaching a client how to obtain a specimen at home for a fecal occult
blood test which of the following action should the nurse instruct the client to take
for three days prior to collecting specimens - ANSWER ✓ Avoid eating red meat