ATI RN Concept-Based Assessment Level 2 Practice A V1 (2026–2027 Updated) | Questions & Answers with Rationales | Verified Answers | 100% Accurate | Grade A

ATI RN Concept-Based Assessment Level 2 Practice A V1 (2026–2027 Updated) | Questions & Answers with Rationales | Verified Answers | 100% Accurate | Grade A Q. A nurse in an emergency department is assessing a client who has hyperthermia. Which of the following findings should the nurse identify as an indication that the client has heat exhaustion? A: Hallucinations B: Vomiting C: Bradycardia D: Seizures ANSWER B: Vomiting Q. A nurse is developing an in-service for a group of coworkers about adolescents' reactions to death. Which of the following information should the nurse include when discussion an adolescent's response to death? A: Adolescents cope with death better than children of other ages. B: Adolescents view funeral services as an opportunity for closure. C: Adolescents are more concerned with the past than the present or future. D: Adolescents often alienate themselves from their peers when grieving. ANSWER D: Adolescents often alienate themselves from their peers when grieving. Q. A nurse is providing teaching to a client who is experiencing malabsorption related to lactose intolerance. Which of the following foods should the nurse recommend to the client as the best nondairy source of calcium? A: Ground beef B: Collard greens C: Cauliflower D: Walnuts ANSWER B: Collard greens Q. A nurse is caring for a client who is receiving heparin therapy and has an aPTT of 92 seconds. Which of the following medications should the nurse anticipate the provider might prescribe for the client? A: Leucovorin B: Vitamin K C: Deferoxamine D: Protamine ANSWER D: Protamine Q. A nurse is assessing a client who is postoperative following the placement of an ileostomy due to complication of ulcerative colitis. In which of the following areas should the nurse expect the ileostomy to be located? (You will hind hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)A: Right lower abdomen superior to umbilicus.B: Left lower abdomen even with the umbilicus.C: Right lower abdomen inferior to umbilicus. ANSWER The nurse should expect a client who is postoperative following the placement of an ascending colostomy to have an ostomy located on the right side of the abdomen, lateral to, and slightly above the umbilicus. Q. A nurse is providing teaching to the parent of an infant who has gastroesophageal reflux about home care. Which of the following statements by the parent indicates an understanding of the teaching? A: "I should feed my infant a larger amount of formula less frequently." B: "I should feed my infant a bottle of formula within 1 hour of bedtime." C: "I should place my infant on his side to sleep." D: "I should add 1 teaspoon of rice cereal to my infant's formula." ANSWER D: "I should add 1 teaspoon of rice cereal to my infant's formula." Q. A nurse is reviewing the laboratory report of a client who is taking exenatide to treat type 2 diabetes mellitus. The nurse should recognize that which of the following laboratory results is an indication of an adverse reaction to the medication? A: HbA1c 6.8% B: Hct 45% C: Creatinine 0.9 mg/dL D: Lipase 185 units/L ANSWER D: Lipase 185 units/L Q. A nurse is assessing a client who is receiving morphine via a PCA pump to manage postoperative pain. The client has a heart rate of 66/min and a respiratory rate of 9/min. Which of the following medications should the nurse anticipate the provider will prescribe for the client? A: Naloxone B: Flumazenil C: Acetylcysteine D: Glucagon ANSWER A: Naloxone Q. A nurse is reviewing the medical record of a client who has a family history of gallstones. Which of the following findings should the nurse identify as a risk factor for developing cholecystitis? A: Client is an adult male. B: Client is taking atorvastatin. C: Client is of Asian descent. D: Client has a history of asthma. ANSWER B: Client is taking atorvastatin. Q. A nurse is assessing a client whose ABG results are pH 7.51, PaCO2 29 mm Hg, and HCO3 24 mEq/L. Which of the following findings should the nurse expect? A: Paresthesias B: Bradycardia C: Muscle flaccidity D: Respiratory depression ANSWER A: Paresthesias Q. A nurse is providing teaching to a client who has diabetes mellitus and a new prescription for extended-release metformin. Which of the following client statements indicates an understanding of the teaching? A: "I will avoid drinking grapefruit juice." B: "I will chew the medication if I can't swallow it whole." C: "I will call the doctor if I have muscle pain in my back." D: "I will take this medication on an empty stomach." ANSWER C: "I will call the doctor if I have muscle pain in my back." Q. A nurse is assessing a client who has a potassium level of 2.6 mg/dL and is receiving potassium chloride by continuous IV infusion. Which of the following findings should the nurse identify as an indication that the potassium infusion has brought the client's potassium level back to the expected reference range? A: The client's ECG shows inverted T waves. B: The client's bowel sounds become hyperactive. C: The client's hand grasp becomes stronger. D: The client's standing systolic BP is within 30 mm Hg of her sitting systolic BP. ANSWER C: The client's hand grasp becomes stronger. Q. A nurse is caring for a client who has cellulitis of the lower extremity. Which of the following actions should the nurse take? (Select all that apply.) A: Apply cold packs to the affected area. B: Treat the affected area with propranolol. C: Elevate the affected area 15.24 cm (6 in) above the heart. D: Place a dry heating pad over the affected area. E: Administer cefazolin intermittent IV bolus C: Elevate the affected area 15.24 cm (6 in) above the heart. ANSWER E: Administer cefazolin intermittent IV bolus Q. The nurse in an emergency department was caring for an adolescent who died following a motor vehicle crash. Which of the following reactions should the nurse expect the client's 10-year-old sibling to exhibit? A: The sibling believes the client will wake up in a few hours. B: The sibling is curious about what will happen to the client's body. C: The sibling will continue to treat the client as though he were still alive. D: The sibling will alienate themselves from her family and friends. ANSWER B: The sibling is curious about what will happen to the client's body. Q. A nurse is caring for a preschooler who has a terminal illness. Which of the following reactions to death should the nurse expect the preschooler to exhibit? (Select all that apply.) A: Fears transmitting their disease to others B: Personifies death as being a type of monster C: Exhibits interest in what happens to the body following death D: Believes death is a temporary type of sleep E: Believes that their own thoughts can cause death D: Believes death is a temporary type of sleep ANSWER E: Believes that their own thoughts can cause death Q. A nurse in an emergency department is caring for a client whose ABG results are pH 7.31, PaCO2 50 mm Hg, and HCO3 25 mEq/L after experiencing an airway obstruction. Which of the following interventions is the nurse's priority for the client? A: Apply oxygen therapy to the client. B: Administer an anti-inflammatory medication. C: Check the client's nail beds. D: Initiate IV fluid therapy. ANSWER A: Apply oxygen therapy to the client. Q. A nurse is developing a plan of care for a preschooler who has heart failure. Which of the following interventions should the nurse include in the plan? A: Assess and record the child's blood pressure every 6 to 8 hr. B: Weigh the child once each week using the same scale. C: Place the