RN COMPREHENSIVE ONLINE PRACTICE FORM A (LATEST 2020)-150 QUESTIONS WITH ALL CORRECT ANSWERS, DOWNLOAD TO SCORE GRADE A+

RN COMPREHENSIVE ONLINE PRACTICE FORM A (150 LATEST QUESTIONS & ANSWERS) Verified By Best Tutor, Download to Score Grade A+ 1. A nurse is performing tracheostomy care for a client who is postoperative following a laryngectomy. Which of the following actions should the nurse take when suctioning the client's airway? Withdraw the catheter if the client begins coughing. Apply suction for 10 seconds. Advance the catheter 2 cm (0.8 in) after resistance is met. Use medical asepsis when performing the procedure. 2. A nurse is preparing to administer a long-acting insulin to a client who has diabetes mellitus. Which of the following actions should the nurse plan to take first? Teach the client reportable adverse effects from the medication. Check the insulin dose with another licensed nurse Administer the insulin at a 90° angle. Clean the insertion site. 3. A nurse is caring for an older adult client in the PACU following general anesthesia. Which of the following findings should the nurse report to the provider? Urine output 120 mL in 4 hr The nurse should monitor urinary output and report any amount less than 30 mL/hr. Systolic blood pressure 12 mm Hg lower than the preoperative level The nurse should report blood pressure changes that are greater than a 15 to 20 mm Hg difference from the client's baseline blood pressure. Audible stridor MY ANSWER Audible stridor, or a high-pitched sound heard in the client's airway indicates edema, laryngeal spasm, secretions, or some type of airway obstruction that could become life-threatening. The nurse should report this finding to the provider. Normal sinus rhythm with an occasional premature ventricular contraction Anesthesia medications and surgery, especially in older adult clients, are common causes of premature ventricular contractions. The nurse should monitor the frequency of the premature ventricular contractions but does not need to report this finding to the provider. 4. A nurse is preparing to administer diazepam 0.3 mg/kg IV bolus to a toddler who weighs 22 lb and is experiencing a grand mal seizure. Available is diazepam solution for injection 5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) 0.6 5. A charge nurse is planning an educational session for staff nurses about working with parents whose terminally ill children are candidates for donating their organs. Which of the following information should the nurse plan to include? Choosing to donate organs can delay the timing of the child's funeral. The family can have the child an open casket without fearing that the organ donation might disfigure the childs body The family should understand that an autopsy is mandatory prior to organ donation. The nurse should introduce the option of organ donation to the parents when first discussing the child's impending death. 6. A nurse manager is planning to make changes to the current scheduling system on the unit. To facilitate the staff 's acceptance of this change, which of the following actions should the nurse manager take first? Provide information about scheduling issues to the staff. MY ANSWER The first stage of the change process is the unfreezing stage, when the nurse should inform the staff about the current staffing issues. This can increase their understanding of why changes are necessary. Ask staff members to participate in a trial of the new scheduling system. Participating in a trial implementation of the new schedule is a component of the moving stage of change. Encourage staff to offer alternate scheduling solutions. Encouraging staff to offer alternate scheduling solutions is a component of the moving stage of change. Involving staff members in the change will make them feel included and less resistant to the new schedule. Develop goals to implement the new scheduling system. Developing goals and objectives to implement the new schedule is a component of the moving stage of change. 7. A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings should indicate to the nurse that the client is having a hemolytic transfusion reaction? Bradycardia Low back pain Hypertension Distended jugular veins 8. A nurse is assessing a client who has macular degeneration. Which of the following findings should the nurse expect? Increased intraocular pressure- s/s of glaucoma Floating dark spots- s/s of retinal detachment Decreased central vision Double vision- s/s of cataracts 9. A nurse working in a long-term care facility is assessing an adult client. Which of the following findings places the client at risk for development of a pressure injury? Report of persistent constipation – diarrhea/ exposure to stool increases risk of pressure injury Hgb 14 g/dL – nutritional status- risk for impaired skin integrity Albumin 4.2 g/dL -nutritional status (def nutrition) Recent weight loss 10. A nurse is teaching about total parenteral nutrition (TPN) and IV lipid emulsions with a client who has an extensive burn injury. Which of the following information should the nurse include? "This type of nutrition is more effective than eating by mouth." -PO is best “You will receive fingersticks for blood glucose testing. -risk of hyperglycemia "TPN is a way to provide vitamins and minerals without increased calories." -calories to patients who are unable to eat/ not have a functioning GI tract "Taking TPN can increase the risk of developing a latex allergy." – egg allergy/ not latex 11. A nurse is caring for a client who has had nausea and vomiting for the past 2 days. The nurse should identify which of the following findings as an indication the client is experiencing fuid volume de deficit? Shortness of breath Visual disturbances Decreased BUN levels •Orthostatic hypotension 12. A nurse is caring for a client who is in labor at 39 weeks of gestation. During the second stage of labor, the nurse observes early decelerations on the monitor tracing. Which of the following actions should the nurse take? Continue observing the fetal heart rate Assist the client to a knee-chest position- r/t umbilical cord prolapses Prepare the client for continuous internal monitoring Prepare for an emergency cesarean birth- late or variable decelerations despite of interventions 13. A nurse is caring for a client who requires physical therapy following discharge. Which of the following actions should the nurse take? Initiate the referral at the time of discharge. MY ANSWER The nurse should initiate the referral as soon as possible after identifying the need. Waiting until the time of discharge can delay the client's recovery. Have the client contact a physical therapist when feeling ready to begin therapy. Instructing the client to contact a physical therapist when feeling ready can significantly delay recovery. The nurse should initiate the referral as soon as possible after receiving a prescription from the provider. Verify that insurance will pay for outpatient physical therapy. The nurse should notify the case manager or social worker of the prescription for physical therapy. They will search for providers that are willing to take the client's insurance and report to the nurse which facilities the client can consider. The client can then choose from that selection of providers. Involve the client in selection of a physical therapy provider. The nurse should involve the client in the referral process, including selection of the physical therapist and the location. 