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

Which ofthe 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

instructionsshould 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

thefollowing 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 thenurse plan to administer?

Desmopressin.

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

daily for 3years. 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 thenurse take first?

Initiate airborne precautions.

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

pain. Whichof 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 ofthe 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. Whichof 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

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

anticipate administering which of the following prescribed medications?