1. The nurse is caring for a client who hasperipherally inserted central catheter (PICC) placed in the rightarm. Which of the following should be included in the plan ofcare
Avoid taking blood pressures in the rightarm
Assess the PICC weekly
Perform dressing changes using cleantechnique
Avoid flushing the PICC
57. A client on continuous tube feed becomes confused, weak, andhas decreased skin turgor. Which lab finding is a priority for thenurse to report to the HCP?
a. sodium 150
b. phosphorus 4.8
c. potassium 3.4
d. calcium 7.8
58) A nurse is caring for a client with a pulmonary embolism andhas a new prescription for enoxaparin 1.5mg/kg/dose subcutaneousevery 12 hr. The client weighs 245 lbs. How many mg should thenurse administer per dose? ( Round to the nearest wholenumber)
59) The nurse caring for a client diagnosed with pneumonia who hasa productive cough and fatigue. Which of the following is anappropriate nursing intervention to assist the client in managingthick secretions and fatigue? SATA
Provide analgesic as ordered to promote patientcomfort
Increase fluid to at least 3L/day
Perform postural drainage every hour
Maintain head of the bed at 10 degrees
Teach the patient how to cough effectively andexpectorate secretions
60) A nurse is caring for a client who has a pulmonary embolus andis receiving a continuous heparin infusion. Which of the followingmedications should the nurse have available to reverse heparinseffects?
Deferasirox
Protamine sulfate
Acetylcysteine
Vit K
61
A client is preparing to have a thoracentesis performedby the physician. In which position should the nurse assist theclient to when preparing for a thoracentesis?
Left lateral with right arm extended above thehead
Supine with head of bed elevated at 45degrees
Sitting upright, leaning on an overbed table with feetsupported
Trendelenburg with bilateral arms extended
62
Which dietary instruction should the nurse provide to a clientdiagnosed with obstructive pulmonary disease (COPD) with a nursingdiagnosis of “imbalanced nutrition, less than bodyrequirements”?
Drink fluids with meals to promote digestion
Avoid foods that cause gas
Eat hot foods to feel less full
Eat low calorie foods
63
A nurse is caring for an adult client admitted to the medicalsurgical unit who is one day post-operative. Which nursing actionis most effective in preventing the development of pneumonia?
Explain and monitor the use of and incentivespirometer
Discontinue humidification delivery device to keepexcess fluid from lungs
Maintain strict bedrest
Restrict the intake of oral fluids
64
While caring for a client diagnosed with active tuberculosis, whichaction by the client would require the nurse to reinforceteaching?
Washes hands after blowing the nose
Wears a standard isolation mask when going to have achest x-ray
Flushes used tissues down the toilet
Coughs without covering the mouth
65
A nurse is caring for a client with diagnosed COPD. Which of thefollowing findings should the nurse expect to access this patient?(SATA)
Dyspnea
Kussmaul’s respirations
Chronic cough
Barrel chest
Bradycardia
66.
A nurse is assessing a client who is takingchlorothiazide. The nurse recognized which of the following is amanifestation of hypokalemia?
Shallow respiration
Hypertensive crisis
Hyperreflexia
Diarrhea
66) A nurse is assessing a client who is takingchlorothiazide sodium. The nurse recognizes which of the followingis a manifestation of hypokalemia?
Shallow respirations
Hypertensive crisis
Hyperreflexia
Diarrhea
67) A nurse is reviewing the medication list for a client who has anew prescription for warfarin. The nurse should recognize thatwhich of the following medications is incompatible withwarfarin?
Vit A
Vit K
Alpralazam
Furosemide
68) A nurse in the emergency department is assessing an older adultclient who has pneumonia. Which of the following findings shouldthe nurse expect?
Unequal pupils
Confusion
Tympany upon chest percussion
Hypertension
69) A nurse is caring for a client who is 12 hours postoperativewith a chest tube connected to a water seal drainage system. Thenurse should take action for which of the followingobservation?
Continuous bubbling in the water sealchamber
Bloody drainage in the collection chamber
The suction control chamber is set at 20cc ofH2O
Fluid level fluctuations in the water sealchamber
70) A nurse is instructing a client who is newly diagnosed withantitubercular medications. Which of the following should the nurseinclude in the teaching?
Medications will need to be taken for the rest of theclient’s life
Medications will need to be taken until the Mantouxtest is negative
The clients family will also need to take medicationsto prevent infection
A course of medication treatment may consist of a3-month initial
