NUR 3525 CM IV FINAL STUDY GUIDE EXAM QUESTIONS AND ANSWERS BEST RATED A+ GUARANTEED SUCCE, Exams of Nursing

Download NUR 3525 CM IV FINAL STUDY GUIDE EXAM QUESTIONS AND ANSWERS BEST RATED A+ GUARANTEED SUCCE and more Exams Nursing in PDF only on Docsity! DO NOT COPY NUR 3525 CM IV FINAL STUDY GUIDE EXAM QUESTIONS AND ANSWERS BEST RATED A+ GUARANTEED SUCCESS LATEST UPDATE 2023 CM IV, EXAM 1 CHAPTERS 8, 9, 10, Lamone Ch 10  A nurse teaches clients at a community center about risks for dehydration. Which client is at greatest risk for dehydration? a.A 36-year-old who is prescribed long-term steroid therapy b. A 55-year-old receiving hypertonic intravenous fluids c. A 76-year-old who is cognitively impaired d. An 83-year-old with congestive heart failure ANS: C  A nurse is assessing clients on a medical-surgical unit. Which adult client should the nurse identify as being at greatest risk for insensible water loss? a.Client taking furosemide (Lasix) b. Anxious client who has tachypnea c. Client who is on fluid restrictions d. Client who is constipated with abdominal pain ANS: B  A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What action should the nurse take next? a.Assess clients rate, rhythm, and depth of respiration. b.Measure the clients pulse and blood pressure. c.Document the findings and continue to monitor. d.Notify the physician as soon as possible. ANS: A  A nurse teaches a client who is at risk for mild hypernatremia. Which statement should the nurse include in this clients teaching? a.Weigh yourself every morning and every night. b.Check your radial pulse twice a day. c.Read food labels to determine sodium content. d.Bake or grill the meat rather than frying it. ANS: C  A nurse is assessing clients on a medical-surgical unit. Which client is at risk for hypokalemia? a. Client with pancreatitis who has continuous nasogastric suctioning b. Client who is prescribed an angiotensin-converting enzyme (ACE) inhibitor c. Client in a motor vehicle crash who is receiving 6 units of packed red blood cells d. Client with uncontrolled diabetes and a serum pH level of 7.33 ANS: A  You are working on a burns unit and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance? A) Metabolic alkalosis B) Hypermagnesemia C) Hypercalce B) The kidneys buffer acids through electrolyte changes. C) The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH. D) The kidneys combine carbonic acid and bicarbonate to maintain a stable pH. Ans: C  You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should you first suspect? Brunner A) Hypophosphatem ia B) Hypocalcemia C) Hypermagnesemia D) Hyperkale mia Ans: B  You are caring for a 65-year-old male patient admitted to your medical unit 72 hours ago with pyloric stenosis. A nasogastric tube placed upon admission has been on low intermittent suction ever since. Upon review of the mornings blood work, you notice that the patients potassium is below reference range. You should recognize that the patient may be at risk for what imbalance? Brunner A) Hypercalcemia B) Metabolic acidosis C) Metabolic alkalosis D) Respiratory acidosis Ans: C  A patient who is being treated for pneumonia starts complaining of sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect? Brunner A) Respiratory acidosis B) Metabolic alkalosis C) Respiratory alkalosis D) Metabolic acidosis Ans: A  You are the nurse evaluating a newly admitted patients laboratory results, which include several values that are outside of reference ranges. Which of the following would cause the release of antidiuretic hormone (ADH)? Brunner A) Increased serum sodium B) Decreased serum potassium C) Decreased hemoglobin D) Increased platelets Ans: A  You are caring for a patient with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis? Brunner A) Hypertension B) Kussmaul respirations C) Increased DTRs D) Shallow respirations Ans: D  The nurse is assessing the patient for the presence of a Chvosteks sign. What electrolyte imbalance would a positive Chvosteks sign indicate? Brunner A) Hypermagnesemia B) Hyponatre mia C) Hypocalcemi a D) Hyperkalemi a Ans: C A nurse is caring for a female client in the ED who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the 10.) A nurse is triaging patients after a chemical leak at a nearby fertilizer factory. The guiding principle of this activity is what? a. Doing the greatest good for the greatest number of people 11.)A nurse is triaging clients in the emergency department. Which client should the nurse classify as nonurgent? a. A 62-year-old with a simple fracture of the left arm 12.)The complex care provided during an emergency requires interdisciplinary collaboration. Which interdisciplinary team members are paired with the correct responsibilities? (Select all that apply.) a. Psychiatric crisis nurse Interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis e. Paramedic Provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration 13.)A nurse assesses a client recently bitten by a coral snake. Which assessment is the priority? a. Respiratory rate and depth 14.)Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action should the nurse take first? a. Assess that the client is breathing adequately 15.) The nurse in the emergency department is performing an assessment on a client who sustained a right finger laceration from a fishhook while fishing. The nurse asks the client which priority question? a. “When did you receive your last tetanus immunization?” 16.) A client is brought to the emergency department by the police after having seriously lacerated both wrists. The initial action that the nurse should take is which step? a. Assess and treat the wound sites 17.) ***With a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid strength? (Question got blurred out) 18.) A nurse is assisting with disaster triage following a bomb explosion in a bus station. Which of the following clients should the nurse identify as being the highest priority? a. A conscious adult with second degree burns on both lower legs 19.) A 6-year-old is admitted to the ED after being rescued from a pond after falling through the ice while ice skating. What action should the nurse perform while rewarming patient? a. Ensuring continuous ECG monitoring 20.) A nurse enters a client’s room and sees that ashes from a cigarette are beginning to ignite trash in a waste basket. Which of the following actions should the nurse take first? a. Rescue the client from immediate danger 21.) A client is admitted to the emergency department with complaints of severe radiating chest pain, and a myocardial infarction is suspected the nurse immediately applies oxygen to the client and plans to take which action first? a. Call the laboratory to prescribe stat blood work b. Notify the coronary care unit to inform them that the client will need admission c. Obtain a 12-lead ECG d. Call radiology to prescribe a chest radiograph 22.) A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first? a. Wash the area of the puncture thoroughly with soap and water. 