1. Which of the nursing interventions by the nurse is appropriate?
a. Teach controlled coughing and deep breathing
b. Provide a brightly lit environment
c. Elevate the head of the bed 30 degrees
d. Encourage minimum
...
1. Which of the nursing interventions by the nurse is appropriate?
a. Teach controlled coughing and deep breathing
b. Provide a brightly lit environment
c. Elevate the head of the bed 30 degrees
d. Encourage minimum intake of 2000 mL/day of clear fluids
2. A client is brought to the emergency room with a 30 percent burn over her lower extremities. Which of the following interventions should the nurse perform first?
a. Clean and dress the wound
b. Remove the clients clothing
c. Administer a tetanus booster d. Initiate a peripheral IV
3. A nurse is caring for a client admitted to the nursing unit from the PACU following a craniotomy. The initial nursing assessment should focus on
a. Intracranial pressure
b. Pupillary reflexes
c. Level of consciousness d. Airway patency
4. A nurse is caring for a client who has just returned from the surgical suite following a thoracotomy. Which of the following postoperative interventions should the nurse give highest priority to?
a. Administer oxygen by mask via cannula at 6 L/min
b. Monitor urinary output via foley catheter every 2hr
c. Assess chest tube drainage hourly
d. Maintain intravenous of D 5 ½ normal saline at 125 mL/hour
5. A nurse is caring for a client who has acute pancreatitis. After the client’s pain has been addressed, which of the following is next intervention to include in the plan of care?
a. Monitor respiratory status every 8 hr
b. Encourage a side-lying position with knees flexed
c. Provide frequent oral hygiene d. Maintain NPO status
6. A nurse in the emergency department is caring for a client who has a myasthenia gravis and is in crisis. The nurse knows that which of the following factors can cause myasthenic crisis?
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