NURS 203 HESI Final . All ANswers Provided

1- A client with multiple sclerosis is receiving beta – 1b interferon every other day. To assess for possible bone marrow suppression caused by the medication, which serum laboratory test findings s hould the nurse monit ...

1- A client with multiple sclerosis is receiving beta – 1b interferon every other day. To assess for possible bone marrow suppression caused by the medication, which serum laboratory test findings s hould the nurse monitor? (Select all that apply) a- 2- A male client with hypercholesterolemia wants to change his diet to help reduce his cholesterol levels. When breakfast items should the nurse encourage the client to eat? (Select all that apply) a- 3- After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? (Select all that apply) 4- A client with major depression who is taking fluoxetine calls the psychiatric clinic reporting being more agitated, irritable, and anxious than usual. Which intervention should the nurse implement? a- 5- An older adult male is admitted with complications related to chronic obstructive Pulmonary Disease (COPD). He reports progressive dyspnea that worsens on exertion and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide? 6- A client with diabetic peripheral neuropathy has been taking pregabalin for 4 days. Which finding indicates to the nurse that the medication is effective? a 7- The nurse is assessing an older adult with type 2 diabetes. Which assessment finding indicates that the client understands long- term control of diabetes? 8- A heparin infusion is prescribed for a client who weights 220 pounds. After administering a bolus dose of 80 units/kg. The nurse calculates the infusion rate for the heparin sodium at 18 units/kg/hour. The available solution is Heparin Sodium 25,000 units in 5% Dextrose Injection 250 ml. The nurse should program the infusion pump to deliver how many ml/hour. (Enter numeric value only. If rounding to the nearest whole number.) 18 9- The nurse is assessing a client with Addison's disease who is weak, dizzy, disoriented, and has dry oral mucous membranes, poor skin turgor, and sunken eyes. Vital signs are blood pressure 94/44, heart rate 123 beats/minute, respiration 22 breaths/minute. Which intervention should the nurse implement first? 10- The nurse assesses an older adult who is newly admitted to a long term care facility. The client has dry, flaky skin and long thickened fingernails. The clients has a medical history of a stroke which resulted in left-sided paralysis and dysphagia. In planning care for the client, which task should the nurse delegate to the unlicensed personnel (UAP)? 11- A client is receiving lidocaine IV at 3 mg/minute. The pharmacy dispenses a 500 ml IV solution of normal saline (NS) with 2 grams of lidocaine. The nurse should regulate the infusion pump to deliver how many ml/hr? (Enter numeric value only. If rounding to the nearest whole number.) 45 12- The nurse is demonstrating wound care to a client following abdominal surgery. In what order should the nurse teach the technique? (Arrange from first action on top to last action on bottom) Remove old dressing using clean gloves. Discard gloves with old dressing Moisten sterile gauze with normal saline. Clean wound from least contaminated area to most contaminated area” Apply sterile gauze dressing to wound area Secure dressing with tape 13- The healthcare provider explains through an interpreter the risks and benefits of a scheduled surgical procedure to a non-English speaking female client. The client gives verbal consent and the healthcare provider leaves, instructing the nurse to witness the signature on the consent form. The client and interpreter then speaker together in the foreign language for an additional 2 minutes until the interpreter concludes, “She says it is OK.” What action should the nurse take next? 14- A client is admitted to a mental health unit after attempting suicide by taking a handful of medications. In developing a plan of care for this client, which goal has the highest priority? a- 15- After receiving report, the nurse can most safely plan to assess with client last? 16- The nurse is assigned to care for a client diagnosed with psoriasis. What behavior by the nurse addresses this client's psychosocial need for acceptance? 17- A 41-week gestation primigravida woman is admitted to labor and delivery for induction of labor. What finding should the nurse report to the healthcare provider before initiating the infusion of oxytocin? 18- The nurse is preparing an older client for discharge following cataract extraction. Which instruction should be included in the discharge teaching? 19- After learning that she has terminal pancreatic cancer, a female client becomes very angry and says to the nurse, “God has abandoned me. What did I do to deserve this?” Based on this response, the nurse decides to include which nursing problem in the client’s plan of care? a- 20- Un infant is unresponsive and gasping for breath. Prior to starting CPR, which site should the nurse palpate for a pulse? C 21- A group of nurses implement a pilot study to evaluate a proposed evidence-based change to providing client care. Evaluation indicates successful outcomes and the nurses want to integrate the change throughout the facility. Which action should be taken? (Select all that apply) 22- The mother of a school age child calls the school to ask when her daughter can return to school after treatment for Pediculosis capitis. What is the nurse best response? (nits liendra) 23- A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first? 24- What is the primary purpose for initiating nursing intervention that promote good nutrition, rest, and exercise, and stress reduction for clients diagnosed with an HIV infection? 25- When assessing a client with acute asthma, the nurse is most likely to obtain which finding? 26- During the admission assessment, the nurse auscultates heart sounds for a client with no history of cardiovascular disease. Where should the nurse listen when assessing the client’s point of maximal impulse (PMI) (Click the chosen location. To change, click on a new location) 27- Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma? 28- A client with multiple sclerosis is experiencing scotomas (blind spots), which are limiting peripheral vision. What intervention should the nurse include in this client's plan of care? 29- The nurse applies a blood pressure cuff around a client’s left thigh. To measure the client’s blood pressure, where should the diaphragm of the stethoscope be placed? (Mark the location on one of the images.) “On left thigh with arrow pointing to inner thigh” 30- Which intervention should the nurse include in the plan of care for a patient with tetanus? Open window shades to provide natural light 31- The nurse is caring for a newborn who arrives in the nursery following a precipitous birth on the way to the hospital. A drug screen of the mother reveals the presence of cocaine metabolites. The infant has a heart rate of 175 beats/ minute, cries continuously, is irritable, and is hyperreactive to stimuli. Which intervention is most important for the nurse to include in this infant’s plan of care? 32- A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client’s teaching plan? (Select all that apply.) a- 33- A client with leukemia undergoes a bone marrow biopsy. The client’s laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure? 34- A client collapses while showering and is found discovered by the nurse while making rounds. The client is not breathing and does not have a palpable pulse. The nurse obtains the Automated External Defibrillator (AED). What action should the nurse implement next? 35- A female client with cancer tells the home care nurse that she has a good appetite but experiences nausea whenever she smells food cooking. What action should the nurse implement? 36- A 13 years-old girl, diagnosed with diabetes mellitus Type 1 at the age of 9, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis? 37- At 1130, the nurse assumes care of an adult client with diabetes mellitus who was admitted with an infected foot ulcer. After reviewing the client’s electronic health record, which priority nursing action should the nurse implement? Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client’s medical record. 38- Following morning care, a client with C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implement first? 39- After a motor vehicle collision a client admitted to the medical unit with acute adrenal insufficiency (Addisonian crisis). Which prescription should the nurse implement? 40- Which instruction is most important for the nurse to provide a client who receives a new prescription for risedronate sodium to treat osteoporosis 41- The unlicensed assistive personnel (UAP) reports that a client’s blood pressure cannot be measured because the client has casts on both arms and is unable to be turned to the prone position for blood pressure measurement in the legs. What action should the nurse implement? 42- The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. What action should the nurse implement immediately? 43- Assessment by the home health nurse of an older client who lives alone indicates that client has chronic constipations. Daily medications include furosemide for hypertension and heart failure and laxatives. To manage the client’s constipation, which suggestions should the nurse provide? (Select all that apply) 44- A male client with diabetes mellitus takes NPH/ regular 70/30 insulin before meals and azithromycin PO daily, using medication he brought from home. When the nurse delivers his breakfast tray, the client tells the nurse that he took his insulin but forgot to take his daily dose of the azithromycin an hour before breakfast as instructed. What action should the nurse implement? 45- After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication? 46- Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What 47- An older male client arrives at the clinic complaining that his bladder always feels full. He complains of a weak urine flow frequent dribbling after voiding and increasing nocturia with difficulty initiating his urine stream action should the nurse implement? 48- A female client on the mental health unit frequently asks the nurse when she can be discharged. Then, becoming more anxious, she begins to pace the hallway. What intervention should the nurse implement first? 