BSN 366 exit HESIFour hours following surgical repair of a compound fracture of the right ulna, the nurse is unable to palpate the client's right radial pulse. Which action should the nurse take first
Elevate the client's right hand on one or two pillows
After placing a 36- week- gestation ne...
Four hours following surgical repair of a compound fracture of the right ulna, the nurse is unable to
palpate the client's right radial pulse. Which action should the nurse take first
Elevate the client's right hand on one or two pillows
After placing a 36- week- gestation newborn in an isolette and drying the infant with several blankets,
what should the nurse implement next?
Remove the wet blankets and linen from the isolette
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A client in the third trimester of pregnancy complains of frequent nasal stiffness and occasional
nosebleeds. Her chest circumference has increased by 5 cm during the pregnancy, and she uses thoracic
breathing. Her diaphragm is elevated and she has an increased costal angle. Which intervention should
the nurse implement?
,Record the respiratory finding in the clients chart as normal
A terminally ill male hospice client who is at home is showing decreased awareness of his surroundings.
His appetite is poor and he often refuses oral intake of solids and liquids. For the past several days he has
been unable to get out of bed. Which action should the hospice nurse implement?
Instruct family to offer client only soft bland foods
A woman was admitted yesterday afternoon with severe abdominal pain. Her pregnancy test and
ultrasound were negative, so an exploratory laparotomy was completed during the night. When coffee
ground materials is observed in the drainage from the nasogastric tube (NGT), which intervention should
the nurse implement?
Verify correct placement of the nasogastric tube
The nurse is reviewing the laboratory values for a client with acute pancreatitis who reports of the
abdominal pain is not as severe as it was on admission. Which laboratory test should the nurse review to
evaluate the clients clinical recovery?
Lipase
While assessing a client who had a laparotomy the previous day, the nurse notices that 300 mL of dark
red fluid has drained from the nasogastric tube in the last hour. Which action should the nurse take first?
take vital signs
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The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis,
and emphysema. Which health care measure is most important for the nurse to recommend to these
clients?
Avoid large crowded areas during the colder months of the year
,The mother of a one-moth-old infant calls the clinic to report that the back of her infant's head is flat.
How should the nurse respond?
Position the infant on the stomach occasionally when awake and active
A woman is brought to the labor and delivery unti after delivering a term infant and the placenta in the
hospital parking lot 10 minutes ago. Which action should the nurse perform first?
Perform a fundal massage
A client has a new prescription for the maximum recommended dosage of pipercillin/tazobactam for
nosocomial pneumonia. The nurse should report which laboratory finding to the healthcare provider
before administering the prescribed dose?
Decrease serum creatine
A client who is admitted with diabetic ketoacidosis (DKA) is demonstrating Kussmaul breathing and has a
severe headache along with nausea. Her arterial blood gases (ABG) are: pH 7.50; PaCO2 30 mmHg; HCO3
24 mEq/L (24mmol/L). Which assessment finding warrants immediate intervention by the nurse?
Fruity breath
When performing postural drainage on a client with Chronic Obstructive Pulmonary disease (COPD),
which approach should the nurse use?
Explain that the client may be placed in five positions
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, A young male client with testicular cancer has a living will that describes his desire that no extraordinary
measures be taken to save his life. The healthcare provider knows the client has a good prognosis and
refuses to write a "do not resuscitate" (DNR) prescription. Which action should the nurse take?
Initiate an ethics committee review
In observing a clients face, which assessment finding requires the most immediate intervention by the
nurse?
Oral mucosa is cyanotic Blue lips
The nurse is assessing a client with cirrhosis and notes that the client has a positive Babinski reflex.
Which action should the nurse take in response to the finding?
Complete a thorough neurological assessment
Which action should the nurse take first after obtaining a urine specimen for culture and sensitivity from
an indwelling urinary catheter?
Ensure continued sterility of the specimen container
The home health nurse observes an older client with unilateral weakness place the walker in front of the
chair for support while rising to a standing position. Which action should the nurse take?
Hold the walker securely to prevent slipping while the client raises
A client with cancer complains of fever, chills, malaise, and headache following administration of a
colony-stimulating factor. Which nursing intervention is most beneficial in helping to reduce the flu like
symptoms?
Monitor lab values for an increase in WBCs
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