1 A nurse is assessing for early signs of compartment syndrome for a client who has a short-leg fiberglass
cast. Which of the following findings should the nurse expect?
A. Capillary refill less than 2 seconds
B. Bounding distal pulses
C. Intense pain with movement
d. Erythema of the toes
c
2 A nurse is monitoring a client who is receiving 2 units packed RBCs. Which of the following manifestations
indicates a hemolytic transfusion reaction?
A. Chills
B. Hypertension
C. Bradycardia
D. Back pain
a
3 A nurse is caring for a client who had a total hip arthroplasty. Which of the following actions should the nurse
take to prevent hip dislocation?
A. Remove the wedge device when turning
B. Place two bed pillows between the legs when in bed
C. Encourage the client to lean forward when attempting to stand
D. Elevate the knees higher than the hips when sitting
b
4 A nurse is assessing a client who is preoperative and reports an allergy to bananas. The nurse should
recognize that the client is at risk for an allergic cross-reactivity to which of the following substances
A. Povidone-iodine
B. Adhesive tape
C. Latex
D. Anesthetics
C
5 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?
A. Place hands on the upper abdomen during inhalation.
B. Position the mouthpiece 2.5 cm (1 in) from the mouth
C. Exhale slowly through pursed lips
D. Hold breaths about 3 to 5 seconds before exhaling
c
6 A nurse is caring for a client who arrives at the emergency department and reports vomiting and diarrhea for
the past 3 days. The client's serum potassium level is 2.8mEq/L. Which of the following interventions should
the nurse implement first?
A. Check the clients hand grasps
B. Administer an IV potassium drip
C. Listen to the client's bowel sounds
D. Initiate cardiac monitoring for the clients
d
Priority question remember, what can I do first, you can start a K+ drip without knowing how their heart is
affected.
7 A nurse is preparing to administer peritoneal dialysis to a client. Which of the following actions should the
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