49- The nurse working on a mental health unit is prioritizing nursing care activities because of a staffing shortage. One practical nurse (PN) is on the unit with the nurse, and another RN is expected to arrive within two hours. Clients need to be awakened and morning medications need to be prepared. Which plan is best for the nurse to implement? 50- A 5-week-old infant who developed projectile vomiting over the last two weeks is diagnosed with hypertrophic pyloric stenosis. Which intervention should the nurse plan to implement? 51- A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 mmHg and he admits that he has not been taking the prescribed medication because the drugs make him “feel bad”. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition? 52- . The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized elderly client with an indwelling urinary catheter every two hours. What additional action should the nurse instruct the UAP to take each time the client is turned? 53- A woman at 24-weeks gestation who has fever, body aches, and has been coughing for the las 5 days is sent to the hospital with admission prescriptions for H1N1 influenza. Which prescriptions has the highest priority? 54- An older female client living in a low income apartment complex tells the home health nurse that she is concerned about her 81 – year old neighbor, a widow whose son recently assumed her financial affairs. Lately, her neighbor has become reclusive, but is occasionally seen walking 55- A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client's plan of care? 56- A nurse who took drugs from the unit for personal use was temporarily released from duty. After completion of mandatory counseling, the impaired nurse has asked nursing administration to allow return to work. When the nurse administrator approaches the charge nurse with the impaired nurse’s request, what action is best for the charge nurse to take? 57- A preschool teacher notifies the school nurse that child A has bitten child B on the arm. Child B’s skin is broken, but is not bleeding. What action should the school nurse take first? 58- At a community health fair, a 50-year-old woman tells the nurse that she has an annual physical exam that includes a clinical breast exam and an annual mammogram. How should the nurse respond? 59 The practical nurse (PN) is assigned to work with three registered nurses (RN) who are caring for neurologically compromised clients. The client with which change in status is best to assign to the PN? The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. which client with which change in status is best to assign to the PN? 60- Prior to surgery, written consent must be obtained. What is the nurse’s legal responsibility with regard to obtaining written consent? 61- The school nurse is screening students for spinal abnormalities and instructs each student to stand up and then touch the toes. Which finding indicates an a student should be referred for scoliosis evaluation? 62- The nurse is planning to assess a client's oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client has a bilateral below-the-knee amputation and pedal pulses that are weak and threaty. What action should the nurse take? a- 63- The nurse provides sliding scale insulin administration instruction to an adult who was recently diagnose with diabetes mellitus. The client demonstrates and understanding on the instructions provided by performing the procedure in which order? (Arrange with the first on top and the last on the bottom.) Obtain blood glucose level Verify the insulin prescription Draw insulin into insulin syringe Cleanse the selected site 64- What is the primary focus of postoperative nursing care for the client with colon trauma? 65- While assessing a client four hours post-thoracentesis, the nurse is unable to auscultate breath sounds on the right side of the chest. What action should the nurse take first? 66- During discharge teaching, the nurse discusses the parameters for weight monitoring with a client who was recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge? 67- A client with osteoporosis related to long-term corticosteroid therapy receives a prescription for calcium carbonate. Which client’s serum laboratory values requires intervention by the nurse? 68- A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents? 69- The nurse is caring for a group of a clients on a surgical unit. Which client should the nurse assess first? 70- A client who is mechanically ventilated is receiving continuous enteral feedings through a nasogastric feeding tube. To prevent aspiration, which intervention is most important for the nurse to implement? 71- After years of struggling with weight management, a middle-age man is evaluated for gastroplasty. He has experienced difficulty with managing his diabetes mellitus and hypertension, but he is approved for surgery. Which intervention is most important for the nurse to include in this client’s plan of care? 72- A client with diabetes mellitus tells the nurse that she uses cranberry juice to help prevent urinary tract infection. What instruction should the nurse provide? 73- After receiving report on an inpatient acute care unit, which client should the nurse assess first? 74- An adolescent male client is admitted to the hospital. Based on Erikson’s theory of psychosocial development, which nursing intervention best assists this adolescent’s adjustment to his hospital stay? 75- A client with skin grafts covering full-thickness burns on both arms and legs is scheduled for a dressing change. The client is nervous and requests that the dressing change be skipped this time. What action is most important for the nurse to take? 76- A continuous infusion of nitroglycerin is prescribed for an adult male admitted with an acute myocardial infarction. The client is experiencing active chest pain that he describes as 8 out of 10. Which intervention is most important for the nurse to implement? 77- When caring for a client with diabetes insipidus (DI), it is most important for the nurse to include frequent assessment for which conditions in the client’s plan of care? 78- The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse report to the healthcare provider? 79- A child with heart failure (HF) is taking digitalis. Which signs indicates to the nurse that the child may be experiencing digitalis toxicity? 80- A client is admitted with hepatitis A (HAV) and dehydration. Subjective symptoms include anorexia, fatigue, and malaise. What additional assessment should the nurse expect to find during the preicteric phase? 81- An older male was recently admitted to the rehabilitation unit with unilateral neglect syndrome as the result of a cerebrovascular accident (CVA). Which action should the nurse include in the plan of care? 82- The nurse is caring for a client with a tracheostomy. Which action should the nurse perform when suctioning the tracheostomy tube? 83- The urinary drainage of a client with a continuous bladder irrigation is becoming increasingly red. Which intervention should the nurse implement? 84- The nurse is preparing to administer a suspension ampicillin labeled, 250mg/5ml, to a 12-year old child with impetigo. The prescription is for 500 mg QID. How many ml should the child receive per day? (Enter numeric value only) 85- A client with a severe prostatic infection that caused a blocked urethra is 3 days post-surgical urinary diversion. The healthcare provider directs the nurse to remove the suprapubic catheter to allow the client to void normally. Which intervention should the nurse implement first? 86- The nurse receives report on four clients who are complaining of increased pain. Which client requires immediate by the nurse ? 87- A client morning assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for nurse to include the in this client’s plan of care? 88- A female client who has a borderline personality disorder is being discharged today. When the nurse makes morning rounds, the clients begins the interaction by complaining about the aloofness of the night shift nurse and expresses joy to see that, ‘’ My favorite nurse is on duty now” Which response is best for the nurse to provide to this client’s dichotomous tendency? 89- The nurse is calculating the one-minute Apgar score for a newborn male infant, and determines that his heart rate is 150 beats/minute, he has a vigorous cry, his muscle tone is good with total flexion, he has quick reflex irritability, and his color is dusky and cyanotic. What Apgar score should the nurse assign to the infant? (Enter the numeric value only.) 8 90- The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first? 91- While changing a client’s chest tube dressing, the nurse notes a crackling sensation when gentle pressure is applied to the skin at the insertion site. What is the best action for the nurse to take? 92- When teaching a group of school-age children how to reduce the risk of Lyme disease which instruction should the camp nurse include? 93- In preparing a nursing care plan for a client admitted with a diagnosis of Guillain-Barre syndrome, which nursing problem has the highest priority? 94- A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients? 95- What Nursing intervention is particularly indicated for the second stage of labor? 96- An adult male with a 6 cm thoracic aneurysm is being prepared for surgery. The nurse reports to the healthcare provider that the client’s blood pressure is 220/112 mmHg, so an antihypertensive agent is added to the client’s IV infusion. Which finding warrants immediate intervention by the nurse? 97- When entering a client’s room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which actions should the nurse implement? 98- A client is admitted with the diagnosis of Wernicke’s syndrome. What assessment finding should the nurse use in planning the client’s care? 99- The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem? 100- A client with complaints of shortness of breath and abdominal pain 1 week after bariatric surgery is admitted for follow-up evaluation. Which assessment finding warrants immediate intervention by the nurse? 101- A client with prescription for “do not resuscitate” (DNR) begins to manifest signs of impending death. After notifying the family of the client’s status, what priority action should the nurse implement? 