Milestone retake.pdf

Milestone review 1. In assessing a child with suspected bacterial meningitis, the nurse should anticipate a recent history of which problem? A. Fracture B. Stomach upset C. Earache D. Chickenpox 2. A client in menopause reports being lactose intolerant. She exercises 3 times a week, d...

Milestone review 1. In assessing a child with suspected bacterial meningitis, the nurse should anticipate a recent history of which problem? A. Fracture B. Stomach upset C. Earache D. Chickenpox 2. A client in menopause reports being lactose intolerant. She exercises 3 times a week, drinks wine 1-3 times a month, and drinks a cup of coffee daily. Which instruction should the nurse provide to the client lower her risk of developing osteoporosis? A. Decrease wine consumption B. Decrease coffee consumption C. Increase calcium intake D. Increase weekly exercise 3. A client with chronic kidney disease is started in hemodialysis. during the first dialysis treatment the clients blood pressure drops from 150/90 mmHg to 80/30mmHg. Which of the following should the nurse do? A. Stop the dialysis treatment B. Lower the head of the chair and elevate feet C. Monitor blood pressure q45 minutes D. Administer 5% albumin Iv. 4. The nurse is reviewing the laboratory values of a client with acute pancreatitis who reports abdominal pain is less severe than experienced on admission. Which laboratory test should the nurse review to monitor the client’s clinical recovery? A. Bilirubin B. Creatinine C. Glucose D. Lipase 5. An unlicensed assistive personal (UAP) reports to the charge nurse that a client who delivered a 7-pound (3,175 gram) infant 12 hours ago is reporting a severe headache. The clients blood pressure is 110/70mmhg. Respiratory rate is 18 breaths/min. heart rate is 74 beats/min and temperature is 98.6. the clients fundus is firm and one fingerbreadth above the umbilicus. Which action should the charge nurse implement first? A. Assign a practical nurse (PN) to reassess the clients vital signs B. Determine if the client received anesthesia during delivery. C. Obtain a STAT hemoglobin and hematocrit D. Notify the healthcare provider of the assessment findings. 6. A male client with schizophrenia continues to talk to others on the mental health unit using tangential speech. which intervention should the nurse implement. A. Tell the client to discuss his ideas with others when his thoughts are more clear. B. Confront the client when he talks rapidly C. Ask the client to repeat his comments D. Teach the client to slow down and focus on the topic by listening to his words 7. The nurse is caring for a laboring client who is GBS pos. which immediate treatment is indicated for this client? A. Artificial rupture of the membranes B. Administration of oxytocin C. Amnioinfusion for the baby D. Administration of antibiotics 8. How should the nurse interpret these arterial blood gas (abg) and pulse oximetry results of a 4-year old child with head trauma: ph 7.41, pco2 44mmhg, p02 94 mmHG. A. Respiratory alkalosis B. Normal acid-base C. Hypercapnia D. Metabolic acidosis 9. A client is hospitalized two days before a scheduled aortic valve replacement with severe shortness of breath and weakness. To reduce cardiac workload, which of the intervention should be included in the plan of care? A. Provide a bedside commode for toileting B. Encourage active range of motion C. Assist with ambulation in the hallway D. Teach to sleep in side-lying position 10. Which intervention is most important for the nurse to include in the plan of care for a client who is 12 hours post- thyroidectomy? A. Prepare to administer radioactive iodine treatments B. Maintain a semi-fowlers position C. Resume antithyroid drug therapy D. Anticipate and monitor for hypothermia. 11. An older client who has Alzheimer’s disease and resides at a long-term memory care unit is having difficulty with organizing thoughts and thinking logically. The client insists to the nurse. Which intervention should the nurse implement? A. Use distraction and therapeutic communication skills B. Clarify reality with the client about delusional thoughts C. Reduce the client’s interaction with others during day D. Awaken the client for reality checks every 4 hours at night. 