Which of these instructions should a nurse include in the teaching plan for a client who had removal of a cataract in the left eye? "Take the prescribed stool softener to avoid increasing intraocular pressure." 2. A client vomits during a continuous nasogastric tube feeding. A nurse should stop the feeding and take which of these actions? Check the residual volume. 3. Which of these actions best demonstrates cultural sensitivity by a nurse?. The nurse asks clients about their beliefs and practices toward pregnancy. 4. Which of these manifestations should a nurse expect to observe in a 3-month-old infant who is diagnosed with dehydration? Tachycardia. 5. When assessing a client's risk of developing nosocomial infection, a nurse plans to determine potential entry portals, which include: the urinary meatus. 6. A client who is on the inpatient psychiatric unit has a history of violence. Which of these actions should a nurse take if the client is agitated? Encourage the client to verbalize feelings. 7. Which of these measures should a nurse include when planning care for a school-aged child during a sickle cell crisis episode? Providing pain relief. 8. Which of these instructions should a nurse include in the plan of care for a 32-week gestation client who had an amniocentesis today? "Call the clinic if you experience any abdominal cramps." 9. An adolescent has a nursing diagnosis of fatigue related to inadequate intake of iron-rich foods. Selection of which of these lunches by the client indicates a correct understanding of foods high in iron content? Beefburger with cheese. 10. A client has been admitted with acute pancreatitis. Which of these laboratory test resultssupports this diagnosis? Elevated serum amylase level. 11. Which of these manifestations, if assessed in a client who is two-hours postoperative after abdominal surgery,should a nurse report immediately? Vomiting and a pulse rate of 106/minute. 12. Which of these observations of a student nurse's behavior while interacting with a client who is crying indicates a correct understanding of therapeutic communication? The student sits quietly next to the client. 13. Which of these actions should a nurse take initially if a client who is diagnosed with diabetes mellitus develops tremors and ataxia? Measure the client's blood sugar level. 14. An elderly client is at increased risk of developing drug toxicity to prescribed medications due to declining hepatic and renal functioning. Which of these strategies should a nurse plan to decrease this risk? Increasing the time interval between medication doses. 15. A client has persistent paranoid delusions that the food on the unit is poisoned. Which of these measures should a nurse include in the client's care plan? Allowing the client to eat food from sealed containers. 16. Thrombophlebitis is a complication that may result due to surgery. Which of these actions should a nurse take in the operating room to prevent this complication from occurring?Apply sequential compression devices. 17. When discussing weigh gain during pregnancy, a nurse should recommend that the total weight gain for a pregnant client who is at ideal body weight for her height is: 25 to 35 pounds. 18. Which of these manifestations, if reported by a client who is 10-weeks-pregnant, supports the diagnosis of ruptured tubal pregnancy? Sharp unilateral abdominal pain. 19. Which of these assignments, if made by a nurse to a nursing assistant, indicatesthat the nurse needs additional instructions regarding the principles of delegation? "Please bathe the client in room 10, administer a back rub, and then evaluate if the back rub eased the client's discomfort." 20. A client has the following order for regular insulin (Humulin R) on a sliding scale: Blood sugar 150-180 mg: Give 2 units regular insulin Blood sugar 181-200 mg: Give 4 units regular insulin Blood sugar 201-220 mg: Give 6 units of regular insulin Blood sugar above 220 mg: Call MD