76. A nurse is examining the abdominal wound of a client who

76. A nurse is examining the abdominal wound of a client who is 3… 76. A nurse is examining the abdominal wound of a client who is 3 days postoperative following a hemicolectomy. Which of the following findings indicates a wound infection?a. Serous wound drainageb. Bruising around the woundc. Crusting along the incisiond. Redness around the incision line99, a nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take?A, leave the television on in the client’s room B, raise all four side rails while the client is in bed ( I don’t think so is the correct answer )C, apply a motion sensor mat to the client’s bed D, move the overbed table away from the bed A nurse is caring for a client who has pneumonia with dyspnea. The client’s ABG results are pH 7.30, PaCO2 50 mm hg, HCO3 26 mEq/L. the nurse should recognize that the client has which of the following acid-base imbalances? a. Metabolic alkalosis b. Metabolic acidocis c. Respiratory alkalosis d. Respiratory acidosis  9. A nurse caring for a client who has a distal radius fracture with a short arm cast applied. Which of the following actions should the nurse take? a. Position the fractured arm below the level of the client’s heart b. Preform neurovascular checks of the affected extremity every 2 hr c. Use a hair dryer to blow hot air into the cast to relieve itching A nurse in a health clinic is collecting data from an older adult client which of the following information in the client’s history increases the risk for osteoporosis? a. The client is a Gardner b. The client has a glass of red wine every evening c. The client walks 3.2 km (2mil) daily d. The client is lactose intolerant  12. A nurse is contributing to the plan of care for a client who has heart failure. Which of the following actions should the nurse include in the plan? a. Obtain weight weekly b. Measure vital signs every 8 hr c. Allow frequent rest periods d. Encourage fluids  13. A nurse is evaluating a client’s acceptance of having a new ileostomy. Which of the following statements by the client indicates acceptance? a. I will attend a support group to help me handle difficulties when they occur b. I have my partner empty the bag for me so I don’t have to look at it c. I wish my sexual relationship with my partner was like it was before d. I look forward to having normal bowel movements again15. The nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube. Which of the following actions should the nurse take? a. flush the two with 90ML of sterile water before and after the feeding b. Rotate the jejunostomy tube once per day c. Elevate the head of the clients bed for one hour after the feeding d. Administered the feeding solution at cold temperature  16. A nurse is reinforcing teaching with a client about breast self-examinations. Which of he following statements by the client indicates an understanding of the teaching? a. I will perform breast exams the day my period begins b. It is common for one breast to be larger than the other c. I will perform breast exams every other month d. It is common for the skin on my breast to dimple 17. A nurse is reinforcing teaching with a client who will undergo a colonoscopy the following week. Which of the following instructions should the nurse include?a. administer enemas 2 days before be procedure b. except the provider to schedule another procedure to remove any polyps c. do not eat or drink anything except water for 12 hours before the procedure d. Restricted diet to clear liquids for one to three days before the procedure  18. A nurse is assisting with the plan of care for an older client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care? a. Monitor the client for weight loss b. Advised the client about increased dry mouth c. Inform the client of adverse effect of diarrhea d. Check the client for increased hypopigmentation under the patch21. A nurse is collecting data from a client about her current pain status. Which of the following s should the nurse ask to determine the quality of the client’s pain?  a. what does your pain feel like b. Is your pain the same as it has been c. Could you rate your pain on a scale from zero to 10 d. Do you have any pain this morning  22. (Picture: exhibit ABC) A nurse is reviewing the medical record of a client who had left sided stroke. Which of the following findings should the nurse expect? a. Blood pressure b. Laboratory results c. Neurological status d. Temperature 23. A nurse is caring for a client who has partial thickness burns on 50% of his body and is receiving total parenteral nutrition. The nurse should actively monitor the client for which of the following? a. increased serum glucose levels b. Intermittent abdominal pain c. Absent bowel sounds d. Decrease calcium levels 25. A nurse is reinforcing discharge teaching with a client who had an abdominal hysterectomy 2 days ago. Which of the following instructions should the nurse include in the teaching? a. dish with warm water to remove vaginal discharge b. Avoid climbing stairs for eight weeks c. Take shower rather than a tub bath d. Expect bright red vaginal bleeding for one week following surgery 27. A nurse is reinforcing teaching with a client who has psoriasis. Which of the following treatment options should the nurse include in the teaching? a. Dermabrasion b. Benzol peroxide c. Oil-based ointment d. phototherapy 28. A nurse is reviewing laboratory values of a client who has severe dyspnea. Which of the following laboratory values indicates heart failure? a. Calcium 9.0 mh/dL b. Sodium 40 meQ c. Potassium 4.0 meQ d. Brain natriuretic peptide 275 pg/mL 29. A burse is collecting data from a client who is taking enoxaparin. The client report starting the use of dietary supplements/ The nurse should report the use of which of the following supplements to the provider? a. Probiotics b. Ginkgo biloba c. Echinacea d. Flaxseed powder 33. A nurse is assisting with discharge teaching for a client who requires oropharyngeal suctioning. The nurse should ensure that which of the following equipment is available for use at home? a. Sterile gloves b. Oral pharyngeal airway c. Water soluble lubricant d. Yankauer catheter 38M-. A nurse is preparing an educational program for staff members regarding a new intravenous pump. Identify the sequence of actions the nurse should take when developing the program.  a. Develop learning objectives for the program b. Identify what skills to teach the staff members c. Conduct program evaluation with staff members d. Schedule several sessions of the program31M. A nurse witnesses a coworker not following facility procedure with discarding the unused portion of control substances, which of the following actions should the nurse take? (select all that apply) a. File an anonymous report of the incident to the nurse manager b. identify all witnesses to the incident c. request that the co-worker to c an incident report d. document a factual account of the incident e. submit an incident report to the risk management Health Science Science Nursing NUR 233

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