Hi can you double check the answers.

Hi can you double check the answers. especially 59 Thank you 1. A nurse is teaching a group of nursing assistants about infection-control measures. What is the priority information to include in this teaching? a. hand-washing techniques* b. proper use of gloves c. administration of antibiotics d. assignment of private rooms Since hand washing is the first line of defense against infection spread, it is the focus of this instruction. Utilizing standard measures, wearing gloves and giving clients individual rooms may also help to stop the transmission of infection. When a responsible organism is found, antibiotics should be started, but a nursing assistant is not qualified to do so. 2. After the change-of-shift report, which patient will the nurse assess first? a. A 40 year old man with continuous eternal feedings who has developed pulmonary crackles* b. A 30-year old man with 4+ generalized pitting edema and severe protein-calorie malnutrition c. A 40- year old woman whose parenteral nutrition infusion bag has 30 minutes of solution left d. A 30 year old woman who gastrostomy tube is clogged after crushed medications were administered. The patient’s data indicate that aspiration has taken place, necessitating an immediate assessment and management. Although the information on the other patients should also be evaluated as soon as possible, it does not appear that any of their conditions are urgently life-threatening. 3. Which of the following measures can reduce or prevent the incidence of atelectasis. a. use of an incentive spirometer* b. chest physiotherapy c. mechanical ventilation d. reducing oxygen requirements. An incentive spirometer encourages lung expansion by requiring the user to take deep breaths. Although it can help move secretions, chest physical therapy cannot stop atelectasis. The progression of atelectasis is unaffected by lowering oxygen demand or putting someone on mechanical ventilation. 4. The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1-inch x 1 inch (3cmx3cm) area on the sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the medical record. a. stage 1 pressure ulcer b. stage 2 pressure ulcer* c. stage 3 pressure ulcer d. stage 4 pressure ulcer Stage 2 pressure ulcers are characterized by partial-thickness skin loss into but no deeper than the dermis. 5.The nurse is providing education to the patient about isometric exercises. Which statement by the patient indicated a good understanding? a. ‘An example of this type of exercise is walking’ b. An example of this type of exercise is kegels* c. An example of this type of exercise is running. d. an example of this type of exercise is swimming. Muscles must be tense and relaxed during isometric exercise without any joint movement. One example is kegel exercise where the tensing and untensing of the pelvic floor muscles. 6. A client is admitted to the preoperative clinic for a breast biopsy. Which information would the nurse enter into the medical record as objective data? a. The client states” I’m worried about the results” b. Blood pressure is 122/84, and the pulse is 100 beats/minute* c. The client reports anxiety at 7 out of 10. d. the client reports the left breast is tender to touch. Objective data – relates to data that can be measured by means of a physical examination, observation, or diagnostic testing. Examples are vital signs, physical findings or patient behaviors observed by the nurse or laboratory test results. Subjective data – a feeling or experience that the patient can have and then communicate to the nurse. Any symptom, idea, emotion, or sensation is regarded as subjective data. 7. The nurse notes documentation that a client is exhibiting Cheyne-Stokes Respirations. On the assessment of the client, the nurse should expect to note which finding? a. Irregular repirations with pauses at the end of inspiration and expiration b. Rhythmic respirations with periods of apnea*. c. Totally irregular respirations in rhythm and depth d. regular rapid and deep, sustained respirations. Cheyne-Stokes Respirations – Periods of apnea and rhythmic breathing patterns may be signs of metabolic malfunction in the basal ganglia or cerebral hemisphere. 