12. The nurse is obtaining a health history from a new client who has a history of kidney stones. Which statement by the client indicates an increased risk for renal calculi? A. Drinks several bottles of carbonated water daily. B. Eats vegetarian diet with cheese 2 to 3 times a day. C. Experiences additional stress since adopting a child D. Jogs more frequently than usual daily routine 13. A adult client presents to the community mental health center accompanied by the clients spouse who reports that the client has been acting impulsively. The client has spent a last-minute decision to take trips, sleeps only 2 to 4 hours a night, and has lost 33 lbs. in the last 2 months. Which nursing problem has the greatest nursing priority? A. Risk for self-directed violence related to impulsive behavior. B. Sleep deprivation related to state of hyperactivity C. Ineffective coping related to biochemical changes D. Imbalanced nutrition related to caloric expenditure 14. A 70 year old client with type 2 diabetes mellitus is hospitalized with an infected ulcer on his right great toe. Which instruction should the nurse give? A. Check the insides and linings of all enclosed shoes before putting the shoes on B. Be sure that you only walk barefoot on soft surfaces, such as fully carpeted rooms. C. Nylon socks provide warmth without trapping excess moisture around your feet D. Open-toed shoes allow air to circulate and help prevent toenail fungus growth. 15. Clients tells the nurse that her biopsy results indicate that the cancer cells are well-differentiated. How should the nurse respond. A. Offer the client reassurance that this information indicates that the client’s cancer cells are benign. B. Explain that these tissue cells often respond more effectively to radiation than to chemotherapy. C. Help the client make plans to begin immediate treatment since her cancer is likely to spread quickly D. Ask the client if the healthcare provider has given her any information about the classification of her cancer 16. Which diet should the nurse provide instruction about for a client who is experiencing acute renal failure? A. High protein, low carbohydrate, low sodium, low potassium B. Low protein, high carbohydrate, low sodium, low potassium. C. Low protein, high carbohydrate, low sodium, high potassium D. High protein, low carbohydrate, low sodium, high potassium. 17. A 12 year-old boy with hemophilia is hospitalized for hemarthrosis of his right knee. He is complaining of server knee pain. Which intervention should the nurse implement? A. Elevate and immobilize right knee in a flexed position. B. Perform range- of motion exercises to the right knee C. Apply hot packs to the right knee D. Give ibuprofen for pain 18. A male hospital employee is pushed out of the way by a female employee because of an oncoming gurney. The pushed employee becomes very angry and swings at the female. the employee is referred for counseling with the staff psychiatric nurse. Which factor in the pushed employee history is most related to the reaction that occurred? A. Was physically abused by his mother B. Hates to be touched by anyone C. Tortured animals as a child D. Is worried about losing his job to a women 19. A client with open-angle glaucoma is using pilocarpine ophthalmic solution, a miotic agent. Which action should the nurse at the eye clinic include in evaluating the effectiveness of the solution A. Palpate eyelids for decreased swelling B. Check amount of drainage from each eye C. Review eye pressure measurements D. Use Snellen charts to assess visual acuity. 20. During the newborn admission assessment, the nurse palpates the newborn scrotum and does not feel the testicles. Which assessment technique should the nurse perform? A. Perform transillumination of the scrotal sac to visualize shadows of the testes. B. Measure the size of the scrotal sac length and width C. Use a fingertip to palpate the inguinal canal for a weakening or indentation D. Observe the urethral opening on the surface of the penis when the newborn voids. 21. A client presents to labor and delivery at 36 weeks gestation reporting bright red vaginal bleeding without contractions. Which result should the nurse review first in the clients medical record? A. Location of placenta on ultrasound report B. ABO blood and Rh status C. Hemoglobin and hematocrit drawn at 28 weeks D. Ultrasound report to confirm gestational age 22. An older client who has Alzheimer’s disease and resides at a long-term memory care unit is having difficulty with organizing thought and thinking logically. The client insists to the nurse of being ready to go home. Which intervention should the nurse implement? A. Reduce the client’s interaction with others during day B. Use distraction and therapeutic commination skills C. Clarify reality with the client about delusional thoughts D. Awaken the client for reality checks every 4 hours at night. 