MICRO 1420 ; PN ATI Exit Review, complete solution guide, College of DuPage.

PN ATI Exit Review 1. A nurse is caring for a group of clients, which of the following can be assigned to an assistive personnel? 2. A nurse is working on a unit for clients with dementia. Which of the following client ...

PN ATI Exit Review 1. A nurse is caring for a group of clients, which of the following can be assigned to an assistive personnel? 2. A nurse is working on a unit for clients with dementia. Which of the following client situations requires the nurse to write an incident report? 3. A nurse is discharging a client who was admitted for newly diagnosed type 2 diabetes mellitus. The client is independent and lives alone. Which of the following should be included in the discharge plan? 4. A nurse is caring for a client who has type 2 diabetes mellitus and a blood glucose level of 60 mg/dL. For which of the following findings should the nurse monirtor? 5. A female client who is an abusive marriage has discusses with the nurse strategies to prevent this abuse. which of the following client statements indicate an understanding of an appropriate strategy? 6. A charge nurse in a long-term care facility is preparing to administer noon insulin to a client. The nurse observes that the assistive personnel (AP) has no documented the client's blood glucose level. Which of the following actions should the charge nurse take first? 7. A client is scheduled for an outpatient colonoscopy. which of the following actions is a nursing responsibility in the informed consent process? 8. A nurse smells alcohol on the breath of an assistive peronnel (AP) during report. Which of the following actions should the nurse take? 9. A nurse from a medical-surgical unit is floating to a postpartum unit. Which of the following clients is an appropriate assignment for the nurse to accept? 10. A nurse in a provider's office is collecting data from a parent of an infant who is being screened for cyctic fibrosis. Which of the following supports a diagnosis of cystic fibrosis? 11. When caring for an assigned group of clients, the nurse should wear gloves when 12. A nurse is preparing a client for surgery. The client tells the nurse that he is concerned about the safety of a large sum of money in his wallet. Which of the following actions is appropriate for the nurse to take? 13. A nurse is caring for a client who is receiving heparin. Which of the following is the appropriate route of administration? 14. A nurse is reinforcing teaching about car seat safety to the parents of a newborn. The nurse should instruct the parents to place the car seat in a 15. A nurse is caring for a client and recognizes the client's rights to confidentiality have been breached in which of the following situations? 16. A nurse is caring for a client who had a femoral-popliteal bypass graft 2 days ago. When monitoring peripheral pulses, the nurse is unable to locate a pulse on the affected leg. Which of the following actions should the nurse take? 17. A nurse is caring for a full-term newborn who was circumcised 6 hrs. ago. Which of the following findings indicates that the newborn is experiencing pain? a. Awakens every 3 hours b. Furrowed Brow c. Oxygen Saturation of 95% d. Positive babinski reflex. 18. A nurse is reinforcing teaching with a client about organ donation. Which of the following client statements indicated a need for further teaching? 19. A Client who is prescribed metoprolol (Lopressor) for hypertension tells the nurse, "I don't want to take this medication because it makes me tired all the time." Which of the following is the appropriate response? 20. A nurse is preparing to administer an IM injection to a client. To reduce the risk of neddlestick injury, the nurse should 21. A nurse is contributing to the discharge plan for a client following surgery. Which of the following findings indicate the need for an interdisciplinary care conference? 22. A client who is 24 hour postoperative suddenly develops chest pain, dyspnea, anxiety, diaphoresis, and cough. Which of the following actions should the nurse take first? 23. A nurse is caring for a 17-year old client who is admitted for an emergency appendectomy. Which of the followign is an appropriate action by the nurse in obtaining informed consent? a. Obtain verbal consent from the client while waiting for the parents to arrive. b. Witness the signature of the client's parent when he arrives. c. Have the client's older sibling give consent if a parent is not available. d. Delay the procedure if the provider cannot contact the parents. 24. A nurse has delegated care to an assistive personnel. At the end of the shift, the Ap asks the nurse to enter data for her because the AP has forgotten her password and needs to leave. Which of the following actions should the nurse take? 25. A nurse is reinforcing discharge teaching to a client following a gastrectomy. To prevent dumping syndrome, which of the following foods should the nurse instruct the client to avoid? 