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The nurse notices clear nasal drainage in a patient newly admitted with facial trauma, including a nasal fracture. The nurse should: A. test the drainage for the presence of glucose. B. suction the nose to maintain airway clearance. C. document the findings and continue monitoring. D. apply a drip pad and reassure the patient this is normal. A. test the drainage for the presence of glucose. Clear nasal drainage suggests leakage of cerebrospinal fluid (CSF). The drainage should be tested for t...

The nurse assesses a patient with shortness of breath for evidence of long-standing hypoxemia by inspecting: A. Chest excursion B. Spinal curvatures C. The respiratory pattern D. The fingernail and its base D. The fingernail and its base Clubbing, a sign of long-standing hypoxemia, is evidenced by an increase in the angle between the base of the nail and the fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and sponginess of the end of the finger. 2. T...

The nurse is assessing a 48-year-old client with a history of smoking during a routine clinic visit. The client, who exercises regularly, reports having pain in the calf during exercise that disappears at rest. Which of the following findings requires further evaluation? 1. Heart rate 57 bpm. 2. SpO2 of 94% on room air. 3. Blood pressure 134/82. 4. Ankle-brachial index of 0.65. 4 An Ankle-Brachial Index of 0.65 suggests moderate arterial vascular disease in a client who is experiencing int...

The nurse is preparing to assist a client with a cuffed tracheostomy tube to eat. What intervention is the priority before the client is permitted to drink or eat? Inflate the cuff Rationale: If a client with a tracheostomy is allowed to eat and the tracheostomy has a cuff, the nurse should inflate the cuff to prevent aspiration of food or fluids. The cuff would not be deflated because of the risk of aspiration. The nurse has implemented a bowel maintenance program for an unconscious client. T...

A client with a productive cough has obtained a sputum specimen for culture as instructed. What is the best initial nursing action? A. Administer the first dose of antibiotic therapy B. Observe the color, consistency, and amount of sputum C. Encourage the client to consume plenty of warm liquids D. Send the specimen to the lab for analysis B. Observe the color, consistency, and amount of sputum A client is brought to the ED by ambulance in cardiac arrest with cardiopulmonary resuscitation (C...

Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching of the gravid client? a. the client's readiness to learn b. the client's educational background c. the order in which the information is presented d. the extent to which the pregnancy is planned A A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be...

A 29 year old male client informs the nurse that he came to the clinic to see if, "Maybe I have lung cancer or something," and wants to get checked out since, "I can't seem to get rid of this body-wracking dry cough that has been hanging around for the last six weeks." Which computer documentation of this client's concerns should the nurse enter? A. Presents with a hacking non-productive cough of 6 weeks duration. B. Describe having a "body-wracking dry cough" of 6 weeks duration. C. ...

A client is reporting chest pain. What statement made by the client helps the nurse to understand the client has a naturalistic belief in the cause of illness? A. "My life is really out of balance." B. "I knew I should have changed my diet." C. "I should have gone to church last week." D. "I forgot to take my medicines last night." A. "My life is really out of balance." A nurse is working in a healthcare facility that serves a diverse population. What action(s) by the nurse will al...

1. In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking? A) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors. B) Note-taking allows the patient to continue at his or her own pace as the nurse records what is said. C) Note-taking allows the nurse to shift attention away from the patient, resulting in an increased comfort level. D) Note-taking allows the nurse to break e...

Which glands are located immediately surrounding the urethral meatus on a woman? Skene's glands Which glands are posterior to the vaginal orifice? Bartholin's (vestibular) glands Which ligament suspends the breasts? Coopers ligament Which glands are responsible for keeping areola lubricated? Montgomery's gland