23.) A nurse is helping to triage a group of clients at a mass casualty incident who were involved in an explosion at a local factory. Which of the following clients should the nurse tag to be the priority for care? a. A client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site 24.) An emergency department nurse is transferring a client to the medical- 34.)How can a nurse assist disaster victim to cope with their experiences? a. Refer to hospital chaplain b. Active listening c. Assist to debrief d. Give emotional outlet 35.)A client presents to the ER after prolonged exposure to the cold, the client is shivering, has slurred speech and is slow to respond to questions, what treatment would the nurse provide for this client? a. Administer warmed intravenous fluids to the client. 36.)An Elderly patient fell and hit their head was transported by ambulance, was unconscious at the scene but is conscious on arrival, triage is urgent, what is the priority assessment the nurse includes during the primary survey of the patient? a. Neurological status? 37.)A nurse is at the scene of a lightning strike during a thunderstorm, what is the priority action of the nurse? a. Move victims and first responders to a sheltered area 38.)A client presents to the ER after prolonged exposure to the cold, the client is shivering, has slurred speech and is slow to respond to questions, What treatment would the nurse provide for this client? a. a. Administer bolus IV fluids b. b. Dry clothing and warm blankets c. c. Lavage d. d. Administer warmed intravenous fluids to the client 39.)The nurse is working ER on hot humid day when a hiker is brought in after collapsing. The hiker is confused and tachycardic temp 105.6. Which IV solution and medication would the nurse administer? a. a. Normal saline, methypredinsolone b. b. Dextrose 5% and benadryl c. c. Lactate and morphine sulfate d. d. Normal saline and lorazepam 40.)A man survived a workplace accident that claimed the lives of many of his colleagues several months ago. The man has recently sought care for the treatment of depression. How should the nurse best understand the man’s current mental health problem? a. a. Common response following a disaster b. b. Most likely feels guilty his actions during the disaster c. c. The man fails to appreciate the fact that he survived 41.). On a hot humid day several client present to the ER with symptoms of heat exposure which client will be treated first? a. a. Client who is anxious and confused b. b. Hypertensive and tachycardic c. c. Nausea and vomiting d. d. normal mental with flu like symptom 42.)A nurse is teaching a group of clients about emergency care for a snake bite. Which of the following information should the nurse include in the teaching? a. a. Apply a tourniquet b. b. Apply ice c. c. Raise the extremity above the level of the heart d. d. Immobilize the extremity with a splint 43.). A nurse has been assigned the role triage nurse after a weather-related disaster. What is the priority action of the nurse? a. a. Perform rapid assessments and determine priority of care b. b. Splint fracture and clean… c. c. Call additional support d. d. Provide psychological support 51.)The nurse is teaching a wilderness survival class. Which statement by a participant indicates that additional teaching is needed? a. a. It is ok to feel a little short of breath when I am climbing but not at rest b. b. My partner should let me know right away if my nose turns white c. c. If I get too cold I can have some brandy d. d. If I can’t think straight, we should descend to a lower altitude CM Exam #2 Ch 26, 37, 51 52.) The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client? a. Administer the prescribed tetanus toxoid vaccine. b. Assess the client’s wounds for signs of infection. c. Encourage the client to breathe deeply every hour. d. Wash your hands on entering the client’s room. ANS: D 53.) The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern? a. I get my chimney swept every other year. b. My hot water heater is set at 120 degrees. c. Sometimes I wake up at night and smoke. d. I use a space heater when it gets below zero. ANS: C 54.) A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive perspective of his or her appearance? a. I will allow my spouse to change my dressings. b. I want to have surgical reconstruction. c. I will bathe and dress before breakfast. d. I have secured the pressure dressings as ordered. ANS: C 55.) The nurse assesses a client who has a severe burn injury. Which statement indicates the client understands the psychosocial impact of a severe burn injury? a.It is normal to feel some depression. b.I will go back to work immediately. c.I will not feel anger about my situation. d.Once I get home, things will be normal. ANS: A 56.) A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first? a. Assess the level of consciousness and pupillary reactions. b. Ascertain the time food or liquid was last consumed. c. Auscultate breath sounds over the trachea and bronchi. d. Measure abdominal girth and auscultate bowel sounds. ANS: C 57.) A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately? a.Arterial pH: 7.32 b.Hematocrit: 52% c.Serum potassium: 6.5 mEq/L d.Serum sodium: 131 mEq/L ANS: C 58.) A nurse teaches a client being treated for a full-thickness burn. Which statement should the nurse include in this clients discharge teaching? a.You should change the batteries in your smoke detector once a year. b.Join a program that assists burn clients to reintegration into the community. c.I will demonstrate how to change your wound dressing for you and your family. d.Let me tell you about the many options available to you for reconstructive surgery. ANS: C 59.) A student is caring for a client who suffered massive blood loss after trauma. How does the student correlate the blood loss with the clients mean arterial pressure (MAP)? a. It causes vasoconstriction and increased MAP. b. Lower blood volume lowers MAP. c. There is no direct correlation to MAP. d. It raises cardiac output and MAP. ANS: B 60.) A nurse is caring for a client after surgery. The clients respiratory rate has 68.) 