Fund 5 Welcome to your Wounds 1. Drag and drop format: Fill in each blank with 1 risk factor and 1 finding. Select 2 The client is at risk for pressure injury due to [condition] and [finding], so the nurse should implement preventative measures. Condition: Immobility, Urinary leakage, Low protein intake Findings: Perineal moisture, Unchanged position >3 hrs, Sacral redness Condition: Urinary leakage Condition: Immobility Condition: Low protein intake Findings: Perineal moisture Findings: Unchanged position Findings: >3 hrs, Sacral redness 2. Which of the following best describes the wound stage? Scenario:A client with limited mobility due to a recent stroke is assessed during morning rounds. Vital Signs: BP 122/78, HR 88, Temp 98.9°F Physical Exam: Erythema on coccyx, skin intact, non-blanchable redness Labs: WNL Deselect Answer Partial-thickness skin loss with red tissue Intact skin with localized erythema Full-thickness loss with adipose tissue Full-thickness loss with exposed bone None 3. Which of the following increase the risk of pressure injuries? (Select all that apply) A nurse is completing a skin integrity assessment. Vitals: BP 128/84, HR 78, Temp 98.6°F Labs: Prealbumin 14 mg/dL, Glucose 106 Assessment: Weak lower extremities, reduced pain sensitivity, BMI 32 Peripheral sensation deficits Limited movement ability Low tissue perfusion BMI of 20 Prealbumin 14 mg/dL 4. A 70-year-old male, bedridden after a hip fracture, has redness over his sacrum that does not blanch when pressed. The nurse suspects a stage 1 pressure injury. What is the priority nursing action? Vital signs: Temperature: 98.9°F (37.2°C) Pulse: 75 beats per minute Respiration: 18 breaths per minute Blood pressure: 130/85 mmHg Physical assessment: Non-blanchable redness over the sacrum, intact skin, with warmth compared to surrounding tissue. The patient reports mild discomfort. Deselect Answer Reposition the patient off the sacral area immediately Apply a moisture barrier cream to the affected area Document the findings and reassess in 4 hours Notify the healthcare provider None 5. A 65-year-old female patient with advanced Alzheimer's disease has a blister on her right heel that has ruptured, exposing partial-thickness skin loss. The nurse suspects a stage 2 pressure injury. What is the priority intervention? Vital signs: Temperature: 99.0°F (37.2°C) Pulse: 80 beats per minute Respiration: 16 breaths per minute Blood pressure: 128/78 mmHg Physical assessment: A shallow open ulcer with partial-thickness skin loss on the right heel, surrounding skin intact with no signs of infection. The patient is non-verbal and does not express discomfort. Deselect Answer Clean the wound with normal saline and apply a moisture-retentive dressing Notify the wound care specialist for further evaluation Elevate the patient’s heel off the bed to relieve pressure Administer prescribed pain medication None 6. A 72-year-old male patient recovering from abdominal surgery has a surgical wound with serosanguineous drainage. During a dressing change, the nurse notices that the wound edges are starting to separate (dehiscence). What is the priority nursing action based on safety and risk reduction? Vital signs: Temperature: 98.7°F (37.1°C) Pulse: 90 beats per minute Respiration: 18 breaths per minute Blood pressure: 125/80 mmHg Physical assessment: Abdominal wound with separating edges and light serosanguineous drainage. No signs of infection present. Deselect Answer Apply a sterile saline-moistened dressing over the wound Notify the healthcare provider immediately Instruct the patient to limit movement and stay in bed Assess the wound for signs of infection and monitor drainage None 7. A 55-year-old female post-op patient reports feeling that "something has given way" while coughing. The nurse assesses the wound and finds complete evisceration of the abdominal contents. What is the nurse's priority action? Vital signs: Temperature: 98.6°F (37°C) Pulse: 110 beats per minute Respiration: 24 breaths per minute Blood pressure: 100/58 mmHg Physical assessment: The abdominal wound is completely open with visible evisceration of internal organs. The patient is anxious and reports significant discomfort. Deselect Answer Cover the evisceration with sterile saline-moistened towels Notify the healthcare provider immediately Position the patient in a low Fowler's position Prepare the patient for emergency surgery None 8. A 75-year-old female, who is bedridden due to a stroke, presents with redness over her sacral area. The nurse notices that the redness does not blanch when pressed. What is the priority action for the nurse? Vital signs: Temperature: 98.7°F (37.1°C) Pulse: 80 beats per minute Respiration: 16 breaths per minute Blood pressure: 130/85 mmHg Physical assessment: Non-blanchable erythema on the sacral area, with intact skin. No drainage or odor present. The patient reports mild discomfort. Deselect Answer Apply a moisture barrier cream to the sacral area Reposition the patient every 2 hours Notify the healthcare provider Massage the area to increase circulation None 9. QuestionA 68-year-old male with a history of immobility due to spinal cord injury is assessed for pressure injuries. The nurse observes a stage 2 pressure injury on his right heel, with partial-thickness skin loss and a shallow open ulcer. Which of the following is the nurse's priority intervention? Vital signs: Temperature: 98.2°F (36.8°C) Pulse: 72 beats per minute Respiration: 18 breaths per minute Blood pressure: 122/80 mmHg Physical assessment: A shallow ulcer with partial-thickness skin loss on the right heel, surrounded by intact skin. No signs of infection or drainage. Deselect Answer Apply a transparent dressing to the ulcer Elevate the patient's heels off the bed Administer prescribed antibiotics Increase the patient's protein intake None 10. A 60-year-old female patient with dementia is admitted for malnutrition and has developed a stage 3 pressure injury on her sacrum. The wound presents with full-thickness skin loss and visible subcutaneous tissue. What is the priority nursing intervention for this patient? Vital signs: Temperature: 99.1°F (37.3°C) Pulse: 85 beats per minute Respiration: 20 breaths per minute Blood pressure: 110/70 mmHg Physical assessment: A stage 3 pressure injury on the sacrum, with full-thickness skin loss and exposed subcutaneous tissue. Moderate drainage noted, but no signs of infection. Deselect Answer Perform a wound culture and start broad-spectrum antibiotics Debride necrotic tissue and apply an appropriate wound dressing Administer IV fluids to support hydration and healing Reposition the patient frequently and offload pressure from the sacral area None 11. A 78-year-old female who is bedridden due to advanced dementia has been admitted to the hospital with malnutrition and dehydration. The nurse notices redness over her heels that does not blanch when