14. A nurse is assessing a client who has sickle cell anemia. The nurse should identify which of the following findings as a manifestation of vaso-occlusive crisis? Diminished reflexes – swelling of extremities/ not diminished reflexes Hematuria- r/t The nurse should identify hematuria as a manifestation of vaso-occlusive sickle cell crisis resulting from ischemia of the kidneys. Hyperglycemia- not related Hearing loss – visual disturbances, not hearing 15. A nurse is teaching a group of guardians about child safety measures. Which of the following statements by a guardian indicates an understanding of the teaching? "I will make sure my 4-year-old child wears a helmet when using a skateboard." Guardians should prevent children who are younger than 5 years old from skateboarding because they are not able to adequately protect themselves from skateboard-related injuries. "I should have my child avoid sun exposure between 10 am and 2 pm." MY ANSWER To prevent sunburns, guardians should apply sunscreen, dress their child in protective clothing, and avoid sun exposure between 1000 and 1400. "I can give my 2-year-old child a whole hotdog on a bun." The guardians should cut a hotdog lengthwise for toddlers to prevent choking. "When my infant is in the carrier, I will place it on a raised, flat surface whenever possible." Guardians should avoid placing carriers on raised surfaces to reduce the risk for falls. 16. A nurse is caring for four clients at the beginning of a shift. After receiving change-of-shift report, which of the following clients should the nurse attend to first? A client who has a temperature of 38.2° C (100.8° F) and requests a cup of ice chips A client who is postoperative and reports a pain level of 5 on a scale from 0 to 10 A client who has voided and is ready for a bladder scan
 A client who is confused and has been attempting to get out of bed 17. A nurse is assessing a client who has been taking lithium carbonate for the past month to treat bipolar disorder. Which of the following assessment findings should the nurse identify as the priority? Lethargy Confusion Polyuria 
Fine hand tremors 18. A nurse manager is on a planning committee to develop an emergency preparedness plan. The nurse should recommend that which of the following actions takes place Contact the triage officer. Contacting the triage officer is important to ensure personnel are available to evaluate incoming clients. However, this is not the first action to take when implementing an emergency preparedness plan. Implement the client tracking system. Implementing the client tracking system is important for making client room assignments and informing family members. However, this is not the first action to take when implementing an emergency preparedness plan. Ask the communications officer to release a press statement. MY ANSWER Asking the communications officer to release a press statement is important to inform the public. However, this is not the first action to take when implementing an emergency preparedness plan. Notify the incident commander. The first action to take when implementing an emergency preparedness plan is to notify the incident commander to initiate the command hierarchy and maintain order. 19. A nurse is planning care for a client who is receiving hemodialysis via an established arteriovenous (AV) fistula in the right arm. Which of the following interventions should the nurse include in the client's plan of care? Notify the provider if a thrill is palpated at the fistula. Auscultate the affected extremity for a bruit Discourage range-of-motion exercises in the affected extremity. Perform venipuncture in the affected extremity. 20. A nurse receives a request from a client to review the information in his medical record. Which of the following responses should the nurse give? "There's a protocol for reviewing your medical record, and I can initiate the process." The client's record is the legal property of the facility, but the client has a right to access the record, obtain a copy of the record, and request corrections to the document if there are discrepancies. According to HIPAA, the nurse is responsible for following the facility's policy when providing the client with access to the medical record. "The medical record has a lot of medical terminology, and it might be di cult for you to understand." "You should really talk to your provider if you have any questions about your treatment." "Some parts of your medical record are restricted, but I can show you the parts that you are allowed to see." 21. A nurse is assessing a client who has obstructive sleep apnea. For which of the following complications should the nurse monitor? Weight loss Urinary retention Hypertension Hypoglycemia 22. A nurse is preparing to administer heparin 5,000 units subcutaneously. Available is heparin injection 10,000 units/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) 0.5 23. A nurse in an emergency department is assessing a client who reports taking methylenedioxymethamphetamine (MDMA). Which of the following findings should the nurse expect? Lethargy Diaphoresis Diaphoresis MY ANSWER Diaphoresis is an expected finding of MDMA use. Additionally, the client might experience increased tactile sensitivity, lowered inhibition, chills, muscle cramping, teeth clenching, and mild hallucinogenic effects. Bradycardia Cough 24. A nurse is caring for a client who has a terminal illness and requests no lifesaving measures if a cardiac arrest occurs. Which of the following statements should the nurse make? A health care proxy is not necessary if the client is alert and able to document their own wishes in a living will. "I will make sure that no one performs any lifesaving measures if your heart stops." The nurse cannot ensure that no one will perform lifesaving measures unless the client has a living will, a health care proxy is in place, or if the provider has written a do-not-resuscitate order at the client's request. "Your provider determines if you should have lifesaving measures if your heart stops." The provider does not decide what lifesaving measures to perform. The client decides and documents these decisions in a living will or verbally informs the provider. "I will provide you with information about medical treatment to include in your living will." MY ANSWER The nurse's responsibility is to provide the client with information about specific instructions for addressing medical treatment in a living will. The nurse should assist the client while they are able to make decisions for themself by providing information about what end-of-life preferences to document. 25. A nurse is administering cyclophosphamide orally to a school-age child who has neuroblastoma. Which of the following actions should the nurse take when administering this medication? Give an antiemetic 30 min after medication administration. - before Monitor blood glucose levels. – no interaction on glucose level Monitor for tumor lysis syndrome.-Tumor lysis syndrome can occur in clients who are diagnosed with acute lymphoblastic leukemia, not neuroblastoma. Maintain hydration with liberal fluid intake-The nurse should offer fluids frequently to maintain hydration and prevent hemorrhagic cystitis, which is an adverse effect of this medication. 26. A nurse is reviewing the urinalysis report of a client who has acute glomerulonephritis. Which of the following findings should the nurse expect? Uric acid crystals - urolithiasis Protein:A client who has glomerulonephritis has increased glomerular permeability, which allows protein to filter into the urine. Therefore, the nurse should expect proteinuria on the urinalysis report. WBCs- client who has a lower urinary tract infection, cystitis, or pyelonephritis. Nitrites -client who has a urinary tract infection. 