child in a supine position for a minimum of 4 hr each day. D: Offer small, frequent meals based on the child's endurance level. ANSWER D: Offer small, frequent meals based on the child's endurance level. Q. A nurse is providing discharge teaching for a client who had lithotripsy to break up calculi in the right kidney. Which of the following findings should the nurse instruct the client to report to the provider? A: Bruising over the right flank area B: Blood-tinged urine C: Urine pH 6.0 D: Painful urination ANSWER D: Painful urination Q. A nurse is teaching the parent of a school-age child who has pediculosis capitis about treating this parasitic infestation. Which of the following instructions should the nurse include? A: Wash bedding, clothes, and towels in hot water in a washing machine. B: Rinse the child's hair with vinegar three times a day. C: Seal items that are not machine washable in plastic bags for 1 week. D: Boil the child's combs, brushes, and hair clips for 5 min. ANSWER A: Wash bedding, clothes, and towels in hot water in a washing machine. Q. A nurse is teaching a client who has asthma about using a metered-dose inhaler. Which of the following client statements indicates an understanding of the teaching? A: "I'll roll the canister between my palms a few times before using it." B: "I'll take a deep breath and blow it out before I inhale the medication." C: "I'll hold the mouthpiece 3 inches in front of my mouth before depressing the canister." D: "I'll hold my breath for up to 5 seconds after inhaling the medication." ANSWER B: "I'll take a deep breath and blow it out before I inhale the medication." Q. A nurse is assessing a client who has COPD and is receiving nebulized acetylcysteine. Which of the following findings should the nurse expect if the medication has been effective? A: Cough has been suppressed. B: WBC count is within expected reference range. C: Blood glucose levels are increased. D: Mucus is thin and white in color. ANSWER D: Mucus is thin and white in color. Q. A nurse is assessing a client who has Graves' disease. Which of the following findings should the nurse expect? A: Somnolence B: Cold intolerance C: Exophthalmos D: Dry, scaly skin ANSWER C: Exophthalmos Q. A nurse is admitting a client who has just been diagnosed with active tuberculosis and has experienced a 5.9 kg (13 lb) weight loss during the past 3 weeks. Which of the following actions should the nurse take first? A: Obtain a sputum sample for mycobacterial culture. B: Administer the first dose of antimycobacterial medications. C: Refer the client to a dietitian to plan a healthy diet. D: Initiate airborne precautions. ANSWER D: Initiate airborne precautions. A nurse is planning care to prevent hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) infection for a client who is immunocompromised. Which of the following interventions should the nurse include to prevent this antibiotic-resistant infection? A: Initiate contact precautions for this client. B: Bathe the client with chlorhexidine wipes. C: Administer ceftaroline to the client as a prophylactic measure. D: Avoid using alcohol-based hand sanitizers after caring for the client B: Bathe the client with chlorhexidine wipes. A nurse is assessing a client who has a calcium level of 6.3 mg/dL. Which of the following findings should the nurse expect? A: Circumoral tingling B: Hypoactive reflexes C: Fatigue D: Anorexia A: Circumoral tingling A nurse is teaching a male client who has hypertension about dietary guidelines to help manage his disorder. Which of the following instructions should the nurse include? A: Reduce sodium intake to 1,500 mg/day or less. B: Maintain a BMI of 30. C: Add high-protein sources, such as beef and pork, to the diet. D: Limit alcohol consumption to no more than three drinks per day. A: Reduce sodium intake to 1,500 mg/day or less. A nurse is providing dietary teaching for a client who has hyperlipidemia due to nephrotic syndrome. Which of the following instructions should the nurse include in the teaching? A: Less than 30% of daily calories should come from fat. B: Decrease caloric intake to less than 25 cal/kg/day. C: Increase sodium intake. D: Limit daily intake of foods high in carbohydrates. A: Less than 30% of daily calories should come from fat. A nurse is teaching a client who is at moderate risk for osteoporosis about ways to help prevent this chronic disease. Which of the following instructions should the nurse include? (Select all that apply.) A: Avoid sun exposure. B: Increase dairy product intake. C: Engage in weight-bearing exercises regularly. D: Increase phosphate intake. E: Reduce excessive caffeine intake B: Increase dairy product intake. C: Engage in weight-bearing exercises regularly E: Reduce excessive caffeine intake A nurse is teaching about foot care with a group of older adults who have type 1 diabetes mellitus. Which of the following information should the nurse include in the teaching? A: Soak feet daily to soften calluses. B: Apply a heating pad to the feet to improve circulation. C: Choose sandals with open toes to wear in the summer. D: Trim toenails straight across to prevent ingrown toenails. D: Trim toenails straight across to prevent ingrown toenails. A nurse is assessing an older adult client who is experiencing malnutrition. Which of the following findings should the nurse expect? A: Periorbital edema B: Diaphoretic skin C: Clubbing of fingers D: Brittle hair D: Brittle hair A nurse is assessing a client who reports gastrointestinal distress. Which of the following findings should indicate to the nurse that the client has cholecystitis? A: Abdominal pain triggered by spicy food B: Abdominal pain that radiates to the right shoulder C: Abdominal pain in the right lower quadrant D: Abdominal pain that is continuous over several days B: Abdominal pain that radiates to the right shoulder A nurse is assessing a client who has social phobia and reports feeling fear and panic when at social gatherings. Which of the following medications should the nurse expect the provider to prescribe? A: Carbamazepine B: Risperidone C: Paroxetine D: Quetiapine C: Paroxetine A nurse in an emergency department is caring for a client who reports abdominal pain, vomiting, and appears dehydrated. The client's ABG results are pH 7.28, PaCO2 36 mm Hg, and HCO3 14 mEq/L. Based on these findings, the nurse should identify that the client has which of the following acid-base imbalances? A: Metabolic acidosis B: Metabolic alkalosis C: Respiratory acidosis D: Respiratory alkalosis A: Metabolic acidosis A nurse is teaching an older adult client who has peripheral neuropathy about a new prescription for duloxetine. Which of the following client statements indicates an understanding of the teaching? A: "It might take several weeks to notice an improvement in my symptoms." B: "I will need to take this medication on an empty stomach." C: "I should take a daily ibuprofen for generalized aches." D: "I will need to decrease my dietary sodium intake while taking this medication." A: "It might take several weeks to notice an improvement in my symptoms." A nurse is teaching a client who has a new prescription for finasteride to treat benign prostatic hyperplasia. Which of the following instructions should the nurse include in the teaching? A: "You might need to take the medication for several months before seeing any relief." B: "This medication will cause an increase in your libido." C: "You might experience prolonged erections while taking this medication." D: "This medication will elevate your blood pressure." A: "You might need to take the medication for several months before seeing any relief." A nurse is teaching a client who