A nurse is assisting with the care of four clients. Which of the following clients is the priority for the nurse to see -A client who has chest tubes and an oxygen Sat of 90% - aclient who has peripheral edema and urinary output of 130 over 4hrs - A client who has a permanent pacemaker with heart rate of 76/min -a client who has pericarditis and temp. 38 c 100.4 - ✔✔- A client who has chest tubes and an oxygen Sat of 90% A nurse is collecting data from a client who was admitted with a Glasgow Coma Scale of 3. Which of the following findings should the nurse expect? - Vacalizes sound -Blinks eyes when asked -Follows motor commands -Nonresponsive Commands - ✔✔Nonresponsive Commands A nurse is monitoring a client who has a pneumothorax and a chest tube in place with a closed chest drainage system connected to low suction. For which of the following findings should the nurse notify the charge nurse - Fluctation of the water level in the water seal chamber -constant bubling in the suction control chamber - periodic bubbling in the water seal chamber - Persistent bubbling in the water seal chamber - ✔✔- Persistent bubbling in the water seal chamber A nurse is reinforcing teaching with a male client who has right sided hemiparesis about preforming ADL's. Which of the following instructions should the nurse include in the teaching -Comb your hair with the unaffected arm -Dress your unaffected side first choose clothing with buttons -shave with your affected side - ✔✔Comb your hair with the unaffected arm A nurse is collecting data from a client and auscultates intermittent high-pitched sounds during inspiration over the lower base of the lungs. The nurse should identify this finding as which of the following lungs sounds - Fine crackles -stridor -rhonchi -friction - ✔✔- Fine crackles A nurse is collecting data from a client who has coronary artery disease. Which of the following manifestations should the nurse identify as an indication that the client has angina ( SatA) - Chest Discomfort Radiated - Pain lasting less that 15mins - Pain that is relieved with rest - ✔✔- Chest Discomfort Radiated - Pain lasting less that 15mins - Pain that is relieved with res A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to see first? - A client who has diabetes mellitus with diaphoretic - ✔✔A client who has diabetes mellitus with diaphoretic A nurse is reinforcing teaching with a young adult client about testicular self-examination. Which of the following instructions should the nurse include? - Examine your testicles after a warm shower - Press each testicle inwardly with your finger - Rinse any soap off your hands before examining your testicle -Perform the self- examination every 2 month - ✔✔Examine your testicles after a warm shower A nurse is collecting data from a client who has tuberculosis and started combination therapy 2months ago. Which of the following diagnostic results indicates that the client is adhering to the medication regimen. - A negative chest X-ray - A negative sputum culture -A negative tuberculin skin test -A negative titer for cytomegalovirus - ✔✔A negative sputum culture A nurse is collecting data from a client who has bacterial meningitis. Which of the following findings should the nurse expect? - Severe Headache - ✔✔Severe Headache A nurse is reinforcing with a client who has pernicious anemia. Which of the following statements by the client indicated an understanding of the teaching - I will be able to switch to a nasal form of cyanocobalamin when my levels stabilize - ✔✔I will be able to switch to a nasal form of cyanocobalamin when my levels stabilize A nurse is reinforcing discharge teaching with a client who has COPD and reports episodes of dyspnea. Which of the following instructions should the nurse include? - Used the pursed lip breathing technique - ✔✔Used the pursed lip breathing technique A nurse is reinforcing teaching with a client who has varicose veins of the right lower extremity. Which of the following instructions should the nurse include in the teaching - Apply elastic support hoes before getting out of bed in the morning - ✔✔- Apply elastic support hoes before getting out of bed in the morning