HESI NCLEX-RN Saunders Review Test 1 | Contains 70 Q&A with Rationale and Test taking strategies | Priority, Giddens and HESI Concepts and the References.

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HERE ARE THE QUESTIONS CONTAINED IN THE ATTACHMENT Saunders Review: HESI NCLEX-RN Test 1 1.ID: 9477033456 A client is being discharged home after a routine hip replacement surgery. The nurse is ins... tructing the client on how to prevent postoperative complications. What statements by the client would indicate the need for further teaching? Select all that apply. A. “Limiting fiber is necessary to avoid diarrhea.” B. “I should empty my bladder when I feel the urge.” C. “Avoiding pain medication will prevent constipation.” D. “I should drink plenty of liquids like iced tea or coffee.” E. “I should continue with my physical therapy and walking.” 2.ID: 9477039828 The nurse is caring for a Vietnamese client diagnosed with tuberculosis. The client speaks limited English. What should the nurse do to ensure the client and family receives the most accurate information? Select all that apply. A. Provide culturally sensitive education. B. Encourage family members to obtain a tuberculosis skin test. C. Provide written instructions in English for the client to reference. D. Encourage the client and family to wash all dishes by hand to prevent the spread of infection. E. Urge all family and close contact community members to seek and complete treatment to enhance compliance. 3.ID: 9477038294 A client with anxiety has just been seen by the health care provider and has been prescribed alprazolam. The client asks the nurse how long it will take for the medication to build up a steady state in her body. If the half life of this medication is approximately 11 hours, approximately how long will it take for this medication to build up and reach a steady state? hours Responses A. 55 4.ID: 9477033419 The nurse is observing the cardiac monitor of a client and notes this cardiac rhythm (refer to figure). What is the initial nursing action? A. Check for a pulse B. Notify the health care provider C. Obtain a 12 lead electrocardiogram (ECG) D. Begin cardiopulmonary resuscitation (CPR) 5.ID: 9477032613 A mother brings her 9-month-old child to see the pediatrician and has concerns that the child may have a developmental delay because the child cannot roll over yet. for the nurse should ask the mother about which risk factors associated with a developmental delay? Select all that apply. A. Age B. Race C. Income D. Chronic illness E. Low birth weight F. Environmental exposure to toxins 6.ID: 9477043118 The nurse in a pediatric unit is planning the staff assignments for children with developmental delays. When planning the assignment, the nurse decides to assign those children who have social or emotional delays amongst different nurses. Which children should be assigned to different nurses? Select all that apply. A. A child with autism B. An infant with fetal alcohol syndrome C. A child with attention deficit disorder D. A child with generalized anxiety disorder E. A child with expressive language disorder 7.ID: 9477035226 The client has been prescribed amoxiciilin 250 mg three times daily for sinusitis. The medication is supplied in a 500 mg tablet. How many tablet(s) would the nurse prepare every 8 hours to administer the dose? Fill in the blank. Record the answer using one decimal place. tablet(s) Responses . 8.ID: 9477039851 The nurse is caring for a client admitted to the hospital for shortness of breath and edema in both lower extremities. The client is prescribed furosemide 40mg by the intravenous route once daily. What information in the chart would warrant the nurse to verify continuing the prescription with the health care provider (HCP)? Refer to chart. a t o r yr a l e s o n a u s c u l t a t i o n sur e 145/94m m Hg 20m g or all y da ily Pe r i p h e r a l Va Se ru m Po tas siu m 3.5m Eq/L At or va st at in 10m g or all s c u l a r Di s e a s e ( P V D) (3.5m m ol/ L) y at be dt im e A. Expiratory rales B. Atorvastatin prescription C. Peripheral vascular disease D. Potassium level of 3.5 mEq/L (3.5 mmol/L) 9.ID: 9477033433 A nurse employed at a nursing home is caring for a client who has recently been transferred from the hospital to the nursing home. The client is confused and is acting out. The nurse suspects the client is suffering from relocation stress. The nurse should include which helpful actions in the plan of care? Select all that apply. A. Encourage friends and family to visit frequently. B. Establish a trusting relationship with the client as soon as possible. C. Change rooms frequently to prevent the client from becoming bored. D. Ensure the client is an active part of decision making regarding their care. E. Allow