Exam (elaborations) NURS 203 HESI Final Exam All Answers Provided

Exam (elaborations) NURS 203 HESI Final Exam All Answers Provided 1- A client with multiple sclerosis is receiving beta – 1b interferon every other day. To assess for possible bone marrow suppression caused by the medication, which serum laboratory test findings should the nurse monitor? (Select all that apply) a- Platelet count b- White blood cell count (WBC) c- Sodium and potassium d- Red blood cell count (RBC) e- Albumin and protein 2- A male client with hypercholesterolemia wants to change his diet to help reduce his cholesterol levels. When breakfast items should the nurse encourage the client to eat? (Select all that apply) a- Sausage patties and eggs b- Whole wheat toast and jam c- Bagels and cream cheese d- Toaster pastries and milk e- Blackberries and oatmeal 3- After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? (Select all that apply) a- Take out dentures and place in a labeled cup b- Apply a body shroud c- Place a small pillow under the head d- Remove resuscitation equipment from the room e- Gently close the eyes 4- A client with major depression who is taking fluoxetine calls the psychiatric clinic reporting being more agitated, irritable, and anxious than usual. Which intervention should the nurse implement? a- Tell the client to have a complete blood count (CBC) drawn b- Instruct the client to seek medical attention immediately c- Encourage him to take the medication at night with a snack d- Explain that these are common side effects of the medication 5- An older adult male is admitted with complications related to chronic obstructive Pulmonary Disease (COPD). He reports progressive dyspnea that worsens on exertion and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide? S - The Marketplace to Buy and Sell your Study Material Downloaded by: mairetpupo | Distribution of this document is illegal NURS 203 HESI Final All Answers Provided S - The Marketplace to Buy and Sell your Study Material a- Restrict daily fluid intake b- Eat meals at the same time daily c- Maintain a low protein diet d- Limit the intake of the high calorie foods 6- A client with diabetic peripheral neuropathy has been taking pregabalin for 4 days. Which finding indicates to the nurse that the medication is effective? a- Granulating tissue in foot ulcer b- Full volume of pedal pulse c- Reduced level of pain d- Improved visual activity. 7- The nurse is assessing an older adult with type 2 diabetes. Which assessment finding indicates that the client understands long- term control of diabetes? a- The fating blood sugar was 120 mg/dl this morning. b- Urine ketones have been negative for the past 6 months c- The hemoglobin A1C was 6.5g/100 ml last week d- No diabetic ketoacidosis has occurred in 6 months. 8- A heparin infusion is prescribed for a client who weights 220 pounds. After administering a bolus dose of 80 units/kg. The nurse calculates the infusion rate for the heparin sodium at 18 units/kg/hour. The available solution is Heparin Sodium 25,000 units in 5% Dextrose Injection 250 ml. The nurse should program the infusion pump to deliver how many ml/hour. (Enter numeric value only. If rounding to the nearest whole number.) 18 9- The nurse is assessing a client with Addison's disease who is weak, dizzy, disoriented, and has dry oral mucous membranes, poor skin turgor, and sunken eyes. Vital signs are blood pressure 94/44, heart rate 123 beats/minute, respiration 22 breaths/minute. Which intervention should the nurse implement first? a- Assess extremity strength and resistance b- Report a sodium level of 132 mEq/L or mmol/L (SI units) c- Measure and record the cardiac QRS complex d- Check current finger stick glucose 10- The nurse assesses an older adult who is newly admitted to a long term care facility. The client has dry, flaky skin and long thickened fingernails. The clients has a medical history of a stroke which resulted in left-sided paralysis and dysphagia. In planning care for the client, which task should the nurse delegate to the unlicensed personnel (UAP)? a- Soak and file fingernails b- Offer fluids frequently c- Monitor skin elasticity d- Ambulate in the hallway 11- A client is receiving lidocaine IV at 3 mg/minute. The pharmacy dispenses a 500 ml IV solution of normal saline (NS) with 2 grams of lidocaine. The nurse should regulate the infusion Downloaded by: mairetpupo | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material pump to deliver how many ml/hr? (Enter numeric value only. If rounding to the nearest whole number.) 