has a deep-vein thrombosis about a new prescription for warfarin. Which of the following client statements indicates an understanding of the teaching? A: "I will stop taking the medication immediately if I experience nausea." B: "I should contact my provider if I notice a pink-tinged color to my urine." C: "I will increase my dietary intake of spinach." D: "I will not be able to use an electric razor while I am taking this medication." B: "I should contact my provider if I notice a pink-tinged color to my urine." A nurse is caring for a client who has had prolonged vomiting, has an NG tube for gastric decompression, and is receiving total parenteral nutrition. The client's ABG results are pH7.48, PaCO2 50 mm Hg, and HCO3 30 mEq/L. Based on these findings, the nurse should identify that the client has which of the following acid-base imbalances? A: Metabolic alkalosis B: Metabolic acidosis C: Respiratory acidosis D: Respiratory alkalosis A: Metabolic alkalosis A nurse is providing discharge teaching to an older adult client who had surgery to treat visual impairment due to cataracts. Which of the following client statements indicates an understanding of the teaching? A: "I will keep an eye patch in place for the first 3 days after surgery." B: "It is okay for me to lift my 2-year-old granddaughter." C: "I will be able run the vacuum cleaner in a day or two." D: "It might take 4 to 6 weeks for my vision to fully improve." D: "It might take 4 to 6 weeks for my vision to fully improve." A nurse is providing teaching to a client who has chronic obstructive pulmonary disease (COPD). Which of the following statements should indicate to the nurse that the client understands the teaching? A: "I should drink 1.5 liters of water daily to keep hydrated." B: "I should make my abdomen rise with each inhalation." C: "I should inhale through my mouth and exhale through my nose." D: "I should limit walks to 10 minutes daily in order to conserve my energy." B: "I should make my abdomen rise with each inhalation." A nurse is reviewing the medical record of a client who is receiving total parenteral nutrition. Which of the following actions should the nurse take? (Click on the exhibit button for additional information about the client.There are three tabs that contain separate categories of data.) A: Stop the client's infusion immediately. B: Notify the provider about the client's blood pressure. C: Clarify the dose of acetaminophen with the provider. D: Administer the prescribed regular insulin D: Administer the prescribed regular insulin A nurse is assessing a 3-month-old infant who has gastroenteritis with severe dehydration. Which of the following findings should the nurse expect? A: Flat anterior fontanel B: Capillary refill 2 seconds C: 5% weight loss D: Absence of tears D: Absence of tears A nurse is teaching disease management techniques to a client who has COPD. Which of the following instructions should the nurse include in the teaching? A: Avoid activities that increase the respiratory rate. B: Use pursed-lip breathing when feeling short of breath. C: Consume a diet high in carbohydrates for increased energy. D: Limit fluid intake to 1.5 L daily B: Use pursed-lip breathing when feeling short of breath. A nurse is teaching a client who has hypertension and a new prescription for atenolol. Which of the following information should the nurse include in the teaching? A: "If you miss a dose, you should take two doses the next morning." B: "You should stop taking this medication immediately if you experience depression." C: "You might experience an increased sensitivity to heat while taking this medication." D: "You should contact your provider if your pulse rate drops below 60 per minute." D: "You should contact your provider if your pulse rate drops below 60 per minute." A nurse is assessing a school-age child who has appendicitis with possible perforation. Which of the following findings should the nurse identify as a manifestation of peritonitis? A: Abdominal distention B: Bradycardia C: Hyperactive bowel sounds D: Slow, deep breathing A: Abdominal distention A nurse is assessing a client who has been taking antacids frequently for gastrointestinal distress. The assessment findings include drowsiness, muscle weakness, bradycardia, and hypotension. Which of the following electrolyte imbalances should the nurse suspect? A: Hypophosphatemia B: Hypochloremia C: Hypermagnesemia D: Hypernatremia C: Hypermagnesemia A nurse is providing teaching to a client who has a hearing impairment and has a new prescription for a hearing aid. Which of the following client statements indicates an understanding of the teaching? A: "I should wipe off the hearing aid each day with an alcohol wipe." B: "I will change the battery in the hearing aid when it makes a whistling sound." C: "I will make sure the hearing aid is off before inserting it in my ear." D: "I should start wearing the hearing aid for at least 1 hour at a time." C: "I will make sure the hearing aid is off before inserting it in my ear." A nurse in an emergency department is assessing a client who reports severe constipation. The nurse should identify which of the following findings as an indication that the client might have a small-bowel obstruction? A: Peripheral edema B: Minimal vomiting C: Intermittent cramping in the lower abdomen D: Visible peristaltic waves in the upper abdomen D: Visible peristaltic waves in the upper abdomen A nurse is discussing lactose-free foods with a client who is experiencing malabsorption due to lactose intolerance. Which of the following foods should the nurse recommend? A: Sour cream B: Soy milk C: Ice cream D: Plain yogurt B: Soy milk A nurse is teaching a client who has scabies about a new prescription for lindane lotion. Which of the following client statements indicates an understanding of the treatment for this parasitic infection? A: "I will apply the lotion once a day for 1 week." B: "I will rub in the lotion thoroughly from my face to my toes." C: "I will wash the lotion off 12 hours after I apply it." D: "I should avoid bathing for 6 hours prior to applying the lotion." C: "I will wash the lotion off 12 hours after I apply it." A nurse is assessing a client who has pernicious anemia. Which of the following findings should the nurse expect? A: Numbness of hands B: Gingival hyperplasia C: Clay-colored stools D: Carotid bruits A: Numbness of hands A nurse is assessing a client who has developed type 1 herpes simplex virus. Which of the following images should the nurse identify as this type of viral infection? A: A red tongue with white streaks. B: A brown and red rash on the left middle abdomen. C: Lips with white and red sores. D: Toes with a crusty rash. C: Lips with white and red sores. Herpes simplex virus infection is a common viral infection in adults. The nurse should identify that this image indicates the type 1 herpes simplex viral infection because the infection causes a recurring cold sore. A nurse is teaching a client who has asthma about medications to treat an acute asthma attack. Which of the following medications should the nurse include in the teaching? A: Fluticasone B: Salmeterol C: Albuterol D: Montelukast C: Albuterol A nurse in a provider's office is assessing a preschooler who has developed contact dermatitis following exposure to poison ivy. Which of the following statements should the nurse make to the child's parent regarding disease management? A: "Wash your child's exposed clothing in cold water using powder detergent." B: "Keep your child away from other children for 10 days after lesions appear." C: "Scrub your child's affected areas with an antibacterial soap every other day." D: "Place