69.)15. A nurse delegates care of a client in traction to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene care for this client? 70.)a. Remove the traction when re-positioning the client. b. Inspect the clients skin when performing a bed bath. c. Provide pin care by using alcohol wipes to clean the sites. d. Ensure that the weights remain freely hanging at all times. 71.)ANS: D 72.) A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3, blood glucose level 198 mg/dL, and temperature 96.2 F (35.6 C). What action by the nurse takes priority? a. Document the findings in the clients chart. b. Give the client warmed blankets for comfort. c. Notify the health care provider immediately. d. Prepare to administer insulin per sliding scale. 73.) A nurse assesses an older adult client who was admitted 2 days ago with a fractured hip. The nurse notes that the client is confused and restless. The clients vital signs are heart rate 98 beats/min, respiratory rate 32 breaths/min, blood pressure 132/78 mm Hg, and SpO2 88%. Which action should the nurse take first? a.Administer oxygen via nasal cannula. b.Re-position to a high-Fowlers position. c.Increase the intravenous flow rate. d. Assess response to pain medications. ANS: A A nurse in the ICU is planning the care of a patient who is being treated for shock. Which of the following statements best describes the pathophysiology of this patient’s health problem? A) Blood is shunted from vital organs to peripheral areas of the body. B) Cells lack an adequate blood supply and are deprived of oxygen and nutrients. C) Circulating blood volume is decreased with a resulting change in the osmotic pressure gradient. D) Hemorrhage occurs as a result of trauma, depriving vital organs of adequate perfusion. 74.) In an acute care setting, the nurse is assessing an unstable patient. When prioritizing the patients care, the nurse should recognize that the patient is at risk for hypovolemic shock in which of the following circumstances? A) Fluid volume circulating in the blood vessels decreases. B) There is an uncontrolled increase in cardiac output. C) Blood pressure regulation becomes irregular. D) The patient experiences tachycardia and a bounding pulse. 75.) When caring for a patient in shock, one of the major nursing goals is to reduce the risk that the patient will develop complications of shock. How can the nurse best achieve this goal? ????????????? 76.)A) Provide a detailed diagnosis and plan of care in order to promote the patients and familys coping. B) Keep the physician updated with the most accurate information because in cases of shock the nurse often cannot provide relevant interventions. C) Monitor for significant changes and evaluate patient outcomes on a scheduled basis focusing on blood pressure and skin temperature. A) Avascular necrosis of bone B) Compartment syndrome C) Fat embolism syndrome D) Complex regional pain syndrome 29. A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion? Confusion – Answer 31. An elderly female with osteoporosis has been hospitalized. Prior to discharge, when teaching the patient, the nurse should include information about which major complication of osteoporosis? A) Bone fracture B) Loss of estrogen C) Negative calcium balance D) Dowager's hump 32. A nurse is caring for a client who is postoperative following a below-the- knee-amputation and will soon undergo fitting for a leg prosthesis. which of the following is an appropriate intervention for this client at this time? a)wrap the stump with an elastic bandage in a figure-eight configuration b)remove the elastic bandage and re-wrap the stump once a day c)wrap the stump with an elastic bandage in a proximal-to-distal direction d)secure the elastic bandage to the lowest joint 33. A nurse is caring for a client who is sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occurs? a.The client complains of pain b.The client develops a life-threatening situation c.The client needs to have an x-ray of the femur preformed d.The client must be repositioned in bed 34. A client returns to the surgical unit from the post anesthesia care unit in skeletal traction. The nurse should take action to correct which of the following problems with the traction setup? A. The ropes are in the center of the wheel grooves B. The weights rest against the foot of the bed C. The weights are equal on each side D. The ropes attach securely attached to the pin. 35. A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client? A. Cryoprecipitates B.Albumin C.Platelets D.Packed Red blood cells 36. A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make? A- DIC is controllable with lifelong heparin usage B- DIC is caused by abnormal coagulation involving fibrinogen C- DIC is a genetic involving a vitamin K deficiency D- DIC is characterized by an elevated platelet count 37. The nurse knows that a patient with crush injuries to the lower extremities is a high risk for what complication? A. Bradycardia B.Hypotension C.Acute kidney injury D. Spinal nerve injury 38. A middle-aged patient has a tight cast on the left lower leg. Which assessment finding would prompt the nurse to assess further for compartment syndrome? A. Diminished pulses B.Discoloration of some of the toes C.Tingling sensation of the upper leg D.Pain more intense than expected based on initial injury 40. A nurse is caring for an adolescent who has a newly applied fiberglass A. 41-year-old man who sustained closed depression fractures of the face when hit with a baseball B.53-year-old woman who had an open abdominal hysterectomy 3 days ago to remove several large fibroid tumors C.67-year-old woman on chronic corticosteroid therapy who had several teeth extracted 2 days ago D. 72-year-old man with severe allergies who is undergoing radiation therapy for early-stage prostate cancer 48. A client who has a plaster leg splint reports a painful pressure sensation under the elastic wrap that is holding the splint in place. What is the nurse’s best initial action? A. Remove the splint to reduce skin pressure B. Perform a neurovascular assessment C. Report the client’s concern to the primary health care provider D. Inspect the skin under the elastic bandage 49. A client who had an elective below-the-knee amputation (BKA) reports pain in the foot that was that was amputated last week. What is the nurse’s most appropriate response to the client’s pain? A. “The pain will go away after the swelling increases.” B.“That’s phantom limb pain, and every amputee has that.” C.