26. A nurse is caring for a client admitted with shortness of breath who will be undergoing arterial blood gas testing. Which of the following client statements indicated an understanding of the purpose of drawing arterial blood gases? 27. A nurse manager is seeking ways to increase cost-effectiveness on the unit. In which of the following client care situations should the nurse manager intervene? 28. A nurse is collecting data from a client who reports recent weight loss and a Chronic cough that is now producing blood-streaked sputum. For which of the following should the nurse expect the client to have diagnostic testing? 29. A nurse is caring for an older adult client with a decreassed level of consicousness. Which of the following is an appraoriate intervention related to the client's mouth care? 30. A nurse in a long-term care facility nots that the assistive personnel lack knowledge of blood glucose monitoring. The nurse should bring this observation to the attention of which of the following personnel? 31. A nurse is reinforcing discharge teaching for a client admitted with an acute myocardial infarction. Which of the following activities is appropriat for the client to participate in during the first two weeks following discharge? 32. A nurse is reinforcing teaching for a client undergoing radiation therapy to the neck. Which of the following should the nurse include? 33. A nurse is providing anticipatory guidance to the parent of a 6-year old child. Which of the following statements by the parent indicated an understanding of appropriate safety precautions for the child? 34. A nurse is collecting data from a client who presents to the clinic reporting vomiting. Which of the following findings indicate that the client is experiencing a fluid volume deficit? 35. A nurse is caring for a client who is recieving warfarin (coumadin) for deep vein thrombosis. The nurse observed that the client's INR is 3.8.Which of the following actions should the nurse take? 36. A nurse is reinforcing teaching with the parents of a 4-month-old infant during a home visit. Which of the following findings in the infant's room indicates a need for further teaching? 37. A nurse is caring for a client who has hepatitis B. When caring for the client, which of the following actions places the nurse at highest risk for acquiring hepatitis B? 38. A nurse is reinforcing dietary teaching with a client whose prepregnancy BMI was 30.5. The nurse evaluates tha the client understands the teaching when she states she will gain. 39. A nurse is reinforcing teaching with school staff about streptococcal infection of the pharynx. The nurse should instruct the staff that the period of contagion for children who have this infection is which of the following? 40. A nurse is caring for a client who is 2 days postperative following a partial bowel resection. The client reports that the "felt something pop" whne he sneezed. The nurse observes an evisceration. After calling for assistance, which of the following actions should the nursetake first? 41. A nurse is caing for a client who is in balanced skeletal traction for a leg fracture. Which of the following should the nurse expect to be included in the care plan? 42. A nurse is using contact precautions while caring for a todlder. Which of the following actions should the nurse take? 43. A client's daughter calls the nurse requesting information about her mother's condition. The client's chart does not specify that information can be released to the daughter. Which of the following is an appropriate response by the nurse? 44. A nurse is reviewing the immunization records of a 9 year old child during a routine physical exam. Which of the following should indicate to the nurse the child is not current with he minimum required immunization? 45. A nurse is reinforcing teaching with a new mother on facility security measure. Which of the follwing statements by the mother indicates that the teaching was effective? 46. A nurse is reinforcing teaching with a client who is at 10 weeks gestation and has a medical history of mild hypertension. The nurse should remind the client to call the clinic if she 47. A nurse is caring for a client who has been placed in restraints. Which of the following is appropriate? 48. A nurse is working on a mental health unit is reviewing policies for client seclusion. For which of the following is seclusion appropriate? 49. A nurse in a long-term care facility has recieved a change-of-shift report on four clients. Which of the following clients should the nurse attend to first? 