NURSING PN HEAL 1701 Fundamentals Practice Test Questions & Answers,100% CORRECT

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NURSING PN HEAL 1701 Fundamentals Practice Test Questions & Answers Fundamentals online practice B 1. A nurse is reinforcing teaching with the caregiver of a client who is near death which of th... e following instructions should the nurse provide? a. encourage meals at three times daily b. Keeping the room warm will help them breathe easier c. Help them onto their left side if they are experiencing nausea d. Provide mouth care at least every two hours D is the correct answer because providing mouth care as needed to a client who is near death will help reduce discomfort from dehydration nausea and dry mucous membranes 2. A nurse working in a community clinic is talking with an older adult client who states that her life has no purpose the nurse should identify that the client is in which of the following stages of Erickson’s theory of psychosocial development? a. Ego integrity versus despair b. Generativity versus self-absorption c. Identity versus role confusion d. Intimacy versus isolation A is the correct answer: the nurse should identify that this client is experiencing the ego integrity versus despair stage of Erickson’s theory of psychosocial development which occurs in the older adult population the nurse should assess the client to reflect on past accomplishments and find pleasure in life rather than focusing on health problems and limitations supporting the client’s ego integrity will help the client cope with the challenges of aging. 3. A nurse is caring for a client who reports itching 30 minutes after receiving a newly prescribed medication which of the following data should the nurse document in the client’s medical record? a. Client is itching from the medication b. Client states I started to itch after taking that medication c. It appears that the client has a rash from the medication d. Rash from medication noted B is the correct answer the nurse should document information using an objective description putting the client’s exact words in quotation marks 4. The nurse is reinforcing teaching about carbohydrate counting with a client who is newly diagnosed with diabetes mellitus which of the following actions should the nurse take? a. Use pictures of different food groups to help the client plan a daily menu b. Ask the client what they already know about meal planning c. Give the client a brochure with simple menus for all meals d. Involve the family in discussion of the client’s meal plan B is the correct answer the first action the nurse should take using the nursing process is to collect data to determine the client’s current level of knowledge then the nurse can plan education to meet the client’s needs 5. A nurse is reinforcing teaching with a client who has pneumonia in a productive cough which of the following instruction should the nurse include in the teaching? a. Your visitors should wear a protective gown b. You should receive a pneumonia vaccine every year c. You should stand 1 foot away from others when coughing d. You should cover your mouth with a tissue when you cough D is the correct answer pneumonia is spread by droplets covering the mouth with a tissue when coughing is an effective method of containing secretions to avoid spreading the infection 6. A nurse is caring for a client and his concerned that the client may have a fecal impaction which of the following is most important question for your nurse to ask? a. What types of food have you eaten b. Are you using any stool softeners or laxatives c. Have you been passing gas d. Have you had any small liquid stools D is the correct answer using the nursing process the first action the nurse should take is collecting data from a client to determine if the client has any findings consistent with a fecal impaction there for the first question the nurse is to ask is if the client has had any small liquid stools which can indicate that there is seepage of liquid feces around the impacted mass. 7. A nurse is contributing to the plan of care for a client who is dying which of the following intervention should the nurse recommend including the families in the plan of care? a. Keep the family updated about the client status b. Suggest that family members return home at night to allow the client to rest c. Encourage the family to come the client’s hair d. Clients’ family what to expect as the client’s death nears e. Ask the family to encourage the client to eat A, C and D are the correct answers the nurse should keep the family updated about the client status to assist the family and planning for the near future the nurse should find simple care activities for the family to reforms such as calm and the client’s hair many family members do not know what to expect the nurse should explain the manifestations of impeding death to reduce the family members anxiety and stress. 8. A nurse is planning to perform intermittent urinary catheterization for a client who is unable to urinate which of the following actions should the nurse take first? a. Perform a bladder scan b. Cleanse the meatus c. Provide perineal care d. Lubricate the catheter A is the correct answer the first action the nurse should take when using the nursing process is to collect data from the client therefore the nurse should evaluate the bladder contents before performing an invasive procedure a bladder scan determines the amount of urine in the bladder and helps the nurse avoid unnecessary catheterization. 