“Your foot has been amputated, so it’s in your head.” D. “On a scale of 0 to 10, how would you rate your pain?” 50. What is the nurse’s priority when doing an admission for a client who has returned directly from the operating suite after a carpal tunnel repair? A.Monitor vital signs, including pulse oximetry B.Check the surgical dressing to ensure that it is intact C.Assess neurovascular assessment in the affected arm D. Monitor intake and output Which clinical manifestation does the nurse recognize that indicates worsening in the condition of a patient in the refectory face of shock Increase respiratory rate A nurse is caring for a client who is 1 day post op following hip open reduction with internal fixation the client is scheduled to begin physical therapy in 30 minutes we should be following action should the nurse take ? Offer to administer analgesia A nurse is caring for a client who has ulna fracture and a new prescription of cyclobenzaprine before administrating which of the following explanations should the nurse provide to explain the purpose of this medication? This medication will relieve muscles spasm that may occur from the fracture Med Surg Exam 3 Ch 11, 12, 13 Brunner Ch 13  Administer oxygen via face mask 10. A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first? a.Depth of respirations b.Bowel sounds c.Grip strength d.Electrocardiogr aphy ANS: A 11. A nurse is assessing a client with hypokalemia, and notes that the clients handgrip strength has diminished since the previous assessment 1 hour ago. Which action should the nurse take first? a.Assess the clients respiratory rate, rhythm, and depth. b.Measure the clients pulse and blood pressure. c.Document findings and monitor the client. d.Call the health care provider. ANS: A 12. A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first? a.Encourage oral fluid intake. b.Connect the client to a cardiac monitor. c.Assess urinary output. d. Administer oral calcitonin (Calcimar). ANS: B 17. A nurse assesses a client with diabetes mellitus who is admitted with an acid- base imbalance. The clients arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L. Which manifestation should the nurse identify as an example of the clients compensation mechanism? a.Increased rate and depth of respirations b.Increased urinary output c.Increased thirst and hunger d.Increased release of acids from the kidneys ANS: A 18. A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L. Which assessment should the nurse perform first? a.Cardiac rate and rhythm b.Skin and mucous membranes c.Musculoskeletal strength d.Level of orientation ANS: A 19. A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What action should the nurse take next? a.Assess clients rate, rhythm, and depth of respiration. b.Measure the clients pulse and blood pressure. c.Document the findings and continue to monitor. d.Notify the physician as soon as possible. ANS: A 20. A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56 mm Hg, PaCO2 65 mm Hg, and HCO3 22 mEq/L. Which clinical situation should the nurse correlate with these values? a.Diabetic ketoacidosis in a person with emphysema b.Bronchial obstruction related to aspiration of a hot dog c.Anxiety-induced hyperventilation in an adolescent d.Diarrhea for 36 hours in an older, frail woman ANS: B 21. A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The clients arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L. Which action should the nurse take first? a.Apply oxygen by mask or nasal cannula. b. Apply a paper bag over the clients nose and mouth. c.Administer 50 mL of sodium bicarbonate intravenously. d. Administer 50 mL of 20% glucose and 20 units of regular insulin. ANS: A 22. A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3 22 mEq/L. Which client condition should the nurse correlate with these results? a. Diarrhea and vomiting for 36 hours b. Anxiety-induced hyperventilation c. Chronic obstructive pulmonary disease (COPD) d. Diabetic ketoacidosis and emphysema ANS: B 23. A nurse evaluates a clients arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3 22 mEq/L. Which intervention should the nurse implement first? a.Assess the airway. b. Administer prescribed bronchodilators. peripherally inserted central catheter. When assessing the client, the nurse notes swelling of the clients arm above the picc insertion site. Which of the following actions should the nurse take first? Measure the circumference of both upper arms 29. The nurse caring for a patient receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the patient is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take? Stop the transfusion immediately. 30. A patient is receiving a blood transfusion and complains of a new onset of slight dyspnea. The nurse's rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurse's most appropriate action? Slow the infusion rate and monitor the patient closely. 31. A patient is receiving the first of two ordered units of PRBCs. Shortly after the initiation of the transfusion, the patient complains of chills and experiences a sharp increase in temperature. What is the nurse's priority action? Discontinue the transfusion. 32. Renal failure can have prerenal, renal, or postrenal causes. A patient presents with acute renal failure and is being assessed to determine where, physiologically, the cause is. If the cause is found to be prerenal, which condition most likely caused it? Heart failure 33. A nurse assesses a clients peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next? a. Apply cold compresses to the IV site. b. Elevate the extremity on a pillow. c. Flush the catheter with normal saline. d. Stop the infusion of intravenous fluids. ANS: D 34. A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the clients chart prior to administering the medication: Client: Thomas Jackson DOB: 5/3/1936 Gender: Male January 23 (Today): Right upper extremity PICC is intact, patent, and has a good blood return. Site clean and free from manifestations of infiltration, irritation, and infection. Sue Franks, RN January 20: Purulent drainage from sacral wound. Wound cleansed and dressing changed. Dr. Smith notified and updated on client status. New orders received for intravenous antibiotics. Sue Franks, RN January 13: Client alert and oriented. Sacral wound dressing changed. Sue Franks, RN January 6: Right upper extremity PICC inserted. No complications. Discharged with home health care. Dr. Smith Based on the information provided, which action should the nurse take? a.Notify the health care provider. b. Administer the prescribed medication. c.Discontinue the