pressed. Which intervention should be the priority to prevent further skin breakdown? Vital signs: Temperature: 98.4°F (36.9°C) Pulse: 72 beats per minute Respiration: 18 breaths per minute Blood pressure: 120/76 mmHg Physical assessment: Redness over heels that is non-blanchable. The patient is malnourished and dehydrated. No drainage or skin breakdown present yet. Deselect Answer Reposition the patient every 2 hours Apply a heel protector to offload pressure from the heels Increase the patient's caloric intake Massage the heels to improve circulation None 12. A 65-year-old male post-stroke patient is admitted to the hospital with left-sided paralysis. He is unable to reposition himself independently. During the skin assessment, the nurse finds a stage 1 pressure injury on his sacrum. What is the priority intervention for this patient? Vital signs: Temperature: 98.6°F (37°C) Pulse: 80 beats per minute Respiration: 18 breaths per minute Blood pressure: 135/82 mmHg Physical assessment: Stage 1 pressure injury on the sacrum with intact skin and non-blanchable redness. The patient has limited mobility and is unable to turn himself. Deselect Answer Increase the patient’s protein intake to promote healing Reposition the patient every 2 hours to relieve pressure Apply a foam dressing to protect the sacral area Administer pain medication to improve comfort None 13. A 64-year-old female patient with a large pressure injury on her sacrum is receiving wound care. The wound is in the proliferative phase of healing, with healthy granulation tissue present. The patient expresses frustration about her limited ability to perform activities of daily living (ADLs). What is the priority nursing intervention? Vital signs: Temperature: 98.2°F (36.8°C) Pulse: 82 beats per minute Respiration: 18 breaths per minute Blood pressure: 135/85 mmHg Physical assessment: Sacral wound with healthy granulation tissue, serous drainage present, and the patient is experiencing reduced mobility and frustration about her ADLs. Deselect Answer Collaborate with occupational therapy to promote independence in ADLs Reassure the patient that her healing process is progressing well Apply a moist dressing to the wound to promote healing Educate the patient on how to prevent further pressure injuries None 14. A 62-year-old male patient is recovering from surgery and has a surgical wound on his abdomen with moderate serosanguineous drainage. The nurse notes that the dressing is moist but not saturated. The patient expresses concern about seeing his wound for the first time during the dressing change. Based on Maslow’s Hierarchy of Needs and the nursing process, what is the priority nursing intervention? Physical assessment: Age: 62 years Serosanguineous drainage on the dressing, moderate amount, wound edges approximated, no signs of infection. Deselect Answer Reassure the patient about the wound’s healing progress and encourage participation in the dressing change. Reinforce the dressing to prevent contamination from the drainage. Educate the patient on the importance of a moist wound environment for healing. Consult a wound care specialist to assist with the dressing change. None 15. A 68-year-old male patient with diabetes is recovering from an abdominal surgery. The nurse is preparing to remove his surgical dressing, which is adhered to the skin. The patient expresses concern about pain during the dressing change. Based on Maslow’s Hierarchy of Needs and the nursing process, what is the priority intervention? Vital signs: Temperature: 98.6°F (37°C) Pulse: 80 beats per minute Respiration: 18 breaths per minute Blood pressure: 130/85 mmHg Physical assessment: Surgical incision with dry edges, dressing adhered to the skin, no signs of infection or drainage. The patient reports mild discomfort with movement. Deselect Answer Gently remove the dressing in the direction of hair growth using the push-pull method Use a pain medication before starting the dressing change Moisten the dressing with saline to make removal easier Explain the procedure to reduce the patient’s anxiety None 16. A 65-year-old male patient with a non-healing pressure injury is being considered for negative pressure wound therapy (NPWT) after other treatments have failed. Based on the nursing process and safety and risk reduction, what is the priority nursing action before initiating NPWT? Vital signs: Temperature: 98.6°F (37°C) Pulse: 76 beats per minute Respiration: 18 breaths per minute Blood pressure: 132/78 mmHg Physical assessment: Stage 4 pressure injury with minimal drainage, no signs of infection, exposed tendons and bone. Deselect Answer Assess the patient for any active bleeding in the wound area Educate the patient on how NPWT works to promote healing Ensure the patient’s nutritional status is adequate to support wound healing Verify that the patient’s wound is free of necrotic tissue None 17. A 70-year-old male patient with chronic lower back pain is prescribed local heat therapy to relieve muscle tension and promote relaxation. Based on Maslow’s Hierarchy of Needs and the nursing process, what is the priority nursing assessment before applying the heat therapy? Vital signs: Temperature: 98.7°F (37.1°C) Pulse: 75 beats per minute Respiration: 16 breaths per minute Blood pressure: 132/78 mmHg Physical assessment: Chronic lower back pain, no open wounds, no signs of infection or inflammation in the area. Patient reports pain level 5/10. Deselect Answer Assess the patient’s skin for signs of redness or injury before applying heat Evaluate the patient’s understanding of how to use heat therapy at home Determine how long the patient has experienced chronic pain Ask the patient to rate their pain before applying the heat therapy None 18. A 55-year-old male with a history of diabetes mellitus is admitted with a stage 2 pressure injury on his sacrum. As part of his care, you are engaging in reflective practice to improve wound care management and evaluating the effectiveness of the plan of care. Based on Maslow's Hierarchy of Needs and the nursing process, what is the priority action in reflecting on and improving your wound care practices? Vital signs: Temperature: 98.6°F (37°C) Pulse: 78 beats per minute Respiration: 18 breaths per minute Blood pressure: 128/80 mmHg Physical assessment: Sacral pressure injury with partial-thickness skin loss, no infection present, wound bed moist and pink, minimal serous drainage. Blood glucose: 180 mg/dL (elevated) Patient reports pain level: 3/10 Question: What is the priority reflective question to ask yourself as you evaluate your wound care practices for this patient? Deselect Answer Did I provide patient-centered care that empowers the patient and their family in the wound care process? How can I better manage the patient’s blood glucose to promote wound healing in the future? Did I follow all hospital policies and procedures related to pressure