ATI RN COMPREHENSIVE PREDICTOR 2019 FORM B-with 100% verified solutions-2024.docx, Exams of Nursing

Download ATI RN COMPREHENSIVE PREDICTOR 2019 FORM B-with 100% verified solutions-2024.docx and more Exams Nursing in PDF only on Docsity! ATI RN COMPREHENSIVE PREDICTOR 2019 FORM B-with 100% verified solutions-2024 1.A nurse is providing teaching about the gastrostomy tube feedings to the parents of a school age child. Which of the following instructions should the nurse take? A. Administer the feeding over 30 min. B. Place the child in as supine position after the feeding. C. Charge the feeding bag and tubing every 3 days. D. Warm the formula in the microwave prior to administration. 2.A nurse is administering digoxin 0.125 mg Po to an adult client. For which of the following findings should the nurse report to the provider? A. Potassium level 4.2 mEq/L. B. Apical pulse 58/min. C. Digoxin level 1 ng/ml. D. Constipation for 2 days. 3. A nurse is caring for a client who is comatose and has advance directives that indicate the client does not want life-sustaining measures. The client’s family want the client to have life-sustaining measures. Which of the following action should the nurse take? A. Arrange for an ethics committee meeting to address the family’s concerns. B. Support the family’s decision and initiate life-sustaining measures. C. Complete an incident report. D. Encourage the family to contact an attorney. D. Wear a mask when changing the linens in the client’s room. 6. A nurse is planning on care for a client who is recovering from an acute myocardial infarction that occurred 3 days ago. Which of the following instructions should the nurse include? A. Perform an ECG every 12 hr. B. Place the client in a supine position while resting. C. Draw a troponin level every 4hr. D. Obtain a cardiac rehabilitation consultation. 7. The nurse is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client’s history is a contradiction to the use of oral contraceptives? A. Hyperthyroidism. B. Thrombophlebitis . C. Diverticulosis. D. Hypocalcemia. 8 A nurse is caring for a client who request the creation of a living will. Which of the following actions should the nurse take? A. Schedule a meeting between the hospital ethics committee and the client. B. Evaluate the client’s understanding of life-sustaining measures. C.Determine the client’s preferences about post mortem care. D. Request a conference with the client’s family. 13. A nurse is caring for a client who has generalized petechiae and ecchymoses. The nurse should expect a prescription for which of the following laboratory tests? A. Platelet count. B. Potassium level. C. Creatine clearance. D. Prealbumin. 14. A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first? A. Place an ice pack over the cast. B. Palpate the pulse distal to the cast. C. Teach the client to keep the cast clean and dry. D. Position the casted extremity on a pillow. 15. A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply) A. Keep objects in the client’s room in the same place. B. Ensure there is high-wattage lighting in the client’s room. C. Approach the client from the side. D. Allow extra time for the client to perform tasks. E. Touch the client gently to announce presence. 16. A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has questions about the disease. To research the nurse should identify that which of the following electronic database has the most comprehensive collection of nursing (Unable to read) articles? A. MEDLINE B. CINAHL. C. ProQuest. D. Health Source. 17. A nurse in an emergency department is assessing newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following should actions should the nurse take first? A. Obtain a baseline ECG. B. Provide total care in performing the client’s ADLs. C. Maintain the client on bed rest. D. Place the client’s left arm on a pillow while he is sitting. 19. A nurse is caring for a client who is in a seclusion room following violent behavior. The client continues to display aggressive behavior. Which of the following actions should the nurse take? A. Confront the client about this behavior. B. Express sympathy for the client’s situation. C. Speak assertively to the client. D. Stand within 30 cm (1 ft) of the client when speaking with them. 20. A nurse is caring for a client who is receiving brachytherapy for treatment of prostate cancer. Which of the following actions should the nurse take? A. Cleanse equipment before removal from the client’s room. B. Limit the client’s visitors to 30 min per day. C. Discard the client’s linens in a double bag. Discard the radioactive source in a biohazard bag 21. A nurse is assessing a client who has left-sided heart failure. Which of the following should the nurse identify as a manifestation of pulmonary congestion? A. Frothy, pink sputum. B. Jugular vein distention. C. Weight gain. D. .Bradypnea B. “Eat foods that are high in sodium” C. “Rise slowly when getting out of bed” D. “Taking furosemide can cause you to be overhydrated” 26. A nurse is creating a plan of care for a newly admitted client who has obsessive- compulsive disorder. Which of the following interventions should the nurse take? A. Allow the client enough time to perform rituals. B. Give the client autonomy in scheduling activities. C. Discourage the client from exploring irrational fears. D. Provide negative reinforcement for ritualistic behaviors. B. The group encourages members to focus on a particular issue. (Mental Health Chapter 8 Page 42) C. The group must be led by a licensed psychiatrist. D. The group encourages clients to form dependent relationships. 31. A nurse manger is reviewing documentation with a newly licensed nurse. Which of the following notations by the newly licensed nurse indicates an understanding of the teaching. UNSURE IF ON THE REPORT A. “OOB with assistance for breakfast” B. “Given 2 mg MSO4 IM for report of pain” C. “Dressing changed qd” D. “Administered 8 u regular insulin sq.” 32. A nurse is preparing to administer eye drops to a school-age child. Identify the actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) 1. Apply pressure to the lacrimal punctum. 2.Ask the child to look upward. 3.Pull the lower eyelid downward. 4.Instill the drops of medication. 5.Place the child in a sitting position. 