A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being
admitted to the hospital with pneumonia. Which of the following assessment findings is the
nurse's priority? - ANSIncreased respiratory secretions
Using the airway, breathing, circulation approach to client care, the nurse should determine
that the priority assessment finding is increased respiratory secretions. Clients who have
ALS may experience respiratory muscle weakness and dysphagia, and excessive
respiratory secretions can impair the ability to clear the airway, which increases the client's
risk for aspiration.
A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of
the following actions should the nurse take first? - ANSCheck for the type and number of
units of blood to administer.
According to evidence-based practice, the nurse should first confirm that the type and
number of units of blood to administer matches what is indicated in the client's medication
administration record.
incorrect:
Obtain the client's vital signs: The nurse should obtain the client's vital signs for a baseline of
comparison. However, evidence-based practice indicates that there is another action that the
nurse should take first.
Describe the blood transfusion procedure to the client.
The nurse should describe the blood transfusion procedure to the client to promote client
understanding.
Initiate a peripheral IV line.
The nurse should ensure the client has large-bore IV access to prevent hemolysis during the
transfusion.
A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the
following interventions should the nurse include in the plan? - ANSEncourage the client to
take deep breaths after the procedure: After a thoracentesis, the client should deep breathe
to re-expand the lung.
incorrect:
Assist the client to hold their arms up during the procedure: The nurse should place the
client in an upright position with their arms resting on an overhead table to widen the
intercostal space and spread the ribs for tube insertion. The nurse should assist a client who
cannot sit up into a side-lying position with the affected side up.
Instruct the client to remain NPO after midnight prior to the procedure.
Keep the client on bed rest for 8 hr following the procedure.
, A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the
following precautions should the nurse implement? - ANSEnsure that the client has a patent
IV: The nurse should ensure the client has IV access in the event that the client requires
medication to stop seizure activity.
incorrect:
Place a padded tongue blade at the client's bedside.
Keep the side rails lowered on the client's bed.
Maintain the client's bed at hip level or above.
A nurse is providing follow-up care for a client who sustained a compound fracture 3 weeks
ago. The nurse should recognize that an unexpected finding for which of the following
laboratory values is a manifestation of osteomyelitis and should be reported to the provider?
- ANSSedimentation rate: An increased sedimentation rate occurs when a client has any
type of inflammatory process, such as osteomyelitis.
incorrect:
Hematocrit
Calcium
Acid phosphatase
A nurse is preparing to present a program about prevention of atherosclerosis at a health
fair. Which of the following recommendations should the nurse plan to include? (Select all
that apply.) - ANSFollow a smoking cessation program is correct. Smoking cessation is an
important lifestyle modification to prevent atherosclerosis.
Maintain an appropriate weight is correct. Preventing obesity through diet and exercise can
help to prevent atherosclerosis.
Eat a low-fat diet is correct. Eating a low-fat diet decreases LDL cholesterol and can prevent
atherosclerosis.
A nurse is caring for a client who has a potassium level of 3 mEq/L (3.5 to 5 mEq/L). Which
of the following assessment findings should the nurse expect? - ANSHypoactive bowel
sounds
Hypokalemia decreases smooth muscle contraction in the gastrointestinal tract leading to
decreased peristalsis.
incorrect:
Positive Trousseaus sign: A positive Trousseau's sign indicates altered calcium levels.
4+ deep tendon reflexes: Deep tendon reflexes are used to monitor magnesium levels.
Deep respirations: Shallow respirations occur with hypokalemia due to respiratory muscle
weakness.
A nurse is providing teaching for a female client who has recurrent urinary tract infections.
Which of the following information should the nurse include in the teaching? - ANSVoid
before and after intercourse: The nurse should instruct the client to empty her bladder before
and after intercourse, which flushes bacteria out of the urinary tract and prevents the
occurrence of infection.
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