injury prevention? How can I ensure I am keeping up with the latest wound care evidence-based practices? None 19. A 72-year-old female patient with a stage 2 pressure injury on her sacrum is due for a dressing change. The nurse observes that the dressing is saturated with serous drainage. What is the priority nursing intervention? Vital signs: Temperature: 98.9°F (37.2°C) Pulse: 76 beats per minute Respiration: 16 breaths per minute Blood pressure: 125/80 mmHg Physical assessment: Stage 2 pressure injury with moderate serous drainage, surrounding skin is intact, and there is no sign of infection. Deselect Answer Replace the saturated dressing with a fresh one Cleanse the wound with sterile normal saline Apply a skin protectant to the intact skin surrounding the wound Notify the healthcare provider about the drainage None Comment 20. A patient is using a reusable external urine collection device to manage chronic urinary incontinence. The nurse notices that the patient is developing erythema and irritation around the genital area. What should the nurse prioritize to prevent further skin damage? Deselect Answer Discontinue the use of the external urine collection device and switch to absorbent briefs. Apply a skin barrier cream to the affected area before reapplying the device. Reduce the patient’s fluid intake to decrease the frequency of incontinence episodes. Use soap and water to clean the irritated area after each episode of incontinence. None 21. A nurse is caring for an older male patient with urinary incontinence and frequent skin breakdown. The healthcare provider orders the use of an external urine collection device to manage the patient's incontinence. What action should the nurse prioritize to prevent complications related to skin integrity? Deselect Answer Secure the external urine collection device tightly to prevent leakage. Ensure the skin is dry and intact before applying the device. Change the device every 12 hours to prevent skin irritation. Increase the patient’s fluid intake to reduce the risk of infection. None 22. A nurse is caring for a male patient with urinary incontinence who has been prescribed a single-use disposable external urine collection device. The patient reports mild skin irritation in the pubic area. What should the nurse prioritize to prevent further skin breakdown? Deselect Answer Switch to a larger external collection device to cover more surface area. Apply a skin barrier protectant before reapplying the collection device. Discontinue the use of the external device and use absorbent briefs instead. Reduce the patient’s fluid intake to prevent further episodes of incontinence. None 23. A 75-year-old female patient with urinary incontinence is prescribed an external urine collection device. The nurse notices that the device has been leaking, and the patient’s skin around the genital area is red and irritated. What should the nurse prioritize to prevent further skin damage? Deselect Answer Discontinue the use of the external urine collection device. Apply a skin barrier cream to protect the irritated area before reapplying the device. Switch to an indwelling catheter to prevent leakage. Reduce the patient’s fluid intake to prevent further leakage. None 24. A nurse is managing four patients with bowel incontinence. Which patient should be prioritized for skin care interventions? Deselect Answer A 65-year-old patient with incontinence who has erythema and mild maceration in the perianal area. A 55-year-old patient with intact skin who uses an external anal pouch for loose stool management. A 70-year-old patient with bowel incontinence and reports of intermittent itching but no visible skin breakdown. A 50-year-old patient with mild incontinence who reports occasional episodes of soiling but has no skin issues. None Time's up Welcome to your Nutrition A nurse is administering a liquid oral medication to a client via an enteral feeding tube. The client suddenly coughs and exhibits signs of respiratory distress. What is the nurse’s priority action? Deselect Answer Continue administering the medication more slowly. Check the placement of the feeding tube. Suction the client’s airway immediately. Notify the healthcare provider. None A nurse is administering medications through a gastric (G-tube) feeding tube. Which of the following actions should the nurse take? (Select all that apply.) Administer each medication separately. Flush the tube with 15–30 mL of water before and after each medication. Use enteric-coated tablets when possible to prevent stomach irritation. Crush sustained-release medications to ensure full absorption. Stop the feeding and leave the tube clamped for 30 minutes after administration if the medication should be given on an empty stomach. click here to see the answers. A nurse is assisting a client with dysphagia during meals. Which interventions should the nurse implement to promote safe swallowing? (Select all that apply.) Deselect Answer Provide thickened liquids instead of thin liquids. Encourage the client to chew food slowly and thoroughly. Offer foods that require minimal chewing, such as mashed potatoes. Allow the client to drink liquids through a straw for easier intake. Observe for pocketing of food in the client’s cheeks after each bite. Click here for the right answer None Which of the following is a key function of dietary fats? A nurse is reviewing dietary education with a client newly diagnosed with fat-soluble vitamin deficiency. Labs: Vitamin D 18 ng/mL, Albumin 3.3 g/dL Vitals: WNL Assessment: Client states, “I’ve been avoiding all fat because I thought it was unhealthy.” Deselect Answer Enhances absorption of certain vitamins Repairs muscle damage Sends electrical signals in nerve Breaks down into glucose for fast energy None A nurse is preparing a presentation about basic nutrients for a group of high school athletes. The nurse should include that which of the following provides the body with the most energy? Deselect Answer Fat Protein Glycogen Carbohydrates None A 60-year-old male with uncontrolled type 2 diabetes mellitus presents with extreme fatigue, polyuria, and blurred vision. His vital signs are BP 90/60 mmHg, HR 120 bpm, RR 26/min, and SpO₂ 96%. Laboratory results reveal a blood glucose level of 650 mg/dL, serum sodium of 130 mEq/L, and serum potassium of 3.2 mEq/L. The client suddenly begins to have a seizure. Which of the following interventions should the nurse perform first? Deselect Answer Administer IV insulin as prescribed Protect the client from injury during the seizure Administer IV potassium chloride as prescribed Recheck the client’s blood glucose level immediately None A 10-year-old female with type 1 diabetes mellitus is brought to the emergency department after being found unresponsive. Her vital signs are BP 100/60 mmHg, HR 120 bpm, RR 20/min, and SpO₂ 99%. The blood glucose level is 38 mg/dL. During the nurse’s