8. The student nurse is working with a preceptor to administer an enema to the client. Which action by the student nurse prompts intervention and redirection by the preceptor? a. The client positioned comfortably in the right side lying Sims position* b The client bedpan is put at the bedside in preparation for use. c. The enema tubing is primed with a solution that has been warmed d. Water-soluble lubricant is applied to the end of the enema tubing. The left lateral or left side-lying sims position is the most appropriate position for giving an enema because of the anatomical characteristics of the colon. 9. The nurse is caring for a patient with hyperkalemia. Which body system assessment is the priority? a. Gastrointestinal b. Neurological c. Cardiac* d. Respiratory The patient is at risk for cardiac arrest and other potentially significant dysrhythmias due to hyperkalemia. heart function depends on potassium balance. With hypokalemia, the respiratory system comes first. For any additional electrolyte imbalances, monitoring of the gastrointestinal and nervous systems would be advised. 10. What defining characteristics are consistent with fluid volume deficit? a. bounding radial pulse, flat neck veins when supine b. dry mucous membranes, thready pulse, tachycardia.* c. Engorged neck veins when upright, bradycardia d. a weight loss of 1 lb (0.5 kg) in 1 week, pale yellow urine. Decreased blood pressure with an elevated heart rate and a weak or thready pulse and dry mucous membrane are hallmark signs of fluid volume deficit. 11. Which action most effectively demonstrates that a new staff member Jana understands the role of scrub nurse? a. monitor change in patient condition b. takes the patient to the postanesthesia area c. documents all patient care accurately d. “I must don full surgical attire and sterile gloves” * The function of a scrub nurse includes preserving asepsis in the operating room. The circulating nurse would do the other tasks. 12. What is the name of the interval when a patient manifests signs and symptoms specific to a type of infection. a. incubation period b. convalescence c prodromal stage d. illness stage * The illness stage is the time frame during which the patient displays symptoms and signs unique to a particular infection kind. The time between a pathogen entering the body and the onset of the first symptoms is known as the incubation period. The prodromal stage is the time period between the emergence of nonspecific symptoms (such a low-grade fever or lethargy) and symptoms that are more specific. The period during convalescence is when acute infection symptoms go away. 13. Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145mEq/L, Potassium 4.5 mEq/L, calcium 4.5 mg/DL? a. Decreased deep tendon reflexes b.Light-headedness when standing up c weak quadriceps muscles d. tingling of extremities with possible tetany. * Muscle tetany, a positive Trousseau’s sign, and tingling in the extremities are symptoms of hypocalcemia. 14. The nurse is assessing a client with multiple traumas who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome? a. Intercostals retractions b. increase respiratory rate* c bilateral wheezing d inspiratory crackles. An elevated RR, which can start anywhere between 1 and 96 hours after the initial bodily trauma, is the earliest observable symptom of ARDS. Increased dyspnea, air hunger, retraction of accessory muscles, and cyanosis accompany this. Clear or fine inspiratory crackles or diffuse coarse crackles may be present in breath sounds. 15. What will the nurse do to test for Trousseau’s sign as a diagnostic test for hypocalcemia? a. hyperextending the clients neck b. Tapping the clients face lightly over the facial nerve. C. addressing vital signs d. inflating a blood pressure cuff on the upper arm.* Trousseau’s sign is considered positive when a carpopedal spasm of the hand and wrist occurs after an individual wears a blood pressure cuff inflated over their systolic blood pressure for 2 to 3 minutes. 16. A nurse conducting Weber’s test. Which action will the nurse take? a. Place a vibrating tuning fork on the patient’s mastoid process. b. Compare the number of seconds heard by bone versus air conduction. c. Compare the patient’s degree of joint movement to the normal level. d. Place a vibrating tuning fork in the middle of the patient’s forehead. * The nurse sets the vibrating tuning fork in the center of the patient’s forehead during the Weber test (lateralization of sound). A vibrating tuning fork is placed on the patient’s mastoid process during a Rinne test (comparison of air and bone conduction), during which the nurse measures the durations of air and bone conduction heard. A test for range of motion involves comparing the patient’s level of joint movement to the usual range. 