your child in an oatmeal bath using tepid water for 15 minutes." D: "Place your child in an oatmeal bath using tepid water for 15 minutes." A nurse is planning care for a client who has generalized anxiety disorder. Which of the following interventions should the nurse include in the client's plan of care? A: Give the client detailed instructions. B: Reframe situations in a positive manner for the client. C: Speak in a brisk manner to the client. D: Avoid involving the client in problem solving B: Reframe situations in a positive manner for the client. A nurse is an emergency department is assessing a client who has type 1 diabetes mellitus. Which of the following findings should the nurse identify as an indication that the client has diabetic ketoacidosis? A: Seizure activity B: Nervousness C: Blood glucose 396 mg/dL D: Serum pH 7.52 C: Blood glucose 396 mg/dL A nurse in an emergency department is assessing a client who is experiencing mild hypothermia. Which of the following manifestations should the nurse expect? A: Stupor B: Decreased pulse C: Slurred speech D: Dysrhythmias C: Slurred speech A nurse is caring for a toddler who sustained a left lower leg fracture in a motor vehicle crash. The toddler, who has light-pigmented skin, received a cast 24 hours ago. Which of the following assessment findings from the casted leg should the nurse report to the provider? A: The toddler's toes are pink in color. B: The toddler's foot swells when dependent. C: The toddler's toe movement is limited. D: The toddler's capillary refill time is less than 2 seconds. C: The toddler's toe movement is limited. A nurse is providing teaching to an adolescent client who has methicillin-resistant Staphylococcus aureus. Which of the following instructions should the nurse provide to prevent the spread of this infection? A: "Expose the infected areas of skin to open air and sunlight as much as possible." B: "Bathe in a tub of warm water using mild soap twice daily." C: "Place soiled dressing bandages in a red biohazard bag for disposal." D: "Do not return to football practice until the infection has healed." D: "Do not return to football practice until the infection has healed." A school nurse is teaching an adolescent who has diabetes mellitus about preventing hypoglycemia during and after baseball practice. Which of the following instructions should the school nurse include? A: "Inject your insulin into the upper thigh on practice days." B: "Consume an extra snack before practice." C: "Increase your regular insulin dosage before lunch on practice days." D: "Take a glucose tablet with a high-carbohydrate beverage after practice." B: "Consume an extra snack before practice." A nurse is assessing a client who has appendicitis. Which of the following findings should the nurse report to the provider immediately? A: WBC 16,000/mm³ B: Board-like abdomen C: Nausea and vomiting D: Temperature of 38° C (100.4° F) B: Board-like abdomen A nurse is assessing a client who reports a new onset of joint pain and stiffness. Which of the following findings should the nurse identify as an indication of osteoarthritis? A: Joint pain improves with rest. B: Joint pain is in both arms and shoulders bilaterally. C: Emotional upset exacerbates joint pain. D: Client is 35 years old. A: Joint pain improves with rest. A nurse is caring for a client who has pneumonia. Which of the following actions is the priority for the nurse to take? -Monitor intake and output -Provide teaching about antibiotic therapy -Administer the influenza vaccine -Observe the client perform incentive spirometry Observe the client perform incentive spirometry When using the airway, breathing, and circulation framework, the priority action the nurse should take is to observe the client perform incentive spirometry. Incentive spirometry improves gas exchange and oxygenation and stimulates coughing, which assists in clearing secretions. A nurse is assessing a client who has hyperthyroidism and has been taking methimazole for 6 months. Which of the following findings indicates a therapeutic response to the medication -The client's skin is warm and moist -The client reports sleeping longer during the night -The client is experiencing increased bowel movements -The client's weight is 1.4 kg (3.1 lb) less than baseline The client reports sleeping longer during the night The nurse should recognize that insomnia is a manifestation of hyperthyroidism. The client's ability to sleep longer during the night indicates a therapeutic response to the medication. A nurse is planning discharge teaching for the guardian of a child who had a cardiac catheterization. Which of the following instructions should the nurse include? -Monitor the site daily for drainage -Leave the pressure dressing on the 48 hr -Administer aspirin if the child reports pain -Resume tub baths in 24hr Monitor the site daily for drainage The nurse should instruct the guardian to monitor the site daily for manifestations of infection, such as drainage, redness, and swelling. The guardian should report these findings to the provider. A nurse is reviewing the medical record of a client who is receiving total parenteral nutrition for a malabsorption disorder. Which of the following findings should the nurse identify as an indication that the client's nutritional status is improving? -Intake of fluid is less than output of urine over the past 2 days -1kg (2.2 lb) weight gain over the past 2 days -Blood glucose 206 mg/dL -Prealbumin 13 mg/dL 1 kg (2.2 lb) weight gain over the past 2 days Total parenteral nutrition is administered to clients who have inflammatory bowel disorders and are unable to tolerate enteral nutrition. A weight gain of 0.5 kg (1.1 lb) daily is an indication that the client is responding to the parenteral nutrition. A nurse is performing a focused assessment on a client who has cholelithiasis and reports pain. Which of the following areas should the nurse assess? Right upper quadrant The nurse should assess the gallbladder for the presence of pain or discomfort as a result of biliary colic, which is caused by a gallbladder stone obstructing the bile duct. The pain can radiate from the right upper quadrant of the client's abdomen to the client's right shoulder. The nurse is providing discharge teaching to a client about managing diverticulitis. Which of the following statements should the nurse include in the teaching? -"Use bisacodyl suppositories to stimulate a bowel movement" -"Avoid lifting objects greater than 50 pounds" -"Consume a clear liquid diet until symptoms resolve" -"Take a probiotic 15 minutes after taking a prescribed antibiotic to prevent antibiotic-related diarrhea" "Consume a clear liquid diet until symptoms resolve" The nurse should recommend the client consume a clear liquid diet until manifestations such as abdominal pain, nausea, and vomiting have resolved. A clear liquid diet is low in fiber and does not stimulate intestinal motility. A nurse is providing teaching to a client who has a methicillin-resistant Staphylococcus aureus (MRSA) skin infection. Which of the following client statements indicates an understanding of the management of antibiotic resistant infections? -I will keep the infected area open to air to help it heal -I can sleep in the same bed as my partner after I have been taking antibiotics for 24 hours -I should sit on upholstered chairs instead of hardback chairs -I will wash all uninfected skin areas with a fresh washcloth I will wash all uninfected skin areas with a fresh washcloth The nurse should instruct the client to wash the uninfected skin areas with a fresh washcloth to prevent contamination of the unaffected areas of the skin with the MRSA infection. A