23. A client with cholelithiasis is admitted with a gallstone lodged in the common bile duct. The client is unable to eat or drink without nausea and vomiting. Which finding should the nurse report to the healthcare provider? A. Flatulence B. Belching C. Yellow sclerae D. Amber urine 24. The nurse is caring for a client who is 24 weeks gestation and reports increased thirst and urination. Which diagnostic test result should the nurse report to the health care provider? A. Fasting blood glucose B. Postprandial blood glucose test C. Hemoglobin A1C D. Oral glucose tolerance test 25. A school aged child presents with new-onset type 1 diabetes mellitus. The nurse should recognize the caregiver demonstrates understanding of how to manage the child’s illness by which statement? A. Insulin injection sites are rotated between arms and legs B. Index fingers should be used for blood glucose testing C. Blood glucose stability can be achieved with a restricted diet D. Long-acting insulin is administered before each meal. 26. The nurse administers a sublingual nitroglycerin tablet to a male client with unstable angina. Which finding is most important for the nurse to report to the healthcare provider? A. Bilateral tinnitus when initially standing up B. Dizziness when rising from the bedside C. Hypotension with a systolic of 90 mmHg. D. Onset of headache after administration 27. A client arrives to the emergency department following a motor vehicle collision. The nurse observes the client experiencing increasing dyspnea and notes absent breath sounds on the left side. Which procedure should the nurse prepare for the client? A. Endotracheal intubation B. Bronchoscopy C. Pulmonary function test D. Chest tube insertion 28. The babysitter of 7- year –old who has type 1 diabetes calls the clinic to report that the child is very irritable, perspiring, and shaking. Which instruction should the nurse provide to the babysitter? A. Give the child an 8 ounce (240)ml glass of milk B. Contact the parents and tell them to call the clinic. C. Inject the child with 6 units of regular insulin. D. Bring the child to the emergency department. 29. A 6-year-old child with heart failure gained 2 pounds in the last 24 hours. Which intervention is most important for the nurse to implement? A. Graph the daily weight for the past week B. Restrict intake of oral fluids C. Assess bilateral lung sounds D. Decrease iv flow rate 30. A client treated for type 2 diabetes mellitus for eight years to the clinic describes elevated blood glucose readings intermittently for the past two months. which finding alerts the nurse that the client may be experiencing additional complications of diabetes? A. WBC 11X 103/ul(11x109/L) B. HbA1c 6.9% (52 mmol/mol). C. Grade 2 pedal edema D. Blood pressure 130/80mmHg 31. The nurse is providing dietary education to a client admitted with an exacerbation of gout. Which foods should be the nurse include in the teaching for the client to avoid? A. Potatoes B. Eggs C. Liver D. Chicken 32. The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a trans-urethral resection of the prostate (turp) which is the best initial nursing action? A. Increase the flow of the bladder irrigation B. Administer prn dose of an antispasmodic agent C. Measure the client’s intake and output D. Provide additional oral fluid intake 33. The nurse is teaching a client who was recently diagnosed with gout how to manage the disease. Which information should the nurse include in the clients teaching plan? A. Fluid intake should increase to at least 3 liters per day B. Family is not a risk factor for developing gout C. Chicken fettucine should be avoided completely. D. There is no correlation between gout and alcohol intake 34. The nurse is caring for a client who is 3 hours postoperative who also received hydromorphone iv 30 minutes ago for severe pain. On entering the clients room the nurse notes the most recent blood pressure reading of 88/56mmHg. The clients respiratory rate is now 14 beats/minute and pulse rate is 94 beats/minute. Which assessment should the nurse complete next? A. Orientation to person and place B. Deep tendon reflexes C. Pupillary response to light D. Level of consciousness 35. the nurse is caring for a client who has a nasogastric tube(NGT) to low suction and receives a prescription to clamp the tube. After the nurse clamps the tube, the client begins to vomit what should the nurse initiate first? A. Assess the