the client to move around the halls as desired to decrease the confusion and acting-out. 10.ID: 9477034772 The nurse is caring for a client in the hospital and is reconciling the client’s home medications. The client is taking Lactobacillus, a probiotic over-the counter medication. The nurse is discussing the supplement with the client. What statement by the client would warrant the need for further teaching? Select all that apply. A. “I can take my probiotic at any time of day or night.” B. “Probiotics can be found in yogurt and some juices.” C. “I should take this supplement to prevent gas and bloating.” D. “Because I’m lactose intolerant, a probiotic would not benefit me.” E. “This supplement will help me avoid getting diarrhea from antibiotics.” 11.ID: 9477042148 The nurse educator is presenting a lecture on child neglect. Which statement by one of the students indicates that the teaching has been effective? Select all that apply. A. “A sign of neglect are bruises on the child’s body.” B. “Neglected children show aggression after age 10.” C. “Neglect is parental failure to meet a child’s basic needs.” D. “Neglected children often have learning problems and low self- esteem.” E. “Neglect occurs when a parent does not seek medical attention for a sick child.” 12.ID: 9477032667 The nurse is obtaining the medical history from an older client with a black eye and bruising to the head. The nurse suspects that the client has been abused, and that there may be a history of abuse. Which statement by the client indicates the need for further questioning by a social worker? Select all that apply. A. “Perhaps I somehow did this to myself.” B. “I tripped over a rug and now I have a black eye.” C. “I got into a car accident yesterday and the airbag deployed.” D. “Well, I don’t remember anything that would have caused the injuries.” E. “Sometimes my grandson becomes angry with me when I can’t give him money.” 13.ID: 9477043128 The nurse is meeting with an older client who was brought into the health care facility for evaluation. According to the family member, the client has lost a large amount of weight recently and does not eat much. Which actions would be the most important for the nurse to take? Select all that apply. A. Assess the client's eyesight. B. Question the client about urinary habits. C. Obtain a list of the client's medications. D. Determine the fit of the client's dentures. E. Assess the client for mental status changes. 14.ID: 9477042181 The nurse is caring for a malnourished client with dementia and a history of rheumatoid arthritis, and is creating a plan of care for the client’s nutrition. Which nursing actions are most appropriate for increasing the client's caloric intake? Select all that apply. A. Provide pain medications as needed. B. Play soft, calming music during mealtimes. C. Serve the food at the appropriate temperature. D. Provide the client with six small meals per day. E. Encourage the client to eat quickly, to prevent fatigue. 15.ID: 9477036624 The nurse is educating a client on obesity. Which statements by the client indicate a need for further teaching? Select all that apply. A. "Type II diabetes is a complication of obesity". B. "I will likely develop obstructive sleep apnea". C. "Physical inactivity is one of the causes of obesity". D. "My heart and lungs are mildly affected by obesity". E. "It is unlikely that I will develop peripheral artery disease". 16.ID: 9477038260 The nurse is attending a teaching sessionatt on communicating with the ill child. Which statement by the nurse indicates that the teaching has been effective? Select all that apply. A. "I will strive to maintain honesty and trust with each child". B. "Children are often reluctant to ask questions, when they fear the answers". C. "Providing as much information as possible will help ease the child's fears". D. "Complete honesty may cause problems for some family and staff members". E. "To prevent misunderstandings, I should ask the child to explain what is known". 17.ID: 9477039896 A client is being assessed for post-partum depression. Which actions by the client would indicate a need for follow-up by the nurse? Select all that apply. A. Not responding to the infant’s cries. B. Crying after talking with spouse on the phone. C. Stating that family was not supportive of the pregnancy. D. Making statements about being fat and unattractive now. E. Stating that that the infant latched on properly during a feeding. 18.ID: 9477038244 The nurse is evaluating a client who is four weeks post-partum. Which statement by the client would indicate a need for intervention? Select all that apply. A. "I feel like giving up." B. "My husband never helps me with the baby." C. "My baby will not stop crying and I can't take it anymore." D. "I wish I could get more than four hours of sleep at a time." E. "My milk has come in and my baby is nursing every 2 hours." 