nurse is providing teaching to a client about preventing hearing loss from trauma. Which of the following instructions should the nurse include in the teaching? -Keep your mouth open when sneezing -Block one nostril when blowing your nose -Use an ear wick candle to remove excess cerumen from the canal -Lubricate cotton-tipped applicators with mineral oil to clean the ear canal Keep your mouth open when sneezing The nurse should instruct the client to keep the mouth open while sneezing to reduce the pressure in the middle ear. Sudden pressure changes can damage the ossicles and perforate the ear drum. A nurse is teaching a client who recently lost his partner to a terminal illness. The client asks how his 4-year-old son is expected to react to the death of his partner. Which of the following information should the nurse include in the teaching? -A preschooler has no concept of death -A preschooler is often interested in what happens to the body after death -A preschooler often believes that death is reversible -A preschooler understands that death happens to everyone A preschooler often believes that death is reversible The nurse should identify that preschoolers tend to have difficulty understanding the reality of death and often believe that it is reversible. Because of magical thinking, the preschooler might think that his thoughts or behavior might have caused the person to die. A nurse is assessing a client who has gestational diabetes and ketoacidosis. Which of the following manifestations should the nurse expect? -Increased urination -Sweating -Dizziness -Loose stools Increased urination The nurse should expect the client to exhibit manifestations of hyperglycemia, including increased thirst, nausea, vomiting, increased urination, flushed dry skin, acetone breath odor, and a weak, rapid pulse. A nurse is assessing a client who has an external fixator to the right lower arm following musculoskeletal trauma. Which of the following findings should indicate to the nurse that the client has developed compartment syndrome? -Serous drainage is present on the pin site dressings -Flushing of the skin on the right arm -Bounding pulse palpated in the radial artery -Numbness to the fingers on the right arm Numbness to the fingers on the right arm The nurse should identify a decrease in sensation, such as numbness and tingling of the fingers, as one of the first indications that the client might be developing compartment syndrome of the right lower arm. Compartment syndrome is the result of edema and ischemia, a complication following musculoskeletal injury. Other manifestations include increased pain, paralysis, pallor, and decreased or absent pulses. A nurse is providing teaching about home care with an adolescent client who has a skin infection caused by MRSA. Which of the following client statements indicates an understanding of the teaching? -I will soak in a bathtub filled one-fourth full of water with one-half cup of bleach -I will wash my clothes in cold water and detergent -I will throw away my razor after using it three times -I will apply imiquimod cream to the lesions before going to bed each night I will soak in a bathtub filled one-fourth full of water with one-half cup of bleach The client should soak for at least 5 min in a bathtub filled one-fourth full of water with ½ cup of bleach once or twice per week. This will help prevent reoccurrence of the infection. A nurse is caring for a client who is experiencing an asthma attack. Which of the following procedures should the nurse use to assess the client's respiratory status? -Peak expiratory flow meter testing -Spirometry monitoring -Pulmonary function testing -Chest x-ray Peak expiratory flow meter testing The peak expiratory flow meter provides a means of evaluating the maximum flow of air the client expels during forceful exhalation. It provides information on how well asthma is being controlled as a part of daily monitoring and can be used when a client is having an asthma attack. The flow meter testing helps to gauge the peak-expiratory zone the client is experiencing and determines if the client should use immediate-acting bronchial dilator inhalers or seek emergency help. A nurse is caring for a client who has renal calculi and is taking oxybutynin for pain. Which of the following findings should the nurse identify as an adverse effect of this medication? -Increased salivation -Bradycardia -Tinnitus -Distended bladder Distended bladder The nurse should identify oxybutynin as having anticholinergic effects that can result in urinary retention. The nurse should monitor the client's intake and output and assess for bladder distention. A nurse is planning discharge for a postpartum client. The client tells the nurse she is having subdermal implant placed for contraception at her 6 week follow-up examination and asks about the adverse effects of the implant. Which of the following manifestations should the nurse include? -Irregular bleeding -Fatigue -Shoulder pain -Recurrent urinary tract infections (UTIs) Irregular bleeding The nurse should inform the client that irregular bleeding is possible when using a subdermal implant as a form of contraception. Other possible adverse effects include amenorrhea, heavy bleeding, headaches, nervousness, nausea, skin changes, and vertigo. With this method, a very small rod is placed on the underside of the upper arm, just underneath the skin. The implant is hardly noticeable and compared to oral contraceptives, the failure rate is less than 1%. One of the major advantages with this method is that fertility rapidly returns after its removal. A nurse in a community health clinic is reviewing data from the medical records of four clients. Which of the following communicable diseases requires reporting by the nurse? -Gonorrhea -Herpes genitalis -Human papillomavirus -Bacterial vaginosis Gonorrhea Gonorrhea is an infectious condition listed on the Nationally Notifiable Infectious Conditions Listing. The nurse should report this communicable disease to the Centers for Disease Control and Prevention. A nurse is caring for a group of clients. Which of the following clients should the nurse identify as being at risk for developing respiratory acidosis? -fever -abdominal ascites -anxious -nasogastric suctioning A client who has abdominal ascites The nurse should identify that a client who has abdominal ascites can experience a restriction of chest expansion, which impairs gas exchange and places the client at an increased risk for developing respiratory acidosis. A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect? -Brown discoloration of the lower extremities -Superficial ulcer on the medial aspect of the ankle -Dependent rubor -Telangiectasias Dependent rubor The nurse should expect redness to the lower extremities, or dependent rubor, when the client's legs are dangling or in a dependent position. A nurse is assessing a client for manifestations of right-sided heart failure. Which of the following findings should the nurse expect? -Jugular vein distention -Fatigue -Angina -Hacking cough Jugular vein distention The nurse should expect to find jugular vein distention (JVD) in the client who has right-sided heart failure due to right ventricular failure and pressure building in the venous system. A nurse is assessing a client for manifestations of GERD. Which of the following findings indicates to the nurse that the client might have GERD? -Decreased salivation -Diarrhea -Tonsillitis -Globus Globus The client who has manifestations of GERD will have globus, which is a feeling of something being in the back of the throat. A nurse is preparing to mix NPH insulin aspart in a single syringe for a client who has type 2 diabetes mellitus. Identify the sequence the nurse should follow. 