27. A nurse is providing colostomy care for a client using a two-piece pouching system. Which of the following actions should the nurse take? Cleanse the skin at the stoma site with povidone-iodine for 15 seconds. The nurse should cleanse the skin at the stoma site using a washcloth and warm water to reduce the risk of skin irritation. Dampen the skin before applying the skin barrier and ostomy pouch. The nurse should thoroughly dry the skin around the stoma using a patting motion before applying the skin barrier to ensure the pouch adheres to the client's skin. Place the skin barrier over the stoma and hold it for 30 seconds. MY ANSWER The nurse should activate the adhesive in the skin barrier by holding it in place over the stoma for 30 seconds. Cut the skin barrier opening 0.6 cm (0.25 in) larger than the stoma. The nurse should cut the skin barrier opening no more than 0.3 cm (0.13 in) larger than the stoma to reduce the risk of skin irritation. 28. A nurse is administering medications to a client who has a percutaneous gastrostomy tube for enteral feedings. Which of the following actions should the nurse take to prevent clogging of the tube? Flush the client's gastrostomy tube with 30 mL of water before administering the medication. MY ANSWER The nurse should flush the gastrotomy tube with at least 30 mL of water before and after medication administration to clear the tube of any residuals and to ensure patency. Crush the client's medications and mix them in with the tube feeding formula prior to administration. The nurse should crush each medication and administer each separately from the tube feeding formula to decrease the risk of residual forming, which can clog the tube. Change the client's feeding bag every 72 hr. The nurse should change the feeding bag and tubing every 24 to 48 hr to prevent clogging and to reduce the risk of infection. Administer multiple prescribed medications at the same time. The nurse should administer each prescribed medication separately to reduce the risk of clogging of the tube. 29. A night shift nurse is giving change-of-shift report to the day shift nurse on a client who is ready for discharge. Which of the following information is the priority for the nurse to communicate to the oncoming nurse? The client needs assistance when transferring from the bed to a wheelchair. MY ANSWER The greatest risk to this client is injury due to a fall. Therefore, the priority information for the nurse to communicate is that the client requires assistance during transfers. The client will have a visit by a home health nurse tomorrow. This information is important for the nurse to communicate because it will affect the client's care at home. However, this is not the priority information for the nurse to communicate. The client's partner will bring clothes for the client to change into prior to discharge. This information is important for the nurse to communicate because it concerns the client's preparation for discharge. However, this is not the priority information for the nurse to communicate. The client often needs encouragement to engage in personal hygiene activities. This information is important for the nurse to communicate because it can affect the care the nurse gives the client. However, this is not the priority information for the nurse to communicate. 30. A nurse is planning teaching about allowable foods for a client who has a history of uric acid-based urinary calculi formation. Which of the following foods should the nurse include in the teaching? Liver MY ANSWER A client who is prone to uric acid calculi should avoid eating organ meats, which contain purine. Oranges A client who is prone to uric acid calculi formation can eat citrus fruits. Chicken A client who is prone to uric acid calculi should avoid eating chicken, which contains purine. Red wine A client who is prone to uric acid calculi should avoid consuming red wines, which contain purine. 31. An RN is planning care for a group of clients and is working with a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the RN delegate to the LPN? Collection of a stool specimen The nurse should delegate collection of a stool specimen to an AP because this task is within the AP's range of function. Preparation of a client's postoperative bed The nurse should delegate preparation of a client's postoperative bed to an AP because this task is within the AP's range of function. Preparation of a teaching plan about pneumonia The RN should prepare the teaching plan because creating a teaching plan is not within the scope of practice for an LPN or the range of function for an AP. Insertion of a nasogastric tube MY ANSWER The nurse should delegate the insertion of a nasogastric tube to the LPN because this task is within the LPN's scope of practice. 32. A nurse is caring for a newborn who has herpes simplex virus (HSV). Which of the following isolation precautions should the nurse initiate? Contact Droplet 
Airborne
 Protective environment 33. A nurse is performing gastric lavage for a client who has gastrointestinal bleeding and an NG tube in place. Which of the following actions should the nurse take? Instill chilled lavage solution into the client's NG tube. Attach the client's NG tube to low intermittent suction. Use 0.9% sodium chloride for irrigation of the NG tube. Instill the lavage solution into the client's NG tube in volumes of 500 mL at a time. 34. A nurse is providing discharge instructions to a client following a total hip arthroplasty. Which of the following instructions should the nurse include? Install a raised toilet seat at home. MY ANSWER The client should use a raised toilet seat at home to minimize hip flexion and prevent hip dislocation. Maintain the hip at an angle greater than 90°. The client should maintain the hip at an angle less than 90° when sitting to minimize hip flexion and prevent hip dislocation. Minimize the use of a walker. The client should use a walker to minimize the risk of falls or injury. Place a pillow under the knees when lying down. The client should not have a pillow under the knees when lying down, because it can impede circulation and result in flexion contractures. 35. A nurse is reviewing the laboratory findings of a client who is experiencing chest pain. The nurse should identify that an elevation in which of the following laboratory values indicates cellular injury of myocardial tissue? Amylase – indicates acute pancreatitis, cholecystitis, renal failure Troponin T – indicates MI 
Low-density lipoprotein (LDL)– indicates coronary artery disease Homocysteine- indicates risk of ischemic heart disease 36. A nurse is talking with the partner of a client who attempted suicide. Which of the following statements by the client's partner should the nurse identify as the priority? "Will my husband be able to continue as the executor of his parents' estate?" "One of my husband's coworkers visited last week to tell me my husband might lose his job." "Do you think it is necessary to postpone our daughter's wedding until my husband is feeling better?" "My husband doesn't know that I've already moved out of the house and led for a divorce." 37. A nurse is interviewing a client who is now without a home due to a natural disaster. After ensuring the client's safety, which of the following actions should the nurse take first? Assist the client with contacting individuals from the client's support system. Give the client information about available community resources for shelter. Suggest the client obtain mental health counseling. Determine the client's perception of the personal impact of the crisis. 38. An assistive personnel (AP) and a nurse are turning a client onto the right side. Which of the following actions by the AP requires the nurse to intervene? Uses a draw sheet to move the client to the left side of the bed Using a draw sheet to move the client reduces friction, which protects the client's skin, reduces workload, and prevents injury to the nurse and the AP. Raises the total height of the bed to waist level Raising the height of the bed to waist level prevents injury by positioning the bed at the nurse's and the AP's center of gravity. Places a pillow under the client's right arm MY ANSWER The AP should place a pillow under the client's left arm to prevent internal rotation of the left shoulder. Lowers the side rails on the left side of the bed Lowering the side rails on one side of the bed prevents the nurse and the AP from straining their bodies. The opposite side rail should remain up to promote client safety. 39. A community health nurse is performing triage tagging following a mass casualty incident. On which of the following clients should the nurse place a black tag? A client who is alert and has a 2.5 cm (1 in) laceration on the forehead A client who has significant head trauma and agonal respirations. A client who has an open fracture of the right forearm
