1. A nurse is preparing to administer thrombolytic therapy to a client who had an ischemic

stroke. Which of the following is an appropriate nursing action?

a. Start the therapy within 8 hr

b. Insert an indwelling urinary catheter after therapy begins

c. Monitor blood pressure every 30 min during the infusion

d. Elevate the head of bed between 25 and 30

2. 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. Exhale slowly through pursed lips

c. Hold breaths about 3 to 5 seconds before exhaling

d. Position the mouthpiece 2.5 cm (1 in) from the mouth

3. 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?

a. Heart rate 90/min

b. Hgb 8.2 g/dL

c. Gastric pH of 3.0

d. Absent bowelsounds

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

should the nurse plan to administer?

a. Regular insulin

b. Furosemide

c. Desmopressin

d. Lithium carbonate

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

daily for 3 years. Which of the following tests should the nurse monitor?

a. Stool for occult blood

b. Urine for white blood cells

c. Fasting blood glucose

d. Serum calcium