A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the following

actions should the nurse take?

1) Provide a diet high in protein.

2) Provide ibuprofen for retroperitoneal discomfort.

3) Monitor intake and output hourly

4) Encourage the client to consume at least 2 L of fluid daily.

A nurse is reinforcing teaching about an esophagogastroduodenoscopy with a client who has upper

gastric pain. Which of the following statements should the nurse include in the teaching?

1) "A flexible tube is introduced through the nose during the procedure."

2) "During the procedure you are in a sitting position."

3) "You will remain NPO for 8 hours before the procedure."

4) "You will be awake while the procedure is performed."

A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a

generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when

documenting this finding in the medical record?

1) Aura phase

2) Presence of automatisms

3) Postictal phase

4) Presence of absence seizures

A nurse is reinforcing teaching with a client who reports right shoulder pain following a laparoscopic

cholecystectomy. Which of the following statements should the nurse make?

1) "The pain results from lying in one position too long during surgery."

2) "The pain occurs as a residual pain from cholecystitis."

3) "The pain will dissipate if you ambulate frequently."

4) "The pain is caused from the nitrous dioxide injected into the abdomen."

A nurse is checking the suction control chamber of a client's chest tube and notes that there is no

bubbling in the suction control chamber. Which of the following actions should the nurse take?

1) Notify the provider.

Answer Rationale:

The nurse should check for kinks and take other measures before notifying the provider.

2) Verify that the suction regulator is on.

3) Continue to monitor the client because this is an expected finding.

4) Milk the chest tube to dislodge any clots in the tubing that may be occluding it.

A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the

following actions should the nurse take? (Select all that apply.)

1) Encourage fluid intake.

2) Monitor the puncture site for hematoma.

3) Insert a urinary catheter.

4) Elevate the client’s head of bed.

5) Apply a cervical collar to the client.

A nurse is assisting with the care of a client who is postoperative following surgical repair of a fractured

mandible. The client’s jaw is wired shut to repair and stabilize the fracture. The nurse should recognize

which of the following is the priority action?