19.ID: 9477036611 The client is being discharged home after the delivery of a healthy infant. The nurse is educating the client on how to prevent postpartum depression. Which activities are the most appropriate for the nurse to suggest? Select all that apply. A. Exercise on a regular schedule B. Eat a healthy, well-balanced diet C. Try to sleep when the baby sleeps D. Don’t overcommit yourself to activities that will be tiring E. Stay home with the baby as much as possible, to promote bonding 20.ID: 9477039870 The nurse is preparing to discharge a child who was treated in the emergency department. Which should the nurse consider when planning medication discharge instructions for the client's parents? Select all that apply. A. Provide the child's parents with a simple dosing schedule. B. Create a medication schedule that fits the parent’s lifestyle. C. Assist the child’s parents in obtaining the medication at an affordable cost. D. Ensure that the child's family is able to read the written discharge instructions. E. Refer the family to the pharmacist with questions about medication side effects. 21.ID: 9477042110 The nurse is preparing to administer blood to a client. Which actions by the nurse are the most appropriate before administration of the blood? Select all that apply. A. Assess laboratory values. B. Obtain and assess vital signs. C. Evaluate the client’s venous access. D. Identify the client by room number and bed. E. Check the health care provider’s prescriptions with another nurse. 22.ID: 9477041089 The nurse is evaluating a medication prescription written by the health care provider. Which pieces of information should the nurse verify has been included in the prescription? Select all that apply. A. The specific dosage B. The client’s home address C. The generic medication name D. The length of time for the administration E. The route and frequency of administration F. 23.ID: 9477039841 The nurse is caring for a postoperative client with a patient controlled analgesia (PCA) pump. When creating the client’s plan of care, which opiate-induced side effects should the nurse monitor? Select all that apply. A. Sedation B. High blood glucose C. Increased appetite D. Nausea and vomiting E. Elevated cardiac enzymes 24.ID: 9477041052 The nurse is providing discharge instructions to a client with rheumatoid arthritis who is taking leflunomide. Which instructions should the nurse give to the client? Select all that apply. A. “You may lose your hair.” B. “It is ok to drink alcohol.” C. “Diarrhea is a common side effect.” D. “It has been shown that leflunomide can cause birth defects.” E. “Leflunomide is a potent medication that is generally tolerated.” 25.ID: 9477034713 The nurse is caring for a client who has been admitted to the intensive care unit with acute pulmonary edema. After assessing the client, the nurse administers furosemide as prescribed. Which actions by the nurse are the most important after administering the medication? Select all that apply. A. Assess lung sounds B. Measure urine output C. Obtain and monitor vital signs D. Document the client’s meal intake E. Assess the client for pitting edema 26.ID: 9477038207 The nurse preceptor is orienting a new nurse on an acute medical-surgical unit and educating the nurse on peripherally inserted central catheters (PICCs). Which statement by the new nurse indicates an understanding of a PICC? Select all that apply. A. “The tip of the PICC line sits in the superior vena cava.” B. “Insertion of the PICC line occurs in the operating room.” C. “PICCs can accommodate infusions of all types of therapy.” D. “PICCs with a lumen size of 14 Fr or larger can be used for blood sampling.” E. “PICCs are the most appropriate for client’s who require short-term antibiotics.” 27.ID: 9477039859 The nurse is assigned to care for a client who needs an intravenous (IV) catheter inserted and will receive an IV infusion of a vesicant medication. When creating a plan of care for the client, which interventions should the nurse include in the plan? Select all that apply. A. Assess the skin integrity B. Monitor the site frequently C. Place the IV at an area of flexion D. Educate the client about the signs and symptoms of infiltration E. Understand the vesicant potential before administering the infusion 28.ID: 9477041010 The nurse is preparing to administer oral potassium chloride to a client. What should the nurse keep in mind about this medication? Select all that apply. A. Potassium has a strong, unpleasant taste. B. Potassium can only be mixed with water. C. Potassium may be taken in a liquid or solid form. D. Potassium chloride can cause nausea and vomiting. E. Potassium may be given as an intramuscular (IM) injection. 