17.The nurse receives a handoff report on the four patients. What patient should the nurse assess first? a. The patient with the right leg pain rated an 8/10 asked for pain medication. b. The patient with a resp rate of 18 breaths/ min c. The patient with a blood pressure of 110/64 d. The patient with a pulse of 42 beats/ min * The patient is experiencing bradycardia. Bradycardia can be life threatening if the heart is unable to maintain a rate that pumps enough oxygen-rich blood throughout the body. 18. A client is recovering from abdominal surgery and has a large abdominal wound. The nurse should encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing. A. oranges* b. milk c. bananas d. chicken Vitamin C levels are particularly high in citrus fruits and juices. Bananas contain a lot of potassium. The B vitamins are abundant in dairy and meat products. 19. A client with acute renal failure has a serum potassium level of 6.5mEq/L (6.5 mmol/L). The nurse should monitor the client for which potential complication? a. Circulatory collapse b. cardiac arrest* c. hemorrhage d. pulmonary edema. hyperkalemia is a potentially life threatening cardiac emergency, especially in patients with renal failure, and can lead to fatal arrhythmias such as ventricular fibrillation or asystole, leading to cardiac arrest. 20. A nurse is caring for a caring who just experienced a generalized seizure. Which of the following action should the nurse perform first? a. Provide client hygiene b. keep the client in a side-lying position* c. Reorient the client to the environment d. Document the duration of the seizure. positioning the patient in side lying will minimize the risk for aspiration. 21. The nurse is caring for a postoperative client who has not voided since before surgery. What is the nurse’s most appropriate action? A. Palpate for the bladder above the symphysis pubis* b. Request an order to insert Foley catheter c. Initiate hourly intake and output measurements d. Force fluids to encourage voiding. The kidneys typically produce 35 to 55 ml of urine in a single hour. Urine would be present in the bladder and would be felt above the symphysis pubis after hours without voiding. 22. A community nurse is assessing a young child who has had a colostomy stoma for several years. The nurse notices that the stoma is pink and moist. What is the best response to the child’s parents about the appearance of the stoma? a. the stoma is irriated: change the appliance more frequently. B.” The stoma looks infected: you need an antibiotic cream c. The stoma looks healthy: continue your present care* d. ” The stoma is too moist; we must try to prevent skin breakdown” The surface of your stoma is the lining of your intestine. It will be pink or red, moist, and a little shiny, hence it is normal. 23. A high school nurse notes that girls on the cross-county team eat together each day. She notes that one of the girls only consumes an apple each day at lunch and has experienced a decline in her athletic performance, which condition the nurse suspect in this girl. a. anorexia nervosa* b. Pheylketonuria (PKU) c. Crohn disease d. Bulimia nervosa Anorexia nervosa is an eating disorder characterized by weight loss due to generally restrict the number of calories and the types of food they eat. The disorder will eventually result in poor performance due to dehydration, (early) glycogen depletion and muscle weakness. 24. The nurse needs to obtain a radial pulse from a patient. What must the nurse do to obtain a correct measurement? a. Place the tips of the two fingers over the groove along the little finger side of the patients wrist. b. Place the thumb over the groove along the little finger side of the patients wrist. c. Place the thumb over the groove along the thumb side of the patients wrist. d. Place the tips of the first two fingers over the groove along the thumb side of the patients wrist.* You can take your radial pulse on either wrist. Feel the pulse in your radial artery between the wrist bone and the tendon on the thumb side of your wrist using the tips of your other hand’s index and third fingers. 25. A nurse is assessing the skin of an immobilized patient. What will the nurse do? a. Use a standardized tool such as the Braden Scale* b. Assess the skin every 4 hours. c. Limit the amount of fluid intake. d. Have special times for inspection so as to not interrupt routine care. The Braden Scale for Predicting Pressure Sore Risk was developed to foster early identification of patients at risk for forming pressure sores. The scale is composed of six subscales that reflect sensory perception, skin moisture, activity, mobility, friction and shear, and nutritional status. 