102- An adult male is admitted to the intensive care unit because he experienced a sudden onset of sharp chest pain and shortness of breath earlier today. Following an emergent pulmonary angiogram, the client is diagnosed with a pulmonary embolism. Which intervention is most important for the nurse to include in this client’s plan of care? 103- A female client presents in the Emergency Department and tells the nurse that she was raped last night. Which question is most important for the nurse to ask? a 104- A client is receiving lactulose (Portalac) for signs of hepatic encephalopathy. To evaluate the client's therapeutic response to this medication, which assessment should the nurse obtain? 105- A male client with schizophrenia tells the nurse that the hospital has installed cameras that watch him and listening devices that record what everyone says. Which nursing problem should the nurse document for this client? 106- A nurse is administering diazepam, a benzodiazepine, 10 mg IV push PRN, as prescribed to a client with alcohol withdrawal symptoms. Which actions should the nurse implement when administering the medication? (Select all that apply) 107- An older male client is admitted to the mental health unit with a sudden onset of global disorientation and is continuously conversing with his mother, who died 50 years ago. The nurse reviews the multiple prescriptions the client is currently taking and assesses his urine specimen, which is cloudy, dark yellow, and has a foul odor. These findings suggest that this client is experiencing which condition? 108- While changing the pressure ulcer dressing of a client who is immobile, the nurse notes that the boundary edges of the wound have increased. Before reporting this finding to the healthcare provider, the nurse should review which of the client’s serum laboratory values? 109- A client is admitted for an exacerbation of heart failure (HF) and is being treated with diuretics for fluid volume excess. In planning nursing care, which interventions should the nurse include? (Select all apply) 110- A 17-year –old adolescent is brought to the emergency department by both parents because the adolescent has been coughing and running a fever with flu-like symptoms for the past 24 hours. Which intervention should the nurse implement first? 111- The nurse provides discharge teaching to a client who was recently diagnosed with diabetes mellitus (DM). After receiving the instructions, the client expresses understanding about when, how, and why to take his prescribed medications at home. Which intervention is most important for the nurse to implement 112- The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning? 113- An IV infusing in a client’s left forearm becomes infiltrated. After removing the IV, which sites should the nurse select as possible site to insert another IV catheter? (Select all that apply) 114- An IV antibiotic is prescribed for a client with a postoperative infection. The medication is to be administered in 4 divided doses. What schedule is best for administering this prescription? 115- A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that her voices are saying, “Kill, Kill” What question should the nurse ask the client next? 116- A client has had several episodes of clear, watery diarrhea that starter yesterday. What action should the nurse implement? 117- The nurse notes that a depressed female client has been more withdrawn and non-communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client? 118- A postpartum client who is bottle feeding develops breast engorgement. What is the best recommendation for the nurse to provide this client? 119- A nurse assesses a client whose hand begins to spasm when the blood pressure cuff is inflated. The client complains of paresthesia in the fingers and toes. Which serum laboratory finding should the nurse expect to find? 120- The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond? 121- An older male resident of a long-term care facility has been scratching his legs for the past 2 days. Which intervention should the nurse implement? 122- In performing the admission assessment for a client experiencing complications of long term Parkinson’s disease, which question by the nurse provides the best information about disease progression? 123- An adult suffered burns to face and chest resulting from a grease fire. On admission, the client was intubated and a 2 liter bolus of normal saline was administered IV. Currently the normal saline is infusing at 250ml/hour. The client’s heart rate is 120 beats/minute, blood pressure is 90/50 mmHg, respirations are 12 breaths/minute over the ventilated 12 breaths for a total of 24 breaths/minute, and the central venous pressure (CVP)is 4 mm H2O. Which intervention should the nurse implement? 124- The nurse is caring for a client who has silvery scaling plaques bilaterally on elbows, forearms, and palms. When scratched, the skin bleeds over these plaques. What is most important to include in this client’s plan of care? 125- After successful resuscitation, a client is given propranolol and transferred to Intensive Coronary Care Unit (ICCU). On admission, magnesium sulfate 4 grams IV in 250 ml D5 W at one gram/hour. Which assessment findings require immediate intervention by the nurse? 126- A small, round raised are appears under the client’s skin as the nurse administers an intradermal medication. What actions should the nurse take? 127- A client who has been newly diagnosed with abnormally high production of antidiuretic hormone reports muscle cramps and twitching. The client also reports a headache and lethargy. These concerns are most likely related to which electrolyte imbalance? 128- The nurse asks the parent to stay during the examination of a male toddler’s genital area. Which intervention should the nurse implement? 129- A woman at 12-week gestation comes to the clinic for her first prenatal visit. After completing a health history, the nurse should discuss which topic about pregnancy at this initial visit? 130- When preparing to transfer a young adult who has a spinal cord injury (SCI) to a rehabilitation center, which information about the client is most important for the nurse to provide to the receiving agency? 131- A client was admitted to the cardiac observation unit 2 hours ago complaining of chest pain. On admission, the client’s EKG showed bradycardia, ST depression, but no ventricular ectopy. The client suddenly reports a sharp increase in pain, telling the nurse, “I feel like an elephant just stepped on my chest” The EKG now shows Q waves and ST segment elevations in the anterior leads. What intervention should the nurse perform? 132- A client newly diagnosed with diabetes mellitus suddenly becomes confused and weak. Which interventions should the nurse implement? (Select all that apply) 133- The nurse assesses a client who had bilateral total knee replacements (TKR) four hours ago the nurse notes that the dressing on the client’s right knee is saturated with serosanguineous drainage. What action should the nurse implement? 134- An older adult with known cognitive impairment residing in a long- term care facility suddenly becomes disoriented and confused. There are no signs of extremity weakness or other neurological changes. Which intervention should the nurse implement? 135- A client with multiple sclerosis (MS) has decreased motor function after taking a hot bath (Uhthoff’s sign). Which pathophysiological mechanism supports this response? 136- The husband of an older woman, diagnosed with pernicious anemia, calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobalamin two days ago. He tells the nurse that he is worried that she might be getting Alzheimer’s disease. What action should the nurse take? 137- A client is receiving enoxaparin 30 mg SUBQ BID. In assessing for adverse effects of the medication, which serum laboratory value is most important for the nurse to monitor? 138- A female client with severe renal impairment is receiving enoxaparin (lovenox) 30 mg SUBQ BID. Which laboratory value due to enoxaparin should the nurse report to the healthcare provider? 139- After receiving the morning report at 0700 on a postpartum unit, which client should the nurse assess first? The client who is 140- Which laboratory results should the nurse closely monitor in a client who has end – stage renal disease (ESRD) 141- Which assessment finding is most important when planning to provide a complete bed bath to a bedfast client? 142- The nurse observes an unlicensed assistive personnel (UAP) applying an alcohol-based hand rub while leaving a client’s room after taking vital signs. What action should the nurse take? 143- Which client problem has the higher priority for the child sickle cell anemia who has a temperature of 101 F (38.3)? 144- A client with chronic kidney disease receives a prescriptions for darbepoetin alfa 40 mcg subcutaneous every 7 days. The darbepoetin alfa vial is labeled, “60 mcg/ml” How many ml should the nurse administer ? (Enter numeric value only. If rounding is required, round to the nearest tenth) 145- A client with metastatic cancer who was taking hydromorphone (Dilaudid) PO at home is now receiving the medication IV while in the hospital. To evaluate if the client is receiving an equianalgesic dose of the Dilaudid, what assessment should the nurse complete? 146- When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority? 147- What instruction should the nurse provide to a client who is preparing to have a cystoscopy ? 148- While assessing a client’s chest tube (CT), the nurse discovers bubbling in the water seal chamber of the chest tube collection device. The client’s vital signs are: blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation 88%. Which interventions should the nurse implement? 149- Nurses working on a surgical unit are concerned about the physicians treatment of clients during invasive procedures, such as dressing changes and insertion of IV lines. Clients are often crying during the procedures, and the physician is usually unconcerned or annoyed by the client’s response. To resolve this problem, what actions should the nurses take? (Arrange from the first action on the top of the list on the bottom) RESPONDIDA Talk to the physician as a group in a non-confrontational manner. Document concerns and report them to the charge nurse Submit a written report to the director of nursing. Contact the hospital’s chief of medical services. File a formal complaint with the state medical board. 