29.ID: 9477036698 The nurse is caring for a client with a latex allergy. Upon entering the client’s room, the nurse should plan to take which action as the priority? A. Perform a skin assessment B. Perform a physical assessment C. Ask if the client needs pain medication D. Remove the banana from the client’s breakfast tray E. 30.ID: 9477043159 The nurse has been assigned to care for an older client with a hip fracture who had surgical repair. After receiving report, the nurse learns that the health care provider has prescribed meperidine for pain management. Which action should the nurse take first? A. Prepare the medication B. Verify the dosage of meperidine C. Assess the client’s pain score before administration. D. Clarify the medication prescription with the health care provider. 31.ID: 9477043140 The nurse is caring for a client recovering from an abdominal aortic aneurysm (AAA) endovascular stent graft. What priority actions should the nurse include in the plan of care? Select all that apply. A. Assess for pedal pulses B. Monitor urinary output C. Administer analgesics as needed D. Keep the head of the bed elevated to at least 60 degrees E. Encourage use of an abdominal pillow when coughing or deep breathing F. 32.ID: 9477042167 The nurse notices that an older client’s skin is very dry. What actions would be appropriate for the nurse to implement into the care plan? Select all that apply. A. Ensure adequate hydration B. Wait 15 minutes after bathing to apply lotion C. Instruct the client to avoid caffeine and alcohol D. Rub skin surfaces dry in order to remove dead skin E. Use lavender scented lotion, which can help add moisture to the skin 33.ID: 9477036653 The nurse is caring for an older Japanese American man being treated in the oncology unit for prostate cancer. In order to provide culturally competent care, the nurse should include what actions in the care plan? Select all that apply. A. Address client by first name to promote a trusting relationship B. Routinely assess for pain, as Japanese Americans often remain stoic C. Provide personal space boundaries if client is in a semi-private room D. Allow for family to visit and participate in the decision-making process E. Encourage the client to verbally express their feelings and thoughts often 34.ID: 9477035276 The nurse is caring for a client in the emergency department who is being treated for major burns and smoke exposure. What information in the medical chart would warrant the nurse to call the Rapid Response Team immediately? Refer to chart. A. Asthma B. Hoarse voice C. Blood pressure of 98/62 mmHg D. Blood glucose of 68 mg/dL (3.7 mmol/L) E. 35.ID: 9477032603 The nurse is caring for a 55-pound child on the pediatric medical surgical unit being treated for Lyme disease. The health care provider has prescribed ceftriaxone (Rocephin) intramuscular 50 mg/kg/day in two divided doses. The nurse should administer how many milligrams per dose? Fill in the blank. mg 36.ID: 9477035297 The nurse is caring for a client with joint pain and is educating the client on pharmacological management of pain with acetaminophen. What statements made by the client would indicate a need for further teaching? Select all that apply. A. “This medication is safe to take with my warfarin.” B. “I should avoid eating grapefruit while taking this medication.” C. “I should not take this medication more often than 3 times per day.” D. “To prevent a stomach ache, I should take this medication with food.” E. “I should report any skin itching or yellowing of the skin to my healthcare provider.” 37.ID: 9477032625 The nurse is providing discharge education to a client that was admitted for treatment with Addison’s crisis and is reviewing the medication hydrocortisone. What statements made by the client would indicate teaching was effective. Select all that apply. A. “ I should take this medication twice a day.” B. “Weight gain is common and I should expect it.” C. “If I forget a dose, I should take two pills the next time.” D. “I may notice my cheeks become fat and rounded but this is okay.” E. “If I notice any swelling or fluid retention, I should notify my healthcare provider.” 