1. After six days on a mechanical ventilator, a male client is extubated
and place on 40% oxygen via face mask. He is awake and cooperative,
but complaining of a severe sore throat. While sipping water to swallow
a medication, the client begins coughing, as if strangled. What
intervention
is most important for the nurse to implement?: Hold oral intake until
swallow evaluation is done.
2. The nurse is interacting with a female client who is diagnosed with
postpartum depression. Which finding should the nurse document as
an objective signs of depression? (Select all that apply): Interacts with
a flat affect.
Avoids eye contact.
Has a disheveled appearance.
3. A client in the postanesthesia care unit (PACU) has an eight (8) on the
Aldrete postanesthesia scoring system. What intervention should nurse
im- plement?: Transfer the client to the surgical floor.
4. In caring for the body of a client who just died, which tasks can be
1/7
,delegate to the unlicensed assistive personnel (UAP)? (Select all that
apply.)-
: Place personal religious artifacts on the
body. Attach identifying name tags to
the body.
Follow cultural beliefs in preparing the body.
5. An adult male reports the last time he received penicillin he developed a
severe maculopapular rash all over his chest. What information should
the nurse provide the client about future antibiotic prescriptions?: Be
alert for possible cross-sensitivity to cephalosporin agents.
6. A client with a 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?: The
client's need for pain medication should be determined.
7. A client with cirrhosis of the liver is admitted with complications related
to end stage liver disease. Which intervention should the nurse
implement? (Select all that apply.): Monitor abdominal girth.
Report serum albumin and globulin
levels. Note signs of swelling and
2/7
, edema.
8. 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?: Report weight gain of 2 pounds (0.9kg) in 24 hours
3/7
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