assessment, the client begins to have a seizure. What is the nurse’s priority action? Deselect Answer Administer an IV bolus of 50% dextrose as prescribed Place the client in the Trendelenburg position Administer IM glucagon as prescribed Ensure the client’s airway is patent and side-lying position is maintained None A nurse is caring for a client who weighs 80 kg (176 lb) and is 1.6 m (5 ft 3 in) tall. Calculate the body mass index (BMI) and determine whether this client’s BMI indicates a healthy weight, underweight, overweight, or obese. A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the client’s meal tray? Deselect Answer Cooked barley Pureed broccoli Vanilla custard Lentil soup None Which of the following actions should the nurse perform when giving this insulin? A nurse is preparing a morning insulin dose. Medication: NPH insulin 20 units subQ Vitals: Glucose 122, BP 118/70 Assessment: No signs of hypoglycemia, patient alert and oriented Deselect Answer Gently roll the insulin vial between palms Inject into deltoid muscle Aspirate before giving the shot Administer within 1 inch of umbilicus None The nurse is preparing to insert an NG tube on a client for stomach decompression. When determining the length of the tube to be inserted, what anatomical locations should the nurse use for measurement? (Select all that apply.) Tip of nose Abdomen Clavicle Earlobe Xiphoid process click here to see the answer. A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following responses should the nurse make? Deselect Answer “Water helps clear the tube so it doesn’t get clogged.” “Flushing helps make sure the tube stays in place.” “This will help you get enough fluids.” “Adding water makes the formula less concentrated.” None Match each age group with the correct nutritional need (High-Protein Needs, Increased Calcium Needs, or Decreased Caloric Needs). Clinical Scenario: The nurse is reviewing the nutritional needs of different age groups to provide education to patients and their families. The nurse is assessing three different patients in a clinical setting: 1️⃣ A 2-week-old newborn brought in for a well-baby checkup. The mother is concerned about the baby’s feeding habits.2️⃣ A 15-year-old adolescent being evaluated for sports participation who has recently become a vegetarian.3️⃣ A 78-year-old older adult with osteoporosis and unintentional weight loss over the last 6 months. The nurse assesses each patient's dietary intake, growth patterns, and laboratory values to provide appropriate nutritional recommendations. Laboratory Results: Lab Test Newborn Adolescent Older Adult Serum Albumin 3.8 g/dL (Normal) 4.1 g/dL (Normal) 3.2 g/dL (↓) Serum Calcium 9.8 mg/dL (Normal) 9.1 mg/dL (Normal) 8.2 mg/dL (↓) Total Protein 6.0 g/dL (Normal) 6.8 g/dL (Normal) 5.5 g/dL (↓) Vitamin D 35 ng/mL (Normal) 30 ng/mL (Normal) 18 ng/mL (↓) Physical Assessment Findings: Newborn: Normal weight gain, breastfeeding well, no abnormalities. Adolescent: Increased physical activity, mild fatigue, and new vegetarian diet. Older Adult: Osteopenia, mild muscle wasting, and reports of poor appetite. Lab Test New born Adolescent Older adult Serum Albumin 3.8 g/dL (Normal) 4.1 g/dL (Normal) 3.2 g/dL (↓) Serum Calcium 9.8 mg/dL (Normal) 9.1 mg/dL (Normal) 8.2 mg/dL (↓) Total Protein 6.0 g/dL (Normal) 6.8 g/dL (Normal) 5.5 g/dL (↓) Vitamin D 35 ng/mL (Normal) 30 ng/mL (Normal) 18 ng/mL (↓) Age group High Protein Needs Increase Calcium Needs Decreased Caloric Needs Newborn and Infants Adolescents Older Adults Newborns and Infants - High-Protein Needs Newborns and Infants - Increased Calcium Needs Newborns and Infants - Decreased Caloric Needs Adolescents - High-Protein Needs Adolescents - Increased Calcium Needs Adolescents - Decreased Caloric Needs Older Adults - High-Protein Needs Older Adults - Increased Calcium Needs Older Adults - Decreased Caloric Needs A nurse is preparing to instill an enteral feeding for a client who has an NG tube in place. Which of the following actions is the nurse’s highest assessment priority before performing this procedure? Deselect Answer Check how long the feeding container has been open. Verify the placement of the NG tube. Confirm that the client does not have diarrhea. Make sure the client is alert and oriented. None A nurse is preparing to administer a crushed oral medication through a client’s nasogastric (NG) tube. Which action should the nurse take first? Deselect Answer Mix the crushed medication with the client’s enteral feeding formula. Verify the placement of the NG tube. Flush the tube with 60 mL of sterile water before administering the medication. Clamp the NG tube for 30 minutes after medication administration. None Verify the client’s last meal and document the fasting status. "I will be asked to take deep breaths and cough after surgery to prevent complications." "I should stop eating or drinking at midnight before my surgery." "I will be able to drive myself home after my procedure." "The nurse will remove my hearing aids before I go into surgery." "I should notify the nurse if I have an allergy to latex or medications." A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take? Deselect Answer Giving the client thin liquids Instructing the client to tuck their chin when swallowing Having the client use a straw Encouraging the client to lie down and rest after meals None A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? (Select all that apply.) Auscultate bowel sounds. Assist the client to an upright position. Test the pH of gastric aspirate. Warm the formula to body temperature. Discard any residual gastric contents. Click here to see the right answer. A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform before beginning the procedure? (Select all that apply.) Review a signal the client can use if feeling any distress. Lay a towel across the client’s chest. Administer oral pain medication. Obtain a Dobhoff tube for insertion. Have a petroleum-based lubricant available. click here for the right answer Which information is essential for calculating this client’s BMI? A client is undergoing a nutrition screening. Height: 5’7” Weight: 190 lbs Vitals: BP 132/88, HR 76 Assessment: Sedentary lifestyle, BMI not yet calculated Deselect Answer Abdominal circumference Skinfold measurements Client’s height 24-hour dietary intake None Carbohydrates provide ____ of energy per gram. Proteins contribute ____ of energy per gram. Proteins help in the growth, maintenance, and repair of body tissues. Sources include ____. A nurse in a senior center is counseling a group of older adults about their nutritional needs. Which of the following information should the nurse include? (Select all that apply.) Older adults are more prone to dehydration than younger adults. The recommended intake of daily fiber decreases in older adults. Many older adults need calcium supplementation. Older adults need more