client’s bowel sounds B. Administer an intravenous antiemetic C. Reconnect the rube to low suction D. Obtain an emesis basin for the client 36. An older client who experienced a cerebrovascular accident (cva) has difficulty with visual perception and eats only half of the food on the meal tray. The client’s family expresses concern about the status. How should the nurse respond to the family’s concern? A. Suggest that the family bring foods from home that the client enjoys eating B. Demonstrate the use of visual scanning during meals to the client and family. C. Explain that weight loss will be reserved after the acute phase of the stroke has ended D. Encourage the family to offer to feed the client when she does not eat her entire meal. 37. the nurse is caring for a toddler with a large unrepaired ventricular septal defect and heart failure. which assessment finding should the nurse expect? A. Pulse oximetry reading within defined limits B. Tachycardia C. Hypotension D. Blood pressure variance across extremities 38. Before administering the initial dose of sumatriptan succinate to a client with a migraine headache, it is most important to determine if the client’s history includes which problem? A. Type 2 diabetes mellitus B. Irritable bowel syndrome C. Coronary artery disease D. Seasonal allergic rhinitis 39. The nurse is assessing a 2-week-old male infant in a community health clinic and notes that his sclera appears slightly yellow. Additionally, urine in his diaper appears tea colored. This child should receive for assessment for what conditions? A. Hirschsprung’s disease B. Intussusception C. Biliary atresia D. Huntington’s disease. 40. A client who had an appendectomy returns to the postoperative unit following recovery from general anesthesia. two hours after being re- admitted to the unit, the client reports of abdominal pain. Which intervention should the nurse implement at this time? A. Question the client about the duration of the pain B. Determine if the client is safe with swallowing C. Auscultate bowel sounds in all quadrants. D. Assess respirations and time of last pain medication 41. During the vaginal delivery of a 10 lb infant, the nurse assesses a new mothers vaginal bleeding and finds that she has saturated two pads in 30 minutes and has a boggy uterus. Which of the following should you do first? A. Increase oxytocin IV infusion B. Have the client empty her bladder C. Inspect the perineum for lacerations D. Perform fundal massage until firm 42. A client with Gulllain-Barre syndrome is transferred to the intensive care unit after three days of lower extremity weakness that has progressed to the T-B leval of the spinal cord. The client is anxious and complaining of …Which intervention should the nurse implement first? A. Keep client NPO until swallowing is evaluated. B. Reassess the level of sensory loss with a pinprick. C. Administer an IV PRN anti-anxiety medication. D. Instruct UAP to assist with activities of daily living. 43. Four days after exposure to coronavirus (COVID-19 a client has a negative COVID19 test result. Eight days after the negative test result, the client presents with fever, fatigue, and cough and the nurse performs a second COVID-19 test. Which action is most important for the nurse to take? A. Explain to the client to inform others that they may have been potentially exposed in the last 14 days! B. Teach the client to wear a mask, hand wash, and social distance to prevent spreading te virus. C. Maintain a 6 feet distance from the client unless wearing N95 respirator and ere for droplet precautions. D. Report the COVID-19 result to the local health department according to CDC guidelines. 44. The nurse is caring for an older client who is admitted due to a change in mental status after two days of nausea and vomiting. The client's home medications include subcutaneous insulin, a daily antihypertensive, and a daily diuretic. Which intervention should the nurse implement first? A. Obtain a capillary blood qlucose level. B. Establish mental status baseline. C. Insert an indwelling Foley catheter. D. Check accuracy of medication list. 45. Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. What information requires the nurse to intervene ? A. Preoperative chest x-ray report is not available. B. Client's pulse oximeter reading is 96%. C. Surgical consent form is not signed. D. Preoperative serum potassium level is 2.8 mEq/L (2.8 mol/L). 