A nurse is preparing to administer thrombolytic therapy to a client who has an ischemic stroke. Which of

the following is an appropriate nursing action?

Elevate the HOB between 25 and 30 degrees.

A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions

should the nurse include in the teaching?

Hold breath about 3 to 5 seconds before exhaling.

A nurse is assessing a client who is 12 hr. postoperative following a colon resection. Which of the

following findings should the nurse report to the surgeon?

Absent bowel sounds.

A nurse is caring for a client who has diabetes insipidus. Which of the following medications should the

nurse plan to administer?

Desmopressin.

A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily for 3

years. Which of the following test should the nurse monitor?

Stool occult blood.

A nurse in the emergency department is assessing a client. Which of the following actions should the

nurse take first?

Initiate airborne precautions.

A nurse is contacting the provider of a client who has cancer and is experiencing breathrough pain. Which

of the following prescriptions should the nurse anticipate?

Transmucosal fentanyl.

A nurse is admitting a client who reports chest pain and has been placed on a telemetry monitor. Which of

the following should the nurse analyze to determine whether the client is experiencing a myocardial

infarction?

ST segment.

A nurse is teaching a client who has ovarian cancer about skin care following radiation treatment. Which

of the following instructions should the nurse include?

Pat the skin on the radiation site to dry it.

A nurse is caring for a client who is receiving a blood transfusion. The nurse observes the client has

bounding peripheral pulses, hypertension, and distended jugular veins. The nurse should anticipate

administering which of the following prescribed medications?

Furosemide.