PICC. d.Switch the medication to the oral route. ANS: B 39. You are caring for a patient who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. During your assessment, you note the patient complains of a new onset of weakness with abdominal pain. Further assessment suggests that the patient likely has a fluid volume deficit. You should recognize that this patient may be experiencing what electrolyte imbalance? A) Hypernatremia B) Hypomagnesemia C) Hypophosphat emia D) Hypercalcemia Ans: D 40. A patient has questioned the nurses administration of IV normal saline, asking whether sterile water would be a more appropriate choice than saltwater. Under what circumstances would the nurse administer electrolyte-free water intravenously? A) Never, because it rapidly enters red blood cells, causing them to rupture. B) When the patient is severely dehydrated resulting in neurologic signs and symptoms C) When the patient is in excess of calcium and/or magnesium ions D) When a patients fluid volume deficit is due to acute or chronic renal failure Ans: A 41. A patients most recent laboratory results show a slight decrease in potassium. The physician has opted to forego drug therapy but has suggested increasing the patients dietary intake of potassium. Which of the following would be a good source of potassium? A) Apples B) Asparagus C) Carrot s D) Bananas Ans: D 42. A patient is diagnosed with severe hyponatremia. The nurse realizes this patient will mostly likely need precautions implemented for what event? a.seizure b. infection c.neutropenia d. high- risk fall Ans: A Book questions: 43. When evaluating the hydration status of a new 84-year-old nursing home client, the nurse observes tenting of the skin on the back of the client’s hand. What is the nurse’s best action? Pg. 169 A. Assess the skin turgor on the client’s forehead (chest/sternum). B. Ask the client when he or she last had anything to drink. C.Examine the client’s dependent body areas, especially the ankles. D. Document this observation in the client’s record as the only action. Ans: A 44. A client is receiving 250 mL of a 3% sodium chloride solution intravenously for severe hyponatremia. Which signs or symptoms indicate to the nurse that this therapy is effective? Pg. 174 A. The client reports hand swelling. B.Bowel sounds are present in all four abdominal quadrants. C.Serum potassium level has decreased from 4.4 to 4.2 D. Blood pressure has increased from 100/50 mmHg to 112/70 mmHg Ans: D 45. A client asks why the provider has recommended that he breathe into a paper bag for several minutes when his anxiety disorder causes him to hyperventilate. What is the nurse’s best response? Pg. 197 A. “Even your exhaled breath still has some oxygen in it, and rebreathing this air ensures that you won’t pass out from lack of oxygen.” B.“When you breath fast, you can lose too much carbon dioxide, and rebreathing this air keeps you from becoming dizzy and failing.” C.“Rapid breathing can lead to dehydration from excessive fluid loss, and should the nurse include? You should receive a prescription for a thiazide diuretic to take with the magnesium You will have your deep tendon reflexes monitored while you are receiving magnesium* 55. Furosemide. Client is at risk for? Dehydration. 56. A nursing student needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing educator determines the student is unprepared for the procedure when the student states which of the following is part of the plan for preparation and administration of the potassium? A. Obtaining a controlled intravenous (IV) infusion pump B. Monitoring urine output during administration C. Preparing the medication for bolus administration D. Diluting the medication in appropriate amount of normal saline Ans: C Exam # 5 1. A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease. a.Asterixis b.Constructional apraxia c.Fetor hepaticus d.Palmar erythema 2. The nurse is caring for a client with liver failure and is performing assessment and the knowledge of the clients increase risk of bleeding. The nurse recognizes that this risk is related to the client inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function? a.Alterations in glucose metabolism b.Retention of bile salts c.Inadequate production of albumin by hepatocytes d. Inability of the liver to use vitamin K 3. A nurse is assessing a client who has cirrhosis which of the following is an expected finding for this client? a.Moist skin b.Spider angiomas c.Blood in the urine d.Black stool 4. A nurse dis assessing a client who has chronic kidney disease a.Intake and output b.Skin turgor c. Daily weight d. Serum sodium level 5. A nurse cares for a middle-aged female client with diabetes mellitus who is being treated for the third episode of acute pyelonephritis in the past year. The client asks, what can I do to help prevent these infections? How should the nurse respond? a.Test your urine daily for the presence of ketone bodies and proteins. b.Use tampons rather than sanitary napkins during your menstrual period. c. Drink more water and empty your bladder more frequently during the day. d. Keep your hemoglobin A1c under 9% by keeping your blood sugar controlled. 11. The charge nurse is orienting a float nurse to an assigned client with an arteriovenous (AV) fistula for hemodialysis in her left arm. Which action by the float nurse would be considered unsafe? a.Palpating the access site for a bruit or thrill b.Using the right arm for a blood pressure reading c.Administering intravenous fluids through the AV fistula d.Checking distal pulses in the left arm 12. A nurse is amending a patient plan of care in light of the fact that the patient has recently developed ascites. What should the nurse include in this patient care plan? A) Mobilization with assistance at least 4 times daily B) Administration of beta-adrenergic blockers as ordered C) Vitamin B12 injections as ordered D) Administration of diuretics as ordered 13. A nurse is preparing to administer blood transfusion to an older adult. Understanding age-related changes what alteration in the usual protocol are necessary for the nurse to implement a. Transfuse each unit over 8 hours b. Hold other IV fluids running c. Transfuse smaller bag of blood d. Pre-medicate to prevent reaction e. Access vital signs more often 14. A nursing student is caring for a client with leukemia. The student asks why the client is still at risk for infection when the clients white blood cell count (WBC) is high. What response by the registered nurse is best? a. If the WBCs are high, there already is an infection present. b. The client is in a blast crisis and has too many WBCs. c. There must be a mistake; the WBCs should be very low. d. Those WBCs are abnormal and don’t provide protection. 