45 12- The nurse is demonstrating wound care to a client following abdominal surgery. In what order should the nurse teach the technique? (Arrange from first action on top to last action on bottom) Remove old dressing using clean gloves. Discard gloves with old dressing Moisten sterile gauze with normal saline. Clean wound from least contaminated area to most contaminated area” Apply sterile gauze dressing to wound area Secure dressing with tape 13- The healthcare provider explains through an interpreter the risks and benefits of a scheduled surgical procedure to a non-English speaking female client. The client gives verbal consent and the healthcare provider leaves, instructing the nurse to witness the signature on the consent form. The client and interpreter then speaker together in the foreign language for an additional 2 minutes until the interpreter concludes, “She says it is OK.” What action should the nurse take next? a- Clarify the client‟s consent through the use of gesture and simple terms b- Have the interpreter co-sign the consent to validate client understanding c- Ask for full explanation from the interpreter of the witnessed discussion d- Have the client sign the consent and the nurse witness the signature 14- A client is admitted to a mental health unit after attempting suicide by taking a handful of medications. In developing a plan of care for this client, which goal has the highest priority? a- Signs a no-self-harm contract. b- Sleep at least 6 hours nightly. c- Attends group therapy every day d- Verbalizes a positive self-image. 15- After receiving report, the nurse can most safely plan to assess with client last? a- An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac Downloaded by: mairetpupo | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material b- An adult client with no postoperative drainage in the Jackson- Pratt drain with the bulb compressed c- An older client with a distended abdomen and no drainage from the nasogastric tube d- An adult client with rectal tube draining clear pale red liquid drainage 16- The nurse is assigned to care for a client diagnosed with psoriasis. What behavior by the nurse addresses this client's psychosocial need for acceptance? a- Wearing gloves when interviewing the client b- Encouraging the client to join a support group c- Shaking the client's hand during an introduction. d- Allowing the client to ventilate feelings 17- A 41-week gestation primigravida woman is admitted to labor and delivery for induction of labor. What finding should the nurse report to the healthcare provider before initiating the infusion of oxytocin? a- Fetal heart tones located in upper right quadrant b- Biophysical profile results showing oligohydramnios c- Regular contractions occurring every 10 minutes d- Sterile vaginal exam reveling 3 cm dilatation 18- The nurse is preparing an older client for discharge following cataract extraction. Which instruction should be included in the discharge teaching? a- Do not read without direct lighting for 6 weeks b- Avoid straining at stool, bending, or lifting heavy objects. c- Irrigate conjunctiva with ophthalmic saline prior to installing antibiotic ointment. d- Limit exposure to sunlight during the first 2 weeks when the cornea is healing. 19- After learning that she has terminal pancreatic cancer, a female client becomes very angry and says to the nurse, “God has abandoned me. What did I do to deserve this?” Based on this response, the nurse decides to include which nursing problem in the client‟s plan of care? a- Ineffective coping b- Spiritual distress c- Acute pain d- Complicated grieving 20- Un infant is unresponsive and gasping for breath. Prior to starting CPR, which site should the nurse palpate for a pulse? Downloaded by: mairetpupo | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material C 21- A group of nurses implement a pilot study to evaluate a proposed evidence-based change to providing client care. Evaluation indicates successful outcomes and the nurses want to integrate the change throughout the facility. Which action should be taken? (Select all that apply) a- Invite data review by the quality improvement department b- Submit a sentinel event report to the research committee c- Propose clinical practice guidelines to the nursing committee d-Obtain informed consent from clients who will receive care e-Arrange inservice training through the educational department 22- The mother of a school age child calls the school to ask when her daughter can return to school after treatment for Pediculosis capitis. What is the nurse best response? (nits liendra) a- When the classroom epidemic subsides b- Two weeks after the last treatment c- As soon as the itching stops d- After the treatment kills all the live lice 23- A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first? a- Review the heart rhythm on cardiac monitors b- Check urinary catheter for obstruction c- Auscultated bilateral breath sounds d-Give PRN dose of lorazepam (Ativan) 24- What is the primary purpose for initiating nursing intervention that promote good nutrition, rest, and exercise, and stress reduction for clients diagnosed with an HIV infection? a- Prevent spread of infection to others Downloaded by: mairetpupo | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material b- Improve function of the immune system c- Increase ability to carry out activities of daily living e- Promote a feeling of general well-being 25- When assessing a client with acute asthma, the nurse is most likely to obtain which finding? a- Pursed lip breathing and clubbing of fingers b- Fever and a high- pitched inspiratory stridor c- A short expiratory phase and hemoptysis d- Cough and musical breath sound on expiration 26- During the admission assessment, the nurse auscultates heart sounds for a client with no history of cardiovascular disease. Where should the nurse listen when assessing the client‟s point of maximal impulse (PMI) (Click the chosen location. To change, click on a new location) 27- Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma? a- Intravenous administration of thyroid hormones b- Oral administration of hypnotic agents c- Intravenous bolus of hydrocortisone d- Subcutaneous administration of vitamin k 28- A client with multiple sclerosis is experiencing scotomas (blind spots), which are limiting peripheral vision. What intervention should the nurse include in this client's plan of care? a- Encourage the use of corrective lenses during the day b- Practice visual exercises that focus on a still object c- Alternate an eye patch from eye every 2 hours Downloaded by: mairetpupo | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material d- Teach techniques for scanning the environment. 29- The nurse applies a blood pressure cuff around a client‟s left thigh. To measure the client‟s blood pressure, where should the diaphragm of the stethoscope be placed? (Mark the location on one of the images.) “On left thigh with arrow pointing to inner thigh” 30- Which intervention should the nurse include in the plan of care for a patient with tetanus? Open window shades to provide natural light a- Encourage coughing and deep breathing b- Minimize the amount of stimuli in the room c- Reposition from side to side every hour 31- The nurse is caring for a newborn who arrives in the nursery following a precipitous birth on the way to the hospital. A drug screen of the mother reveals the presence of cocaine metabolites. The infant has a heart rate of 175 beats/ minute, cries continuously, is irritable, and is hyperreactive to stimuli. Which intervention is most important for the nurse to include in this infant‟s plan of care? a- Initiate infant sepsis protocol b- Implements seizure precautions c- Refer to protective child services d- Formula feed every 3 hours 32- A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client‟s teaching plan? (Select all that apply.) a- Take an additional dose for signs of hyperglycemia b- Recognize signs and symptoms of hypoglycemia. c- Report persist polyuria to the healthcare provider. Downloaded by: mairetpupo | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material d- Use sliding scale insulin for finger stick glucose elevation. e- Take Glucophage with the morning and evening meal. 33- A client with leukemia undergoes a bone marrow biopsy. The client‟s laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure? a- Observe aspiration site. b- Assess body temperature c- Monitor skin elasticity d- Measure urinary output 34- A client collapses while showering and is found discovered by the nurse while making rounds. The client is not breathing and does not have a palpable pulse. The nurse obtains the Automated External Defibrillator (AED). What action should the nurse implement next? a- Follow the prompts of the AED b- Apply the AED pads to the client’s chest c- Wipe the client’s chest dry d- Move the client from the bathroom 35- A female client with cancer tells the home care nurse that she has a good appetite but experiences nausea whenever she smells food cooking. What action should the nurse implement? a- Encourage family members to cook meals outdoors and bring the cooked food inside b- Advise the client to replace cooked foods with a variety of different nutritional supplements c- Assess the client‟s mucus membranes and report the findings to the healthcare provider d- Instruct the clients to take an antiemetic before every meal to prevent excessive vomiting. 36- A 13 years-old girl, diagnosed with diabetes mellitus Type 1 at the age of 9, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis? a- Ate an extra peanut butter sandwiches before gym class b- Incorrectly drew up and administered too much insulin c- Was not hungry, so she skipped eating lunch d- Has had a cold and ear infection for the past two days 37- At 1130, the nurse assumes care of an adult client with diabetes mellitus who was admitted with an infected foot ulcer. After reviewing the client‟s electronic health record, which priority nursing action should the nurse implement? Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client‟s medical record. Downloaded by: mairetpupo | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material a- Administer insulin per sliding scale b- Assess appearance of foot wound c- Obtain antibiotic peak and trough levels d- Initiate hourly urine output measurements 38- Following morning care, a client with C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implement first? a- Relieve any kinks or obstruction in the client‟s Foley tubing b- Asses the client‟s blood pressures every 15 minutes c- Administer a prescribed PRN dose of hydralazine (Apresoline) e-Teach the client to recognize symptoms of dyreflexia 39- After a motor vehicle collision a client admitted to the medical unit with acute adrenal insufficiency (Addisonian crisis). Which prescription should the nurse implement? a- Determine serum glucose levels b- Withhold potassium additives to IV fluids c- Give IV corticosteroid replacement d- Prepare to initiate IV vasopressors 40- Which instruction is most important for the nurse to provide a client who receives a new prescription for risedronate sodium to treat osteoporosis a- Remain upright after taking the medication b- Increase intake of foods rich in calcium c- Begin a weight-bearing exercise plan e- Schedule a bone density test every year. 41- The unlicensed assistive personnel (UAP) reports that a client‟s blood pressure cannot be measured because the client has casts on both arms and is unable to be turned to the prone position for blood pressure measurement in the legs. What action should the nurse implement? a- Advise the UAP to document the last blood pressure obtained on the client graphic sheet b- Estimate the blood pressure by assessing the pulse volume of the client‟s radial pulses c- Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed d- Document why the blood pressure cannot be accurately measured at the present time Downloaded by: mairetpupo | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material 42- The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. What action should the nurse implement immediately? a- Change the dressing using a compression bandage b- Test fluid on the dressing for glucose c- Document the findings in the electronic medical record d- Mark drainage area with a pen and continue monitor 43- Assessment by the home health nurse of an older client who lives alone indicates that client has chronic constipations. Daily medications include furosemide for hypertension and heart failure and laxatives. To manage the client‟s constipation, which suggestions should the nurse provide? (Select all that apply) a- Decrease laxative use to every other day, and use oil retention enemas as needed. b- Include oatmeal with stewed pruned for breakfast as often as possible. c- Increase fluid intake by keeping water glass next to recliner. d- Recommend seeking help with regular shopping and meal preparation. e- Report constipation to healthcare provider related to cardiac medication side effects. 44- A male client with diabetes mellitus takes NPH/ regular 70/30 insulin before meals and azithromycin PO daily, using medication he brought from home. When the nurse delivers his breakfast tray, the client tells the nurse that he took his insulin but forgot to take his daily dose of the azithromycin an hour before breakfast as instructed. What action should the nurse implement? a- Provide a PRN dose of an antacid to take with the azithromycin right after breakfast b- Offer to obtain a new breakfast tray in an hour so the client can take the azithromycin c- Instruct the client to eat his breakfast and take the azithromycin two hours after eating d- Tell the client to skip that day‟s dose and resume taking the azithromycin the next day 45- After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication? a- Ask the client about gastrointestinal pain b- Measure the client‟s fluid intake and output c- Monitor the client‟s serum electrolyte levels d- Auscultate for bowel sounds in all quadrants 46- Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room? a- Ensure that the knot can be quickly released. b- Tie the knot with a double turn or square knot. c- Move the ties so the restraints are secured to the side rails. d- Ensure that the restraints are snug against the client's wrist. Downloaded by: mairetpupo | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material 47- An older male client arrives at the clinic complaining that his bladder always feels full. He complains of a weak urine flow frequent dribbling after voiding and increasing nocturia with difficulty initiating his urine stream action should the nurse implement? a- Palpate the client‟s suprapubic area for distention b- Advise the client to maintain a voiding diary for one week c- Instruct in effective techniques to cleanse the glans penis d- Obtain urine specimen for culture and sensitivity 48- A female client on the mental health unit frequently asks the nurse when she can be discharged. Then, becoming more anxious, she begins to pace the hallway. What intervention should the nurse implement first? a- Review the current treatment plan with the client b- Inform the healthcare provider about the client‟s behaviors c- Determine if the client has PRN medication for anxiety d- Explore the client‟s reasons for wanting to be discharged. 