9. A nurse is preparing to perform a wound irrigation for a client who has a stage three pressure injury which of the following supplies to the nurse plan to use a. Piston syringe b. Barrier ointment c. Chilled irrigation solution d. Sterile cotton balls A Is the correct answer the nurse should use an irrigation or piston syringe with an angiocatheter attached to irrigate wounds because it provides a gentle flow of solution to flush debris from the wound. 10. A nurse is assisting with the admission of an older adult client with an acute care facility the client states that they are afraid to go to sleep fearing they will not wake up which of the following is a therapeutic response the nurse should make? a. I will have the nursing staff check on you frequently during the night b. You are right to be afraid this is a new place for you c. I will give you your prescription sleeping medications to help you fall asleep d. Describe your concerns about sleeping to me D is the correct answer this statement is open ended and allows for further communication this addresses the clients concerns and builds trust. 11. A nurse is reinforcing teaching with a client who speaks a different language than the nurse which of the following actions should the nurse take? a. Avoid using gestures when communicating with the client b. Communicate with a client using a translation dictionary c. Speak loudly when communicating with the client d. It was printed materials written in the current client’s language D is the correct answer the nurse should use printed materials written in the client’s language to reinforce teaching for the client and promote understanding. 12. A nurse is planning care for a group of clients the nurse should expect to witness an informed consent for a client who will undergo which of the following procedures? a. Administration of an enema b. Performance of paracentesis c. Insertion of an indwelling catheter d. Placement of an NG tube Bea is the correct answer the nurse should expect to witness the informed consent for a client prior to an invasive diagnostic procedure such as paracentesis. 13. A nurse is contributing to the plan of care for a client who practice Islam which of the following question should the nurse asked the client to clarify the client’s religious preferences? a. Do you receive holy communion b. Do you follow a kosher diet c. Do you consume pork products d. Do you oppose receiving a blood transfusion if needed C is the correct answer clients who practice Islam do not consume pork or alcohol 14. A nurse manager is reinforcing teaching of a group of newly licensed nurses about the disclosure of client health information on nurse can disclose health information without the clients written permission to which of the following entities? a. And insurance agency offering a life insurance policy b. A family member who requests the client’s diagnostics c. Physical therapist who is involved in the client’s care d. An employer completing a pre-employment screening C is the correct answer according to HIPPA guidelines a nurse is allowed to disclose personal health information to members of the healthcare team involved in the clients 15. A nurse is reinforcing teaching with a partner of a client who is in Mobil which of the following instructions should the nurse give the partner about turning the client in bed? a. Keep your feet close together b. Tighten your stomach muscles c. Straighten your knees d. Bend at the waist Bea is the correct answer the nurse should instruct the client partner to tighten the abdominal and gluteal muscles to protect their back. 16. A nurse is evaluating the crutch walking technique of a client who is required to keep weight off of their right leg which of the following is the proper crutch gate for this client? a. Four point b. Three point c. Two point d. Swing through Bea is the correct answer the nurse should identify that the client needs to be able to bear weight on the unaffected leg therefore the three-point gait provides at least two points of support at all times. 17. A nurse is contributing to the plan of care for four clients which of the following clients should the nurse initiate airborne precautions? a. Client who has pneumonia b. A client who has measles c. Client who has pertussis d. A client who has MRSA Bea is the correct answer the nurse should initiate airborne precautions for a client who has measles 18. A nurse in an acute care setting is documenting Postmortem care in a client’s medical record which of the following information should the nurse include in the documentation? a. Completion of an incident report b. Name of the nurse certifying the client’s death c. Release of personal belongings form d. One client identifies her at the time of client’s death C is the correct answer the nurse should document the release of the client’s personal belongings form and the articles the nurse gave to the family. 19. A nurse is caring for a client who is postoperative following a mastectomy the client states I can barely look at myself in the mirror the client should identify that the client is expiring which of the following? a. Complicated grief b. Maturational loss c. Disenfranchised grief d. Actual loss D Is the correct answer the nurse should identify that the client’s comments indicate an actual loss which is a loss that occurs when the person can no longer feel see here or no one object another person or a part of themselves such as the loss of a body part. 20. A nurse in a long-term care facility is collecting admission data from a client who uses a hearing aid which of the following actions should the nurse take? a. Sit beside the client b. Speak slowly and loudly to the client c. Dim the lights in the client’s room d. Choose a private room for the interview D is the correct answer the nurse should use a private room which will minimize background noise the client is able to hear what the nurse is saying. 