• Rational: reservoir bag should not deflate completely during inspiration and the client’s respiratory rate is within normal limits. • During shift report, the central electrocardiogram (EKG) monitoring system alarms. W
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• Rational: reservoir bag should not deflate completely during inspiration and the client’s respiratory rate is within normal limits. • During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate firs? • Respiratory apnea of 30 seconds • During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should the nurse take first? • Check the client for lacerations or fractures • At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid
getting a headache. Which action should the nurse take first? • Inform the anesthesia care provider • After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first? • Listen with the bell at the same location • A 66-year-old woman is retiring and will no longer have a health insurance through her place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs? • Medicare
• A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline? • Toasted wheat bread and jelly
• Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse that the client is experiencing a complication? • “I have a headache that gets worse when I sit up”
• “I am having pain in my lower back when I move my legs”
• “My throat hurts when I swallow”
• “I feel sick to my stomach and am going to throw up”
• An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement?
• Obtain a clean catch mid-stream specimen
• The nurse is assisting the mother of a child with phenylketonuria (PKU) to
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