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- What consideration should the nurse keep in mind regardingthe use of side rails for a confused patient?a. They prevent confused patients from wandering.b. A history of a previous fall from a bed with raised siderails is insignificant.c. Alternative measures are ineffective to prevent wandering.d. A person of small stature is at increased risk for injuryfrom entrapment.The student nurse is preparing to assess the pulses of a client during the bedside physical assessment. Which pulses are typically palpated? (Can only be one answer) A. Femoral B. Dorsalis pedis C. Carotid D. BrachialWhich putse should the nurse palpate during rapid assessment of an unconscious adult? O a. Carotid O b. Femoral O c. Radial O d. Brachial
- The nurse is preparing to assess a clients vital sign.Which vital sign should the nurse assess first. A.Temperature B.Pulse C.Respiration D.Blood PressureA nurse is caring for an immobile client. What is the priority assessment of this client? A. Palpate for edema B. Auscultation of lung sounds C. Auscultate for bowel sounds D. Inspect the skin for injuryThe nurse is preparing to assess a client's vital signs. Which vital sign should the nurse assess first? A. Temperature B. Pulse C. Respiration D. Blood Pressure Explain each answer why it is correct and not
- On assessment the nurse note that the fetus is developing fetal distress. Immediately the nurse place the mother to which best position to relieve compression of the vena cava and to promote venous return. A. Dorsal Recumbent position B. Turn mother to the left side and elevate the legs C. Turn the mother to the right side and flex the leg D. Supine positionA client admitted with shortness of breath and palpitations currently take a antiarrhythmic dronedarone, which action should the nurse take to prevent? A. Measure orthostatic blood pressure B. Obtain a 12 lead ECG reading daily C. Assess the client’s apical pulse daily D. Provide continuous ECG monitoringNitroglycerin patches have been ordered for a client with a history of angina. What teaching will the nurse give to this client?a. Keep the patches in the refrigerator.b. Use the patches only if the chest pain is severe.c. Remove the old patch before applying a new one.d. Apply the patch only to the upper arm or thigh areas.Why letter c is the right answer and why the other options are incorrect
- The nurse is caring for a preterm newborn with nasal flaring, grunting, and sternal retractions. After, administering surfactant, which assessment is the MOST important for the nurse to monitor? A. Arterial blood gases B. Breath sound C. Oxygen saturation D. Respiratory rateQuestion The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation? A. An obstruction is present in the chest tube. B. The client is developing subcutaneous emphysema. C. The chest tube system is functioning properly. D. There is a leak in the chest tube system.