21. A nurse is caring for a client who has dysphasia following a stroke which of the following intervention should the nurse use when feeding the client? a. Open the client a straw to drink liquids b. Place the food towards the back of the client’s mouth c. Encourage the client to lie down and rest for 30 minutes after meals d. Instruct the client to tilt their head forward while eating D is the correct answer a client who has dysphasia following a stroke should set up right with her head tilted forward to facilitate swallowing and to prevent aspiration. 22. A nurse is reinforcing teaching with a client who is scheduled for a bladder scan which of the following instruction should the nurse include in teaching? a. You will need to sign a consent form before we begin this procedure b. I will place a gel pad directly above your pubic area before I place the probe c. You will need to hold your urine for one hour prior to the procedure d. You will receive a contrast dye through an IV catheter prior to the scan Bea is the correct answer the nurse should use a gel pad which promotes ultrasound transmission an accurate measurement the correct placement of the ultrasound device is just above the symphysis pubis. 23. A nurse is caring for a client who has been vomiting and has diarrhea which of the following findings should the nurse identify as an indication of fluid volume deficit? a. Bun of 18 mg/dL b. A thready pulse c. Hemoglobin 15 g/dL d. Prominent neck veins Bea is the correct answer a client who has a fluid volume deficit will have thready peripheral pulses 24. A nurse is caring for a client who is receiving intermittent enteral feedings which of the following is the first action the nurse should take? a. Measure a client’s gastric residual before each feeding b. Change the bag and tubing every 24 hours c. Document the intake and output d. Flush the tubing with 30 milliliters of water after each feeding A is the correct answer when using the nursing process, the first action the nurse should take his assessment there for obtaining gastric residual volume is the priority action for the nurse to take. 25. A nurse is planning to administer medication to a client who has C-diff which of the following actions should the nurse plan to take to prevent the transmission of this infection to others? a. Clean hands with an alcohol-based hand rub immediately after removing gloves b. Remove the cover down in the client’s room after providing care c. Place the client in a room with a negative pressure airflow d. For a mask when administering oral medications to the client Bea is the correct answer the nurse should initiate contact precautions for clients who have C- diff infection contact precautions include the removal of the cover down and other personal protective equipment inside the client’s room to prevent spread of infection. 26. A nurse is caring for four clients which of the following client should the nurse use the therapeutic communication technique of silence? a. A client who plans to leave the facility against medical advice b. Client who informed the nurse that they have made their funeral arrangements c. A client who tells the nurse that the night shift nurse did not bring their medication d. Child who has just experienced the death of a child D is the correct answer silence is a therapeutic communication technique to use when a client is grieving it demonstrates caring and patience and allows the client to speak when they are ready to do so. 27. A nurse is caring for a client who has an indwelling urinary catheter which of the following actions should the nurse take? a. Clean the perineal area at least once a day b. Empty the drainage bag when it is ¾ full c. Flush the catheter with sterile water daily d. Disconnect the drainage bag when emptying in measuring urine A is the correct answer the nurse should clean the perineal area at least once per day to reduce the risk of infection 28. A nurse is providing care to four clients in an acute care setting the nurse should identify that which of the following client statements presents an ethical dilemma? a. I might file a lawsuit because of how my surgery went b. Please don’t tell my doctor but I am taking my mother’s oxycodone c. Please don’t get me out of bed this morning it hurts too much d. I don’t want to take my medicine it makes me sick to my stomach Bea is the correct answer this situation poses an ethical dilemma for the nurse because there is a conflict between what the client is asking of the nurses and the nurse’s responsibility to protect the client from harm during hospitalization. 29. A nurse working in a hospital overhears the following conversation between two other nurses on the elevator which of the following nursing actions should you follow? “I heard that the wound on Mr. Jones his leg is from his neighbor’s dog biting him. People should really take better care of their pets.” a. Inform the nurses that the neighbor’s dog did not cause the wound b. Tell the nurses to change the topic of conversation c. Complete an incident report upon returning to the unit d. Report the nurse’s conversation to the client’s provider Bea is the correct answer the nurse has the responsibility to protect the clients right to confidentiality and should intervene on the client’s behalf a breach of client confidentiality can result in liability for those involved. 30. Nurse is caring for a client who has a new prescription for oxygen at 7 L per minute via simple face mask which of the following actions should the nurse take to ensure client safety? a. Keep the side holes of the mask closed b. Ensure the reservoir bag is inflated upon expiration c. Apply petroleum jelly to the client’s nostrils d. Attach a humidifier to the base of the flowmeter D is the correct answer the nurse should attach a humidifier at the base of the flowmeter to moisten the air for the client this action will prevent dry mucous membranes when the client is receiving oxygen at a greater rate than 4 L per minute. 