50. A nurse is applying a condom catheter to a male client who is incontinent. Which of the following is an approriate technique to use? 51. A nurse is assisting a client to move up in bed. Which of the following actions should the nurse take? 52. A nurse is supervising an assitive personnel (AP). During the morning meal, the nurse observes the AP accidentally spill a cup of coffee on a client. Which of the following actions should the nurse take? 53. A nurse is reinforcing teaching to a first-time mother about toddler safety. The nurse should recognize the client's understanding of the teaching when the client states, "I will 54. A nurse is preparing a sterile field to peform a dressing change. Which of the following actions should the nurse take? 55. A nurse is collecting data from an adolescent client who is a victim of sexual abuse. The nurse recognizes the use of the defense mechanism of suppression when the client states, 56. A client is prescribed 2g of ampicillin. The pharmacy dispenses this medication in 500 mg tablets. Which of the following should the nurse give the client? 57. A nurse is providing home care to a client and is reinforcing teaching regarding home safety. Which of the following by the client indicates a need for further teaching? 58. A Client with emphysema asks the nurse why he has difficulty exhaling. Which of the following statements by the nurse is appropriate? 59. A nurse is caring for a client who was admitted 12 hours ago and is experiencing acute alcohol withdrawal. Which of the following is an expected finding for the client? 60. A nurse is caring for a client who is in active labor and is accompanied by her partner. The client and her partner tell the nurse they were unable to attend childbirth preparartion classes. Which of the following responses by the nurse supports the partner's involvement during labor? 61. A nurse is planning tracheostomy care for a client in a long-term care facility. Which of the following actions should the nurse plan to take first? 62. A nurse in a provider's office is reinforcing teaching with the parents of a school-age child who has an active case of pediculosis capitis. Which of the following should be included in the teaching? 63. A nurse caring for the mother of a newborn finds the client crying in her room. The client tells th nurse, "I don't think I can handle caring for a baby." Which of the following nursing interventions is appropriate? 64. A nurse is assisting with the care of a 36-year-old client who is at 16 weeks of gestation an is scheduled for an amniocentesis. The nurse recognizes that the client understands the amniocentesis is performed to identigy 65. A nurse is caring for client who is requsting assistance with smoking cessation. For which of the follwing medications should the nurse anticipate having to reinforce teaching? 66. A nurse is caring for a client who is 12hr postpartum. The nurse observes an increase in vaginal bleeding. Which of the following actions should the nurse plan to take first? 67. A nurse is caring for a client with diabetes mellitus who has an order for daily morning insulin before breakfast. The client refuses his blood glucosse check at 0700. Which of the following actions should the nurse take? 68. A nurse in a long-term care facility is reviewing a client's laboratory results. The client's potassium level is 5.8 mEq/L. Which of the following findings should the nurse expect? 69. A nurse is collecting data during a well-child visit of a 12-month-old infant. Which of the following statements made by the parent indicates a need for further evaluation? 70. A nurse is caring for a client who is receiving IV therapy. The nurse suspects fluid infiltration. Which of the followin findings should the nurse expect at the insertion site? 71. A nurse is caring for a client who is newly diagnosed with type 1 diabetes mellitus. The nurse should recognize that the client needs a referral for diabetic education when the client 72. A nurse is reinforcing discharge instructions regarding umbilical cord care to the mother of a newborn. Which of the following statements by the mother indicates the teaching was effective? 73. A nurse in a long term care facility is planning to perform hygiene care for a newly admitted male client with Parkinson's diseae who is ambulatory. Which of the following is an appropriate statemnt by the nurse prior to starting routine care? 74. A client who is participating in an anger management session explains that his recent behaviors are related to his job loss. Which of the following defense mechanisms is the client using? 75. A nurse is reinforcing teaching with a new mother of a full-term newborn about breastfeeding. The newborn is 5 days old. Which of the following statements by the mother indicates an understanding of the teaching? 76. A nurse is reinforcing teaching to the parent of a child who has been prescribed ferrous sulfate (Feosol) in liquid form. Which of the following statements made by the parent indicates the teaching was effctive? 