150- While transferring a client with a chest tube from the bed to a stretcher, the chest becomes disconnected from the water-seal drainage container. The nurse immediately immerses the end of the tube in a container of sterile water. What action should the nurse implement next? 151- After diagnosis and initial treatment of a 3-year-old with Cystic fibrosis, the nurse provides home care instructions to the mother, which statement by the child's mother indicates that she understands home care treatment to promote pulmonary functions? 152- The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection? 153- The nurse is performing a peritoneal dialysis exchange on a client with chronic kidney disease (CKD). Which assessment finding should the nurse report to the healthcare provider? 154- A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h are prescribed. What action should the nurse include in this client’s plan of care? 155- At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the client’s medical record. Based on date contained in the record, what action should the nurse take before assisting the client with ambulation: 156- The nurse administers an antibiotic to a client with respiratory tract infection. To evaluate the medication’s effectiveness, which laboratory values should the nurse monitor? Select all that apply 157- A male client with angina pectoris is being discharged from the hospital. What instructions should the nurse plan to include to the discharge teaching? 158- The nurse offers diet teaching to a female college student who was diagnosed with iron-deficiency anemia following her voluntary adoption of a lacto-vegetarian diet. What nutrients should the nurse suggest this client eat to best meet her nutritional needs while allowing her to adhere to a lacto-vegetarian diet? 159- The public nurse health received funding to initiate primary prevention program in the community. Which program the best fits the nurse’s proposal? 160- A client is admitted to the labor and delivery unit early labor and the nurse assesses the status of her contractions. The frequency of contractions is most accurately evaluated by counting the minutes and seconds in which manner? 161- The nurse is preparing to send a client cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to start of the procedure? 162- A client who is admitted to the intensive care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first? 163- During the administration of albuterol per nebulizer, the client complains of shakiness. The client´s vital signs are heart rate 120 beats/minutes, respirations 20 breaths/minute, blood pressure 140/80. What action should the nurse take? 164- When attempting to establish risk reduction strategies in a community, the nurse notes that regional studies indicate a high number of persons with growth stunting and irreversible mental deficiencies caused by hypothyroidism (cretinism). The nurse should seek funding to implement which screening measure? 165- While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action should the nurse take? 166- What should the nurse conduct an Allen´s test? 167- A client with acute renal failure (ARF) is admitted for uncontrolled type 1 diabetes Mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is the most important for the nurse to include in this client’s plan of care? 168- An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies. What is the best response by the nurse? 169- An S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take? 170- The healthcare provider prescribes a fluid challenge of 0.9% sodium chloride 1,000 ml to be infused over 4 hours. The IV administration set delivers 10gtt/ml. How many gtt /minute should the nurse regulate the infusion? (Enter numeric value only. If rounding is required, round to the nearest whole number) 42gtt/min 171- When conducting diet teaching for a client who is on a postoperative full liquid diet, which 171- A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond? 172- A client with myasthenia Gravis (MG) is receiving immunosuppressive therapy. Review recent laboratory test results show that the client’s serum magnesium level has decreased below the normal range. In addition to contacting the healthcare provider, what nursing action is most important? 173- Which client should the nurse assess frequently because of the risk for overflow incontinence? A client 174- A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking hot baths at night no relief of his discomfort. What action should the nurse take? 175- An older client comes to the clinic with a family member. When the nurse attempts to take the clients health history, the client does not respond to questions in a clear manner. What action should the nurse implement first? 176- What intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an IV site in the client's arm? 177- A mother brings her child, who has a history of asthma, to the emergency room. The child is wheezing and speaking one world between each breath. The child is anxious, tachycardia, and has labored respirations. Which assessment is most important for the nurse to obtain? 178- A client takin clopidogrel reports to the onset of diarrhea. Which nursing action should the nurse implement first? 179- A 12-year-old client who had an appendectomy two days ago is receiving 0.9%normal saline at 50ml/hour. The client´s urine specific gravity is 1.035. What action should the nurse implement? 180- The nurse is assessing a client with pulmonary edema who is reporting two pillow orthopnea and paroxysmal nocturnal dyspnea. The nurse identifies rapid shallow respirations and use of accessory muscles. Which action should the nurse include in the client´s plan of care? 181- Following and gunshot wound, an adult client a hemoglobin level of 4 grams/dl (40 mmol/L SI). The nurse prepares to administer a unit of blood for an emergency transfusion. The client has AB negative blood type and the blood bank sends a unit of type A Rh negative, reporting that there is not type AB negative blood currently available. Which intervention should the nurse 182- The healthcare provider prescribes potassium chloride 25 mEq in 500 ml D_5W to infuse over 6 hours. The available 20 ml vial of potassium chloride is labeled, “10 mEq/5ml.” how many ml of potassium chloride should the nurse add the IV fluid? (Enter numeric value only. If is rounding is required, round to the nearest tenth.) 12.5 183- A young adult male who is being seen at the employee health care clinic for an annual assessment tell the nurse that his mother was diagnosed with schizophrenia when she was his age and that life with a schizophrenic mother was difficulty indeed. Which response is best for the nurse to provide? 184- After 2 days treatment for dehydration, a child continues to vomit and have diarrhea. Normal saline is infusing, and the child´s urine output is 50ml/hour. During morning assessment, the nurse determines that the child is lethargic and difficult to arouse. Which action should the nurse implement? 185- The healthcare provider prescribed furosemide for a 4-year-old child who has a ventricular septal defect. Which outcome indicates to the nurse that this pharmacological intervention was effective? 186- A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the nurse implement? 187- A young adult client was admitted 36 hours ago for a head injury that occurred as the result of a motorcycle accident. In the las 4 hours, the client´s urine output has increased to over 200 ml-hour. Before reporting the finding to the healthcare provider, which intervention should the nurse implement? 188- A clinical trial is recommended for a client with metastatic breast cancer, but she refuses to participate and tells her family that she does not wish to have further treatments. The client’s son and daughter ask the nurse to try and convince their mother to reconsider this decision. How should the nurse respond? 189- The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendations should the nurse provide this client? (Select all that apply) 190- When obtaining subjective data from a client, what intervention should the nurse implement first? 191- A 46-year-old male client who had myocardial infarction 24-hours ago comes to the nurse’s station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which nursing problem should the nurse formulate? 192- A nurse working on an endocrine unit should see which client first? 193- The nurse implements a tertiary prevention program for type 2 diabetes in a rural health clinic. Which outcome indicates that the program was effective? 194- An older adult resident of a long-term care facility has a 5-year history of hypertension. The client has a headache and rate the pain 5 on a pain scale 0 to 10. The client’s blood pressure is currently 142/89. Which interventions should the nurse implement? (Select all that apply) 195- The healthcare provider changes a client’s medication prescription from IV to PO administration and double the dose. The nurse notes in the drug guide that the prescribed medication, when given orally, has a high first-pass effect and reduces bioavailability. What action should the nurse implement 196- The charge nurse of a cardiac telemetry unit is assigning client care to a registered nurse (RN) and a practical nurse (PN). Which client should be assigned to the RN? 197- While caring for a client with bilateral chest tubes, the bubbling in the water-seal chamber of the right chest tube stops. What action is most important for the nurse to take? 198- An adult client presents to the clinic with a large draining ulcers on both lower legs that are characteristic of Kaposi´s Sarcoma lesions. The client is accompanied by two family members. What action should the nurse take? 199- The nurse is managing the care of a client with Cushing’s syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply) 200- The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing actions should the nurse assign to the PN? (Select all that apply.) A. Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM). B. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty C. Perform daily surgical dressing change for a client who had an abdominal hysterectomy D. Initiate patient controlled analgesia (PCA) pumps for two clients immediately postoperative E. Start the second blood transfusion for a client twelve hours following a below knee amputation 201-A client is admitted to a medical unit with the diagnosis of gastritis and chronic heavy alcohol abuse. What should the nurse administered to prevent the development of Wernicke's syndrome? 202- What information should the nurse include in the discharge teaching plan of a client with low back pain who is taking cyclobenzaprine to control muscle spasms? 203- A client with chronic kidney disease has an arteriovenous (AV) fistula in the left forearm. Which observation by the nurse indicates that the fistula is patent? 204- When implementing a disaster intervention plan, which intervention should the nurse 205- A client with eczema is experiencing severe pruritus. Which PRN prescriptions should the nurse administer? (Select all that apply) 206- A lethargic one-hour-old infant is brought to the nursery for further assessment. In what order should the nurse assess this infant? ( Arrange the first on the top, and the last item on the bottom) Heel stick Respirations Heart rate Temperature 207- A male client approaches the nurse with an angry expression on his face and raises his voice, saying, ´´ My roommate is the most selfish, self –centered, angry person I have ever met. If the loses his temper one more time with me, I am going to punch him out’’ The nurse recognizes that the client is using which defense mechanism? 208- The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, ptosis, mouth drooping and, aspiration pneumonia. What is the priority nursing assessment that should be done before administering this medication? 209- The nurse is admitting a client from the post anesthesia unit to the postoperative surgical care unit. Which prescription should the nurse implement first? 210- On admission to the Emergency Department, a female client who was diagnosed with bipolar disorder 3 years ago reports that this morning she took a handful of medications and left a suicide note for her family. Which information is most important for the nurse to obtain? 211- A client present s to the healthcare provider with fatigue, poor appetite, general malaise, and vague joint pain that improves mid- morning. The client has been over the counter ibuprofen for several months. The healthcare provide makes an initial diagnosis of rheumatoid arthritis (RA). Which laboratory test should the nurse report to the healthcare provider ? (Select all apply) 212- A female client is admitted for diabetic crisis resulting from inadequate dietary practices. After stabilization, the nurse talks to the client about her prescribed diet. What client characteristic is most import for successful adherence to the diabetic diet? 213- An infant is receiving penicillin G procaine 220,000 units IM. The drug is supplied as 600,000 units/ml. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth) 0.4 Rationale: Calsulate using the formula, desired dose (220,000 units) over dose on hand (600,000 units) x the volume of the available dose (1 ml). 220,000 / 600,000 x 1 ml = 0.36 = 0.4 ml 214- A client with chronic alcoholism is admitted with a decreased serum magnesium level. Which snack option should the nurse recommend to this client? 215-A male client is returned to the surgical unit following a left nephrectomy and is medicated with morphine. His dressing has a small amount of bloody drainage, and a Jackson-Pratt bulb surgical drainage device is in place. Which interventions is most important for the nurse to include in this clients plan of care? 216- The nurse discontinues a continuous IV heparin infusion for a male client on strict bedrest, and is now preparing to administer the clients first dose of enoxaparin. Prior to giving this subcutaneous injection, which assessment finding requires additional intervention by the nurse? 217- The nurse is caring for a client who is receiving continuous ambulatory peritoneal dialysis (CAPD) and notes that the output flow is 100ml less than the input flow. Which actions should the nurse implement first? 218- When administer ceftriaxone sodium intravenously to a client before surgery, which assessment finding requires the most immediate intervention by the nurse? 219- After assessing an older with a suspected cerebrovascular accident (CVA), the nurse documents the client´s right upper arm weakness and slurred speech. When the client complains of a severe headache and nausea, the clients neurological assessment remains unchanged. Which action should the nurse implement first? 220- The nurse observes an unlicensed assistive personnel (UAP) who is preparing to provide personal care for a client who requires contact precautions. The UAP has applied a gown and gloves and secured the tops of the gloves over the gown sleeves. What action should the nurse take? 221- An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client ran one year ago, his spouse states that the client no longer runs, bur sits and watches television most of the day. Which is most important for the nurse to include in this client’s plan of care for today? 222- An older adult male who had an abdominal cholecystectomy has become increasingly confused and disoriented over the past 24 hours. He is found wandering into another client’s room and is return to his room by the unlicensed assistive personnel (UAP). What actions should the nurse take? (Select all that apply). 223- A client with bleeding esophageal varices receives vasopressin (Pitressin) IV. What should the nurse monitor for during the IV infusion of this medication? 224- A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which assessment finding warrants immediate intervention by the nurse? 225- A client with multiple sclerosis is receiving baclofen 15 mg PO three times daily. The drug is available in 10 mg tablets. How many tablets should the nurse administer in a 24 hour period? (Enter numeric Value only. If rounding is required, round to the nearest tenth) 4.5 226- The nurse is completing a neurological assessment on a client with a closed head injury. The Glasgow Coma Scale (GCS) score was 13 on admission. It is now assessed at 6. What is the priority nursing intervention based on the client´s current GCS? 227- Two days after an abdominal hysterectomy, an elderly female with diabetes has a syncopal episode. The nurse determines that her vital signs within normal limits, but her blood sugar is 325mg/dL or 18.04 mmol/L (SI). What intervention should the nurse implement first? 228- When washing soiled hands the nurse first wets the hands and applies soap. The nurse should complete additional actions in which sequence? (Arrange from first action on top to last action on botton.) RESPONDIDA Rub hands palm to palm Interlace the fingers Dry hands with paper towel turn off water faucet 229- A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him “feel bad”. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition? 230- A client who underwent an uncomplicated gastric bypass surgery is having difficult with diet management. What dietary instruction is most important for the nurse to explain to the client? 231- Four clients arrive on the labor and delivery unit at the same time. Which client should the 232- The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN? 233- The nurse enters the room of a client with Parkinson’s disease who is takin carbidopa-levodopa. The client is arising slowly from the chair while the unlicensed assistive personnel (UAP) stands next to the chair. What action should the nurse take? 234. A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider? 235- A client with renal disease seems axious and presents with the onset of shortness of breath, lethargy, edema, and weight gain. Which action should the nurse implement first? 236- A nurse who is working in the emergency department triage area is presented with four clients at the same time. The client presented with which symptoms requires the most immediate intervention by the nurse? 237- The nurse changes a Pleuravac® chest drainage system for a client whose chest collection unit is filled to capacity. After unclamping the attached chest tube, the nurse turns on the suction to 20 cm water pressure, and 125 ml of serosanguineous drainage is obtained. Which location on the Pleuravac® indicates this volume of drainage from the chest tube? (Click the chosen location. 238- A client with a pneumothorax is admitted for insertion of a chest tube that is attached to suction with a chest drainage system. The nurse verifies that the suction level is at 20 cm water pressure. Which location on the chest drainage system indicates this finding? 239- The nurse determines that 850 ml of serosanguineous drainage is in the Pleuravac chest drainage system of a client who is 12 hours postoperative for the removal of lung tumor. Which location on the chest collection unit indicates the finding? (Click the chosen location. To change, click on the new location.) 240- The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective? 241- During a postpartum assessment of a client who is 5 hours post vaginal delivery, the nurse determines the fundus is 3 finger breadths above the umbilicus and positioned to the client’s side. Which action should the nurse implement first? 242-The nurse is inspecting the thoracic region of an adolescent client. Which finding is consistent with scoliosis. 243- While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client’s laboratory values? 244- A client who is admitted to the medical unit with fluid volume overload has 2+ dependent edema in the lower extremities and a serum sodium level of 115mEq/L. Which assessment should the nurse complete next? 245- A client who will be going to surgery states no known allergies to any medications. What is the most important nursing action for the nurse to implement next? 246- A nurse who works in the nursery is attending the vaginal delivery of a term infant. What action should the nurse complete prior to leaving the delivery room? 247- A client who had a recurrent episode of urolithiasis is admitted for acute flank pain in the upper right abdominal quadrant, diaphoresis, and vomiting. After medicating the client for pain, the nurse strains the client’s urine and collects granules and stones. Which action is most important for the nurse to implement next? 248- The nurse assesses a client one hour after starting a transfusion of packed red blood cells and determines that there are no indications of a transfusion reaction. What instructions should the nurse provide the unlicensed assistive personnel (UAP) who is working with the nurse? 