calories than they did when they were younger. Older adults should consume a diet low in carbohydrates. Click here to see the right answer. A nurse is assessing a client who is at high risk for aspiration. Which of the following actions should the nurse take? (Select 2.) Giving the client thin liquids Instructing the client to tuck their chin when swallowing Having the client use a straw Encouraging the client to lie down and rest after meals Click here to see the right answer. A 70-year-old male with a history of heart failure and diabetes presents with lethargy and muscle weakness. His vital signs are BP 132/76 mmHg, HR 48 bpm, RR 20/min, and SpO₂ 96%. His potassium level is 6.8 mEq/L. Which of the following interventions should the nurse implement immediately? Select all that apply. Administer IV calcium gluconate Administer IV insulin and dextrose Monitor the client’s ECG for changes Administer oral potassium supplements Encourage potassium-rich foods such as bananas and oranges A 50-year-old woman who has been receiving total parenteral nutrition (TPN) for several weeks due to bowel surgery is at risk for hypokalemia. Her current vital signs are BP 110/70 mmHg, HR 102 bpm, RR 16/min, and SpO₂ 97%. Her laboratory findings show a serum potassium level of 3.0 mEq/L. What additional findings should the nurse assess for? Select all that apply. Shallow respirations Constipation Hyperglycemia Polyuria Hyperactive deep tendon reflexes A 60-year-old female recovering from surgery is receiving an IV infusion of D5W. She is now reporting confusion, fatigue, and muscle weakness. Her vital signs are BP 110/65 mmHg, HR 90 bpm, RR 18/min, and SpO₂ 97%. Her serum sodium level is 122 mEq/L. Based on these findings, which of the following nursing interventions is appropriate? Select all that apply. Discontinue the D5W infusion Administer hypertonic saline solution Implement seizure precautions Encourage oral intake of fluids Monitor neurologic status closely A 52-year-old female with a history of alcoholism presents with muscle tremors and confusion. Her vital signs are BP 120/75 mmHg, HR 105 bpm, RR 18/min, and SpO₂ 97%. Laboratory results show a serum magnesium level of 1.0 mEq/L. Based on these findings, which of the following additional physical assessment findings should the nurse expect? Select all that apply. Positive Chvostek’s sign Muscle cramps Tetany Prolonged PR interval on ECG Hyperactive deep tendon reflexes A 65-year-old male receiving TPN for severe malnutrition has been on the therapy for 5 days. His vital signs are BP 130/85 mmHg, HR 90 bpm, RR 18/min, and SpO₂ 98%. Laboratory results show a blood glucose level of 250 mg/dL, serum sodium of 140 mEq/L, and potassium of 4.0 mEq/L. During assessment, the nurse notes that the client has increased thirst, dry mucous membranes, and frequent urination. What complication is the client most likely experiencing? Deselect Answer Hyperglycemia Fluid overload Hypokalemia Hyperkalemia None A 58-year-old female who recently had bowel surgery is receiving TPN through a central venous catheter. Her vital signs are BP 120/75 mmHg, HR 85 bpm, RR 18/min, and SpO₂ 97%. The nurse performs a central line dressing change and prepares to hang a new bag of TPN. Which of the following actions should the nurse take to prevent infection? Select all that apply. Use sterile technique during the dressing change Change the TPN tubing every 24 hours Wear clean gloves when handling the TPN bag Ensure the TPN solution is at room temperature before administration Monitor the client for signs of infection, such as fever or redness at the insertion site Click here to see the answers. A 45-year-old male with Crohn’s disease is receiving lipid emulsion therapy in addition to TPN. His vital signs are BP 125/80 mmHg, HR 88 bpm, RR 20/min, and SpO₂ 99%. The nurse notes that the infusion is running at the correct rate, but the client complains of a slight headache and discomfort at the IV site. Which of the following should the nurse do next? Deselect Answer Slow the infusion rate Stop the infusion and notify the provider Assess for allergic reaction signs, such as rash or dyspnea Check the IV site for signs of infiltration or phlebitis None A 45-year-old male with Crohn’s disease is receiving lipid emulsion therapy in addition to TPN. His vital signs are BP 125/80 mmHg, HR 88 bpm, RR 20/min, and SpO₂ 99%. The nurse notes that the infusion is running at the correct rate, but the client complains of a slight headache and discomfort at the IV site. Which of the following should the nurse do next? Deselect Answer Slow the infusion rate Stop the infusion and notify the provider Assess for allergic reaction signs, such as rash or dyspnea Check the IV site for signs of infiltration or phlebitis None A nurse in a senior center is counseling a group of older adults about their nutritional needs. Which of the following information should the nurse include? (Select all that apply.) Older adults are more prone to dehydration than younger adults. The recommended intake of daily fiber decreases in older adults. Many older adults need calcium supplementation. Older adults need more calories than they did when they were younger. Older adults should consume a diet low in carbohydrates. Click here to see the right answer. Fats provide ____ of energy per gram. Match each nutrient with the correct primary function (Energy or Tissue Repair & Maintenance). A <strong data-start="145" data-end="160">33-year-old</strong> patient is admitted with <strong data-start="186" data-end="232">malnutrition and unintentional weight loss</strong> over the past three months. The patient has a history of <strong data-start="290" data-end="334">Crohn’s disease and chronic pancreatitis</strong>, leading to <strong data-start="347" data-end="371">malabsorption issues</strong>. The nurse assesses the patient’s dietary intake, nutritional status, and <strong data-start="446" data-end="467">laboratory values</strong> to determine appropriate interventions.