77. A nurse is preparing to administer 0.9% sodium chloride 1,000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? 78. A nurse is reinforcing teaching to a group of adolescent males. Which of the follwing statements made by a student indicates a need for further teaching? 79. An infant is admitted to a pediatric unit following a motor-vehicle crash with a subsequent head injury. For which of the following should the nurse monitor to identify increased intracranial pressure? 80. A nurse is caring for a client who is terminally ill and requires ongoing palliative care. Which of the fllowing interventions is consistent with the goals of this type of care? 81. A nurse in an inpatient psychiatric unit is a caring for a client who was raised in an Asian culture. Which of the following communication techniques demonstrates cultural sensitivity. 82. A nurse is caring for a client who has an order for a 12-lead ECG. Which of the following actions should the nurse take? 83. A newly admitted client tells the nurse that he does not have an advance directive. Which of the following is the appropriate action for the nurse to take? 84. A nurse is observing a client who is in the manic phase of bipolar disorder. The client states, "Don't need to eat today. Where's the money? Time to write that speech." The nurse should document this as which of the following? 85. A nurse is reinforcing dietary teaching to a client who has end-stage renal failure. Which of the following instructions should the nurse include in the teaching? 86. A nurse is assisting with the admission of a client who attempted suicide. When the nurse processes the client's belongings, which of the following items should the nurse remvoe from the client's suitcase? 87. A nurse is collecting data from a client at an urgent care clinic. The client tells the nurse that she hasn't been able to sleep since the death of her father 2 days ago. Which of the following is the nurse's priority action? 88. A nurse is planning care for a client who is 6 hours postoperative following a right knee arthroplasty. Which of the following interventions should the nurse include in the client's care plan? 89. A nurse in pediatric clinic is reviewing the history of a 11-year-old child. Which of the following immunizations should the nurse anticipate administering? 90. A nurse is caring for a client who was recently diagnosed with paranoid schizophrenia and is taking risperidone (risperdal). Which of the following statements by the family indicates a need for further teaching? 91. A nurse is caring for a newly postoperative client who has unilateral breath sounds and asymmetrical chest expansion. The nurse should recognize these findings are indicative of which of the following and should be reported to the provider? 92. A nurse is planning care for a client with delirium. Which of the following should the nurse recognize as interfering with the client's recovery? 93. A nurse is caring for a client who has paranoid schizophrenia and believes that she is being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make? 94. A nurse is monitoring a client who is in labor. Which of the following findings needs further evaluation? 95. A nurse is taking the vital signs of an adult client who has just been transfered from the PACU to the clinical unit. Which of the following findings should the nurse recognize as the most significant? 96. A nurse observes a client who has Alzheimer's disease and is experiencing aphasia. Which of the following behaviors should the nurse expect? 97. A nurse in a long-term care facility is caring for an older adult client who has a history of hypertension. Which of the following is indicative of transient ischemic attacks? 98. A nurse is caring for a client experiencing alcohol withdrawal. Which of the following medications should the nurse anticipate administering? 99. A nurse is caring for a cliet who has borderline personality disorder. The client states, "I look forward to seeing you in the morning because the night nurse treats me badly." Which of the following behaviors is the client likely demonstrating? 100. A nurse is planning a health-promotion program for high school students. Which of the following facts about cigarette smoking is likely to be most effective in changing the adolescents' attitudes towards smoking? 101. A nurse is caring for a school-age child whose family adheres to a vegan diet in the home. The nurse should recognize the child is at risk for deficiency of which of the following? 102. A nurse is caring for a client who has esophageal cancer. A gastrostomy tube is in place and the client is receiving continuous tube feedings. Which of the following actions should the nurse take? 103. A nurse is reinforcing teaching with a group of expectant parents regarding the proper use of car seat. Which of the following statements by a parent indicates an understanding of the teaching? 