31. The nurse is preparing to document information about the client’s lower legs which are swollen with 6 mm edema which of the following information should the nurse document? a. +1 pitting edema b. +2 pitting edema c. +3 pitting edema d. +4 pitting edema C is the correct answer the nurse should document +3 pitting edema when there is deep indentation of the tissue which is about 6 mm. 32. A nurse is collecting data from a client who is two days post-operative following a colostomy placement which of the following findings should the nurse report to the provider? a. Purple colored stoma b. Protrusion of the stoma c. Small amount of bleeding from the stoma d. Intestinal gas in the pouch A is the correct answer the stoma should be reddish pink and moist a purple color is drama is an indication of poor circulation and the nurse should report this to the finding provider immediately. 33. A nurse is reinforcing teaching with a new parent who is concerned about sudden infant death syndrome which of the following statements by the client indicates the understanding of the teaching? a. I will place my baby on her side to sleep b. I should avoid giving my baby a pacifier c. I will remove all stuffed animals for my baby’s crib d. I will cover my baby with a light blanket when she is sleeping C is the correct answer the nurse should reinforce the need to remove all stuffed animals and toys when the infant is sleeping to reduce the risk for SIDS 34. A nurse is caring for a client who is scheduled for surgery the following day during the night the client is unable to sleep and is restless which of the following statements should the nurse make? a. It must be difficult facing this type of surgery b. Other clients who have had this surgery have done just fine c. This facility is known for providing excellent care for people who need this type of surgery d. I can request a sleeping pill if you think that will help A is the correct answer stating that it must be difficult to be in this position is an open ended and non-judge mental statement that allows the client to talk about their fears. 35. A nurse is preparing a client for a Romberg test which of the following statements should the nurse make? a. stand with your feet together in your arms at your side b. After I placed the tuning fork tell me when you no longer hear the sound c. I’m going to stroke the lateral side of the bottom of your foot d. Touch each fingertip as quickly as possible with your thumb A is the correct answer the Romberg test measures stability with and without the ice closed the nurse should instruct the client to stand with their feet together in their arms at their sides. 36. A nurse is reinforcing teaching with a client about self-administration of ophthalmic drops which of the following instruction should the nurse include? a. You will need to look to the side when you put the drops in your eye b. You should put the drops directly in the center of your eyeball c. You should cleanse your eye from the inner to the outer edge prior to putting the drops in d. Should avoid pressing on the tear duct after putting the drops in your eye C is the correct answer the nurse should instruct the client to cleanse that I from the inner to the outer canthus to prevent contamination of the lacrimal duct. 37. Nurse is caring for a client who reports difficulty sleeping at home which of the following recommendations should the nurse provide to promote a restful home sleep environment? a. Perform muscle relaxation before bedtime b. Exercise vigorously one hour prior to going to bed c. Drink a cup of hot chocolate at bedtime d. Change the time you go to sleep each day A is the correct answer the nurse should encourage the client to perform muscle relaxation to reduce anxiety and induce sleep 38. A nurse is preparing to obtain a client’s vital signs which of the following actions should the nurse take when washing their hands? a. Rinse their forearms with running water before applying soap b. Hold her hands above elbow level while washing and rinsing c. Generate a leather by rubbing their hands together vigorously for five seconds d. Turn off the faucet with a clean paper towel after drying hands D is the correct answer. If the nurse’s hands are wet or the paper towel is wet when they turn off the Fossett they increase the risk of transferring micro-organisms from the faucet back to their hands. 39. A client who is scheduled to undergo surgery tells the nurse that they do not understand the procedure and are reconsidering their decision to have it which of the following actions should the nurse take? a. Offer information about alternative therapies to the procedure b. Contact a family member to convince the client to change their mind c. Tell the client the benefits of the surgery d. Notify the charge nurse of the clients concerns D is the correct answer the nurse should notify the charge nurse of the clients concerns the charge nurse can then inform the provider that the client requires further explanation of the procedure. 40. A nurse is demonstrating the use of a transparent film dressing over a clients superficial wound which of the following information about the transparent film dressing should the nurse include? a. This dressing keeps the wound bed dry b. This dressing allows the wound bed to breathe c. This dressing requires a secondary dressing d. This dressing requires paper tape to secure Bea is the correct answer the transparent dressing is applied to allow oxygen to pass through the dressing this is referring to as breathing and promotes healing of the wound. 