15. A client newly diagnosed with acute pancreatitis and admitted to the acute medical unit. How should the nurse most likely explain the pathophysiology of this patient health problem a. Toxins have accumulated and inflamed your pancreas b. Bacterial likely migrated from your intestines and became lodged in your pancreas c. A virus that was likely already present in your body has begun to attack your pancreatic cells d. The enzymes that your pancreas produces have damaged the pancreas itself. 16. The nurse is caring for a patient with polycystic kidney disease. Which assessment finding requires immediate nursing intervention? A. Temperature of 99° F B. Blood pressure of 170/90 C. Heart rate of 100 beats/min D. Urine output less than 30 cc/hr 17. A patient’s assessment and diagnostic testing are suggestive of acute pancreatitis. When the nurse is performing the health interview, what assessment questions address likely etiologic factors? Select all that apply. A) How many alcoholic drinks do you typically consume in a week? B) Have you ever been tested for diabetes? C) Have you ever been diagnosed with gallstones? D) Would you say that you eat a particularly high-fat diet? E)Does anyone in your family have cystic fibrosis? 18. A nurse plans care for a client with acute pancreatitis. Which intervention should the nurse include in this client plan of care to reduce discomfort? a. Administer morphine sulfate intravenously every 4 hours as needed. b. Maintain nothing by mouth (NPO) a. Maintaining oxygen saturation of 89% b. Minimal crackles and wheezes in lung sounds c. Maintaining a balanced intake and output d. Limited shortness of breath upon exertion 24. A nurse assesses a client who is recovering from a nephrostomy. Which assessment findings should alert the nurse to urgently contact the health care provider? (Select all that apply.) a.Clear drainage b.Bloody drainage at site c.Client reports headache d. Foul- smelling drainage e. Urine draining from site 25. A nurse is performing an admission assessment of a patient with a diagnosis of cirrhosis. What technique should the nurse use to palpate the patient’s liver? A) Place hand under the right lower abdominal quadrant and press down lightly with the other hand. B) Place the left hand over the abdomen and behind the left side at the 11th rib. C) Place hand under right lower rib cage and press down lightly with the other hand. D) Hold hand 90 degrees to right side of the abdomen and push down firmly. 26. A nurse in a clinic is caring for a client who has a history of alcohol abuse and reports bruising and frequent nosebleeds. For which of the following is the client at risk? a)Cirrhosis b)Diabetes c)Hepatitis A d)Malnutrition 27. A patient with a history of injection drug use has been diagnosed with hepatitis C. When collaborating with the care team to plan this patient’s treatment, the nurse should anticipate what intervention? A) Administration of immune globulins B) A regimen of antiviral medications C) Rest and watchful waiting D) Administration of fresh-frozen plasma (FFP) 28. Which assessment finding requires immediate nursing intervention in a patient with severe ascites? A. Confusion B. Temperature 38.2º C C. Tachycardia, rate 110 beats/min D.Shallow respirations, rate 32 breaths/min 29. The family of a neutropenic client reports the client is not acting right. What action by the nurse is the priority? a.Ask the client about pain. b. Assess the client for infection. c.Delegate taking a set of vital signs. d.Look at today’s laboratory results. 30. A nurse is caring for a postoperative 70-kg client who had major blood loss during surgery. Which findings by the nurse should prompt immediate action to prevent acute kidney injury? (Select all that apply.) C) Remove the catheter promptly and have the catheter tip cultured. D) Administer a bolus of IV normal saline as ordered. 35. A patient with portal hypertension has been admitted to the medical floor. The nurse should prioritize which of the following assessments related to the manifestations of this health problem? A) Assessment of blood pressure and assessment for headaches and visual changes B) Assessments for signs and symptoms of venous thromboembolism C) Daily weights and abdominal girth measurement D) Blood glucose monitoring q4h 36. A client with acute kidney injury has a blood pressure of 76/55 mm Hg. The health care provider ordered 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client is starting to develop shortness of breath. What is the nurse’s priority action? a.Calculate the mean arterial pressure (MAP). b. Ask for insertion of a pulmonary artery catheter. c.Take the clients pulse. d.Slow down the normal saline infusion. 37. A nurse is assessing a client receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client BP is 80/64. Which of the following action should nurse take first? a.Inform the provider b.Notify the lab c.Stop the infusion of blood d.Obtain a urine sample 38. A nurse working with clients with sickle cell disease (SCD) teaches about self- management to prevent exacerbations and sickle cell crises. What factors should clients be taught to avoid? (Select all that apply.) a.Dehydration b.Exercise c.Extreme stress d. High altitudes e. Pregnancy 39. A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of the following lab values? a. Calcium b. Amylase c. Red blood cell count 40. A client with chronic kidney disease states, I feel chained to the hemodialysis machine. What is the nurses best response to the clients statement? a.That feeling will gradually go away as you get used to the treatment. b.You probably need to see a psychiatrist to see if you are depressed. c.Do you need help from social services to discuss financial aid? d.Tell me more about your feelings regarding hemodialysis treatment. 41. A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan? A. Include foods high in starch and proteins. B. Include foods high in fiber. C. Avoid foods high in fat. D. Avoid foods high in sodium. 