 A client who is unconscious and has a rapid, thready radial pulse 40. A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. Which of the following precautions should the nurse implement? Airborne The nurse should implement airborne precautions for a client who has an infection spread by air, such as tuberculosis or measles. Droplet The nurse should implement droplet precautions for a client who has an infection spread by droplets, such as pneumonia and influenza. Contact MY ANSWER The nurse should implement contact precautions for a client who has an infection spread by direct contact, such as MRSA. Protective environment The nurse should implement a protective environment for a client who has immunosuppression caused by conditions such as cancer treatment. 41. A nurse is teaching a client about foods high in vitamin A. Which of the following foods should the nurse recommend as having the highest amount of vitamin A? 1 medium raw carrot-most vit A 1/2 cup cooked spinach 
1/2 cup cooked butternut squash 1 cup sliced cantaloupe 42. A nurse is caring for a client who had a recent stroke. Prior to transferring the client to the bedside commode, which of the following actions should the nurse take first? Ask for help with a two-person assist transfer. Assess the client for functional limitations Request a mechanical lift device. Medicate the client for pain. 43. A nurse is conducting visual acuity testing using the Snellen letter chart for a school-age child who has eyeglasses. Which of the following instructions should the nurse give to the child? "You should leave your glasses off throughout the testing." MY ANSWER The nurse should screen the child with visual correction first, then repeat the screening without visual correction. "You should stand 15 feet away from the chart." The nurse should instruct the child to stand 3 m (10 feet) away from the chart during testing. "You should get three symbols on a line correct to pass the line." The nurse should tell the child that in order to pass a line, the child should identify four of the six symbols correctly. "You should keep both eyes open during the testing." The nurse should instruct the child to keep both eyes open during visual acuity testing. 44. A nurse is caring for a client who is at 37 weeks of gestation and is experiencing abruption placentae. Which of the following findings should the nurse expect? Persistent uterine contractions The nurse should expect a client who has abruptio placentae to experience persistent uterine contractions, board-like abdomen, and dark red vaginal bleeding. Bright red vaginal bleeding MY ANSWER The nurse should expect a client who has placenta previa to experience a relaxed uterus and bright red vaginal bleeding. With abruptio placentae the nurse should expect to find dark red vaginal bleeding. Hyperactive deep-tendon reflexes The nurse should expect a client who has preeclampsia to have hyperactive deep-tendon reflexes. Fundal height of 40 cm The nurse should expect a client who has placenta previa to have a fundal height that is greater than expected gestational age. 45. A nurse is assessing a client who has Raynaud's disease. Which of the following findings should the nurse expect? Butterfly rash over the cheeks and nose A client who has lupus erythematosus is likely to have a butterfly rash over the cheeks and nose. Report of pain in the joints of the lower extremities A client who has osteoarthritis is likely to have pain in the joints of the lower extremities. Blanching of the fingers and toes MY ANSWER A client who has Raynaud's disease can have blanching of the fingers and toes in response to exposure to cold or emotional stress. Pallor develops first, then cyanosis, followed by redness or heat as the vessels reperfuse, before the skin returns to the client's baseline tone. Scaly patches over the knees and elbows A client who has psoriasis is likely to have scaly patches over the knees and elbows. 46. A nurse is preparing to administer 15 units of regular insulin along with 20 units of NPH insulin. Which of the following actions should the nurse plan to take? Inject 20 units of air into the NPH insulin vial . Shake the NPH insulin vial vigorously to mix the insulin.
 Use a new needle to draw up the insulin from the second vial. Draw the longer-acting insulin into the syringe first. 47. A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm3. Which of the following interventions should the nurse include in the plan? Encourage friends and family to visit the child. Withhold administering the varicella vaccine to the child. Collect a daily urine specimen from the child to check for proteinuria. Provide a low-protein diet for the child. 48. A nurse is preparing a sterile field in order to insert an indwelling urinary catheter for a male client. Which of the following techniques should the nurse use to maintain surgical aseptic technique? Open the top outer flap of the package toward the body. Clean the penis with the nondominant hand. 
Don sterile gloves after opening the lubricant packet. • Set the catheter tray on the overbed table at waist height. 49. A home health nurse is assessing a 2-week-old newborn who had a birth weight of 3.64 kg (8 lb) and is being breastfed. Which of the following findings indicates effective breastfeeding? The newborn nurses every 4 hr during the day and sleeps through the night. The newborn has six to eight wet diapers per day. The newborn's current weight is 3.18 kg (7 lb). The newborn has sticky, greenish stools. 50. A community health nurse is reviewing the medical records of four newly diagnosed clients. The nurse should identify which of the following clients as having a nationally notifiable infectious condition? A client who is pregnant and has cytomegalovirus (CMV) CMV, a herpes virus, is not on the list of nationally notifiable infectious conditions reportable to the CDC. CMV can cause mild influenza-like symptoms or no symptoms in adults. Women who are pregnant can transmit a primary infection to the fetus in utero and during vaginal delivery. An adolescent client who has foodborne botulism MY ANSWER The nurse should report botulism to the CDC because this information is necessary for the prevention and control of this disease. Clients who ingest the botulism toxin can develop dysphasia, drooping eyelids, and vision changes, and in 12 to 36 hr can develop neurologic symptoms such as symmetric, flaccid paralysis and cranial nerve impairment. A child who has erythema infectiosum Erythema infectiosum is not on the list of nationally notifiable infectious conditions reportable to the CDC. Parvovirus is the cause of erythema infectiosum, which results in a facial rash that is red, raised, or inflamed that spreads over the body. A young adult client who has herpes simplex virus type 1 (HSV-1) HSV-1 is not on the list of nationally notifiable infectious conditions reportable to the CDC. It causes painful blisters to form on the mouth or the genitals. Transmission of HSV-1 can occur during sexual contact. 