26. A patient is dehydrated and needs an infusion of isotonic fluids to correct dehydration. Which intravenous fluid is appropriate for this patient? a. Dextrose 10% in water (D10W) B. Dextroe 5% in water (D5W)* C. Dextrose 5% in 0.9% sodium chloride( D 5NS; D 0.9% NaCl) d. Dextrose 5 % in lactated Ringers ( D 5 LR) An isotonic solution is 5% dextrose in water (D5W). The majority of the water then enters cells by osmosis after leaving free water behind that quickly dilutes extracellular fluid as it enters cells. This process aids in rehydrating the body. 27. An infection control nurse has identified a problem related to infection control procedures on a medical unit that has a high census of clients diagnosed with tuberculosis. The nurse has decided to conduct an in-service education program for the staff about the required transmission- based precautions. The nurse determines that the program was successful based on which statement by the staff? a. It is okay to leave the client’s room door open to allow for interaction with the staff. b. “If the client needs to be transported, transport personnel needs to wear a mask” c. “The client needs to be placed in a private, negative air pressure room.”* d.” When wearing a respirator, it needs to be removed before leaving the clients room” Because of the difference in air pressure between inside and outside the room, these spaces are known as negative pressure rooms. This guarantees that when the door is opened, potentially hazardous air or other particles won’t leak outside into uncontaminated areas. 28. A client has a potassium level of 6.1 mEq/L, which medication would the nurse anticipate giving? a. Potassium supplements b. Sodium Tablets c Kayexalate* d. Calcium gluonate. Given that the client’s potassium level is high, kayexalate would be prescribed to assist lower it. 29. Which nutrients are considered macronutrients? Select all that apply a. minerals b. carbohydrates* c. fats* d. vitamins e. proteins* Carbohydrates, fat and protein are called macronutrients. They are the nutrients you use in the largest amounts. Macronutrients are the nutritive components of food that the body needs for energy and to maintain the body’s structure and systems 30.Which element is part of the chain of infection? Select all that apply. One, some, or all responses may be correct. A . a vaccine schedule b. a susceptible host* c. reservoir* d. an infectious agent* e. a clean surrounding the six links in the chain of infection are the infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host. 31.When auscultating a client’s chest, a nurse assesses a second heart sound (S2). What would the nurse determine is the cause of this sound. a. closing of the aortic and pulmonic valves * b. closing of the mitral and tricuspid valves c. opening of the mitral and tricuspid valves d. opening of the aortic and pulmonic valves. 32. The nurse is teaching hypertension management to a patient who is taking antihypertensive drugs. Which statement made by the patient indicates a need for further clarification? a. When my blood pressure becomes normal, I no longer need to take medication.* b.” When I get out of bed in the morning, I should first sit for a few moments and then stand.” c.” Keeping my blood pressure under control reduces my risk for a heart attack” d. “Losing weight can reduce my need for blood pressure medication.” you shouldn’t stop taking blood pressure medications even if your blood pressure is normal. They can cause potentially dangerous side effects that can lead to withdrawal symptoms.It’s really important to take your medicine as directed. 33. A male client 30 years of age is postoperative day 2 following a nephrectomy ( kidney removal) but has not yet mobilized or dangled at the bedside. Which of the following is the nurse’s best intervention in this clients care? a. Show the client the expected outcomes on his clinical pathway that relate to mobilization. b. Respect the client’s wished to remain in his bed and ask him when he would like to begin mobilizing. c. Educate the client about the benefits of early mobilization and offer to assist him.