46. The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with type 2 diabetes. nurse include in the plan of care for this client? A. The nurse will encourage the client to walk thirty minutes every day B. The nurse will demonstrate the procedure for accurate eye care C. The client's blood pressure readings will be less than 160/90 mmHg D. The client's hemoglobin A1C will be less than 7.0% (0.07) in 3 months. 47. A middle aged client is admitted to the hospital for the new onset of a non-productive cough, elevated temperature, and sweating. The healthc: provider makes a preliminary diagnosis of community-acquired pneumonia (CAP. Which prescription should the nurse address first? A. Comprehensive metabolic panel. B. Portable chest radiograph C. Arterial blood gases (ABGs). D. Complete blood count (CBC). 48. A client with hypertension who was taking hydrochlorothiazide has a new prescription for hydrochlorothiazide in combination win valsartan. an angiotensin I What assessments most important for the nurse to complete before administering the medication'? A. Review intake and output B. Assess oxygen saturation. C. Measure blood pressure D. Palpate for pedal edema. 49. The nurse is caring for a client that had a thyroidectomy 24 hours ago. The client reports experiencing numbness and tingling of the face which of the following interventions should the nurse implement first A. Inspect the neck for increase in swelling. B. Open and prepare the tracheostomy kit. C. Assess lung sounds for laryngeal stridor. D. Monitor for presence of Chvostek's sign. 50. The nurse is caring for a client with elevated parathyroid hormone levels. which safety precaution should the nurse include in the plan of care ? A. Aspiration B. Falls C. Suicide D. Hypothermia 51. Following a transurethral resection of the prostate (TURP), a client is discharged from the hospital with an indwelling urinary catheter. Which instruction important for the nurse to include in the discharge teaching plan? A. Dunk 3 liters or water each day B. Clamp the catheter when taking a shower. C. Eliminate all spicy foods from your diet. D. Avoid driving a car for 2 weeks. 52. A client who is receiving packed red blood cells suddenly develops nausea and vomiting. Which action should the nurse take first? A. Stop the infusion of blood. B. Assess the client's blood pressure. C. Administer an antiemetic. D. Notify the healthcare provider. 53. A female reports to the nurse that she has uncontrollable urine loss when coughing or sneezing. Which action should the nurse recommend? A. Urinate every two to three hours. B. Reduce intake of processed foods. C. Drink non-caffeinated colas only. D. Limit the daily intake of water. 54. The nurse assesses a male client with hyperthyroidism and identifies that the client has exophthalmos and lid retraction. What pathophysiology is the likely cause of these findings? A. Fluid accumulation. B. Medication reaction C. Ocular immobility D. Bacterial infection 55. A client is diagnosed with diverticulosis following a colonoscopy the client denies any symptoms, and asks the nurse what to expect which is the best response by the nurse? A. As the sacs enlarge pain may be experienced in the lower abdomen B. Episodes of burning pain commonly experienced C. Symptoms may not occur unless sacs become inflamed. D. Appetite loss with resultant feelings of weakness is common problems 56. A client presents to the emergency room vomiting dark brown emesis and in severe abdominal pain. The client reports to the nurse of recently being diagnosed with adenocarcinoma of the small intestine. After auscultating bowel sounds and obtaining vital signs, which prescription should the nurse implement next? A. Send the client to x-ray for a flat plate of the abdomen. B. Give a prescribed analgesic for temperature above 1010 = (38.39 C) C. Place an indwelling urinary catheter and attach a bedside drainage unit. D. Insert a nasogastric tube (NG) and attach to low intermittent suction 57. After administering an antihypertensive medication to an older client, which actions should the nurse implement? SATA A. Instruct the client to call the nurse before getting out on bed B. Verify that the client understands how to use the call button C. Assess the client's blood pressure before getting out of bed. D. Maintain the head of the client's bed always elevated. E. Insert an indwelling Foley catheter to monitor urinary output. 