49- The nurse working on a mental health unit is prioritizing nursing care activities because of a staffing shortage. One practical nurse (PN) is on the unit with the nurse, and another RN is expected to arrive within two hours. Clients need to be awakened and morning medications need to be prepared. Which plan is best for the nurse to implement? a- Wake all the clients and instruct them go to dining area for medication administration b- Explain to the clients that it will be necessary to cooperate until another RN arrives c- Ask the PN to administer medications as clients are awakened so both nurses are available d- Allow the clients to sleep until a third staff person can assist with unit activities 50- A 5-week-old infant who developed projectile vomiting over the last two weeks is diagnosed with hypertrophic pyloric stenosis. Which intervention should the nurse plan to implement? a- Instruct the mother to give the child sugar water only b- Maintain intravenous fluid therapy per prescription c- Provide Pedialyte feedings via the nasogastric tube d- Offer the infant Pedialyte feedings every 2 hours. 51- A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 mmHg and he admits that he has not been taking the prescribed medication because the drugs make him “feel bad”. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition? a- Stroke secondary to hemorrhage b- Acute kidney injury due to glomerular damage c- Heart block due to myocardial damage d- Blindness secondary to cataracts Downloaded by: mairetpupo | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material 52- . The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized elderly client with an indwelling urinary catheter every two hours. What additional action should the nurse instruct the UAP to take each time the client is turned? a- Empty the urinary drainage bag b- Feed the client a snack c- Offer the client oral fluids e- Assess the breath sounds 53- A woman at 24-weeks gestation who has fever, body aches, and has been coughing for the las 5 days is sent to the hospital with admission prescriptions for H1N1 influenza. Which prescriptions has the highest priority? a- Ringers Lactate IV 125ml/8 hours b- Obtain specimens for cultures c- Assign private room d- Vital signs q4 hours 54- An older female client living in a low income apartment complex tells the home health nurse that she is concerned about her 81 – year old neighbor, a widow whose son recently assumed her financial affairs. Lately, her neighbor has become reclusive, but is occasionally seen walking outside wearing only robe and slippers. What response should the nurse offer? a- Explain that it is not unusual for older adults to suffer from dementia which often causes such behaviors b- Tell the client to talk to a healthcare provider before reporting suspicion of neglect to the authorities c- Provide the number for Adult Protective Services so the client can report any suspicion of elder abuse d- Encourage the client to avoid becoming involved the neighbor‟s problems, for one‟s own protection 55- A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client's plan of care? a- Observe for bleeding side effects related to heparin therapy. b- Assess blood pressure and heart rate at least q4 hours c- Measure calf girths to evaluate edema in the affected leg d- Encourage mobilization to prevent pulmonary embolism 56- A nurse who took drugs from the unit for personal use was temporarily released from duty. After completion of mandatory counseling, the impaired nurse has asked nursing administration to allow return to work. When the nurse administrator approaches the charge nurse with the impaired nurse‟s request, what action is best for the charge nurse to take? Downloaded by: mairetpupo | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material a- Ask to meet with the impaired nurse‟s therapist before allowing the nurse back on the unit b- Meet with staff to assess their feelings about the impaired nurse‟s return to the unit c- Since treatment is completed, assign the nurse to routine RN responsibilities d- Allow the impaired nurse to return to work and monitor medication administration 57- A preschool teacher notifies the school nurse that child A has bitten child B on the arm. Child B‟s skin is broken, but is not bleeding. What action should the school nurse take first? a- Apply antibiotic cream to Child B‟s arm immediately b- Determine if Child A has a history of Hepatic C or HIV c- Determine the date of Child B‟s latest tetanus booster d- Wash Child B‟s arm thoroughly with soap and water 58- At a community health fair, a 50-year-old woman tells the nurse that she has an annual physical exam that includes a clinical breast exam and an annual mammogram. How should the nurse respond? a- Ask the woman if she also performs monthly breast self-exams. b- Advise the woman that mammograms are only needed every two years at her age. c- Encourage the woman to explore her fears about breast cancer. d- Comment the woman for adhering to the recommended cancer detection guidelines. 