38.ID: 9477038285 The nurse is caring for a client in active labor. The nurse notices that the fetal heart rate pattern is demonstrating late decelerations. Which position should the nurse assist the client into? Refer to figures 1-4. A. B. C. D. Rationale: 39.ID: 9477043150 A client is being treated on the medical surgical unit for a deep vein thrombosis (DVT). The client will be discharged home on oral anticoagulants. What information in the client’s medical record would warrant the need for teaching? Refer to chart. Hi st or y a n d Ph ys ic al La b o r a t o r y Fi n d i n g s Me d i c a t i o n s Ir o n- d e fic ie nt a n e m ia So d i u m 142m Eq/ L( 142m m o l/ L) Li s i n o p r i l 10m go r a l l yd a i l y 10p ac k ye ar hi st Po s i t i v e Vi t a m i n D or yof s mok in g D- Di m e r 400I Ud a i l y A. Sodium result B. D-Dimer result C. Vitamin D 400 IU daily D. 10 pack year history of smoking 40.ID: 9477039802 The post-operative client is experiencing moderate pain and requests pain medication from the nurse. The prescription reads: morphine 4 mg intravenous (IV) push every three hours as needed. The morphine is supplied in an ampule of 10 mg/mL. How many milliliters should the nurse administer? Fill in the blank and record your answer using the one decimal place. mL Responses A. 0.4 41.ID: 9477041034 The nurse is caring for an older client who is being treated for malnutrition. Which actions by the nurse would be the most appropriatewhen providing for this client’s care and comfort? Select all that apply. A. Ask if the client lives alone. B. Evaluate the fit of the client’s dentures. C. Educate the client on how to choose healthy foods. D. Determine if the client qualifies for any food services. E. Recommend that the client choose over-the-counter medications for ailments. 42.ID: 9477032683 The nurse is planning care for a client who is confused. The nurse should include which actions in the client’s care plan? Select all that apply. A. Allow a pet visit B. Play soft, calming music C. Toilet the client every 2 to 3 hours D. Evaluate the client for signs of pain E. Apply restraints as needed if the client becomes agitated 43.ID: 9477038218 The nurse is working in the emergency department when a client with heat exhaustion is brought in. Which actions would be the appropriate in order to effectively treat the client? Select all that apply. A. Remove any restrictive clothing. B. Administer salt tablets to the client. C. Apply cool water soaks to the client. D. Give the client an oral rehydrating solution. E. Apply ice packs to the client’s neck and groin. Awarded 3.0 points out of 4.0 possible points. 44.ID: 9477032654 The nurse is caring for a client who has just come in to the emergency department to receive treatment. The client reports a bite from a brown recluse spider. The nurse assesses the bite mark and notes that it is possibly infected. Which actions should the nurse take? Select all that apply. A. Apply ice to the site. B. Contact a surgeon immediately. C. Apply a non-sterile dressing to the site. D. Cleanse the area with a topical antiseptic. E. Assess the date of the client’s last tetanus shot. 45.ID: 9477033492 The nurse is educating a client on how to prevent altitude sickness. Which statements indicate that the teaching has been effective? Select all that apply. A. “I will drink plenty of water.” B. “I will wear sunscreen and high quality goggles.” C. “I will plan a quick ascent when changing to a higher altitude.” D. “I will refrain from consuming alcohol when I am at a high altitude.” E. “I will pay attention to the manifestations of altitude-related illnesses.” 46.ID: 9477032646 The nurse is educating a child’s parents on using the behavior modification technique of discipline. Which statement should the nurse make to the parents? A. “All behaviors should be acknowledged.” B. “Rewards are given at the end of the training period only.” C. “Negative behaviors are recorded where the child can see them.” D. “Corporal punishment should not be used to encourage good behaviors.” 47.ID The nurse is caring for a client who has been diagnosed with bladder cancer. Which action should the nurse take as a priority when planning psychosocial care for this client? A. Assess all urine for the presence of blood B. Question the client about insurance coverage C. Assess the client’s ability to cope with the diagnosis D. Ask the client if there is a history of cancer in the family 48.ID: 9477043106 A client has come to the emergency department complaining of burning with urination. What should the nurse consider a priority when providing care in order to maintain the client’s psychosocial integrity? A. Use medical terminology when speaking to the client. B. Provide the client with as much privacy as possible during the examination. C. Explain to the client that all questions will be answered at the time of discharge. D. Administer medications as soon as they are prescribed by the health care provider. 49.ID: 9477036669 The nurse is educating an older client on sources of stress. Which statements by the client indicate that the teaching has been effective? Select all that apply. A. “Relocating to a nursing home causes stress.” B. “Financial hardships can be a cause of stress.” C. “A lifestyle change such as retiring can cause stress.” D. “A history of anxiety can be a source of stress in the older person.” E. “The birth of a new grandchild is often a source of stress for the older person.” 