0.A nurse is assisting with planning care for a client who is recovering from a lefthemispheric stroke. Which of the following interventions should the nurse include in the
plan?
1) Control impulsive behavior.
2) Com
...
0.A nurse is assisting with planning care for a client who is recovering from a lefthemispheric stroke. Which of the following interventions should the nurse include in the
plan?
1) Control impulsive behavior.
2) Compensate for left visual field deficits.
3) Re-establish communication.
4) Improve left-side motor function.
11.A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should
monitor the client for which of the following manifestations?
1) Hypotension
2) Polyphagia
3) Hyperglycemia
4) Bradycardia
12.A nurse is reviewing the laboratory results of a client who is postoperative and has a
respiratory rate of 7/min. The arterial blood gas (ABG) values include:
pH 7.22
PaCO2 68 mm Hg
Base excess -2
PaO2 78 mm Hg
Oxygen saturation 80%
Bicarbonate 28 mEq/L
Which of the following interpretations of the ABG values should the nurse make?
1) Metabolic acidosis
2) Respiratory acidosis
3) Metabolic alkalosis
4) Respiratory alkalosis
13.A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD).
The nurse should recognize that which of the following statements by the client indicates a
need for further teaching?
1) "I will avoid crossing my legs at the knees."
2) "I will use a thermometer to check the temperature of my bath water."
3) "I will not go barefoot."
4) "I will wear stockings with elastic tops."
14.A nurse is reinforcing teaching with a client who reports right shoulder pain following a
laparoscopic cholecystectomy. Which of the following statements should the nurse make?
1) "The pain results from lying in one position too long during surgery."
2) "The pain occurs as a residual pain from cholecystitis."
3) "The pain will dissipate if you ambulate frequently."
4) "The pain is caused from the nitrous dioxide injected into the abdomen."
15.A nurse is checking the suction control chamber of a client's chest tube and notes that there
is no bubbling in the suction control chamber. Which of the following actions should the
nurse take?
1) Notify the provider.
Answer Rationale:
The nurse should check for kinks and take other measures before notifying the provider.
2) Verify that the suction regulator is on.
3) Continue to monitor the client because this is an expected finding.
4) Milk the chest tube to dislodge any clots in the tubing that may be occluding it.
16.A nurse is assisting with the care of a client immediately following a lumbar puncture.
Which of the following actions should the nurse take? (Select all that apply.)
1) Encourage fluid intake.
2) Monitor the puncture site for hematoma.
3) Insert a urinary catheter.
4) Elevate the client’s head of bed.
5) Apply a cervical collar to the client.
17.A nurse is assisting with the care of a client who is postoperative following surgical repair
of a fractured mandible. The client’s jaw is wired shut to repair and stabilize the fracture.
The nurse should recognize which of the following is the priority action?
1) Relieve the client's pain.
2) Check the client’s pressure points for redness.
3) Provide oral hygiene.
4) Prevent aspiration.
18.A nurse is collecting data from a client who has scleroderma. Which of the following
findings should the nurse expect?
1) A dry raised rash
2) Excessive salivation
3) Periorbital edema
4) Hardened skin
19.A nurse is caring for an older adult client who has dysphagia and left-sided weakness
following a stroke. Which of the following actions should the nurse take?
1) Instruct the client to tilt her head back when she swallows.
2) Place food on the left side of the client's mouth.
3) Add thickener to fluids.
4) Serve food at room temperature.
20.A nurse is caring for a client who has partial-thickness and full-thickness burns of his head,
neck, and chest. The nurse should recognize which of the following is the priority risk to
the client?
1) Airway obstruction
2) Infection
3) Fluid imbalance
4) Contractures
21.A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia
gravis and is to start taking neostigmine. Which of the following instructions should the
nurse include in the teaching?
1) Take the medication 45 minutes before eating.
2) Expect diaphoresis as a side effect of the neostigmin
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