58. The nurse is providing care for clients on a medical unit where meals are served upon request. The nurse plans to administer a scheduled dose mixed insulin: insulin, isophane suspension and regular insulin at 0/30 to a client with diabetes mellitus. Upon entering the room, the nurse lea the client requested a late breakfast for 0930. Which action should the nurse take? A. Withhold the insulin unticoserto ne meal B. Administer the insulin as scheduled at 0730 C. Notify the pharmacy of the mealtime change. D. Offer the client a snack of juice and crackers. 59. A client is experiencing high levels of stress caused by social situations that involve performance and judgment. The client receives a prescription for a short-term medication. Which class of medications should the nurse expect to administer to the client? A. Selective serotonin reuptake inhibitors. B. Norepinephrine reuptake inhibitors. C. Antipsychotics D. Benzodiazepines. 60. The nurse is performing the preoperative assessment for a client scheduled for a vertebroplasty of the cervical spine. Which finding should the nurse notify the healthcare provider of prior to the procedure? A. White blood cells 9,000/ul (9X10/L) B. Hematocrit 38% (0.38). C. Hemoglobin 12 g/dl (120g/l) D. Platelet count 40,000x103/uL(40,000x10/L) 61. During an assessment, the nurse determines that a client with hypothyroidism has a goiter. An increase in which laboratory test results supports which findings? A. Iodine B. Calcium C. Serum T3 and T4 D. Thyroid stimulating hormone (tsh) 62. Which intervention should the nurse implement to help prevent osteoporosis in a client who had bariatric surgery? A. Administer supplemental iron. B. Identify foods high in vitamin D. C. Encourage increased intake of milk. D. Discuss importance for vitamin A 63. The nurse is caring for an older client who is admitted due to change in mental status after two days of nausea and vomiting. The clients home medications include subcutaneous insulin, a daily antihypertensive, and a daily diuretic. Which intervention should the nurse implement first? A. Obtain a capillary blood glucose level. B. Establish mental status baseline. C. Insert and indwelling foley catheter. D. Check accuracy of medication list. 64. In planning care in the immediate postoperative period, which factor has the highest priority in determining the frequency of vital sign assessment? A. Client’s condition B. Healthcare providers prescription C. Unit policy and procedures D. Staffing considerations 65. An older client is admitted after falling while walking. The left leg is externally rotated and shorter than the right leg, and the client is having severe pain and tingling in the left foot. The nurse is unable to palpate pedal pulses. Which action is most important for the nurse to implement. A. Review admission hemoglobin results B. Evaluate client’s ability to wiggle toes. C. Palpate left lower extremity skin for coolness D. Use a Doppler to assess bilateral pedal pulses. 66. The nurse observes that a newly admitted client with Parkinson’s disease exhibits a mask like facial appearance. Which additional nursing assessment takes priority in response to this fining? A. Respiratory rate B. Swallowing ability C. Neck flexion D. Speech patterns 67. After several days of coughing and taking acetaminophen to treat temperature of 101f. a client with diabetes mellitus DM is admitted to the hospital with an upper respiratory infection. Several hours after admission, the client reports having a severe headache and feeling dizzy. which intervention should the nurse take? A. Administer an antipyretic. B. Reassess vital signs. C. Obtain sputum for culture. D. Obtain a fingerstick glucose. 68. A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the post anesthesia unit. before selecting which medication to administer, which action should the nurse implement? A. Determine which prescription will have the quickest onset of action. B. Compare the clients pain scale rating with the prescribed dosing C. Ask the client to choose which medication is needed for the pain. D. Document the clients report of pain in the electronic medial record. 69. While planning care for a client that is experiencing pain, which outcome statement should the nurse include in the plan of care? A. Report a 5-point decrease on a 1 to 10 pain scale one hour after analgesia B. Request no prn pain medications after experiencing a precipitating cause. C. Be pain free and sleep through the night. D. Learn four pain management techniques. 