249- To reduce the risk of symptoms exacerbation for a client with multiple sclerosis (MS), which instructions should the nurse include in the client’s discharge plan? (Select all that apply). 250- The nurse notes that an older adult client has a moist cough that increase in severity during and after meals. Based on this finding, what action should the nurse take. 260- An older client is having photocoagulation for macular degeneration. What intervention should the nurse implement during the post procedure care in the outpatient surgical unit? 261- The nurse is assessing a client with left-sided heart failure who reports nocturia and dyspnea. The nurse identifies pulsus alternans and crackles in all lung fields. Which action is best to include in the client’s plan of care? 262- The nurse plans to contact the healthcare provider regarding a client’s need for a belt restraint. What information is most important to report to the healthcare provider? 263- The nurse is teaching a male adolescent recently diagnose with type 1 diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate the effectiveness of the teaching? . 264- A client with leukemia who is receiving a myleosupressive chemotherapy has a platelet count of 25,000/mm3. Which intervention is most important for the nurse to include in this client’s plan of care? 265- Three hours following a right carotid endarterectomy, the nurse notes a moderate amount of bloody drainage on the client’s dressing. Which additional assessment finding warrants immediate intervention by the nurse. 266- A client is admitted with pyelonephritis and cultures reveal Escherichia coli infection. The client is allergic to penicillins, and the healthcare provider prescribed vancomycin IV. The nurse should plan to carefully monitor the client for which finding during IV administration? 267- A young female adult wander into the Emergency Department. She is disheveled and confused and states, "My date must have put something in my drink. He took my car, and I think he raped me. I don't exactly remember, but I know he hurt me." How should the nurse respond? 268- While assessing an older client’s fall risk, the client tell the nurse that they live at home alone and has never fallen. What action should the nurse take? 269- A female client with fibromyalgia asks the nurse to arrange for hospice care to help her manage the severe, chronic pain. Which interdisciplinary team member should the nurse consult to assist the client? 270- A client with pneumonia has arterial blood gases levels at: pH 7.33; PaC02 49 mm/ Hg; HC03 25mEq/L; Pao., 95. What intervention should the nurse implement based on these results? 271- Which nursing responsibility is related to health promotion and teaching for the client with rheumatoid arthritis? 272- Which class of drugs is the only source of a cure for septic shock? 273- Prior to insertion of indwelling urinary catheter, what client information is most important for the nurse to obtain. 274- The charge nurse observes a new nurse preparing to administer an intramuscular injection. The new nurse is attaching a 24-gauge needle. What action should the charge nurse take? 275- An older client with a history of pernicious anemia has developed ataxia and paresthesia. In planning care, which nursing intervention has the highest priority? 276- An adult female client tells the nurse that though she is afraid her abusive boyfriend might one-day kill her, she keeps hoping that he will change. What action should the nurse take first? 278- A young adult female college student visits the health clinic in early winter to obtain birth control pills. The clinic nurse asks if the student has received an influenza vaccination. The student stated she did not receive vaccination because she has asthma. How should the nurse respond? 279- Dopamine 5mcg/kg/ minute IV is prescribed for a client who weighs 132 pounds. The pharmacy dispenses a 500 ml IV solution of 0.9 % normal saline with dopamine 1600 mg. The nurse should program the infusion pump to deliver how many ml/hour? ( Enter numeric value only. If rounding is required, round to the nearest tenth.) 5.6 280- The nurse is explaining the need to reduce salt intake to a client with primary hypertension. What explanation should the nurse provide? 281- A client with a newly diagnosed type 2 diabetes mellitus, awakens in the morning with a temperature of 101.6 F (38.7C). The client calls the clinic nurse and reports taking the morning dose of metformin after obtaining a morning fasting blood glucose of 325mg/dl (18mmol/L). Which instruction should the nurse provide to the client? 282- When preparing for a bone marrow aspiration, the nurse should place the client in which position to ensure access of the aspiration site? 283- When admitting a client with a diagnosis of transient ischemic attack (TIA), which intervention is most important for the nurse to include in this client’s plan of care? 284- A low risk primigravida at 28-weeks gestation arrives for her regular antepartal clinic visit. Which assessment finding should the nurse consider within normal limits for this client? 285- The nurse should withhold medication if the client’s serum potassium level is 6.2 mEq/L or 286- A client is admitted with heart failure and left ventricular hypertrophy. Which intervention is most likely to avert development of cardiomegaly and improve myocardial contractility? 287- An adolescent girl with anorexia nervosa is within 10 pounds of her normal weight and is being discharge from the mental health unit with a prescription for fluoxetine (prozac). Which instruction is most important for the nurse to provide the parent listen for the daughter expressions of wanting to harm herself 288- A client who was admitted yesterday with severe dehydration is complaining of pain a 24-gauge IV with normal saline is infusing at a rate of 150 ml/hour. Which intervention should the nurse implement first? 289- A client at 12- weeks gestation is admitted to the antepartum unit with a diagnosis of hyperemesis gravidarum. Which action is most important for the nurse to implement? 290- A male client with a history of mitral valve prolapse is admitted because of fever and dyspnea on exertion, and is diagnosed with acute infective endocarditis. During the admission assessment, the nurse observes multiple areas of petechiae on the client’s skin. Which interventions should the nurse include in the client’s plan of care? (Select all that apply) 291- The nurse is teaching a group of women about osteoporosis and exercises. The nurse should emphasize the need for which type of regular activity. 292- A client is admitted with complains of a racing heart, light headedness, and shortness of the breath. The cardiac monitor displays supraventricular tachycardia (SVT). Which intervention should the nurse implement first? 293- The nurse is caring for an adult male client who was admitted to intensive care unit (ICU) following a motor vehicle collision in which he sustained a crushing injury to the chest. Which statement regarding a pulmonary contusion is accurate? 294- Several days after having a computed tomography scan (CT scan) with contrast for lower abdominal pain, an older male adult is admitted with acute kidney injury (AKI). The client’s urinary output is 10ml/hour, his heart rate is 125 beats/minute , and basilar crackles are audible. Which laboratory value in the client’s electronic record requires intervention by the nurse? 295- Handwashing is the most important intervention aimed at reducing the spread infection in the hospitalized population. What mechanical describes the effect that handwashing has upon the chain of infection? 296- What instruction should the nurse provide the parents of a 3-year-old boy with a BMI-for-age at the 97th percentile? 297- An older male client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side. When entering the room, the nurse finds the client’s wife tearful and trying unsuccessfully to give him a drink of water. What action should the nurse take? 298- A client is receiving intravenous (IV) fluids by gravity infusion and exhibits signs of fluid volume overload. When assessing the client’s IV delivery system, where should the nurse assess first? B 299- A young adult male who was in a motorcycle collision experienced a laceration of the gastrocnemius muscle. Which instruction should the nurse to provide to the practical nurse (PN) who is caring for this client? 300- The charge nurse is planning for the shift and has a registered nurse (RN) and a practical nurse (PN) on the team. Which client should the charge nurse assign to the RN? 301-(VIDEO) The nurse observes an unlicensed assistive personnel (UAP) perform catheter care as seen in the video. What action should the nurse take? (Please view the video before selecting the option that applies. To repeat the video, click the play button again) 302- The charge nurse is making assignments on a psychiatric unit for a practical nurse (PN) and a newly licensed registered nurse (RN). Which client should be assigned to the RN. 303- A client is receiving a secondary infusion of erythromycin 1 grams in 100 ml dextrose 5%in water (D5W) to be infused in 30 minutes. How many ml/hour should infusion pump? (Enter numerical value only) 200 304- The nurse is caring for a 3-month -old infant who is one day after a pylorotomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing both knees to the chest. What action should the nurse take? 304- A male client reports to the clinic nurse that he has recently experienced symptoms of polyuria, polyphagia, and polydipsia. Which laboratory findings are significant for the nurse to report to the healthcare provider? (Select all that apply) 305- Four hours after the nurse administers interferon alfa subcutaneously to a client, the client develops a headache, muscle aches and a fever of 101.8 F (38.8 C). What action should the nurse implement? 306- A client received a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, what action should the nurse implement? 307- An older adult woman is brought to the emergency department by her daughter guaiac test who reports that her mother has recently becomes confused. Further assessment indicates that the client has had the flu and has been vomiting for the past two days and she currently takes medications for diabetes, hypertension, and heart failure. Which intervention should the nurse implement first? 