<br /><br /> <table> <tbody> <tr> <td width="156"> <p>Lab Test</p> </td> <td width="156"> <p>Value Range</p> </td> <td width="156"> <p>Range</p> </td> <td width="156"> <p>Interpretation</p> </td> </tr> <tr> <td width="156"> <p>Serum Albumin</p> </td> <td width="156"> <p>2.8 g/dL</p> </td> <td width="156"> <p>3.5 - 5.0 g/dL</p> </td> <td width="156"> <p>↓ (Malnutrition)</p> </td> </tr> <tr> <td width="156"> <p>Total Protein</p> </td> <td width="156"> <p>5.4 g/dL</p> </td> <td width="156"> <p>6.4 - 8.3 g/dL</p> </td> <td width="156"> <p>↓ (Protein Deficiency)</p> </td> </tr> <tr> <td width="156"> <p>Serum Glucose</p> </td> <td width="156"> <p>65 mg/dL</p> </td> <td width="156"> <p>70 - 110 mg/dL</p> </td> <td width="156"> <p>↓ (Low Energy Reserves)</p> </td> </tr> <tr> <td width="156"> <p>Serum Lipase</p> </td> <td width="156"> <p>98 U/L</p> </td> <td width="156"> <p>10 - 140 U/L</p> </td> <td width="156"> <p>Normal</p> </td> </tr> <tr> <td width="156"> <p>Vitamin B12</p> </td> <td width="156"> <p>200 pg/mL</p> </td> <td width="156"> <p>200 - 900 pg/mL</p> </td> <td width="156"> <p>↓ (Deficiency, Likely Malabsorption)</p> </td> </tr> <tr> <td width="156"> <p>Iron</p> </td> <td width="156"> <p>40 mcg/dL</p> </td> <td width="156"> <p>50 - 150 mcg/dL</p> </td> <td width="156"> <p>↓ (Possible Anemia)</p> </td> </tr> </tbody> </table> <br /> <h3 data-start="1125" data-end="1164"><strong data-start="1129" data-end="1162">Physical Assessment Findings:</strong></h3> <ul data-start="1165" data-end="1434"> <li data-start="1165" data-end="1220"><strong data-start="1167" data-end="1193">Body Mass Index (BMI):</strong> 17.2 kg/m² (Underweight)</li> <li data-start="1221" data-end="1273"><strong data-start="1223" data-end="1242">Muscle Wasting:</strong> Present in upper extremities</li> <li data-start="1274" data-end="1329"><strong data-start="1276" data-end="1295">Skin Integrity:</strong> Delayed wound healing, dry skin</li> <li data-start="1330" data-end="1372"><strong data-start="1332" data-end="1349">Energy Level:</strong> Fatigue and weakness</li> <li data-start="1373" data-end="1434"><strong data-start="1375" data-end="1405">Gastrointestinal Symptoms:</strong> Mild diarrhea and bloating</li> </ul> <br /> <p> </p> <table> <tbody> <tr> <td width="208"> <p>Nutrition </p> </td> <td width="208"> <p>Energy</p> </td> <td width="208"> <p>Tissue Repair & Maintenance</p> </td> </tr> <tr> <td width="208"> <p>Carbohydrates</p> </td> <td width="208"> <p> </p> </td> <td width="208"> <p> </p> </td> </tr> <tr> <td width="208"> <p>Fats</p> </td> <td width="208"> <p> </p> </td> <td width="208"> <p> </p> </td> </tr> <tr> <td width="208"> <p>Proteins</p> </td> <td width="208"> <p> </p> </td> <td width="208"> <p> </p> </td> </tr> <tr> <td width="208"> <p>Vitamins</p> </td> <td width="208"> <p> </p> </td> <td width="208"> <p> </p> </td> </tr> </tbody> </table> Carbohydrates - Energy Carbohydrates - Tissue Repair and Maintenance Fats - Energy Fats - Tissue Repair and Maintenance Proteins - Tissue Repair and Maintenance Proteins - Tissue Repair and Maintenance Vitamins - Energy Vitamins - Tissue Repair and Maintenance Click here to see the right answers. A 70-year-old female receiving TPN for nutritional support following bowel obstruction surgery has been on TPN for 7 days. Her vital signs are BP 118/76 mmHg, HR 82 bpm, RR 18/min, and SpO₂ 96%. Laboratory results reveal a serum magnesium of 1.0 mEq/L, potassium of 3.0 mEq/L, and serum calcium of 8.5 mg/dL. Which of the following interventions should the nurse anticipate based on these lab results? Select all that apply. Administer a potassium su Administer a magnesium supplement Reduce the rate of TPN infusion Monitor the client for signs of muscle weakness or cramps Encourage oral calcium supplements What is the correct method to transfer blood onto the reagent strip? Deselect Answer Smear the blood onto the strip. Squeeze the blood onto the strip. Touch the puncture site to stimulate bleeding. Hold the test strip next to the blood on the fingertip. None Which of the following items are required for blood glucose testing? Sterile gloves Antiseptic cleaner Reagent strips Reusable lancet Cotton balls Why is blood glucose testing preferred over urine glucose testing for monitoring blood glucose levels? Deselect Answer Blood glucose testing is faster. Urine glucose testing is inaccurate unless glucose levels exceed 220 mg/dL. Blood glucose testing is less painful. Urine glucose testing requires special equipment. None Which of the following instructions should the nurse provide? A nurse is counseling a client with new-onset hypertension. Vitals: BP 148/92 Labs: Sodium 141 mEq/L Assessment: Client states, “I eat a lot of fast food and canned soups.” Deselect Answer Check nutrition labels before purchasing foods Substitute processed meats for lean protein Use commercial salad dressings sparingly Limit canned soup to 2 bowls per day None Which healthcare team member should the nurse contact? A client recovering from a stroke reports trouble swallowing during breakfast. Assessment: Coughing after sips of water, voice hoarseness Vitals: Temp 99.5°F, O2 sat 95% Diet: Regular solids and thin liquids Deselect Answer Dentist Physical therapist Speech-language pathologist Respiratory therapist None Time's up Welcome to your Surgical Client 1. The nurse should recognize that this client is at risk for developing a pressure injury primarily due to which of the following factors? Scenario:A 78-year-old client admitted for pneumonia has been immobile in bed for 48 hours. Current findings: Vital Signs: BP 110/72, HR 96, Temp 99.4°F Labs: Albumin 2.7 g/dL, Prealbumin 13 mg/dL Physical Assessment: sacral redness, reduced calf tone, skin warm and dry Deselect Answer Decreased circulation Increased collagen Increased muscle mass Decreased serum calcium None 2. A nurse is assessing a postoperative client with a surgical wound. Which finding places the client at the greatest risk for delayed wound healing? Deselect Answer Hemoglobin level of 8.5 g/dL Blood glucose level of 140 mg/dL Albumin level of 3.5 g/dL White blood cell (WBC) count of 8,000/mm³ None 3. Which of the following findings indicates potential lidocaine toxicity? A nurse monitors a client receiving local lidocaine for laceration repair. Vitals 15 min post-injection: HR 114, RR 26 Assessment: Tinnitus, numbness around lips, lightheadedness Deselect Answer Diarrhea Fever of 100.4°F Tingling or numbness around the mouth Elevated systolic pressure None 4. A nurse is caring for a client with a newly placed colostomy. The client states, "I don’t think I can take care of this on my own." Which response by the nurse is most appropriate? Deselect Answer "It’s normal to feel that way at first. Let’s practice together so you feel more comfortable." "You will get used to it quickly, and it won’t be as hard as you think." "Your provider will give you instructions when you go home." "Don’t worry, home health nurses will take care of it for you." None 5. What action should the nurse take? A client with abdominal surgery has a Penrose drain in place. Assessment: Thin serosanguinous drainage noted Physical Exam: Periwound skin intact, no erythema Vitals: Temp 98.7°F, HR 84 Deselect Answer Clean from outside to inside Place perforated gauze around the drain Connect to low-pressure suction Empty drainage when half full None 6. What action should the nurse take? A client with abdominal surgery has a Penrose drain in place. Assessment: Thin serosanguinous drainage noted Physical Exam: Periwound skin intact, no erythema Vitals: Temp 98.7°F, HR 84 Deselect Answer Clean from outside to inside Place perforated gauze around the drain Connect to low-pressure suction Empty drainage when half full None 7. A nurse is preparing a client for surgery. Which action should the