41. The nurse is caring for a client who has dyspnea caused by a respiratory infection the nurse should assess the client into which of the following positions? a. Orthopneic b. Dorsal recumbent c. Sims d. Prone A is the correct answer I should assist the client into the orthopneic position by having the client sit upright either in bed or in a chair and lean forward this position allows maximum chest expansion and facilitate breathing. 42. A nurse is caring for a client who has a new diagnosis of cancer which of the following actions by the nurse maintains the client confidentiality? a. Sharing the client’s prognosis with a member of the client’s family b. Discussing the client status with a member of the spiritual support team c. Collaborating with a nurse from another unit about the client’s care d. Providing client information to another nurse at change of shift D is the correct answer the nurse can share information with other staff who are caring for the client because it is essential to maintain continually of the care and does not violate the client’s confidentiality the nurse should only share information about the client with those directly involved in the client’s care. 43. A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure their blood pressure daily which of the following client statements indicates an understanding of the teaching? a. I will wait 15 minutes after drinking coffee to measure my blood pressure b. I will measure my blood pressure while my arm is elevated above my heart c. I should remove constrictive clothing prior to measuring my blood pressure d. I should measure my blood pressure immediately after eating breakfast C is the correct answer the nurse should instruct the client to remove constrictive clothing prior to measuring their blood pressure because constrictive clothing can cause falsely elevated blood pressure readings 44. A nurse and an assistive personnel are providing postmortem care for a deceased client prior to visitation by the family which of the following actions by the AP requires intervention by the nurse? a. Gathering the client’s personal belongings b. Removing the client’s dentures c. Placing absorbent pads under the client’s buttocks d. Closing the client’s eyes Bea is the correct answer the client’s dentures should remain in place in order to give the face on natural appearance. 45. A nurse is preparing to remove staples from a client’s incision which of the following action should the nurse take? a. Lift the staple remover one squeeze in the handle b. Avoid completely closing the handle after squeezing c. Expect the staples to bend at each outer side of the stable d. Remove the staple from the skin after both sides are visible D is the correct answer the nurse should remove the staples from the skin after both sides of the staple are visible which indicate proper dislodgment of the staple and prevents pulling on the skin around the incision which can cause needless discomfort. 46. A nurse is contributing to the plan of care for a client who is at risk for developing foot drop due to immobility which of the following intervention should the nurse recommend including in the plan? a. Flex the client’s feet using pillows b. Support the client’s feet with foot boots c. Placed a hand roll under the client’s heels d. Remove ankle foot orthotic devices at bedtime Bea is the correct answer the nurse should support their feet in dorsiflexion with foot boots to prevent foot drop. 47. A nurse is checking a client for a pulse deficit after a detecting in an irregular heart rate which of the following action should the nurse take? a. Count the clients radial and apical pulse is simultaneously with another nurse b. Calculate the client’s pulse for 30 seconds then multiplied by two c. Assist the client to a sideline position d. Auscultate the area of the client’s chest over the ERB’s point A is the correct answer the nurse should have another nurse count the radio pulse as they count the apical pulse. A pulse deficit occurs when there are differences between the radial and apical pulse rates 48. A nurse is preparing to administer a medication to a preschooler and must convert the child’s weight from pounds to kilograms the child weighs 30 pounds how many kilograms does a child weigh? (round the answer to the nearest 10th) 30/2.2= 13.6 49. A nurse is caring for a group of clients in a long-term care facility which of the following actions should the nurse take to prevent healthcare associated infections for these clients? a. Place immunocompromised clients in the same room b. Wash hands after removing gloves c. Use anti-microbial hand gel after refilling a client’s water pitcher d. Clean the stethoscope with an antimicrobial wipe after obtaining vital signs e. Administer a prophylactic dose of antibiotics prior to discharge B, C, D are the correct answers the nurse should perform hand hygiene after removing gloves to prevent the transmission of microorganisms from one setting or client to another. The nurse should perform hand hygiene after touching a client supplies to prevent transmission of microorganisms. The nurse should wipe all equipment used for multiple clients with an antimicrobial wipe to prevent the transmission of microorganisms from one client to another 50. The nurse is reinforcing teaching about advance directives with a client who has end- stage renal disease which of the following client statements indicates an understanding of the teaching? a. I know that I can change my advance directives if I need to in the future b. My health care surrogate will make my healthcare decisions as soon as I have signed the power of attorney c. My family can overrule the decisions made by my health care surrogate d. Advance directives from one state are valid in another state A Is the correct answer the client can change their advance directives at their discretion 51. A nurse is caring for a client who has chronic pain the nurse recommends that the client concentrate on a memory of pleasurable experience which of the following complementary therapies is the nurse suggesting? a. Art therapy b. Thai Chi c. Guided imagery d. Biofeedback C is the correct answer guided imagery is a technique that can produce physical changes in the body such as decreasing pain levels by concentrating on a visualization of a pleasurable of a memory. 