1. A nurse is preparing to administer thrombolytic therapy to a client who has 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 the bed 25 degrees and 30 degrees
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 bowel sounds
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?
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