* D Document the clients noncompliance and reiterate the consequences of delaying mobilization. Early ambulation helps the body’s circulation of oxygen while preserving normal breathing patterns. Ambulation increases circulation, which can aid in preventing the formation of blood clots that can lead to strokes. Walking increases blood flow, which helps wounds heal more quickly. 34. Which of the following needles would the nurse choose for an SQ injection? a. 22 gauge, 1 inch b. 19 gauge, 1 inch c. 23 gauge, 1 1⁄2 inch d .25 gauge, 5/8 inches * 35.The nurse is caring for a patient who is receiving vancomycin to treat a severe infection. The next Vancomycin dose is due to be administered at 10: 00 AM. What time will the nurse draw the vancomycin serum trough level? a. 7:30 am b. 9:30 am* c. 1:30 pm d 11:30 am 36. A febrile preschool-aged child presents to the after-hours clinic. Varicella( chickenpox) is diagnosed on the basis of the illness history and the presence of small, circumscribed skin lesions filled with serous fluid. Which type of skin lesion will the nurse report? a. pustules b. papules c. wheals d. vesicles* a tiny, liquid-filled sac created by a membrane. Substances are moved into or out of cells by vesicles. Drugs can be delivered to bodily cells using vesicles created in a lab. 37. The nurse is caring for a 48- year old client with hyperkalemia. Which of the following interventions would the nurse provide for the client? Select all that apply. a. administer insulin and D50 as per MD orders * b. monitor cardiac status and ECG * C. Hold Potassium Supplements * d. Administer IV potassium chloride via IV push e. Administer IV potassium chloride slowly as per MD orders Adults with severe cardiotoxicity or cardiac arrest brought on by hyperkalemia should be treated according to American Heart Association guidelines by receiving an intravenous infusion of 25 grams of 50% dextrose combined with 10 units of normal insulin over a period of 15 to 30 minutes. Mild to moderate hyperkalemia causes depression of conduction between adjacent cardiac myocytes, manifesting on ECG as prolongation of the PR and QRS intervals. People with hyperkalemia or kidney disease should not take potassium supplements. Potassium chloride is a medication used in the management and treatment of hypokalemia. 38. A client has an impairment of cranial nerve II. To maintain safety in the home, the nurse should teach the spouse to implement which measure? a. Keep traveled paths in home free of clutter b. Lower the temperature setting of the hot water heater. C. Speak to the client in a loud voice. d. Serve food that is not too hot or too cold. The optic nerve, which controls vision, is located on cranial nerve II. In order to prevent falls, the nurse might encourage the family to keep walkways clear of clutter. Loud verbal communication with the client may help make up for cranial nerve VIII impairment (vestibulocochlear). The front two-thirds and posterior one-third of the tongue are each controlled by cranial nerves VII (facial) and IX (glossopharyngeal), respectively. If the customer has nerve damage in their extremities, turning down the hot water heater’s temperature would be helpful. 39. Which of the following is a sign and symptom of hyperkalemia? a. constipation b. muscle strength c. hypoactive bowl sounds d. diarrhea * When your blood potassium levels get too high, you develop hyperkalemia. A vital nutrient present in food is potassium. This nutrient supports the health of your muscles and nerves. However, an excess of potassium in the blood can harm the heart and result in a heart attack. 40. Which of the following terms is used to describe the inability to breathe easily except in an upright position? a. hemoptysis b. orthopnea * c. dyspnea d. hypoxemia Orthopnea is a type of breathing difficulty that only occurs while a person is lying down; it disappears when they are standing or sitting up. Although it can come from other illnesses, orthopnea is frequently a sign of heart failure or lung disease. 41. A small-bore tube is placed. Which technique will the nurse use to best verify tube placement? A. X-RAY* B. aspirations of contents c. auscultation d. pH testing. X-ray examination is the most reliable technique for confirming the placement of small-bore feeding tubes. Testing for pH and aspiration of contents are not perfect methods. 