52. A nurse is caring for a client who has chronic kidney disease the nurse should identify that which of the following findings is the priority to report to the provider? a. Client reports voiding three times during the night b. Client reports burning and discomfort of urination c. The client white blood cell count is 11,000/mm3 d. The client’s output was 60 mL for the last three hours D is the correct answer when using the urgent versus non-urgent approach and client care the nurse should determine that the priority finding to report to the provider is a urinary output of 60 mL over three hours this finding represents oliguria and can indicate decrease in kidney perfusion or function. 53. A nurse is assisting with the care of a client who has a prescription for IV therapy the client tells the nurse that they have numerous allergies which of the following allergies should the nurse bring to attention of the charge nurse prior to the initiation of the therapy? a. Eggs b. Latex c. Seafood d. Bee stings Bea is the correct answer nurses use products containing latex including gloves tourniquets and IV tubing to deliver IV therapy. Clients who have an allergic reaction to latex can have a wide range of manifestation such as itching and hives to more serious reaction such as dyspnea and laryngospasm. 54. Nurse is assisting with the admission of a client to a medical surgical unit which of the following findings should the nurse identify as an indication the client is malnourished? a. Heart rate is 89 bpm b. Pink mucous membranes c. Pallor with scaly skin d. Body mass index of 23 C is the correct answer the nurse should identify that pallor along with scaly skin can indicate malnutrition the skin should be smooth and have the same hue as other areas of sun exposed skin and clients who are well nourished. 55. A nurse in a provider’s office is providing care for a client who has minimal exposure to sunlight which of the following intervention should the nurse recommend? a. Reduce intake of calcium rich foods b. Use sunscreen with skin protection factor of 8 c. Take vitamin D supplements d. Use a tanning bed two hours weekly C is the correct answer the human body requires sunlight exposure to synthesize vitamin D therefore the nurse should recommend that a client who has minimal sunlight exposure take supplemental vitamin D. 56. A nurse is collecting data from a client following a lumbar puncture the nurse should identify which of the following findings as a potential adverse effect of this procedure? a. Fluid overload b. Diarrhea c. Headache d. Difficulty voiding C is the correct answer the nurse should identify that a headache can be an adverse effect following a lumbar puncture to minimize the clients discomfort the nurse should administer analgesics offer fluids and maintain the client in a dorsal recumbent position for the length of time prescribed by the provider. 57. A nurse is caring for a client who has limited mobility which of the following actions should the nurse take to maintain the clients skin integrity? a. Use warm water when bathing the client b. Place a donut shaped cushion in the client’s chair c. Massage reddened areas or a bony prominences d. Maintain the client in high Fowler’s position A is the correct answer. The nurse should use warm water to be the client because hot water can dry and damaged the skin. 58. A nurse is collecting data from a client who is one day post-operative following abdominal surgery which of the following findings is the priority for the nurse to report to the provider? a. The client reports incisional pain as seven on a scale of 0 to 10 b. The client reports increased nausea and chills c. The client has an oral temperature of 101.3°F d. Client has tenderness and warmth in their calf D is the correct answer when using the airway breathing and circulation approach to client care the nurse should determine that the priority finding to report is tenderness and warmth in the client’s calf which could indicate the presence of thrombus if it moves from the van to the heart brain or lungs it could cause life-threatening complications. 59. A nurse is providing oral hygiene for a client who is unconscious identify the sequence of steps the nurse should take 1) Assess the clients gag reflex 2) Position the client on their side with their head turned to the side 3) Place a towel under the client’s head with an emesis basin under the chin 4) Separate the clients upper and lower teeth with an oral airway device 5) Cleanse the clients mouth using a toothbrush 60. A nurse is documenting client care in a client’s electronic health record which of the following entries should the nurse include in the documentation? a. Complained about having incisional pain b. Voided adequate amounts throughout the shift c. Became short of breath when ambulating d. Appeared to be sleeping while in bed C is the correct answer the nurse should include objective and significant information about the client when documenting client data in the electronic health record. [Show More]

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