51. A nurse is caring for a client who has bipolar disorder. The nurse observes that the client is becoming increasingly restless. The client is pacing the unit and speaking rapidly, frequently using profanities and sexual references. Which of the following actions should the nurse take first? Provide an opportunity for the client to express their feelings. The nurse should demonstrate empathy and allow the client an opportunity to express their feelings. However, this is not the first action the nurse should take. Move the client to a quiet place away from others. MY ANSWER The client's behavior indicates the greatest risk is injury to others. Therefore, the first action the nurse should take is to prevent harm to other clients by moving the client to a quiet place away from others. State expectations that set limits on the client's behavior. The nurse should state expectations that set limits on the client's behavior so that the client knows what the nurse expects. However, this is not the first action the nurse should take. Administer a PRN dose of haloperidol to calm the client. The nurse might need to administer a PRN dose of haloperidol to calm the client. However, this is not the first action the nurse should take. 52. A nurse in an outpatient mental health clinic is working with a client who has post-traumatic stress disorder (PTSD) and asks the nurse to recommend a nonpharmacological therapy to use to provide relief of the manifestations. Which of the following complementary therapies should the nurse teach the client to use to help alleviate the distress? Spinal manipulation Acupuncture Therapeutic touch Guided imagery 53. A case manager is reviewing the medical records of several clients. For which of the following clients should the nurse request an interprofessional care conference? A client who has diabetes mellitus and has had repeated hospitalizations for diabetic ketoacidosis A client who has alcohol use disorder and has decided to start attending Alcoholics Anonymous meetings A client who was admitted for dehydration and is receiving a continuous IV infusion A client who has a history of two prior miscarriages and has ruptured membranes at 38 weeks of gestation 54. A nurse is caring for a client who states, "My boss accused me of stealing yesterday. I was so angry I went to the gym and worked out." The nurse should recognize the client is demonstrating which of the following defense mechanisms? Displacement Displacement occurs when a client transfers emotions of a particular situation to another nonthreatening situation. Regression Regression occurs when a client reverts to a childlike pattern of behavior that might have been exhibited previously. Suppression Suppression is the denial of a disturbing feeling or situation. Sublimation The client is exhibiting behaviors consistent with sublimation, which is displayed when a client substitutes socially unacceptable behavior for acceptable behavior. 55. A nurse is caring for an older adult client. Which of the following findings should the nurse recognize as a physiological change associated with aging? Decreased blood pressure Increased cardiac output Increased oral temperature Decreased lung expansion 56. A client who is 24 hr postoperative following abdominal surgery refuses to ambulate. Which of the following actions should the nurse take first? Ask the client to rate their pain level. Assist the client in changing positions. Administer a PRN analgesic medication. Explain the importance of early ambulation. 57. A nurse is providing discharge instructions to a client who has a new prescription for warfarin. Which of the following client statements should the nurse identify as an indication that the client understands the teaching? "I should report a change in the color of my stools."-client that red, black, or tarry stools can indicate bleeding, an adverse effect of warfarin, and the client should report these findings to the provider. "I can take acetaminophen to treat a headache."- increase the risk for bleeding. "I will take a calcium supplement while taking this medication." -client should maintain consistent intake of foods containing vitamin K. "I will return in a month to have my blood tested." - daily blood draws for the first 5 days to establish appropriate warfarin dosage. 58. A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements should the nurse include in the teaching? "Place your baby's car seat at a 30-degree angle." The nurse should instruct the parent to place the newborn's car seat at a 45° angle. Newborns' heads are large in proportion to their body and they do not have the muscle strength to hold their heads upright. "Your baby's car seat should be rear-facing until he is 6 months old." The nurse should instruct the parent that the newborn should remain rear-facing in the back seat of the vehicle until the age of 2 or until reaching the age and weight the car seat manufacturer recommends. In a collision, this position decreases the force on the newborn's head and neck. "Swaddle your baby in a light blanket before placing him in the car seat." The nurse should instruct the parent to place a blanket over the newborn once secure in the car seat. Blankets, coats, or heavy clothing can make it difficult to secure the shoulder harnesses tightly, leading to injury in the event of a collision. "Secure the retainer clip at the level of your baby's armpits." MY ANSWER The nurse should instruct the parent to secure the retainer clip at the level of the newborn's axillae. The bones of the rib cage and sternum provide protection to underlying organs in the event of a collision. Placing the clip on the abdomen increases the risk for injury to internal organs. 59. A nurse is caring for a client who has an STI that must be reported to the state health department. Which of the following actions should the nurse take? Tell the client to self-report to the state health department. It is not the client's responsibility to report this information to the local public health department. Require that the client speak with a public health nurse. The client is not required to speak with a public health nurse. Explain to the client why this information will be shared. MY ANSWER It is the responsibility of the nurse to advocate for the client, provide confidential information, and explain legal requirements. Reporting communicable disease occurrences helps with identifying outbreaks and overall disease trends. Refer the client to a social worker for counseling. The client does not need to be referred to a social worker for counseling. The nurse should provide information about the prevention of spreading the STI. 60. A nurse is providing dietary teaching to the parents of a 6-month-old infant. Which of the following instructions should the nurse include? Provide the infant with 1 cup of cereal. Infants' portion sizes in general should be 1 Tbsp per year of age. For infants under 12 months of age, 1/2 to 3/4 Tbsp is appropriate. Give the infant 240 mL (8 oz) of juice per day. The parents should offer the infant 100% fruit juice, not to exceed 120 to 180 mL (4 to 6 oz) per day, after 6 months of age. Introduce new foods one at a time over 5 to 7 days. MY ANSWER The parents should introduce new foods one at a time over 5 to 7 days to identify potential food allergies. Give whole milk first, then small amounts of solid food. The parents should not offer the infant whole milk, because the majority of the infant's calories should come from human milk or commercial, iron-fortified formula. 