50.ID: 9477041068 The nurse is caring for a client with bipolar disorder. When creating a care plan for this individual, which should the nurse include? Select all that apply. A. The client will understand what bipolar disorder is. B. The client will ask the nurse to refill the prescriptions each month. C. The client will be able to manage the symptoms of bipolar disorder. D. The client will perform activities of daily living (ADLs) independently. E. The client will state the importance of taking medications as prescribed. 51.ID: 9477035263 The nurse is creating a plan of care for a client that will undergo a total joint replacement. What should the nurse include in the client’s plan of care? Select all that apply. A. Teach interventions to reduce client anxiety B. Educate the client on what to expect after surgery C. Complete a physical assessment before the surgery D. Include the client’s family in discussions about the surgery E. Allow time for the surgeon to address questions after the surgery 52.ID: 9477036632 The nurse is caring for a client with a blood pressure of 80/54 mmHg. Which actions should the nurse take because of the risk of hypovolemic shock? Select all that apply. A. Insert a large-bore intravenous (IV) line B. Anticipate administering blood products C. Keep intravenous fluids to be administered cold D. Anticipate administering Ringer’s lactate solution E. Perform assessments and monitor the client closely 53.ID: 9477041022 The nurse is providing care to a client. After assessing the client, the nurse determines that the client’s self ability to change position is compromised. Which actions should the nurse take to reduce the risk of skin break down? Select all that apply. A. Assess the skin daily B. Implement a turning schedule C. Decrease the risk for skin shearing D. Keep the client’s skin clean and dry E. Document skin breakdown prevention measures in the plan of care 54.ID: 9477036644 The nurse is creating a plan of care for a client with a respiratory infection. Which actions should the nurse include in the plan of care to prevent the spread of infection? Select all that apply. A. Clean the client’s room daily B. Wash hands when they are soiled C. Wear gloves when giving a bath to the client D. Keep fingernails short and without nail polish E. Place a mask on the client’s face when transporting to other departments 55.ID: 9477039814 The nurse is caring for a client with cancer who has a sealed implant of a radioactive source. Which actions should the nurse take to promote safety for staff and visitors? Select all that apply. A. Keep the client’s door closed B. Limit each visitor to 1 hour per day C. Wear a lead apron while providing care D. Assign the client to a semi-private room E. Remove dressings and linens from the room as they are soiled 56.ID: 9477034751 The nurse provides information to a unlicensed assistive personnel (UAP) about caring for a client with neutropenia. Which statements by the UAP indicate that teaching has been effective? Select all that apply. A. “I should practice good hand washing.” B. “The client needs mouth care at least every 12 hours.” C. “The client may not have a high fever if infection occurs.” D. “Any sores or skin irritations should be reported right away.” E. “I need to take precautions to protect myself from the client’s illness.” 57.ID: 9477034736 The nurse is caring for a client who expresses an interest in alternative therapies to reduce the risk of illness and disease. What noninvasive activities should the nurse recommend to the client? Select all that apply. A. Yoga B. Meditation C. Biofeedback D. Acupuncture E. Herbal therapy 58.ID: 9477035254 The nurse is educating a new registered nurse (RN) about the Healthy People 2020 goals. Which statements by the RN indicate that teaching has been effective? Select all that apply. A. “Healthy People 2020 aims to promote healthy behaviors.” B. “Healthy People 2020 aims to make healthcare more affordable.” C. “Healthy People 2020 aims to improve the health of the geriatric population.” D. “Healthy People 2020 aims to eliminate preventable disease, disability, injury, and preventable death.” E. “Healthy People 2020 aims to create social and physical environments that promote good health for all.” 59.ID: 9477036685 The nurse is completing a health history on a client who is 12 weeks pregnant. Which findings should alert the nurse to the risk of potential parenting problems? Select all that apply. A. The client reports feeling depressed B. The client has new health insurance C. The client states that she likes hospitals D. The client states that the father is not supportive E. The