42. A client presents to the emergency department in sickle cell crisis. What intervention by the nurse takes priority? a.Administer oxygen. c.Soon the shockwaves will get rid of my gallstone d.They will put medication into my gallbladder to dissolve the stones 48. A nurse is providing dietary teaching to a client who has a history of recurring calcium oxalate kidney stones. Which of the following instructions should the nurse include in the teaching a.Drink 3 L of fluid every day b.Eat 12 oz animal protein daily c.Take 3000 mg of vit C daily d.Restrict calcium intake to one serving daily 49. In the care of a patient with acute pancreatitis, which assessment parameter requires immediate nursing intervention? A) Heart rate of 105 beats/min B) Serum glucose of 136 mg/dL C) Blood pressure of 102/76 mm Hg D) Respiratory rate of 28 breaths/min 50. A 23-year-old African American male with a history of sickle cell disease had an emergent open reduction and internal fixation of his right femur after a car crash. What is the initial postoperative nursing priority? A. Treating the patient's pain B.Ensuring adequate IV hydration C. Titrating oxygen to a Spo2 >95% D. Examining the surgical incision for signs and symptoms of infection Exam 6 Care 1. A nurse assesses a patient who is recovering from anterior cervical discectomy and fusion. infusion. Which complication would alert the nurse to urgently communicate with the healthcare provider? a. Inability to shrug shoulders b. Difficulty swallowing d. Weak pedal pulses 2. A patient with a documented history of seizure disorder experience is a generalized seizure. What ae action is most = b. Open the patients jaws to insert an oral airway c. Place patient in high fowlers position d. Restrain the patient to prevent injury 3. A nurse a nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) three weeks ago. Which of the following in should the nurse include in the client’s rehabilitation program? b. Improve left-side motor function c. Learn control impulsive behavior d. Compensate for loss of perception 4, The nurse working in the emergency department assesses a patient who has symptoms of stroke. For what modifiable risk factors would the nurse assess? (Select all that apply) e. Diabetes 5. A nurse is presenting discharge instructions to a client who has MS. The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate? Plan to relax in a hot tub spa each da c. Engage in a vigorous exercise program d. Wear an eye patch on the right eye at all times 6. The student learning about neurological disorders remembers that key features of increased intracranial pressure include which of the following: (unsure of this one) c. Aphasia 7. A patient with a stroke is being evaluated for fibrinolytic therapy. What information from the patient or family is most important for the nurse to obtain? a. Other medical conditions b. Loss of bladder control c. Progression of symptoms d. Time of symptom onset 8. A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take? a. Obtain the clients heart rate b. Place the client in high Fowlers position c. Administer a nitrate antihypertensive d. Assess the client for bladder distention 9. A client with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a client with this diagnosis? a. Pain upon ankle dorsiflexion of the foot b. Numbness and tingling in the lower extremities c. Neck flexion produces flexion of knees and hips d. Inability to stand with eyes closed and arms extended without swaying 10.a patient is receiving plasmapheresis. What action by the nurse best prevents infection in this patient? a. Giving antibiotics prior to treatments b. Performing appropriate hand hygiene c. Monitoring the patient’s vital signs d. Placing the patient in protective isolation 11.A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? a. Tachypnea b. Decreased level of consciousness c. Bilateral weakness of extremities d. Hypotension 12.The nurse is providing patient teaching to a patient with early stage Alzheimer's disease in her family. The patient has been prescribed donepezil hydrochloride (Aricept). What should the nurse explain to the patient and family about this drug? a. It slows the progression of Alzheimer's disease b. It cures AD in a small minority of patients c. It removes the patient's insight that he or she has AD d. It limits the physical effects of AD and other dementias 13.A middle-aged woman Has sought care from her primary care provider an undergone diagnostic testing that has resulted in the diagnosis of MS. What sign or symptom is most likely to have promoted the woman to seek care? a. Personality changes b. Difficulty in coordination c. Cognitive declines d. Contractures 14.an emergency room nurse initiates care for a patient with a cervical spinal cord injury who arrives via emergency medical service. What action would the nurse take first? a. Obtain vital signs b. Assess level of consciousness c. Evaluate respiratory status d. Administer oxygen therapy 15.A nurse is teaching a client who is taking benztropine to treat Parkinson's disease. The nurse should instruct the client to report which of the following adverse effects? a. Excess salivation b. Slow pulse c. Diarrhea d. Difficulty voiding 16.A patient with Guillain-Barre syndrome is admitted to the hospital. The nurse plans care giving priority to the interventions that address which priority patient problem? a. Low fluid volume c. Numbness if the tongue d. Vertigo 23.A patient with a TBI has nonreactive and dilated pupils. What would the nurse anticipate? a. Loss of vision b. Projectile vomiting c. Intense headache d. Brain stem herniation 24.A patient scheduled for a magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepared the patient for the MRI should prioritize which of the following action? a. Withholding stimulants 24 to 48 hours prior to exam b. Instructing the patients to void prior to the MRI c. Removing all metal-containing objects d. Initiating an IV line for administration of contrast 25.The nurse is providing care for a patient who is unconscious. What nursing intervention takes highest priority? a. Inserting a nasogastric tube as ordered b. Maintaining a patent airway c. Providing appropriate pain control d. Maintaining accurate records of intake and output 26.A nurse promotes the prevention of lower back pain by teaching patients at a community center. Which instruction would the nurse include in this education? a. Wear flat instead of high-heeled shoes to work each day b. Participate in an exercise program to strengthen muscles c. Keep your weight within 20% of your ideal body weight d. Purchase a mattress that allows you to adjust the firmness 27.A nurse is caring for a client who has expressive aphasia following a cerebral vascular accident (CVA). which of the following parameters should the nurses assess the clients pain level? a. A self-report pain rating scale b. Behavioral indicators and effect c. Pulse and blood pressure findings