61. A nurse is teaching a client who has a new prescription for digoxin about manifestations of toxicity. Which of the following findings should the nurse include in the teaching? Constipation (diarrhea = toxicity) Nausea Wheezing – r/t anaphylaxis Muscle rigidity (muscle rigidity= toxicity) 62. A nurse is assessing a client during the immediate postpartum period. Which of the following findings requires immediate intervention by the nurse? Intermittent cramping Intermittent cramping, also known as afterpains, is nonurgent because it is an expected finding for a client who is in the immediate postpartum period. To ease the cramping, the nurse can apply heat or instruct the client to lie prone. However, there is another finding that is the nurse's priority. Moderate lochia rubra Moderate lochia rubra is nonurgent because it is an expected finding for a client who is in the immediate postpartum period. The nurse should report excessive lochia rubra and large clots to the provider. However, there is another finding that is the nurse's priority. Boggy uterus MY ANSWER When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a boggy uterus, which can indicate uterine hemorrhage. The nurse should immediately intervene to stimulate uterine contractions and prevent blood loss. If the uterus becomes relaxed during the postpartum period, the client will rapidly lose blood because no permanent thrombi have formed at the placenta. Perineal edema Perineal edema is nonurgent because it is an expected finding for a client who is in the immediate postpartum period. Perineal edema occurs due to the excessive amount of pressure experienced during vaginal birth. The nurse can offer ice packs or sitz baths to relive the perineal discomfort. However, there is another finding that is the nurse's priority. 63. A nurse is caring for a client who has end-stage Alzheimer's disease. The adult child of the client says to the nurse, "I don't know why I bother to visit my mother anymore." Which of the following responses should the nurse make? "Your mother might still know you are here." This statement is nontherapeutic because the nurse is offering an opinion and is dismissing the adult child's concerns. "Why do you feel that way?" This statement is nontherapeutic because the nurse is asking a "why" question which can make the adult child feel the need to know why certain feelings occur and implies wrongdoing. This might cause the adult child to feel defensive. "It seems like you feel your visits are a waste of time." MY ANSWER The nurse is using a clarifying technique that facilitates the nurse's understanding of the adult child's feelings. "Are you sure you would not want to see your mother again?" This statement is nontherapeutic because the nurse is showing disapproval, which can make the adult child feel as though feelings of sadness and frustration should not be expressed. 64. A nurse is planning care for a client who is receiving heparin to treat a deep-vein thrombosis of the left lower leg. Which of the following interventions should the nurse include in the plan of care? Maintain the client on bed rest. Restrict the client to 1 L of fluid per day.
 Place cool compresses on the edematous area. Elevate the a effected leg. 65. A nurse in an acute mental health facility is planning care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the client's plan of care? Give the client a choice of foods and beverages. Supervise the client during and after eating.
 Encourage casual conversation about food during meal times. Provide opportunities for the client to choose their own meal times. 66. A nurse is providing discharge instructions to a client who has a new prescription for amitriptyline to treat depression. The nurse should identify that which of the following client statements indicates an understanding of the teaching? "I should avoid eating smoked meat, cheeses, and ripe avocados while taking this type of medication." -MAOI avoid tyramine "I should watch for common reactions like dry mouth and constipation." "I will be at increased risk for high blood pressure while taking this medication." – risk of hypo "I will take my daily dose of this medication every morning before breakfast." -qHS 67. A nurse manager is assisting with the orientation of a newly licensed nurse. Which of the following actions by the nurse requires the nurse manager to intervene? Informs the provider about a client's suicide plan Notifes the health department of a client's diagnosis of chlamydia Reports suspected child maltreatment to social services Tells the hospital chaplain a client's diagnosis 68. A clinic nurse is caring for a client who is in the first trimester of pregnancy. The client reports using acupressure bands on both wrists. Which of the following statements by the client indicates that this therapy is having the desired effect? "I have not had any food cravings." "The spotting I was having has stopped." "I don't feel depressed anymore." "I have not vomited as much recently." 69. A nurse manager is reviewing unit records and discovers that client falls occur most frequently during the hours of 0530 and 0730. Which of the following actions should the nurse take when conducting a root cause analysis? Investigate environmental factors that might be contributing to client injury during these hours. MY ANSWER When conducting a root cause analysis, the nurse should look at the factors that could possibly lead to the clients' falls. This can include environmental factors that might be causing the problem. Review the performance evaluations of nurses who work during these hours. When conducting a root cause analysis, the nurse does not look at the individual performance of staff members. Implement a plan to transition from team nursing to primary care nursing during these hours. When conducting a root cause analysis, the nurse should focus on identifying the cause of a problem, not potential solutions to the problem. Discuss a plan with the providers to reduce the use of barbiturate sedatives prior to these hours. When conducting a root cause analysis, the nurse should focus on identifying the cause of a problem, not potential solutions to the problem. 70. A nurse is caring for a client who is immediately postoperative following a total vaginal hysterectomy. Which of the following actions should the nurse take first? Measure the client's vital signs. Reposition the client.
 Encourage the client to use an incentive spirometer. Administer pain medication. 71. A nurse is assessing a client who is 2 hr postoperative following a cardiac catheterization. Which of the following information should the nurse report to the provider? Pain level Pain at the insertion site or back discomfort is an expected finding following a cardiac catheterization. The nurse should administer pain medication to the client and follow up with a pain reassessment. Neurologic status MY ANSWER This client is experiencing slurred speech and extremity weakness, which are indications of a stroke, a potential complication of cardiac catheterization. The nurse should report these findings to the provider. Laboratory results The hematocrit and hemoglobin levels are within the expected reference ranges. The nurse should report a decrease in these levels, which could indicate hemorrhage, a potential complication of cardiac catheterization. Urinary output The urinary output is within the expected reference range. The nurse should report a urinary output of less than 30 mL/hr, which can indicate dehydration, a potential complication of cardiac catheterization due to the contrast medium acting as an osmotic diuretic. 72. A nurse is caring for a client who is 12 hr postoperative, is receiving PCA for pain control, and requires a blood pressure check in 10 min. Which of the following staff members should the nurse assign to collect this information? An RN who is monitoring a client who started receiving a blood transfusion 5 min ago An assistive personnel (AP) who just began performing a bed bath
 A licensed practical nurse (LPN) who is reinforcing discharge instructions with a client An assistive personnel (AP) who is assisting a client to return to bed 73. A nurse is planning care for a client who has a deficit with cranial nerve (CN) II. Which of the following actions should the nurse plan to take? Keep the client resting in bed. Ask the client to restate directions. 