42. A patient in the emergency department is reporting left lower abdominal pain. Which proper order will the nurse follow to perform the comprehensive abdominal examination? a. inspection, palpation, auscultation b. inspection, auscultation, palpation* c, percussion, palpation, auscultation d. percussion, auscultation, palpation. An abdominal exam follows a somewhat different protocol than other evaluations. Start with an inspection, then move on to auscultation. The likelihood of changing the frequency and nature of bowel sounds is reduced by utilizing auscultation prior to palpation. 43. Which areas are at risk for development of pressure ulcers in immobile patients? Select all that apply. a. elbows * c. coccyx* c. heels* d. chest e. buttocks* The medical problems of those most at risk for developing bedsores prevent them from changing positions or force them to spend the majority of their time in a bed or chair. The skin covering bony body parts, such as the elbows, heels, ankles, hips, tailbone, and buttocks, is where bedsores most frequently appear. 44. The edges of a patients incision are approximated, and no drainage is noted. Which type of healing does this signify? a. granulation b. secondary intention c. tertiary intention d. primary intention * The healing of a wound in which the edges are closely re-approximated is referred to as healing by first (primary) intention, also known as primary closure. In this kind of wound healing, scarring and little granulation tissue production result in a direct union or restoration of continuity. 45. The nurse is caring for a patient who is receiving an IV antibiotic. The patient reports new signs and symptoms, including a rash and pruritus. The nurse understands that this is which kind of response from medication? a. idiosyncratic reaction b. allergic reaction* c. side effect d. toxic effect Following intravenous vancomycin administration, red man syndrome (RMS), a common allergic reaction to vancomycin,often manifests as a rash on the face, neck, and upper body. 46. A client must receive a blood transfusion of packed red blood cells (RBC’S) for severe anemia. What I.V. fluid should the nurse use to prime the tubing before hanging this blood product? a. Dextrose 5% in water as this is considered an isotonic solution. b. Current guidelines suggest that no priming is needed since blood products must be infused alone. c. The normal saline solution as this is considered an isotonic solution d. Lactated Ringer’s solution as this is considered an isotonic solution. Blood transfusions are administered using normal saline solution. Dextrose or lactated Ringer’s solutions can result in blood clotting or RBC hemolysis. There is currently no recommended “no priming” approach without NSS. 47. The nurse administers medication to a patient. Shortly afterward, the patient develops an itchy rash all over his body and reports feeling very unwell. What is the priority action of the nurse? a. Determine if the patient is having an difficulty breathing* b. Document the reaction in the patients chart. c. Obtain and order for hydrocortisone cream to relieve the itching. d. Leave the patient to notify the physician and the pharmacist. The patient may be beginning to experience an allergic reaction to the medicine, which can cause shortness of breath and airway swelling, therefore the nurse must first ascertain whether the patient is having any breathing difficulties. 48. The nurse is assessing skin lesions. Which would the nurse recognize as the priority for referral for a skin biopsy? a. asymmetrical, tan with a s defined border, 3 mm b. symmetrical; dark brown with regular border; 7mm c. symmetrical; brown with regular borders d. asymmetrical; brown with a black; irregular bored; 6.5 mm* Sign of Malignant Melanoma ABCDE A= Asymmetrical lesion B= Irregular Border instead of smooth C= Color: not uniform- usually more than one color shade. D= Diameter is usually greater than 6mm E= Evolving: changes in size shape or color. 49. A nurse has completed discharge teaching for a client , which involves instructions for changing a leg dressing. Which statement would indicate that the teaching has been effective? a. the dressing should be changed next time I have an appointment with my healthcare provider b. I will report any signs of redness or drainage when I change the dressing.* c. I don’t need to worry about this dressing because the home health nurse will change it. d. I should change this dressing once a week when it starts to hurt. Infection warning indicators should be continuously checked on wounds. Erythema (redness), induration (area of hardened tissue), pain, edema, purulent exudate (yellow or green drainage), and wound odor are indications of localized wound infection. Any new indications of infection should be reported to the healthcare provider along with the anticipated request for a wound culture. 