When there is evidence that a client may have fluid in the lungs, a nurse should first:
A. Reposition the client
B. Notify the physician
C. Obtain a chest x-ray examination
D. Have the client cough and deep breathe
D
D. Client should cough and deep breathe first when dullness over lung tissue may be created by presence of fluid.
A. If chest excursion is reduced, depth of breathing is reduced by pain, postural deformity, or fatigue—first reposition client.
B. Physician should be notified second when dullness over lung tissue may be created by presence of fluid.
C. Chest x-ray examination should be obtained third when dullness over lung tissue may be created by presence of fluid.
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The client refuses a scheduled medication. Documentation on the client's medication administration record (MAR) should be completed:
a. by circling the dosage time and initialing it b. by circling the dosage time, citing the exact reason for withholding the medication, and initialing the entry c. by drawing a diagonal line through the time and initialing it d. by leaving the dosage time blank on the MAR
When being interviewed, a 50-year-old patient says that he cannot see the newspaper as well as he used to. What is the reason this patient vision has changed from near to far?
a. The ciliary muscle changes the pupil size. b. The lens of the eye changes shape as the ciliary muscle contracts and relaxes. c. Nearsightedness has set in. d. Clouding of the vitreous humor has oc-curred.
A patient is 5 feet 6 inches tall, weighs 102 pounds, and is constantly worried about getting "too fat" and is refusing to eat. The nurse assesses that the patient is suffering from:
1. bulimia. 2. anorexia nervosa. 3. malabsorption. 4. peptic ulcer.
The nurse is caring for a frail elderly client who has a chronic pressure ulcer. The nurse understands that this wound is not healing due to: Select all that apply
1. An inadequate blood supply in the tissue. 2. Repeated prolonged insults to the tissue. 3. Disruptive underlying pathologic processes. 4. Recent trauma. 5. Pneumonia.