308- A mother runs into the emergency department with s toddler in her arms and tells the nurse that her child got into some cleaning products. The child smells of chemicals on hands, face, and on the front of the child's clothes. After ensuring the airway is patent, what action should the nurse implement first? 309- In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client’s respiratory rate is 14 breaths / minute. What action should the nurse implement? 310- During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should the nurse take first? 311- 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? 312- 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? 313- 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? 314- 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? 315- Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse that the client is experiencing a complication? 316- An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement? 317- The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the child’s dietary restrictions. Which foods are contraindicated for this child? 318- Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3-minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide? 319- Which breakfast selection indicates that the client understands the nurse’s instructions about the dietary management of osteoporosis? 320- The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse (RN)? 321- A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician’s office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child’s foot. Which action should the nurse implement first? 322- The mother of an adolescent tells the clinic nurse, “My son has athlete’s foot, I have been applying triple antibiotic ointment for two days, but there has been no improvement.” What instruction should the nurse provide? 323- A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences 324- A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and palpitations. Which finding is most important for the nurse to assess to the client? 325- The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only.) 75 326- The pathophysiological mechanisms are responsible for ascites related to liver failure? (Select all that apply) 327- The nurse is auscultating a client’s heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio first to select the option that applies) 328- The healthcare provider prescribes ceftazidime (Fortax) 35 mg every 8 hours IM for an infant. The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration of 100 mg/ml. How many ml should the nurse administered for each dose? (Enter numeric value only. If rounding is required, round to the nearest tenth) 329- The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete? 330- A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining of shortness of breath. The client tells the nurse that she wants “no heroic measures” taken if she stops breathing, and she asks the nurse to document this in her medical record. What action should the nurse implement? 331- A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement? 332- A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the nurse to ask? 333- After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse? 334- After the nurse witnesses a preoperative client sign the surgical consent form, the nurse signs the form as a witness. What are the legal implications of the nurse’s signature on the client’s surgical consent form? (Select all that apply) 335- Following surgery, a male client with antisocial personality disorder frequently requests that a specific nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the charge nurse implement? 336- A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take? 337- The client with which type of wound is most likely to need immediate intervention by the nurse? 338- The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client’s plan of care? 339- When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention? 340- When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely explanation for failure to locate the gallbladder by palpation? 341- A woman with an anxiety disorder calls her obstetrician’s office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman? 342- An older male client with a history of type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first? 343- A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse’s decision to hold the client’s scheduled antihypertensive medication? 344- Which client is at the greatest risk for developing delirium? 345- Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)? 346- Which location should the nurse choose as the best for beginning a screening program for hypothyroidism? 347- A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling “very tired”. Which nursing intervention is most important for the nurse to implement? 348- A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab is important for the nurse to review before contacting the health care provider? 349- What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning? 350- A client receiving chemotherapy has severe neutropenia. Which snack is best for the nurse to recommend to the client? 351- Which action should the school nurse take first when conducting a screening for scoliosis? 352- An unlicensed assistive personnel (UAP) assigned to obtain client vital signs reports to the charge nurse that a client has a weak pulse with a rate of 44 beat/ minutes. What action should the charge nurse implement? 353- After a sudden loss of consciousness, a female client is taken to the ED and initial assessment indicate that her blood glucose level is critically low. Once her glucose level is stabilized, the client reports that was recently diagnosed with anorexia nervosa and is being treated at an outpatient clinic. Which intervention is more important to include in this client’s discharge plan? 354- A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform? 355- The nurse administers an antibiotic to a client with respiratory tract infection. To evaluate the medication’s effectiveness, which laboratory values should the nurse monitor? Select all that apply 356- A client is admitted to isolation with the diagnosis of active tuberculosis. Which infection control measures should the nurse implement? 357- A school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In what position should the nurse place the child? 358- A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma? 359- A female client with breast cancer who completed her first chemotherapy treatment today at an out-patient center is preparing for discharge. Which behavior indicates that the client understands her care needs 360- Which instruction should the nurse provide a pregnant client who is complaining of heartburn? 361- A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely? 362- A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amount of liquid stool. Which action should the nurse implement? 363- After changing to a new brand of laundry detergent, an adult male reports that he has a fine itchy rash. Which assessment finding warrants immediate intervention by the nurse? 364- The nurse should teach the parents of a 6 year-old recently diagnosed with asthma that the symptom of acute episode of asthma are due to which physiological response? 365- A 10-year-old who has terminal brain cancer asks the nurse, "What will happen to my body when I die?" How should the nurse respond? 366- The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which findings? Select all that apply: 367- The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, ptosis, mouth drooping and, aspiration pneumonia. What is the priority nursing assessment that should be done before administering this medication? 368- The nurse who is working on a surgical unit receives change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse? 369- The nurse is caring for a client who had gastric bypass surgery yesterday. Which intervention is most important for the nurse to implement during the first 24 postoperative hours? 370- When preparing to discharge a male client who has been hospitalized for an adrenal crisis, the client expresses concern about having another crisis. He tells the nurse that he wants to stay in the hospital a few more days. Which intervention should the nurse implement? 371- In caring for a client with Cushing syndrome, which serum laboratory value is most important for the nurse to monitor? 372- Azithromycin is prescribed for an adolescent female who has lower lobe pneumonia and recurrent chlamydia. What information is most important for the nurse to provide to this client? 373- A client in the emergency center demonstrates rapid speech, flight of ideas, and reports sleeping only three hours during the past 48h. Based on these finding, it is most important for the nurse to review the laboratory value for which medication? 374- A male client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the healthcare provider? . 375- A client was admitted to the cardiac observation unit 2 hours ago complaining of chest pain. On admission, the client’s EKG showed bradycardia, ST depression, but no ventricular ectopy. The client suddenly reports a sharp increase in pain, telling the nurse, “I feel like an elephant just stepped on my chest” The EKG now shows Q waves and ST segment elevations in the anterior leads. What intervention should the nurse perform? 376- The nurse is developing a teaching program for the community. What population characteristic is most influential when choosing strategies for implementing a teaching plan? 377- A client is being discharged with a prescription for warfarin (Coumadin). What instruction should the nurse provide this client regarding diet? 378- A client who had a small bowel resection acquired methicillin resistant staphylococcus aureus (MRSA) while hospitalized. He treated and released, but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention. 