59- (ESTA PREGUNTA TIENE DOS FORMAS DIFERENTES DE PREGUNTAR AQUI LES DEJO LAS DOS OPCIONES LA RESPUESTA ES LA MISMA) The practical nurse (PN) is assigned to work with three registered nurses (RN) who are caring for neurologically compromised clients. The client with which change in status is best to assign to the PN? The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. which client with which change in status is best to assign to the PN? a- Diabetic ketoacidosis whose Glasgow Coma Scale score changed from 10 to 7 b- Subdural hematoma whose blood pressure changed from 150/80 mmHg to 170/60 mmHg c- Myxedema coma whose blood pressure changed from 80/50 mmHg to 70/40 mmHg d- Viral meningitis whose temperature changed from 101° F ( 38.3 C) to 102° F (38.9C). 60- Prior to surgery, written consent must be obtained. What is the nurse‟s legal responsibility with regard to obtaining written consent? a- Validate the clients understanding of the surgical procedure to be conducted b- Explain the surgical procedure to the client ask the client to sign the consent form c- Ask the client or a family member to sign the surgical consent form d- Determine that the surgical consent form has been signed and is included in the client‟s record Downloaded by: mairetpupo | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material 61- The school nurse is screening students for spinal abnormalities and instructs each student to stand up and then touch the toes. Which finding indicates an a student should be referred for scoliosis evaluation? a- Inability to touch toes b- Asymmetry of the shoulders when standing upright c- Audible crepitus when bending d- An exaggerated upper thoracic convex curvature 62- The nurse is planning to assess a client's oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client has a bilateral below-the-knee amputation and pedal pulses that are weak and threaty. What action should the nurse take? a- Document that an accurate oxygen saturation reading cannot be obtained b- Elevate to client's hands for five minutes prior to obtaining a reading from the finger c- Increase the oxygen based on the clients breathing patterns and lung sounds d- Place the oximeter clip on the ear lobe to obtain the oxygen saturation reading 63- The nurse provides sliding scale insulin administration instruction to an adult who was recently diagnose with diabetes mellitus. The client demonstrates and understanding on the instructions provided by performing the procedure in which order? (Arrange with the first on top and the last on the bottom.) Obtain blood glucose level Verify the insulin prescription Draw insulin into insulin syringe Cleanse the selected site 64- What is the primary focus of postoperative nursing care for the client with colon trauma? a- Monitoring for elevated coagulation studies b- Observation for and prevention of fistulas c- Monitoring for signs of hyponatremia d- Observation for and prevention of infection 65- While assessing a client four hours post-thoracentesis, the nurse is unable to auscultate breath sounds on the right side of the chest. What action should the nurse take first? Downloaded by: mairetpupo | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material a- Instruct the client to perform cough and deep breathing exercises b- Assess the client‟s vital signs and respiratory effort c- Administer oxygen per nasal canula per PNR protocol d- Document assessment findings in client‟s medical record 66- During discharge teaching, the nurse discusses the parameters for weight monitoring with a client who was recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge? a- Obtain at the same time every day b- Report weight gain of 2 pounds (0.9kg) in 24 hours c- Keep a daily weight record d- Limit intake of dietary salt 67- A client with osteoporosis related to long-term corticosteroid therapy receives a prescription for calcium carbonate. Which client‟s serum laboratory values requires intervention by the nurse? a- Total calcium 9 mg/dl (2.25 mmol/L SI) b- Creatinine 4 mg/dl (354 micromol/L SI) c- Phosphate 4 mg/dl (1.293 mmol/L SI) d-Fasting glucose 95 mg/dl (5.3 mmol/L SI) 68- A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents? a- Children usually resume their toileting behaviors when they leave the hospital b- A retraining program will need to be initiated when the child returns home c- Diapering