104. A nurse is preparing to apply a pulse oximeter to a client's finger. Which of the following actions should the nurse take before applying the sensor? 105. A nurse is caring for a client who is asking about the technique of effleurage and its use in labor and delivery. Which of the following responses should the nurse make regarding this technique? 106. A nurse is administering hydromorphone (Dilaudid) to a client who is experiencing postoprerative pain. Which of the following is an adverse affect of this medication? 107. A nurse is administering medication. A client states, "I know that the inderal helps my blood pressure, but I don't like the way it makes me feel. I don't think I'll take it today." Which of the following actions should the nurse take? 108. A nurse is reinforcing teaching with a client regarding the use of guided imagery to relieve back pain. Which of the following statements made by the nurse is appropriate? 109. A nurse is caring for an older adult client who is postoperative following a total hip replacement. The client is incontinent of stool and urine. To prevent skin breakdown, the nurse should 110. A client comes to the clinic with reports to nasal congestion. Which of the following medications should the nurse anticipate that the primary care provider will prescribe? 111. A nurse is provider's office is reinforcing teaching to the parents of a school-age child who has an ankle sprain. The nurse should include which of the following statements in the teaching? 112. A nurse is caring for a client with a closed head injury. Which of the following findings should indicate to the nurse a need for futher data collection? 113. A nurse is reinforcing teaching regarding management of penetrating eye injuries with a parent of a school-age child during a sports physical. Which of the following statements by the child's parent indicates an understanding of the teaching? 114. A nurse is reinforcing teaching to the parents of an infant who has pavlik harness. Which of the following statements should the nurse include in the teaching? 115. A nurse is caring for a client in a mental health inpatient facility who reports auditory and visual hallucinations. Which of the following should the nurse recognize as indicating the client is most in need of intervention? 116. A nurse is reinforcing teaching for a client who has just started taking amitriptyline (Elavil). Which of the following should the nurse include as an adverse effect of this medication? 117. A nurse in a long-term care facility is caring for a client who uses a continuous positive airway pressure (CPAP) machine at night for sleep apnea. The client reports daytime sleepiness. Which of the following actions should the nurse take first? 118. A nurse is caring for a client in the provider's office who has is experiencing an episode of acute asthma. The nurse should aminister which of the following medications? 119. A nurse is assisting with the care of a client who is recieving IV therapy of 0.9% sodium chloride. The client recieved 200mL more than prescribed in 1 hr because the infusion pump was set incorrectly. Data collection reveals that the client is stable. This incident does not meet the criteria of malpractice because 120. A nurse is reinforcing teaching with a client who is undergoing chemotherapy to treat laryngeal cancer and has developed mucositis. Which of the following client statements indicates an understanding of the teaching? 121. A nurse is caring for a toddler who is addmitted to the pediatric unit and is 2 hr postoperative following a tonsillectomy. Which of the following findings is a sign of hemorrhage? 122. A nurse is caring for an adolescent client who has anorexia nervosa. Which of the following findings should the nurse expect? 123. A nurse has administered cephalexin (Keflex) to a client. Which of the following is the earliest indicator of an anaphylatic reaction? 124. A nurse is admitting a client with active tuberculosis. Which of the following is an appropriate nursing intervention? 125. A nurse is providing change-of-shift report on four clients. Which of the following is most important for the nurse to include in the report? 126. A nurse is caring for a client who has an order for NPH insulin (Humulin N) 10 units and regulat insulin (humulin R) 15 units SQ. Which of the following actions should the nurse perform first? 127. A nurse discovers a fire in the trash can of a client's room. Which of the following actions should the nurse take first? 128. A client has a large, deep ulcer on her right hip. The primary care provider has prescribed a woman vacuum to be applied. Which of the following is an appropriate nursing action? 