50. On admission of a client to the post anesthesia care unit( PACU), the blood pressure is 126/82. Thirty minutes after admission, the blood pressure falls to 114/72 with pulse of 74 and warm, dry skin. Which action by the nurse is the most appropriate? a. Increase the IV fluid rate b. continue to take vitals every 15 minutes* c. administer oxygen therapy at 100% per mask d. notify the anesthesia care provider immediately. It only needs to be monitored on an ongoing basis if there is a minor decrease in postoperative blood pressure, a normal pulse, and warm, dry skin. Hypovolemic or hemorrhagic shock would be indicated by hypotension with tachycardia and/or chilly, clammy skin, necessitating communication of the ACP, enhanced fluid delivery, and high-concentration oxygen therapy. 51. The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mm Hg(30 mmol/L) and HCO3- of 20 mEq/L. The nurse analyzes these results as indicating which condition? A. metabolic acidosis, compensated b. respiratory alkalosis, compensated * c. metabolic alkalosis, uncompensated d. respiratory acidosis, uncompensated. When there is a respiratory issue, the pH and Paco2 will have the opposite impact of what is normal (7.35-7.45). The pH is above normal in this condition, while the Pco2 is low. The pH is higher when there is alkalosis. 52. The nurse is caring for a client with Clostridium difficile infection. Prior to entering the room, which step would the nurse take? a. apply a face mask b. apply foot protection c. put on goggles d. put on a gown* A patient with Clostridium difficile needs to be isolated from contact people. For this client, a gown and gloves are the best possible solutions. 53. The nurse is caring for a client who needs a hypertonic IV solution. What solutions are hypotonic? Select all that apply? a. 10% dextrose in water * b. 5%NS* C. 0.45% sodium chloride d. 0.33 NS E. 0.9 sodium chloride. 10% dextrose in water, 5% dextrose in 0.9% saline, 5% dextrose in 0.45% saline, and 5% dextrose in lactated Ringer’s solution are examples of hypertonic fluids. The solutions of 0.45% sodium chloride and 5% dextrose in 0.225% saline are not hypertonic solutions. 54. The nurse receives a handoff report on four patients. Which patient should the nurse assess first? a. The patient with right leg pain rated 8/10 asked for pain medication b. the patient with resp rate 18 breaths/ min c the patient with blood pressure of 110/64 d. the patient with a pulse of 42 beats/ min* Adults in good health should have a pulse of 60 to 100 beats per minute. if the heart can’t deliver enough oxygen-rich blood to the body because to a very slow heart rate. You might experience this and feel weak, exhausted, and out of breath. 55. Fifteen minutes after beginning of a blood transfusion the patient complains of having a headache and chills. The patient also has an elevated temperature. The nurse should first? a. Stop the transfusion and run separate NS line.* b. Recheck the blood with a second nurse and take the vital signs every ten minutes. c. Take the vital signs and slow down transfusion d. Call the doctor and document. A transfusion reaction is seen in the patient. Stopping the transfusion and maintaining a patent IV line are the immediate nursing interventions. The other choices might be mentioned, but they aren’t the top priority in this instance. 56. The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH= 7.53, Pao2= 72 mm, and HCO3= 28 mEq/L. Which conclusion about the client should the nurse make? a. the client is probably hyperventilating* b. the client is probably overreacting c. the client is fluid volume overload d. the client has acidotic blood. The blood gas findings for respiratory alkalosis confirm that this patient is showing signs of hyperventilation. The patient can address the problem’s root cause by breathing into a paper bag, which will help them retain carbon dioxide and lower their oxygen levels to normal. 57. Several laboratory test are prescribed for a client, and the nurse reviews the results of the test. Which laboratory test results should the nurse report? Select all that apply. A.

******CLICK ORDER NOW BELOW AND OUR WRITERS WILL WRITE AN ANSWER TO THIS ASSIGNMENT OR ANY OTHER ASSIGNMENT, DISCUSSION, ESSAY, HOMEWORK OR QUESTION YOU MAY HAVE. OUR PAPERS ARE PLAGIARISM FREE*******."