1. Inject air into the vial equal to the amount of NPH insulin prescribed 2. Inject air into the vial equal to the amount of insulin aspart prescribed 3. Withdraw the prescribed volume of insulin aspart into the syringe 4. Withdraw the prescribed volume of NPH insulin into the syringe A nurse is assessing a client who has acute cholecystitis. Which of the following findings should the nurse expect? Select all that apply A: Fever B: Dyspepsia C: Pain radiating to the left shoulder D: Blood-tinged stools E: Eructation - Fever, Dyspepsia, Eructation A nurse is caring for a client who has developed cellulitis in a lower extremity. Which of the following actions should the nurse take? -Apply warm dary packs initially then apply cool moist packs to the lower extremity -Elevate the extremity 7.6 to 15.2 cm above heart level -Gently massage the affected extremity for 10-15 min every shift -Apply a topical corticosteroid to any open areas on the affected extremity twice per day Elevate the extremity 7.6 to 15.2 cm above heart level The nurse should elevate the client's affected extremity 7.6 to 15.2 cm (3 to 6 in) above the heart to promote venous return and decrease edema. A nurse is teaching about ezetimibe with a client who has hyperlipidemia. Which of the following client statements indicates an understanding of the teaching? -I should avoid this medication with milk -I will return to have my cholesterol levels checked in 2 weeks -I can expect to lose weight while taking this medication -I understand that muscle tenderness is an expected result of this medication I will return to have my cholesterol levels checked in 2 weeks A nurse is monitoring a client who has metabolic acidosis due to salicylate overdose. For which of the following findings should the nurse monitor? -Flushed, dry skin -Seizures -Hyperreflexia -Positive Trousseau's sign Flushed, dry skin The nurse should monitor a client who has metabolic acidosis for manifestations of warm, flushed, and dry skin due to vasodilation from an increased respiratory rate and the loss of CO2. A nurse in an emergency department is caring for a client who has appendicitis. Which of the following actions should the nurse take? -restrict oral intake to clear fluids -place a heating pad on the client's abdomen -place the client in semi-Fowler's position -Administer an enema Place the client in semi-Fowler's position The nurse should place the client in semi-Fowler's position to contain abdominal drainage in the lower abdomen and prevent it from seeping into the peritoneum. A nurse is participating in a health fair by providing screenings for osteoporosis. Which of the following should the nurse recognize as a risk factor for the disease? -BMI 26 or above -Excessive sun exposure -Frequent weight-bearing exercise -Hip fracture 6 months ago Hip fracture 6 months ago The nurse should recognize that a client who has a history of hip fracture, especially after the age of 50, is at greater risk for developing regional osteoporosis. A nurse is reviewing a client's home medication list during admission to a long-term care facility. The nurse should identify that the client takes which of the following medications to manage osteoarthritis? Select all that apply A: Lidocaine 5% patches B: Celecoxib C: Vancomycin D: Cyclobenzaprine E: Glucosamine - Lidocaine 5% patches, Celecoxib, Cyclobenzaprine, Glucosamine A nurse is assessing a client who has renal calculi. For which of the following findings should the nurse notify the provider immediately? -Flank pain with radiation toward the scrotum -150 mL emesis -Oliguria with bladder distention -Blood pressure 160/90 mmHg Oliguria with bladder distention The greatest risk to this client is injury due to bladder obstruction as indicated by decreased urinary output in the presence of bladder distention. The calculi can create an obstruction of the bladder neck or urethra. The nurse should identify this as a medical emergency and notify the provider immediately. A nurse is reviewing the laboratory results of a client who is taking sulfasalazine to treat ulcerative colitis. Which of the following laboratory findings should the nurse identify as an adverse effect of sulfasalazine? -Total bilirubin 0.8 mg/dL -WBC count 4,000/mm^3 -Platelets 190,000/mm^3 -Creatinine 1 mg/dL WBC count 4,000/mm^3 Agranulocytosis, or a very low WBC count, is an adverse effect of sulfasalazine. This condition results in a decreased WBC count. The nurse should identify that a WBC count of 4,000/mm3 is less than the expected reference range of 5,000 to 10,000/mm3, indicating an adverse effect of the medication. A nurse is assessing an infant whose guardian reports, "My baby has been crying nonstop, has a fever, and has been pulling at her ear." Which of the following manifestations should the nurse expect for an infant who might have otitis media ? -Enlarged postauricular lymph nodes -Increased flatulence with constipation -Indicates a desire to such more frequently -Slow bounding heart rate Enlarged postauricular lymph nodes The nurse should expect an infant who has otitis media to have enlarged postauricular and cervical lymph nodes, fever, pain, rhinorrhea, vomiting, and diarrhea. The fever might be as high as 40° C (104° F). A nurse is reviewing the laboratory results of an adult male client who has hyperlipidemia and is making lifestyle changes to improve his cholesterol levels. Which of the following findings indicates to the nurse that the client has achieved a therapeutic response? -LDL 168 mg/dL -HDL 50 mg/dL -Total cholesterol 268 mg/dL -Triglycerides 250 mg/dL HDL 50 mg/dL This finding indicates that the client has achieved a therapeutic response from a lifestyle change because the HDL is within the expected reference range of greater than 45 mg/dL for an adult male client. A nurse is assessing a client who is experiencing diarrhea and vomiting and has a sodium level of 124 mEq/L. Which of the following manifestations should the nurse expect? -Orthostatic hypotension -Hoarse voice -Neck vein distention -Muscle twitching Orthostatic hypotension The nurse should monitor the client who has a sodium level of 124 mEq/L for orthostatic hypotension. The expected reference range for sodium is 136 to 145 mEq/L. Other manifestations of hyponatremia include decreased deep tendon reflexes, headache, confusion, and lethargy. A nurse is admitting a client who has peptic ulcer disease and an upper gastrointestinal bleed. Which of the following manifestations should the nurse expect? Select all that apply A: Dark, tarry stools B: Bright red emesis C: Increased heart rat eD: Increased blood pressure E: Bounding peripheral pulses - Dark tarry stools, bright red emesis, increased heart rate A nurse is assessing a client for manifestations of left-sided heart failure. Which of the following findings should the nurse expect? -Weight gain -Enlarged liver -Distended abdomen -Cool extremities Cool extremities The nurse should expect to find cool extremities in the client who has left-sided heart failure due to a decreased cardiac output leading to impaired tissue perfusion. A nurse is providing teaching about home care with a parent of a child who has scabies. Which of the following statements by the parent indicates an understanding of the teaching? A: "I should apply the cream only to the areas where there is a rash. "B: "I should wash my child's bed linens and clothing in hot water and detergent." C: "I should expect my child's rash to go away within 72 hours after starting treatment." D: "I should leave the cream on my child for 4 hours before washing it off." I should wash my child's