129. A nurse is reinforcing teaching to a client who has been taking dig 0.25 mg PO daily for 6 months, which of the following indicates a need for further teaching? 130. A nurse recevies a verbal order for a client to recieve a stat dose of meperidine (demerol) 100 mg PO. she administers the medication, charts the administration, and then realizes she has admiistered Phentoin (dilantin) 100 mg PO. After obtaining the client's vital signs, which of the following actions should the nurse take? 131. A nurse is administering medication to a client. Which of the following actions is appropriate for the nurse to take? 132. A nurse is reinforcing discharge teaching to a client who is prescribed propylthiuracil. for which of the following should the nurse instruct the client to monitor and report to the provider immediately? 133. A nurse is reinforcing foot care to a client with diabetes mellitus. Which of the following clients statements indicate to the nurse a need for further teaching? 134. A nurse is caring for a client who has heart failure and is taking furosemide (lasix). Which of the following statements made by the client indicates a need for the nurse to intevene? 135. A nurse is reinforcing teaching to a client who has a new prescription for transdermal nitroglycerin (Nitro-Dur). Which of the following statements indicates the client understands the teaching? 136. A nurse is caring for a client who is 2 days postoperative. The client has a prescription for acetaminophen 300mg with codeine 30 mg (Tylenol #3), 1 tablet every 3 to 4 hr PRN for pain. The nurse inadvertently gave the client 2 tablets. Which of the following is the proper place to document this error? 137. A nurse is caring for a client in a mental health unit who is pacing back and forth and wringing his hands. Which of the following interventions should the nurse implement? 138.A nurse is reinforcing teaching about levothyroxine (synthroid) to a client has hypothyroidism. Which of the following should the nurse instruct the client to expect? 139. A nurse is caring for a client who is in bed and experiencing a toni-clonic seizure. Which of the following actions should the nurse take? 140. A nurse is preparing to irrigate a wound of a client who has methicillin-resistant Staphylococcus aureus (MRSA).The nurse should use which of the following personal protective equipment? 141. A nurse is collecting data for a client who has been recieving medroxyprogesterone acetate (Depo-Provera) for the past 6 months. Which of the following statements made by the client should be reported to the provider? 142. A nurse is reinforcing teaching with a new mother regarding the use of breast milk. Which of the following statements by the mother indicates an understanding of the teaching? 143. A nurse in a long-term care facility is caring for a client who has spinal cord injury. The client is demonstrating menaifestations of autonomic dysreflexia. Which of the following actions should the nurse take first? 144. A nurse is caring for a toddler who was admitted for pneumonia. Which of the following findings has the highest priority? 145. A nurse is reinforcing teaching for a client regarding various forms of contraception. The nurse should recognize that the client understands the instructions if she says, "I will 146. A nurse is preparing to administer K+ gluconate (kaon) 60mEq PO in three equally divided doses. Available is K+ gluconate 20 mEq/15 mL. How many mL should the nurse administer with each dose? 147. A nurse is reinforcing teaching to a client who has GERD and is prescribed raintidine (Zantac). Which of the following indicates an understanding of the teaching? 148. A nurse is reinforcing teaching with a client diagnosed with diabetes mellitus requiring insulin injections. Which of the following statements made by the client indicates understanding of the teaching? 149. A client newly diagnosed with bipolar disorder asks the nurse, "How long will I have to take lithium?" Which of the following is an appropriate response by the nurse? 150. A nurse in the birthing unit is assisting with the care of a client who is at 38 weeks gestation and has bring red vaginal bleeding but denies pain. 151. A nurse is reinforcing teaching regarding the dietary intake needed to reduce the risk of neural tube defects with a client who is planning to become pregnant. 152. The parent of a 3 year old child tells the nurse that he is concerned because his daughter has begun playing with an imaginary friend. Which of the following is an appropriate response by the nurse? 153. A nurse is reinforcing teaching regarding home care with a client who is scheduled for discharge following a coronary artery bypass graft. understands teaching? 154. A mother of two small children tells the nurse, "I just dont know what to do about my cancer. Ive seen three doctors, and each one recommended a different treatment options." appropriate response. 