A nurse is administering a tap water enema to a client who has constipation. The client reports
abdominal cramping during installation of the enema. Which of the following actions should the
nurse take? - ANS-Slow the rate of fluid flow.
A nurse is assisting with the care of four clients. Which of the following clients is the priority for
the nurse to see? - ANS-A client who has chest tubes and an oxygen saturation of 90%
A nurse is caring for a client who has a new diagnosis of moderate Alzheimer's disease. Which
of the following provider prescriptions should the nurse expect? - ANS-Donepezil 5mg PO daily
A nurse is caring for a client who has burns to the face, neck, and upper chest. The client has
expressed concerns regarding the change to the physical parents. Which of the following
actions should the nurse take? - ANS-Encourage the client to ask questions about their
treatment.
A nurse is caring for a client who has deep vein thrombosis. Which the following actions should
the nurse take to promote venous return? - ANS-Maintain the use of compression stockings
except when bathing the client.
A nurse is caring for a client who has type 1 diabetes mellitus and has undergone a
below-the-knee amputation. Which of the following is the highest priority finding? - ANS-Skin
flap of the residual limb is cool to the touch.
A nurse is caring for a client who is experiencing difficulty using utensils to eat following a
stroke. Which of the following referrals should the nurse recommend? - ANS-Occupational
therapist
A nurse is caring for a client who is preoperative and does not speak the same language as the
nurse. Which of the following actions should the nurse take? - ANS-Incorporate the use of
pictures as a communication tool.
A nurse is caring for a client who is receiving bolus enteral feedings and is prescribed digoxin
and furosemide. Which of the following actions should the nurse take? - ANS-Flush the tube
with water before and after each medication.
A nurse is collecting data from a client and osculates intermittent high-pitched sounds during
inspiration over the lower base of the lungs. The nurse should identify this finding as which of
the following lung sounds? - ANS-Fine crackles
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