The plan of care for a patient at risk for cardiac complications during the immediate postoperative period would include which of the following? Select all that apply
1. Monitoring the patient's heart rate continuously
2. Administering intravenous fluids as ordered
3. Assessing the patient's skin color and capillary refill frequently
4. Assessing the patient's peripheral pulses bilaterally
5. Evaluating for bowel sounds hourly
ANS: 1, 2, 3, 4
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A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority?
a. Educating the client on adherence to the treatment regimen b. Encouraging the client to eat a well-balanced diet c. Informing the client about follow-up sputum cultures d. Teaching the client ways to balance rest with activity
The nurse is planning to perform a breast examination of a female client. When preparing the client for the examination, the nurse will inform the client to expect which techniques? Select all that apply
1. Inspection. 2. Palpation. 3. Percussion. 4. Auscultation. 5. Client interview.
During insertion of a Foley catheter, the patient grimaces as the balloon is inflated. The nurse should:
a. withdraw the catheter. b. ask the patient to bear down. c. continue to inflate the balloon. d. advance the catheter into the bladder.
While conducting a complete bed bath for a male patient, the nurse inspects the scrotum for: (Select all that apply.)
A) Swelling B) Lumps C) Discharge D) Wrinkled skin E) Veins