70. While taking the health history of a male adolescent client, the nurse learns that he is currently taking an anticonvulsant drug for a seizure disorder. He also tells the nurse that he is embarrassed by the appearance of his gums. which drug is this client taking? A. Phenobarbital B. Phenytoin C. Carbamazepine D. Valproic acid 71. An older client with advancing Parkinson disease exhibits increasing confusion with agitation and hallucinations during morning showers and breakfast mealtime. Which action should the nurse take? A. Clarify reality when experiencing hallucinations. B. Use distraction and therapeutic communication skills. C. Reduce the client’s interaction with other during the day. D. Awaken the client earlier to begin morning care. 72. A client with diabetes mellitus is admitted with an upper respiratory infection. Which changes in blood glucose management should the nurse tell the client to do? A. Increased oral fluid intake. B. Higher doses of insulin C. Restriction of caloric intake D. Fewer fingerstick glucose checks 73. Which dietary instructions is most important for the nurse to explain to a client who had gastric bypass surgery? A. Reduce intake of fatty foods B. Chew slowly and thoroughly C. Eat small frequent meals. D. Sip fluids with each meal 79. When providing education for a client newly diagnosed with type 1 diabetes , which information is most important for the nurse to provide? a. Provide printed material about the treatment of diabetes b. Encourage wearing a medical alert identification bracelet c. Explain the importance of counting carbohydrate intake d. Teach how to recognize and treat hypoglycemia 89. The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with type 2 diabetes. Which outcome____ the nurse include in the plan of care for this client? a. The nurse will encourage the client to walk thirty minutes every day b. The nurse will demonstrate the procedure for accurate eye care c. The client’s blood pressure reading will be less than 160/90 mmHG d. The clients hemoglobin A1C will be less than 7.0% (0.07) in 3 months 91. An older male client is brought to the emergency department by his daughter. He is complaining of abdominal pain and the inability to urinate, ex_____ of incontinence. What action should the nurse implement first? a. Insert an indwelling catheter to drain the bladder of retained urine b. Obtain a urine sample from incontinence for culture and sensitivity c. Administer intravenous pain medication for ongoing abdominal pain d. Scan bladder to determine the amount of urine in the bladder 92. A client is admitted for treatment of acute diverticulitis with associated nausea and vomiting. Which serum laboratory value is most important for the nurse to monitor during treatment? a. Liver enzymes b. Albumin and protein levels c. White blood cell count d. Platelets count 93. A middle-aged client is admitted to the hospital for the new onset of nonproductive cough, elevated temperature, and sweating. The healthcare provider makes a preliminary diagnosis of community acquired pneumonia (CAP). Which prescription should the nurse address first a. Comprehensive metabolic panel b. Portable chest radiograph c. Arterial blood gases (ABGs) d. Complete blood count(CBC) 94. The nurse is caring for a client with elevated parathyroid hormone levels. Which safety precaution should the nurse include in the plan of care a. Aspirations b. Falls c. Suicide d. Hypothermia 95. A male client with heart failure calls the clinic and reports nor being able to put on his shoes because being too tight. Which additional information should the nurse obtain? a. has his weight changed in the last several days? b. what time did he take his last medications? c. is he still able to tighten his belt buckle? d. how man hours did he sleep last night? 96. how should the nurse explain to a male client why those with benign prostatic hyperplasia BPH often experience urinary retention? A. Abnormal growth results in loss of bladder muscle tone B. Inflammation causes spasms of the gland. C. Nerve compression decreases the sensation that the bladder is full. D. The enlarged gland compresses the urethra. 97. a client recently diagnosed with early stage Alzheimer’s disease receives a prescription for donepezil, an acetylcholinesterase inhibitor. which of the following should the nurse include in the client medication teaching? A. Instruct the client to get month liver function studies to assess for liver failure. B. Explain that the psychiatrist has prescribed the maximum dose and will decrease it gradually. C. Discuss the fact that donepezil slows the progression of the disease over the next year. D. Encourage the client to avoid foods high in vitamin k, such as green leafy vegetables.