bed linens and clothing in hot water and detergent A nurse is reviewing the laboratory records of a client who has AIDS. Which of the following laboratory results should the nurse review to determine if the client is at risk for malnutrition? A: WBC count B: Albumin level C: CD4 T cell count D: C-reactive protein level Albumin level A nurse is assessing for adverse medication reactions with a client who reports taking more than the recommended doses of acetaminophen for the management of chronic pain. Which of the following findings should the nurse identify as an adverse effect of acetaminophen? A: Elevated aspartate aminotransferase levels B: Decreased skin turgor C: Elevated WBC count D: Decreased audio acuity Elevated aspartate aminotransferase levels A nurse is teaching a client who has COPD about preventing pneumonia. Which of the following client statements indicates an understanding of the teaching?" A. I will drink one and a half liters of fluids every day." B: "I will get the pneumonia vaccine yearly." C: "I will spray an aerosol disinfectant in my house every day." D: "I will wash my hands whenever I come home from the grocery store." I will wash my hands whenever I come home from the grocery store A nurse in a provider's office is reviewing the medical record of a client who has COPD. Which of the following findings is the priority for the nurse to report to the provider? A: Chest x-ray results show increased lung space. B: Sputum culture shows gram positive bacteria. C: SpO2 level is 88%. D: Weight loss of 1.4 kg (3 lb) since prior visit. Sputum culture shows gram positive bacteria A nurse is providing teaching for a client who has peripheral neuropathy of the lower extremities. Which of the following client statements indicates an understanding of the teaching? A: "I should wash my feet with soap before I try to treat my calluses." B: "I should limit wearing the same shoes 2 days in a row." C: "I should use home remedies to treat any blisters or sores on my feet." D: "I should use adhesive tape to secure a dressing on my foot when I have skin breakdown." I should limit wearing the same shoes 2 days in a row A nurse is providing teaching about exercise to a client who has osteoarthritis. Which of the following information should the nurse include? A: Increase daily intake of foods containing vitamin A. B: Limit alcohol consumption to 10 oz daily .C: Perform exercises to strengthen the abdominal core. D: Start a daily jogging regimen Perform exercise even on days when joints are painful A nurse is planning teaching for an adolescent who has exercise-induced asthma and has new prescriptions for cromolyn and albuterol inhalers. Which of the following instructions should the nurse plan to include in the teaching? A: Inhale the second puff of cromolyn 2 min after the first. B: Use the cromolyn following exercise if shortness of breath occurs. C: Use the albuterol prior to planned exercise. D: Cleanse the albuterol mouthpiece once every 2 weeks. Use albuterol prior to planned exercise A nurse is assessing a client who has acute pyelonephritis. Which of the following findings should the nurse expect? A: Pain with palpation to the substernal notch B: Urinary burning C Ecchymosis over the flank D: Radiating pain to the right shoulder Urinary burning A nurse is reviewing the laboratory results of a client who is scheduled for surgery and notes a potassium level of 6 mEq/L. Which of the following ECG findings should the nurse expect? A: Heart rate 64/min B: Tall T waves C: Shortened PR interval D: QRS 0.08 seconds Tall T-waves A nurse is counseling a client who recently lost her partner in a motor-vehicle crash. Which of the following reactions should the nurse identify as part of the second stage of the grieving process? A: Persistent feelings of hopelessness B: Loss of self-esteem C: Chronic physical manifestations D: Feeling anger toward family members Feeling anger toward family members A nurse is providing teaching about home care to the parent of a child who has pediculosis capitis. Which of the following information should the nurse include? A: Soak the child's combs and brushes in hot water for 5 min .B: Rinse the child's hair each day with 236.5 mL (1 cup) of vinegar .C: Seal the child's nonwashable toys in plastic bags for 7 days. D: Comb the child's hair daily with an extra fine-tooth comb. Comb the child's hair daily with an extra fine-tooth comb A nurse is assessing a client who has generalized anxiety disorder and is experiencing a moderate level of anxiety. Which of the following manifestations should the nurse expect? A: Focuses on the source of the anxiety B: Exhibits an inability to speak C: Experiences auditory hallucinations D: Feels surroundings are unreal Focuses on the source of anxiety A nurse is providing teaching about home care to the parent of an adolescent who has infectious mononucleosis. Which of the following manifestations should the nurse intruct the parent to report to the provider? A: Swollen cervical lymph nodes B: Exudate on tonsils C: Lack of energy D: Onset of abdominal pain onset of abdominal pain A nurse is reviewing the medical record of a client who has decreased urinary output. Which of the following findings should the nurse identify as a risk factor for the development of pyelonephritis? Diabetes mellitus A nurse is reviewing the medical record of a client who has AIDS and is experiencing anorexia. Which of the following medications should the nurse expect the provider to prescribe to reduce the client's risk of failure to thrive? A: Megestrol B: Ondansetron C: Famotidine D: Pancrelipase Megestrol A nurse is evaluating a client's understanding of dietary teaching to treat hyperlipidemia. Which of the following menu choices by the client indicates an understanding of the teaching? A: A black bean burger on a whole grain bun B: Oatmeal with whole milk C: A baked potato with butter D: A pork sausage patty on a biscuit A black bean burger on a whole grain bun A nurse is providing dietary teaching for a client who has GERD. The nurse should instruct the client to avoid which of the following items? A: Caffeinated coffee B: Shell fish C: Apple juice D: Green beans Caffeinated coffee A nurse is assessing a client who has a partial obstruction of the large bowel. Which of the following manifestations should the nurse expect? Ribbon-like stools A nurse is admitting an infant who has pertussis. Which of the following actions should the nurse take? Initiate droplet precautions for the infant A nurse is caring for a client who is experiencing a hyperglycemic-hyperosmolar state related to complications of diabetes mellitus. Which of the following findings should the nurse expect? A: Fruity-scented breath B: Serum glucose 350 mg/dLC: pH 7.32 D: Hypotension Hypotension A nurse is assessing a client who has a new diagnosis of hypothyroidism. Which of the following manifestations should the nurse expect? A: Cold intolerance B: Diaphoresis C: Weight loss D: Tachycardia Cold intolerance A nurse is caring for a client who has possible appendicitis. Which of the following actions should the nurse take? A: Palpate the left lower quadrant of the abdomen to check for rebound pain. B: Start IV fluid replacement. C: Treat the client's pain with oral opioid analgesics given with food. D: Administer a suppository to the client in preparation for surgery. Start IV fluid replacement A nurse is planning discharge teaching for the parent of a newborn. Which of the following information should the nurse include? A: "Cover your newborn with a light blanket while she is sleeping." B: "Do not bathe your newborn immediately after she eats." C: "Place your newborn in a crib with a