379- A postoperative female client has a prescription for morphine sulfate 10 mg IV q3 hours for pain. One dose of morphine was administered when the client was admitted to the post anesthesia care unit (PACU) and 3 hours later, the client is again complaining of pain. Her current respiratory rate is 8 breaths/minute. What action should the nurse take? 380- Which intervention is most important for the nurse to include in the plan of care for an older woman with osteoporosis? 381- Based on the information provided in this client’s medical record during labor, which should the nurse implement? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client’s medical record) 382- An unlicensed assistive personnel UAP leaves the unit without notifying the staff. In what order should the unit manager implement this intervention to address the UAPs behavior? (Place the action in order from first on top to last on bottom.) 383- A client with intestinal obstructions has a nasogastric tube to low intermittent suction and is receiving an IV of lactated Ringer’s at 100 ml/H. which finding is most important for the nurse to report to the healthcare provider? 384- Which type of Leukocyte is involved with allergic responses and the destruction of parasitic worms? 385- Several months after a foot injury, and adult woman is diagnosed with neuropathic pain. The client describes the pain as severe and burning and is unable to put weight on her foot. She asks the nurse when the pain will “finally go away.” How should the nurse respond? 386- One day following an open reduction and internal fixation of a compound fracture of the leg, a male client complains of “a tingly sensation” in his left foot. The nurse determines the client’s left pedal pulses are diminished. Based on these finding, what is the client’s greatest risk? 387- The nurse is completing a head to be assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the nurse? 388- Following the evacuation of a subdural hematoma, an older adult develops an infection. The client is transferred to the neuro intensive care unit with a temperature of 101.8 F (39.3 C) axillary, pulse of 180 beats/minute, and a blood pressure of 90/60 mmHg. What is the priority intervention to include in this client’s plan of care? 389- The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client? 390- The family of an older woman reports that they are no longer capable of caring for her at home. While performing the admission assessment at long-term care facility, the nurse determines that the client is incontinent of urine, has dry mucous membranes and has a large bruise on the coccyx. Which interventions should the nurse include in the plan of care? (Select all that apply.) 391- The nurse is measuring the output of an infant admitted for vomiting and diarrhea. During a 12 hour shift, the infant drink 4 ounces of Pedialyte. Vomits 25 ml, and voids twice. The dry diaper weight 105 grams. Which computer documentation should the nurse enter in the infant’s record? 392- An adult client with a broken femur is transferred to the medical surgical unit to await surgical internal fixation after the application of an external traction device to stabilize the leg. An hour after an opioid analgesic was administered, the client report muscle spasms and pain at the fracture site. While waiting for the client to be transported to surgery, which action should the nurse implement!? 393- Which client´s vital signs indicating increased intracranial pressure (IPC) should the nurse report to the healthcare provider? 394- The nurse enters the room of a client who is awaiting surgery for appendicitis. The unlicensed assistive personnel (UAP) has a helped the client to a position of comfort with the right leg flexed and has applied a heating pad to the client´s abdomen to relieve the client´s pain. Which action should the nurse implement first? 395- The nurse is inspecting the thoracic region of an adolescent client. Which finding is consistent with scoliosis? 396- When preparing a client for discharge from the hospital following a cystectomy and urinary diversion to treat bladder cancer, which instruction is most important for the nurse to include in the client´s discharge teaching plan? 397- A client a traumatic brain injury becomes progressively less responsive to stimuli. The client has a “Do Not Resuscitate” prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side as previously scheduled. What action should the nurse take? . 398- While caring for a client´s postoperative dressing, the nurse observes purulent wound drainage. Previously, the wound was inflamed and tender but without drainage. Which is the most important action for the nurse to take: 399- In assessing a client with diabetes mellitus Type 1, the nurse that the client´s respirations have changed from 16 with a normal depth to 32 and deep, and the client has become lethargic. What assessment data should the nurse obtain next? 400- When caring for a client who has acute respiratory distress syndrome (ARDS), the elevates the head of bed 30 degrees. What is the reason for this intervention? 401- While assisting a client who recently had a hip replacement onto the bed pan, the nurse notices that there is a small amount of bloody drainage on the surgical dressing, the client´s skin is warm to the touch, and there is a strong odor from the urine. Which action should the nurse take? 402- A male client with heart failure (HF) reports heart palpations and difficulty breathing when Lying flat. When he requests additional pillows, the nurse determines that his heart rate is 125 beats/ minute, and respiratory rate is 22 breaths/ minute. Which intervention is most important for the nurse to implement? 403- The nurse is teaching a male client who recently diagnosed with gout. Which statement indicates that the client understands how to manage his gout? 404- A client with a new diagnosis of Raynaud´s disease lives alone. Which instruction should the nurse include in this client´s discharge teaching plan? 405- A client who is admitted to the medical unit with fluid volume overload has 2+ dependent edema in the lower extremities and a serum sodium level of 115 mEq/L (115MMOl/L). Which assessment should the nurse complete next? 406- A 6-year-old child who had surgery yesterday absolutely refuses to use the incentive spirometer. Which intervention should the nurse implement? 407- A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain; increasing weakness; and fatigue. Which laboratory test should the nurse stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor? 408- A client with hyperthyroidism is receiving propranolol. Which finding indicates that the medication is having the desired effect? 409- When is it most important for the nurse to assess a pregnant client´s deep tendon reflexes (DTRs)? 410- When conducting an admission assessment of a newborn infant, the nurse identifies a loud, harsh heart murmur. The healthcare provider prescribes an echocardiogram. What action is most important for the nurse to include in the infant´s plan care? 411- A client with rapid respirations and audible rhonchi is admitted to the intensive care unit because of a pulmonary embolism (PE). Low-flow oxygen by nasal cannula and weight based heparin protocol is initiated. Which intervention is most important for the nurse to include in this client´s plan of care? 412- One year after being discharge from the burn trauma unit, a client with a history of 40 percent full thickness burns is admitted with bone pain and muscle weakness. Which intervention is should the nurse include in this client´s plan of care? 413- The nurse identifies an electrolyte imbalance, an elevated pulse rate, and an elevated blood pressure for a client with chronic kidney disease. Which is the most important action for the nurse to take? 414- A nurse determines that more than 25% of the students at a middle school are overweight. The nurse presents the information at a parent-teacher meeting. What action is most important for the nurse to include in the meeting? 415- The nurse is completing the admission assessment of s 3-year-old who is admitted with bacterial meningitis and hydrocephalus. Which assessment finding is evidence that the child is experiencing increased intracranial pressure (ICP)? 416- While assessing an older client´s fall risk, the client tells the nurse that they live at home alone and has never fallen. What action should the nurse take? 417- A client is admitted with acute pancreatitis. The client admits to drinking a pint of bourbon daily. The nurse medicates the client for pain and monitors vital signs every 2 hours. Which finding should the nurse report immediately to the healthcare provider? 418- An older client with a 3day history of abdominal distention is admitted with a small bowel obstruction. The nurse inserts a nasogastric tube and attaches it to low intermittent suction. Which ongoing client assessment takes priority when providing care? 419- The nurse is completing an admission assessment for a male client with paranoid schizophrenia. The client tells the nurse that the staff dislikes him. What action should the nurse take? 420- After spending two weeks in the intensive care unit being treated for severe burns, a client is transferred to a progressive care unit with extensive dressings, a large healing wound, and a central venous access catheter. Which intervention should the nurse include in the plan of care? 421- A client is receiving ophthalmic drops preoperatively for a cataract extraction and asks the nurse why the healthcare provider has prescribed all these medications. Which information should the nurse included when responding to this client? (Select all that apply.) 422- The nurse is ready to insert an indwelling urinary catheter as seen in the picture. At this point in the procedure, what actions should the nurse take before inserting the catheter? (Select all that apply) 422- In evaluating the effectiveness of a postoperative client’s intermittent pneumatic compression devices, which assessment is most important for the nurse to complete? 423- The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first? 424- An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full thickness burns to all surfaces of both lower extremeties. What percentage of body surface area should the nurse document in the electronic medical record (EMR)? 425- The nurse is assessing a Vietnamese client who has terminal lung cancer when a family member comes to visit and brings ethnic food from home for the client. The client is on a soft mechanical regular diet. What intervention should the nurse implement?