client is homeless and often stays in local shelters 60.ID: 9477035241 When conducting the preoperative interview with the client, the client reports an allergy to shellfish. Which agent is most likely to cause an allergic reaction in this client? A. Latex B. Medical tape C. Providone-Iodine D. Intravenous (IV) fluids E. 61.ID: 9477034795 Which actions should the nurse take to adequately prepare a client for a thoracentesis? Select all that apply. A. Explain the procedure to the client B. Instruct the client not to move during the procedure C. Teach the client to take slow, deep breaths during the procedure D. Tell the client to expect a stinging sensation from the anesthetic E. Inform the client that it is common to feel pressure from the needle insertion 62.ID: 9477038228 The nurse is providing discharge teaching to the client who had a thoracentesis about the manifestations of a pneumothorax. Which statements should the nurse make to the client to help the client recognize signs/symptoms of a pneumothorax? Select all that apply. A. “Frequent coughing should be reported.” B. “Be sure and report any bluish color to the skin.” C. “A pneumothorax can cause a feeling of air hunger.” D. “Discomfort on the unaffected side should be evaluated immediately.” E. “Presents of a slanted trachea in the neck region need to be reported.” 63.ID: 9477035287 The nurse is caring for a client on a ventilator. Which symptoms should alert the nurse to the possibility of absorption atelectasis? Select all that apply. A. Crackles in the lungs B. Diminished lung sounds C. Decrease in blood pressure D. Increase in red blood cell count E. High oxygen saturation readings 64.ID: 9477042192 The nurse is caring for a client with heat stroke, who is being cooled with a cooling blanket. Which actions should the nurse take to ensure that the intervention is effective? Select all that apply. A. Administer antipyretics B. Rapidly lower the core temperature C. Monitor temperature continuously until it is stable D. Monitor for patency of the airway and prepare for intubation if necessary E. Prepare to insert an intravenous line for administration of fluids as needed 65.ID: 9477042129 Which interventions should be included in the care of a client with a chest tube? Select all that apply. A. Change the chest tube each shift. B. Assess the insertion site for signs of infection. C. Assess the water seal chamber for a continuous, strong bubbling. D. Keep the drainage system lower than the level of the client’s chest. E. Alert the health care provider (HCP) if drainage in the tube stops in the first 24 hours. 66.ID: 9477032637 The nurse is providing care to a client with chronic peripheral arterial disease (PAD). Which assessments findings should alert the nurse to the onset of an acute arterial occlusion? Select all that apply. A. Cyanosis of the skin in the affected extremity B. Skin temperature cool to touch in the affected extremity C. Client complaints of problems moving the affected extremity D. Complaints of sudden and severe pain in the affected extremity E. Bounding pulse in the affected extremity below the level of the occlusion 67.ID: 9477039882 Which manifestations are specifically noted in a client with right-sided heart failure.? Select all that apply. A. Ascites B. Hepatomegaly C. Breathlessness D. Dependent edema E. Neck vein distention 68.ID: 9477031490 The client with heart failure is preparing to be discharged from the hospital. Which interventions should the nurse include in the client’s discharge teaching plan? Select all that apply. A. Teach the client coping strategies B. Develop a regular exercise program C. Educate the client about dietary restrictions D. Give the client a minimal role in the self-management program E. Provide the client with a list of current medications and dosing times 69.ID: 9477038275 The nurse is educating a client on how to self-manage care at home, following an admission to the hospital for heart failure. Which statements by the client indicate that teaching has been effective? Select all that apply. A. “I will weight myself daily.” B. “I will wear my oxygen at night as prescribed.” C. “I will follow up with my health care provider (HCP) as scheduled.” D. “I will report new signs and symptoms to my home care nurse when she visits.” E. “I have my medications and dosages written down for easy review and administration.” 70.ID: 9477033404 The client has been diagnosed with valvular disease. Which interventions should the nurse be prepared to discuss with the client? Select all that apply. A. Surgical management B. Required dietary changes C. Medication management D. Placing limits on physical activity E. Monitoring for an irregular heart rhythm [Show More]

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