bumper pad." D: "Wash your newborn's face with a mild soap." Do not bathe your newborn immediately after she eats A nurse is caring for a client who has right-sided hemiparesis following a stroke. Which of the following images is an indication that the nurse is correctly assisting the client to ambulate? One hand on gait belt walking behind the patient on affected side (right side) A nurse is teaching a client who has a new diagnosis of peripheral neuropathy about foot care. Which of the following statements should the nurse include? A: "Wear open-toe shoes to allow air to circulate around your feet. "B: "Use a heating pad set on low to warm your feet when they feel cold." C: "File your toenails straight across to prevent ingrown toenails." D: "Apply a thin layer of lotion between your toes twice per day." File your toenails straight across to prevent ingrown toenails A nurse is developing a plan of care for a client who is scheduled to have an induction of labor due to a fetal demise. Which is the following actions should the nurse include? A: Limit the amount of time the client spends with the newborn after birth. B: Discourage the client from having other family members see the newborn. C: Inform the client that an autopsy of the newborn is required by federal law. D: Bathe, diaper, and dress the child before bringing the newborn to the client Bathe, diaper, and dress the child before bringing the newborn to the client A nurse is assessing a school-age child who has asthma and shortness of breath. Which of the following assessment findings should the nurse identify as the priority? A: Inaudible lung sounds B: Persistent cough C: Yellow zone peak flow meter reading D: Prolonged expiration phase Inaudible lung sounds A nurse is reviewing a client's medical record prior to a laparoscopic appendectomy. Which of the following findings should the nurse report to the provider? A: Prothrombin time 12 seconds B: History of sinusitis several times each year C: BMI of 24 D: Report of urinating small amounts twice daily Report of urinating small amounts twice daily A nurse is providing discharge teaching to the parents of a newborn about crib use. Which of the following statements should the nurse make? A: "Arranging small stuffed animals in the crib is recommended to provide a feeling of security for your baby." B: "Moving the crib near a window in the nursery will provide your baby with necessary fresh air and natural light." : "Dressing your baby in a one-piece sleeper for bedtime will replace the need to use a blanket or a sheet." D: "Placing your baby on her tummy in the crib will hasten drowsiness and provide a more restful night's sleep." Dressing your baby in a one-piece sleeper for bedtime will replace the need to use a blanket or a sheet A nurse is teaching a group of newly licensed nurses about hypothermia and the care of a client who has frostbite to the fingers and toes from cold exposure. Which of the following information should the nurse include in the teaching about frostbite? A: Slowly institute rewarming of the affected areas. B: Place the affected areas of frostbite in a warm water bath. C: Massage the affected areas of frostbite. D: Position the affected areas of frostbite flat after warming Place the affected areas of frostbite in a warm water bath A nurse is assessing a client who has developed Clostridium difficile as an adverse effect to ciprofloxacin. Which of the following medications should the nurse expect the provider to prescribe to treat the C. difficile? Vancomycin A nurse is assessing a client in the triage room of an emergency department. Based on the client findings, which of the following actions should the nurse take? Place a surgical mask on the client A nurse is developing a plan of care for a client who is 1 hr postoperative following open carpal tunnel release to treat a musculoskeletal injury. Which of the following interventions should the nurse include in the plan? A: Elevate the client's arm above the heart. B: Apply heat to the client's surgical site. C: Instruct the client to avoid moving their fingers. D: Monitor the client's ability to complete wrist range-of-motion. Elevate the client's arm above the heart A nurse is assessing a 6-month-old infant who has gastroenteritis with mild dehydration. Which of the following findings should the nurse expect? A: Absence of tears when crying B: Loss of 6% of body weight C: Sunken anterior fontanel D: Capillary refill greater than 2 seconds Capillary refill greater than 2 seconds A nurse is reviewing the laboratory results of an adult client who has metabolic alkalosis. Which of the following findings should the nurse expect? A: Calcium 9.5 mg/dL B: Bicarbonate 23 mEq/L C: Potassium 3 mEq/L D: pH 7.4 - Potassium 3 mEq/L A nurse is assessing a newly admitted client who has an intense fear of heights. Which of the following clinical names for this fear should the nurse document in the client's medical record? A: Agoraphobia B: Xenophobia C: Acrophobia D: Glossophobia Acrophobia A nurse is caring for a client who has generalized anxiety disorder. Which of the following medications should the nurse plan to administer? Escitalopram A nurse is assessing a 6-month-old infant who has bacterial pneumonia. Which of the following manifestations should the nurse expect? A: Protruding tongue B: Facial flushing C: Nasal flaring D: Tympany with chest percussion nasal flaring A nurse is caring for a school-age child who was admitted to the emergency department for acute asthma exacerbation. Which of the following actions should the nurse take first? A: Encourage the child to take frequent sips of cool fluids. B: Apply humidified oxygen with a simple mask .C: Start a peripheral access IV. D: Administer an albuterol nebulizer treatment Apply humidified oxygen with simple mask A nurse is caring for a client who has deep vein thrombosis and is receiving heparin via continuous IV infusion. The client has a positive fecal occult blood test and abdominal tenderness upon palpation. Which of the following prescription should the nurse expect the provider to prescribe? A: Vitamin K B: Protamine sulfate C: Flumazenil D: Acetylcysteine Protamine sulfate A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? Stay with the client until manifestations subside A nurse is conducting a visual assessment for a client who is at risk for developing glaucoma. Which of the following findings should the nurse identify as a risk factor for this condition? A: Heredity B: Gender C: Anemia D: Hypoglycemia Heredity A nurse is reviewing the medical record of a client who has age-related macular degeneration (AMD). Which of the following findings should the nurse identify as a risk factor for this visual impairment? A: Male sex B: Hypertension C: Chronic obstructive pulmonary disease D: Osteoporosis Hypertension A nurse is providing teaching for a client following cataract surgery. Which of the following statements indicates to the nurse that the client understands the teaching? A: "I will have my best vision 3 weeks after my surgery." B: "I should report a creamy white discharge from my eye to my doctor." C: "I will avoid getting water in my eyes until the second day after surgery." D: "I should avoid using the vacuum cleaner for several weeks." I should avoid using the vacuum cleaner for several weeks A nurse is caring for a client who has severe hypothermia. Which of the following actions should the nurse take? Contact a specialized team to place the client on cardiopulmonary bypass A nurse is assessing a client for manifestations of heat stroke. Which of the following findings should the nurse expect? A: Hypertension B: Somnolence C: Oliguria D: Bradycardia