d. Scheduled treatments in client illness 28.A patient with MS has developed dysphasia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform? a. Arrange for the patient to receive a low residual diet b. Suction the patient following each meal c. Position the patient upright during feeding d. Withhold liquids until the patient has finished eating 29.the nurse learns that the pathophysiology of Gillian-Barre syndrome includes segmental demyelination. The nurse understands that this causes what? a. Paralysis of affected muscles b. Slowed nerve impulse transmission c. Paresthesia in upper extremities d. Delayed afferent nerve impulses 30.A nurse is assessing a client who has Parkinson's disease. Which of the following manifestation should the nurse expect? a. Pruritus b. Bradykinesia c. Hypertension d. Xerostomia 31.A patient with myasthenia gravis asked the nurse to explain the disease. What response by the nurse is best? a. MG is a viral infection of the dorsal root of sensory nerve fibers b. MG consists of trauma induced paralysis of specific cranial nerves c. MG is an inherited destruction of peripheral nerve endings and junctions d. MG is an autoimmune problem in which nerves do not cause muscles to contract 38.A nurse is in a client’s room when the client begins having a tonic clonic seizure. Which of the following action should the nurse take first? a. Turn the clients head to the side b. Loosen the clothing around the client's waist c. Check the client's motor strength d. Document the time the seizure began 39.You are providing care for an 82-year-old man whose signs and symptoms of Parkinson's disease have become more severe over the past several months. The man tells you that he can no longer do as many things for himself as he used to be able to do. What factor should you recognize as impacting your patient’s life most significantly? a. Loss of independence b. Neurologic deficits c. Age related changes d. Tremors and decreased mobility 40.The critical care nurses is admitting a client in myasthenic crisis to the ICU. The nurse should prioritize what nursing action in the immediate care of this client? a. Facilitating ABG analysis b. Suctioning secretions c. Administering tube feedings d. Providing ventilatory assistance 41.A nurse in the emergency Department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (select all that apply) a. Absence of bowel sounds b. Hyperthermia c. Weakened gag reflex d. Hypotension e. Polyuria 42.A 69-year-old client is brought to the ED by ambulance because a family member found them lying on the floor disoriented and lethargic. The HCP suspects bacterial meningitis and admits the client to the ICU. What interventions should the nurse perform? Select all that apply. a.Obtain a blood type and crossmatch b. Administer antipyretics as prescribed c. Monitor pain levels and administer analgesics d. Perform frequent neurological assessments e. Place the client in a positive pressure isolation 43.A nurse is caring for a patient with paraplegia who is scheduled to participate in a rehabilitation program. The patient states, “I do not understand the need for rehabilitation; the paralysis will not go away, and it will not get better.” How should the nurse respond? https://quizlet.com/371825381/chapter-43-iggy- practice-questions- flash-cards/ a. “The rehabilitation program will teach you how to maintain the functional ability you have and prevent disability.” b. "Rehabilitation programs have helped many clients with your injury. You should give it a chance." c. "When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first." d. "If you don't want to participate in the rehabilitation program, I'll let the provider know." 44.A nurse is teaching a client who experiences migraine headaches and is prescribed a beta blocker. Which statement would the nurse include in this client’s teaching? a. “Take this drug as prescribed, even when feeling well, to prevent vascular changes associated with migraine headaches.” b.“This medication will have no affect on your heart rate or blood pressure.” c. “Take this medication only when you have prodromal symptoms indicating an onset of a migraine headache.” d.This drug will relieve the pain during the aura phase soon after a headache has started.” Exam 7: Chapters 28, 31, 32 1. A nurse is assessing a client who has a pulmonary embolism. Which of the clinical manifestations should the nurse expect to find? (Select all that apply) https://quizlet.com/127301096/ati-med-surge-ch-24-pulmonary- embolism-flash-cards/ A. Bradypnea B. Pleural friction rub C. Hypertension D. Petechiae 6. A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following should the nurse include in the teaching? A. Apply a vest restraint if self-extubation is attempted. B. Monitor ventilator settings every 8 hr. C. Document tube placement in centimeters at the angle of jaw. D. Assess breath sounds every 1 to 2 hr. Ans: D 7. An unlicensed assistive personnel (UAP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse takes priority? a. Assess the client's lung sounds. b. Assign a different UAP to the client. c. Report the UAP to the manager. d. Request thicker liquids for meals. Ans: A 8. A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the client's pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate? a. Call the operating room to inform them of a pending emergency case. b. No action is needed at this time; this is a normal finding in some clients. c. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask. d. Stay with the client and have someone else call the provider immediately. Ans: D 9. The nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention? https://quizlet.com/378998013/chapter-27-assessment-of-the- respiratory- system-flash-cards/ A. Patient’s heart rate is 55 beats/min; nurse withholds pain medication B. Patient’s respiratory rate is 18 breaths/min; nurse decreases oxygen flow rate C. Patient has reduced breath sounds; nurse calls physician immediately D. Patient states that he is dizzy; nurse applies oxygen and pulse oximetry Ans: C 10. A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention should the nurse include in this client's plan of care? A. Assistance with activities of daily living B. Physical therapy activities every day C. Oxygen therapy at 2 liters per nasal cannula D. Complete bedrest with frequent repositioning Ans: A 11. A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the client's face is puffy and the eyelids are swollen. What action by the nurse takes priority? A. Assess the client's oxygen saturation.