155. A nurse is reinforcing discharge instructions for an older adult client regarding management of hypertension. Which of the following should the nurse instruct the client to do when evaluating for the presence of orthostatic hypotension? 156. A nurse is reinforcing teaching with a client who is scheduled to undergo a fiberoptic bronchoscopy. Which of the following client statements indicates an understanding of the procedure? 157. A nurse is caring for a client who is in labor and has requested an alternative birthing plan. The client is experiencing back pain. Which of the following nursing actions is most effective? 158. A nurse is caring for a postoperative client who has a midline abdominal incision and notes dehiscence of the wound edges with protrusion of internal organs. Which of the following actions should the nurse take? 159. A nurse is collecting data from a cient who is pregnant and has hypermesis gravidarum. Which of the following finding should the nurse expect? 160. A nurse is caring for a postoperative client and obtains a pulse oximeter reading of 89%. Which of the following interventions should the nurse take first? 161. A nurse receives report on four clients. The nurse should first collect data about the client who has 162. A clinic nurse is reviewing laboratory values for a client who is at 34 weeks of gestation. Which of the following laboratory values should the nurse report to the provider? 163. A client who has inoperable cancer tells the nurse that she does not want to pursue the recommended treatment. She asks if the provider can force her to have the treatment. appropriate response. 164. A nurse is caring for a client receiving PRBCs. The following finding should the nurse recognize as indicative of excess fluid volume? 165. A nurse is caring for a client who was placed in a cast 12 hr ago due to a fractured left tibia. Which of the following findings is the highest priority? 166. A nurse is collecting data from a female client who wishes to begin oral contraception. Which of the following is a contraindication to the use of oral contraceptives? 167. A nurse is monitoring a client who is receiving a unit of packed red blood cells (PRBCs). The nurse recognizes an allergic reaction when the client reports 168. A nurse is reinforcing teaching to a client who is scheduled for electroconvulsive therapy. Which of the following statements by the client indicates and understanding of the teaching? 169. A nurse finds a client's wife crying in the hallway. she states, "I just don't know how I am going to go on after he is gone." Which of the following is an appropriate responses by the nurse? 170. A nurse is caring for a client whose previous blood pressure reading have been within the expected reference range. The clien'ts current blood pressure reading is suddenly elevated above the expected range. Which of the following factors can contribute to a false high blood pressure reading? 171. A nurse is caring for a client who is experiencing respiratory acidosis. The nurse should expect which of the following serum pH levels? 172. A woman who is postmenopausal presents to a clinic for a well-woman examination. She tells the nurse that she does not understand the need for a Pap test because she is no longer experiencing menses. Which of the following responses by the nurse is appropriate? 173. A nurse in provider's office is talking on the phone with a parent of a school-age child who has varicella. The parent asks the nurse when the child can return to school. The nurse tells the parent the child is no longer contagious when 174. A nurse is collecting data from a client who is in her third trimester of pregnancy during a routine prenatal visit to the provider's office. The client reports she feels dizzy, has clammy skin, and becomes pale while lying down. The nurse should tell the client that when she feels this way, she should do which of the following? 175.A nurse should monitor a client who is taking Lasix for which of the following adverse effects? 176. A nurse is implementing a bladder training program for a client after a cerebrovascular accident. Which of the following inteventions by the nurse is appropriate for the client? 177. A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect? 178. A nurse is reinforcing teaching to an adult client who is prescribe Lipitor. The nurse should advise the client that which of the following is an adverse effect of this medication and should be reported to the provider? 179. A nurse is planning client care for a shift. Which of the following should the nurse plan to delegate to an assistive personnel? 180. A nurse is assisting with the admission of an adolescent client who is suspected of having bacterial meningitis. Which of the following findings should the nurse expect?