Clear objects from the client's walking area. Evaluate the client's ability to swallow. 74. A nurse is teaching the parent of a school-age child about administering ear drops. Which of the following responses by the parent indicates an understanding of the teaching? "I should administer the ear drops as soon as I remove them from the refrigerator." The nurse should instruct the parent to allow otic medication stored in the refrigerator to warm to room temperature prior to administration to prevent dizziness and pain. "I should pull the top of the ear upward and back while instilling the medication." MY ANSWER The nurse should instruct the parent to pull the pinna upward and back in children older than 3 years of age to straighten the ear canal and allow the medication to reach the entire canal. For children younger than 3 years of age, the parent should gently pull the pinna downward and back. "I should massage behind the ear after I instill the drops." The nurse should instruct the parent to gently massage the tragus on the area anterior to the ear to allow the medication to reach the entire canal. "I should have my child lie on the affected side for a few minutes after I put the drops in the ear." The nurse should instruct the parent to have the child remain lying on the unaffected side for a few minutes after instilling the medication to allow the medication to remain in the ear canal. 75. A nurse is assessing a preschooler who has cystic fibrosis and has been receiving oxygen therapy for the past 36 hr. Which of the following findings should the nurse identify is an indication that the client has developed oxygen toxicity? Wheezes Clients who develop oxygen toxicity are more likely to have crackles and substernal chest pain than wheezes. Tachycardia Tachycardia indicates the client has hypoxemia, is working hard to obtain oxygen, and requires oxygen therapy. Restlessness MY ANSWER Restlessness indicates the client has hypoxemia, is working hard to obtain oxygen, and requires oxygen therapy. Substernal pain The nurse should identify substernal pain as a manifestation of oxygen toxicity due to the increased work of breathing, such as in a preschooler who has cystic fibrosis. 76. A nurse working on a medical-surgical unit receives a telephone call requesting the status of a client from an individual who identifies themself as the client's parent. Which of the following actions should the nurse take? Ask the caller for verification of their identity. Give the caller limited information about the client.
 Transfer the phone call to the client's room. 
Inform the caller that they should obtain permission from the client's provider. 77. A nurse is assessing a client who has skeletal traction for a femur fracture. Which of the following findings should the nurse identify as the priority? Muscle spasms of the affected extremity A pain rating of 6 on a scale from 0 to 10 Upper chest petechiae- The greatest risk to this client is organ damage from fat embolism syndrome, a life-threatening complication of fractures. In fat embolism syndrome, a fat embolus enters the blood stream and can obstruct blood vessels of a major organ, such as the lung, kidney, or brain. Manifestations include petechiae on the upper torso, dyspnea, hypoxia, headache, lethargy, and confusion. Therefore, the nurse should identify this as the priority finding. Ecchymosis over the fractured area 78. A charge nurse overhears two staff nurses in the hallway discussing the nutritional status of a client who has anorexia nervosa. Which of the following actions should the charge nurse take? Apologize to the client for the nurses' actions. Advise the nurses that they are being insubordinate. Tell the nurses to stop the discussion.
 Document the incident in the client's medical record. 79. A nurse is assessing a client who has antisocial personality disorder. Which of the following manifestations should the nurse expect? Lack of remorse Sensitivity to rejection – r/t narcissistic personality disorder Extreme mood swings – r/t bipolar disorder Self-mutilating behavior- r/t borderline personality disorder 80. A charge nurse assigns a newly licensed nurse to care for a client who has a chest tube. The nurse expresses concern about having limited experience with monitoring chest tube drainage. Which of the following actions should the charge nurse take first to provide teaching about chest tubes? Refer the nurse to the procedure manual. Use a diagram to explain the procedure to the nurse. Demonstrate the procedure to the nurse.
 Ask the nurse about their knowledge of the procedure. The first action the charge nurse should take using the nursing process is to assess the newly licensed nurse's knowledge about the procedure. By assessing the nurse's knowledge, the charge nurse can identify the nurse's learning needs. 81. A nurse is caring for a client who has a fractured femur and has had a fiberglass leg cylinder cast for 24 hr. Which of the following assessment findings should the nurse identify as the priority? The client reports leg itching under the cast around the mid-upper thigh area. The client reports increased pain when the leg is lowered below the level of the heart. The client's cast became wet during a sponge bath. 
The client's heel is reddened and tender. 82. A nurse is caring for a client who has a potassium level of 3 mEq/L. For which of the following manifestations should the nurse monitor? Increased bowel sounds -hypokalemia Dry, sticky mucous membranes -hypernatremia Decreased deep tendon reflexes- hypokalemia Numbness and tingling of the extremities -hypocalcemia 83. A nurse is caring for a client who is 4 hr postpartum and has a boggy uterus with heavy lochia. Which of the following actions should the nurse take first? Administer oxygen. The nurse should administer oxygen to improve gas exchange. However, there is another action the nurse should take first. Initiate an infusion of oxytocin. The nurse should initiate an infusion of oxytocin to promote uterine contractions. However, there is another action the nurse should take first. Massage the uterus to expel clots. MY ANSWER Using the evidence-based practice approach to client care, the nurse should identify that the priority action is massaging the client's uterus. Uterine massage will expel clots and increase uterine firmness, resulting in decreased bleeding. Obtain a CBC. The nurse should obtain a CBC to monitor the status of the client. However, there is another action the nurse should take first. 84. A charge nurse observes a staff nurse document a dressing change in a client's chart that was not performed. Which of the following actions should the charge nurse take first? Ensure that the staff nurse changes the dressing. It is the charge nurse's role to advocate for the client to receive the care the provider prescribed. However, this is not the first action the charge nurse should take. Notify the nurse manager. The charge nurse should notify the nurse manager that the occurrence happened. However, this is not the first action the charge nurse should take. Complete an incident report. The charge nurse should complete an incident report describing the occurrence. However, this is not the first action the charge nurse should take. Gather more information about the staff nurse's actions. MY ANSWER The first action the nurse should take when using the nursing process is to assess the reasons for the staff nurse's negligent actions. Therefore, the charge nurse should gather additional information and discuss the issue with the staff nurse before deciding on the next course of action. 85. A nurse is caring for an adolescent client who has a new diagnosis of terminal cancer. When discussing the client's prognosis with the parents, the nurse should recognize which of the following responses by the parents as an example of rationalization? "Our child wouldn't have this terminal diagnosis if the doctor had diagnosed the cancer sooner." By attributing the cause of the adolescent's prognosis to the provider's failure to diagnose the illness sooner, the parent is using the defense mechanism of displacement. "Let's go on that family vacation we've got planned. We will deal with this when we return." By exhibiting a conscious denial of the adolescent's prognosis until the family returns from vacation, the parent is using the defense mechanism of suppression. "Maybe this is better for our child because we don't want any suffering through chemotherapy treatments." MY ANSWER By justifying the adolescent's prognosis by searching for a more personally acceptable explanation for the impending loss, the parent is using the defense mechanism of rationalization. "This isn't possible. Just last week the doctor said that the cancer was responding well to treatment." By focusing on disbelieving the news about the adolescent's prognosis, the parent is using the defense mechanism of denial. 86. A nurse is assessing a client who has schizophrenia and is taking chlorpromazine. Which of the following findings is the priority for the nurse to report the provider? Temperature 39.4° C (102.9° F) The greatest risk to this client is injury from neuroleptic malignant syndrome, a potentially life-threatening adverse effect of chlorpromazine that can cause the client to have a high temperature, dysrhythmia, decreased level of consciousness, and a labile blood pressure. Therefore, the priority finding for the nurse report to the provider is a fever. Headache- common s/e Constipation- common s/e Dry mouth- common s/e 87. A home health nurse is providing teaching to a client who has hepatitis A. Which of the following instructions should the nurse include? •Use hydrogen peroxide to clean kitchen surfaces. Seal nonwashable items in a plastic bag for 2 weeks. Wear a surgical mask when in public. 