nurse take first before sending the client to the operating room (OR)? Deselect Answer Ensure the client has signed the informed consent form. Administer preoperative sedative medication as prescribed. Remove the client's dentures and jewelry. Verify the client’s last meal and document the fasting status. None 8. Which action is appropriate? A nurse is irrigating a post-op abdominal wound. Vitals: BP 118/76, Temp 99.1°F Wound: 3 cm dehisced site, no foul odor, no tunneling Orders: Irrigate BID with NS Deselect Answer Hold tip 0.5 in above wound Irrigate from most contaminated area Irrigate until solution is clear Use chilled irrigant None 9. Which finding confirms healing by primary intention? A client with a surgical incision is being assessed on POD 3. Wound: Incision line approximated, no drainage Vitals: Temp 98.6°F, HR 72 Labs: WBC 7.1, Glucose 92 Deselect Answer Granulation tissue in wound bed Skin edges sutured closed Prolonged wound healing Wound contaminated at time of injury None 10. Which of the following actions should the nurse take to minimize the client's risk for skin breakdown? A 76-year-old client is recovering from hip surgery. They remain in bed most of the day. Vital Signs: BP 124/82, HR 86, Temp 98.8°F Labs: Albumin 2.8 g/dL Assessment: Braden score of 15, dry skin, diminished appetite Deselect Answer Encourage a high-calorie, nutrient-dense diet Reposition the client every 4 hours Massage bony areas to increase circulation Elevate the head of the bed to 45 degrees at all times None 11. A nurse is preparing a sterile field for a dressing change. Which action by the nurse breaks sterility and requires the setup to be restarted? Deselect Answer Holding sterile objects above waist level Turning away from the sterile field momentarily Keeping sterile items within the 1-inch border of the sterile drape Placing sterile gloves on before touching sterile supplies None 12. Which of the following signs is most consistent with sepsis? A 55-year-old patient developed pneumonia after surgery. Upon assessment the following was found: Vital Signs: BP 86/58, HR 112, Temp 101.8°F, RR 24 Labs: WBC 16,000/mm³, Lactate 3.2 mmol/L Assessment: Disoriented, shivering, minimal urine output Deselect Answer Change in mental status High blood sugar Elevated blood pressure Diarrhea None 13. Which finding supports the nurse’s suspicion of complication of post surgery of not taking in enough fluids? A nurse is assessing an elderly client admitted to the floor after surgery, 2 days later with dizziness and fatigue. Vitals: BP 94/60, HR 108, Temp 99.3°F Labs: Na+ 150, BUN 25 Assessment: Skin turgor slow to return, dry mucous membranes, dark urine Deselect Answer Concentrated, dark-colored urine Normal skin moisture Elevated systolic pressure Bulging neck veins None 14. A nurse is setting up a sterile field for a procedure. Which of the following actions maintain sterility? (Select all that apply.) Open the first flap of a sterile package away from the body. Keep sterile items at least 2 inches from the edge of the sterile drape. Reach across the sterile field to grab a sterile object. Discard a sterile package that has a tear in the wrapper. Place sterile objects directly onto the sterile field using sterile gloves or sterile forceps. 15. A nurse is caring for an unconscious client who requires an emergency surgical procedure. No family members or legal representatives are available to provide consent. What is the nurse’s best action? Deselect Answer Proceed with the surgery without informed consent since it is an emergency. Delay the surgery until a family member can be contacted. Obtain a court order for emergency consent before proceeding. Request that another healthcare provider sign the consent form. None 16. Which action is within the nurse’s legal role regarding informed consent? A nurse is caring for a client who is scheduled for a cardiac catheterization. The provider has already explained the procedure. Assessment: Client alert, oriented, verbalizes understanding Chart: Consent form is unsigned Deselect Answer Confirm the client’s mental capacity and willingness to sign Describe the step-by-step risks of the procedure Offer alternative treatment options Provide detailed surgical technique information None 17. Which anesthesia method causes a complete loss of consciousness and no responsiveness? A nurse is assisting in the pre-op area. A client is undergoing major abdominal surgery. Assessment: Client anxious but responsive Orders: General anesthesia planned VS: BP 136/84, HR 78 Deselect Answer Regional nerve block Local topical agent General anesthesia Conscious sedation None 18. A nurse is setting up a sterile field when a sterile gauze pad falls outside the sterile field. What is the nurse’s best action? Deselect Answer Pick up the gauze pad with sterile gloves and place it back in the sterile field. Use sterile forceps to move the gauze back onto the sterile field. Discard the gauze pad and obtain a new sterile one. Continue the procedure since only one item was contaminated. None 19. Which type of anesthesia is commonly administered for this procedure? A client is scheduled for a colonoscopy. Vitals: BP 118/70, HR 72 Assessment: Client states, “I don’t want to be awake during this at all.” Deselect Answer Short-acting IV sedation Inhaled general anesthesia Nerve block below the waist Local numbing of abdominal area None 20. A nurse is assisting a client with a lower back injury to reposition in bed. Which technique should the nurse use to minimize strain on the client’s back? Deselect Answer Encourage the client to sit up and use their arms to push themselves into position. Use a logrolling technique when turning the client to their side. Elevate the client’s legs higher than the heart before repositioning. Place a firm pillow under the lower back before turning the client. None 21. A nurse is preparing to obtain informed consent for a client’s surgical procedure. Which of the following statements are true regarding informed consent? (Select all that apply.) The healthcare provider is responsible for explaining the procedure, risks, and alternatives to the client. The nurse can obtain consent if the provider is unavailable. The client must sign the consent form voluntarily and without coercion. If the client is unconscious, a legally authorized representative can provide consent. A client who received opioid pain medication 30 minutes ago can still provide informed consent. 22. A nurse is repositioning a client with a lower back injury. Which of the following interventions should the nurse implement? (Select all that apply.) Keep the client's spine in alignment while turning. Elevate the head of the bed to 90 degrees before repositioning. Use assistive devices such as a draw sheet to reduce strain. Encourage the client to bend their knees before being repositioned. Place a pillow under the knees when the client is in the supine position. 23. A nurse is planning care for a bedridden client to prevent complications related to immobility. Which interventions should be included in the care plan? (Select all that apply.) Deselect Answer Perform passive range-of-motion exercises daily. Place a pillow under the client’s knees to prevent discomfort. Apply anti-embolism stockings as prescribed. Encourage a diet high in fiber and adequate fluid intake. Assess the client’s skin for redness or breakdown daily. None 24. A 68-year-old client has been on bed rest for five days following hip surgery. The nurse is providing education on preventing complications of immobility before the client is discharged home. Which statement by the client indicates a correct understanding of ways to reduce the adverse effects of immobility? Deselect Answer "I should perform ankle pumps and leg exercises in bed to help with circulation." "I should avoid deep breathing exercises because they could strain my healing hip." "Drinking less water will help prevent swelling in my legs while I’m less active." "I should stay in bed as much as possible to allow my hip to heal completely." None 25. A 60-year-old female recovering from surgery is receiving an IV infusion of D5W. She is now reporting confusion, fatigue, and muscle weakness. Her vital signs are BP 110/65 mmHg, HR 90 bpm, RR 18/min, and SpO₂ 97%. Her serum sodium level is 122 mEq/L. Based on these findings, which of the following nursing interventions is appropriate? Select all that apply. Discontinue the D5W infusion Administer hypertonic saline solution Implement seizure precautions Encourage oral intake of fluids Monitor neurologic status closely 26. A nurse is caring for a client with dysphagia who is at risk for aspiration. Which action should the nurse take first when assisting the client with oral intake? Deselect Answer Encourage the client to drink water with meals. Instruct the client to tuck their chin while swallowing. Place the client in a high Fowler’s position before feeding. Offer large bites of food to facilitate easier swallowing. None 27. Match each nutrient with the correct primary function (Energy or Tissue Repair & Maintenance). A <strong data-start="145" data-end="160">33-year-old</strong> patient is admitted with <strong data-start="186" data-end="232">malnutrition and unintentional weight loss</strong> over the past three months. The patient has a history of <strong data-start="290" data-end="334">Crohn’s disease and chronic pancreatitis</strong>, leading to <strong data-start="347" data-end="371">malabsorption issues</strong>. The nurse assesses the patient’s dietary intake, nutritional status, and <strong data-start="446" data-end="467">laboratory values</strong> to determine appropriate interventions.<br /><br /> <table> <tbody> <tr> <td width="156"> <p>Lab Test</p> </td> <td width="156"> <p>Value Range</p> </td> <td width="156"> <p>Range</p> </td> <td width="156"> <p>Interpretation</p> </td> </tr> <tr> <td width="156"> <p>Serum Albumin</p> </td> <td width="156"> <p>2.8 g/dL</p> </td> <td width="156"> <p>3.5 - 5.0 g/dL</p> </td> <td width="156"> <p>↓ (Malnutrition)</p> </td> </tr> <tr> <td width="156"> <p>Total Protein</p> </td> <td width="156"> <p>5.4 g/dL</p> </td> <td width="156"> <p>6.4 - 8.3 g/dL</p> </td> <td width="156"> <p>↓ (Protein Deficiency)</p> </td> </tr> <tr> <td width="156"> <p>Serum Glucose</p> </td> <td width="156"> <p>65 mg/dL</p> </td> <td width="156"> <p>70 - 110 mg/dL</p> </td> <td width="156"> <p>↓ (Low Energy Reserves)</p> </td> </tr> <tr> <td width="156"> <p>Serum Lipase</p> </td> <td width="156"> <p>98 U/L</p> </td> <td width="156"> <p>10 - 140 U/L</p> </td> <td width="156"> <p>Normal</p> </td> </tr> <tr> <td width="156"> <p>Vitamin B12</p> </td> <td width="156"> <p>200 pg/mL</p> </td> <td width="156"> <p>200 - 900 pg/mL</p> </td> <td width="156"> <p>↓ (Deficiency, Likely Malabsorption)</p> </td> </tr> <tr> <td width="156"> <p>Iron</p> </td> <td width="156"> <p>40 mcg/dL</p> </td> <td width="156"> <p>50 - 150 mcg/dL</p> </td> <td width="156"> <p>↓ (Possible Anemia)</p> </td> </tr> </tbody> </table> <br /> <h3 data-start="1125" data-end="1164"><strong data-start="1129" data-end="1162">Physical Assessment Findings:</strong></h3> <ul data-start="1165" data-end="1434"> <li data-start="1165" data-end="1220"><strong data-start="1167" data-end="1193">Body Mass Index (BMI):</strong> 17.2 kg/m² (Underweight)</li> <li data-start="1221" data-end="1273"><strong data-start="1223" data-end="1242">Muscle Wasting:</strong> Present in upper extremities</li> <li data-start="1274" data-end="1329"><strong data-start="1276" data-end="1295">Skin Integrity:</strong> Delayed wound healing, dry skin</li> <li data-start="1330" data-end="1372"><strong data-start="1332" data-end="1349">Energy Level:</strong> Fatigue and weakness</li> <li data-start="1373" data-end="1434"><strong data-start="1375" data-end="1405">Gastrointestinal Symptoms:</strong> Mild diarrhea and bloating</li> </ul> <br /> <p> </p> <table> <tbody> <tr> <td width="208"> <p>Nutrition </p> </td> <td width="208"> <p>Energy</p> </td> <td width="208"> <p>Tissue Repair & Maintenance</p> </td> </tr> <tr> <td width="208"> <p>Carbohydrates</p> </td> <td width="208"> <p> </p> </td> <td width="208"> <p> </p> </td> </tr> <tr> <td width="208"> <p>Fats</p> </td> <td width="208"> <p> </p> </td> <td width="208"> <p> </p> </td> </tr> <tr> <td width="208"> <p>Proteins</p> </td> <td width="208"> <p> </p> </td> <td width="208"> <p> </p> </td> </tr> <tr> <td width="208"> <p>Vitamins</p> </td> <td width="208"> <p> </p> </td> <td width="208"> <p> </p> </td> </tr> </tbody> </table> Carbohydrates - Energy Carbohydrates - Tissue Repair and Maintenance Fats - Energy Fats - Tissue Repair and Maintenance Proteins - Tissue Repair and Maintenance Proteins - Tissue Repair and Maintenance Vitamins - Energy Vitamins - Tissue Repair and Maintenance Click here to see the right answers. 28. Which instruction should the nurse give to reduce the risk of respiratory complications? A client is 1 day post-op from abdominal surgery. Assessment: Slight crackles at lung bases, O2 sat 94%, incision site intact Vitals: Temp 99.2°F, RR 20 Deselect Answer “Lie flat when doing your breathing exercises.” “Breathe in through your mouth to expand your lungs. “Hold a pillow over your incision while you cough.” “Perform coughing every 4 hours while awake.” None 29. Which lab value is the nurse’s priority to report to the provider? A nurse reviews morning labs for a client admitted with generalized weakness. Vitals: BP 110/64, HR 98, Temp 98.7°F EKG: Slight flattening of T wave Labs: Potassium: 3.0 mEq/L Sodium: 135 mEq/L BUN: 9.5 mg/dL Creatinine: 0.4 mg/dL Deselect Answer Sodium level of 135 mEq/L Potassium level of 3.0 mEq/L BUN of 9.5 mg/dL Creatinine of 0.4 mg/dL None Time's up Post navigation Previous Previous post: Fund 4Next Next post: Fund 6