Limit family visits to 30 min periods. 88. A nurse manager is preparing a newly licensed nurse's performance appraisal. Which of the following methods should the nurse manager use to evaluate the nurse's time management skills? Compare the nurse's time management skills to the skills of coworkers. Review client satisfaction reports about the nurse's performance.
 Ask another staff nurse to evaluate the nurse's time management skills. Maintain regular notes about the nurse's time management skills. 89. A nurse is preparing to administer enoxaparin to a client. Identify the area the nurse should use to administer the injection. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) A 90. A nurse is assessing a client who has multiple sclerosis. Which of the following manifestations should the nurse expect? Abdominal striae Abdominal striae are a manifestation of Cushing's syndrome. Masklike face Masklike face is caused by rigidity of the facial muscles and is a manifestation of Parkinson's disease. Nystagmus MY ANSWER Nystagmus is involuntary eye movements and muscle spasticity, which are manifestations of multiple sclerosis. Ptosis Ptosis is the drooping of the upper eyelids due to a decreased level of acetylcholine and is a manifestation of myasthenia gravis. 91. A nurse is reviewing the ABG results of a client who has COPD. The results include a pH of 7.3, PaO2 56 mm Hg, PaCO2 54 mm Hg, HCO3- 26 mEq/L, SaO2 87%. Which of the following is the correct interpretation of these values? Uncompensated metabolic acidosis Uncompensated respiratory acidosis Compensated respiratory acidosis Compensated metabolic acidosis 92. A nurse is caring for a newborn whose parent asks why the baby is receiving vitamin K. The nurse should explain to the parent that the newborn should receive vitamin K to prevent which of the following? Bleeding MY ANSWER The nurse should explain to the parent that newborns are deficient in vitamin K and should receive it following birth because this deficiency can lead to bleeding. Potassium deficiency Vitamin K does not prevent potassium deficiency in a newborn. Infection Vitamin K does not prevent infection in a newborn. Hyperbilirubinemia Vitamin K does not prevent hyperbilirubinemia in a newborn. 93. A nurse is caring for a toddler who has infectious gastroenteritis. Which of the following actions should the nurse take? Include chicken broth in the toddler's diet. The nurse should identify that chicken and beef broths contain excessive amounts of sodium and very few carbohydrates. Feed the toddler the BRAT diet. The BRAT diet (bananas, rice, applesauce, and toast) contains little nutritional value, inadequate amounts of protein and electrolytes, and is high in simple carbohydrates. It is contraindicated for a child who has acute diarrhea. Initiate oral rehydration therapy for the toddler. MY ANSWER Infectious gastroenteritis can lead to dehydration. The nurse should treat the toddler with oral rehydration therapy to replace fluids lost by diarrhea. Soft or pureed foods can be given along with the oral rehydration therapy. After adequate rehydration has occurred, a regular diet can be resumed. Offer the toddler flavored gelatin. Gelatin is high in carbohydrates, low in electrolytes, and high in osmolality, which can prolong diarrhea and electrolyte imbalance. 94. A nurse is assessing a client who is experiencing autonomic dysreflexia. Which of the following findings should the nurse expect? (Select all that apply.) Nystagmus is incorrect. The nurse should expect a client who has autonomic dysreflexia to experience spots in the visual field. Facial flushing is correct. The nurse should expect a client who has autonomic dysreflexia to have facial flushing. Flushing occurs from the point of the lesion upward. Diplopia is incorrect. The nurse should expect a client who has autonomic dysreflexia to have blurred vision. Nasal congestion is correct. The nurse should expect a client who has autonomic dysreflexia to have nasal congestion. Headache is correct. The nurse should expect a client who has autonomic dysreflexia to have a severe headache. 95. A nurse in a clinic receives a call from a guardian whose child has varicella. The guardian asks when the child can return to school. Which of the following responses should the nurse make? "When the lesions no longer itch." "Three days after the lesions appeared." "When crusts have formed on every lesion." The child should return to school once all the lesions have crusted over. Varicella is no longer contagious after crusts have formed on all lesions. "When the lesions disappear." 96. A nurse is caring for a client who is at 28 weeks of gestation. The client asks the nurse to explain what causes her to have constipation. Which of the following responses should the nurse make? "Estrogen levels decreaseduring pregnancy, causing the stool to become hardened." Estrogen and progesterone levels increase during pregnancy, leading to decreased peristalsis and relaxation of the smooth muscles of the intestine, which can result in constipation. "Decreased water absorption in the intestine during pregnancy causes constipation." The intestine absorbs more water from the stool during pregnancy, leading to constipation. "The intestine absorbs iron less efficiently during pregnancy, leading to constipation." The small intestine absorbs iron more readily during pregnancy due to increased maternal needs, leading to constipation. "The enlarged uterus compresses the intestines and causes constipation." MY ANSWER During the second and third trimesters, the size and weight of the growing uterus cause both displacement and compression of the intestines. These changes cause a decrease in motility, leading to constipation. 97. A nurse is initiating discharge planning for a client who had a stroke and is experiencing right- sided weakness. Which of the