5 2 3 4 1 33. A nurse is caring for a client who speaks a language different from the nurse. Which of the following should the nurse take? A. Request an interpreter of a different sex from the client. B. Request a family member or friend to interpret information for the client. C. Direct attention toward the interpreter when speaking to the client. D. Review the facility policy about the use of an interpreter. Which of the following statements by the client indicates the need for a referral to physical therapy? A. “I have been experiencing more tremors in my left arm than before” B. “I noticed that I am having a harder time holding on to my toothbrush” C.“Lately, I feel like my feet are freezing up, as they are stuck to the ground” D.“Sometimes, I feel I am making a chewing motion when I’m not eating” 38. A nurse is reviewing laboratory data for a client who has chronic kidney disease. Which of the following findings should the nurse expect? A. Increased creatine. B. Increased hemoglobin. C. Increased bicarbonate. C. A client who received 2 units of packed RBCs 6 hr. ago for a postpartum hemorrhage. D. A client who delivered precipitously 36 hr. ago and has a second- degree perineal laceration. 42. A nurse in a provider’s office is reviewing the laboratory results of a group of clients. Which to report? A. Herpes simplex. B. Human papillomavirus C. Candidiasis D. Chlamydia 43. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to adietitian A. A client who has a prescription for warfarin and states “I will need to limit how much spinach I eat”. B. A client who has gout and states, “I can continue to eat anchovies on my pizza.” C. A client who has a prescription for spironolactone and states “I will reduce my intake of foods that contain potassium”. D. A client who has (Unable to read) and states “I’ll plan to take my calcium carbonate with a full glass of water”. 44. A nurse is preparing to measure a temperature of an infant. Which of the following action should the nurse take? A. Place the tip of the thermometer under the center of the infant’s axilla. B. Pull the pinna of the infant’s ear forward before inserting the probe. C. Insert the probe 3.8 cm (1.5in) into the infant’s rectum. D. Insert the thermometer in front of the infant’s tongue. 45. A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella rooster. Which of the following information should the nurse include? D. Children who have varicella are contagious 4 days before the first vesicle eruption. 46.A nurse is reviewing the laboratory report of a client who has been having lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect? A. Withhold the next dose. B. Increase the dosage. C.Discontinue the medication. D.Administer the medication. 47. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse administer? A. B. Pregabali Lorazepa D. m Colchic i n e Codeine . 48. A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take? A. Prime IV tubing with 0.9% sodium chloride. B. Use a 24-gauge IV C. catheter Obtain filter less IV tubing. D. Place blood in the warmer for 1 hr. C. n 49. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following should the toddler participate? D. Warm toast with margarine. 51. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take? A. Obtain the newborn’s body temperature using a tympanic thermometer. B. (Unable to read) FACES pain scale. C. Auscultate the newborn’s apical pulse for 60 seconds. D. Measure the newborn’s head circumference over the eyebrows and below the occipital prominence. (NOT) 52. A nurse is caring for a client who is at 38 weeks gestation, is in active labor, and has ruptured membrane. Which of the following actions should the nurse take? A. Insert an indwelling urinary catheter. B. Apply fetal heart rate monitor. C. Initiate fundal massage. D. Initiate an oxytocin IV infusion. 53. A nurse is assessing a client who is 30 min postoperative following an arterial thrombectomy. Which of the following findings should the nurse to report? A. Chest pain B. Muscle spasms. C. Cool, moist skin. D. Incisional pain. 54. A nurse is completing an incident report after a client fall. Which of the following competencies of Quality and Safety Education for Nurse is the use demonstrating? A C. Evidence based practice. D. Informatics. B. Patient (Unable to read) . Quality improvement. 55. A nurse is talking with another nurse on the unit and smells alcohol on her breath. Which of the following actions should the nurse take? A. Confront the nurse about the suspected alcohol use. B. Inform another nurse on the unit about the suspected alcohol use. following actions should the nurse take first? A. Notify the provider. B. Report the incident to the nurse manager. C.Monitor vital signs. D.Fill out an incident report. 59. A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make? A. “Dehydration is treated with calcium supplements” B. “Dehydration can increase the risk of preterm labor” C.“Dehydration associated gastroesophageal reflux” D.“Dehydration is caused by a decreased hemoglobin and hematocrit” 60. A nurse is receiving a change-of-shift report for an adult female client who is postoperative. Which of the following client information should the nurse report? A. (Unable to read) B. (Unable to read) C.Answer might be lower platelets. D.(Unable to read) 61. A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as clinical staff. Which of the following instructions should the nurse include? A. Use the client’s children to provide interpretation. B. (Answer was the nurse was going to do the interpretation) C.Offer client’s translation services for a nominal fee. D.Evaluate the clients’ understanding at regular intervals. A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching? . se 8 8 es © © © © © Leaving a nasogastric tube clamped after administering oral medication a0 Documenting communication with a provider in the progress notes of the client's medical record Administering potassium via IV balus Placing a yellow bracelet on a client who is at risk for fells 62C 2 oO 63 A A nurse is developing a plan of care for @ client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan? eo 8 © © © © 6 Ask the client directly what he is hearing. Encourage the client ta lie down In a quiet room. Avoid eye contact with the client. Refer to the hallucinations as if they are real. cao A nurse is preparing to perform a sterile wound irrigation and dressing change for a client. Which of the following actions by the nurse indicates a break in surgical aseptic technique? © Applying a sterile gown after applying a sterile mask © Balancing the bottle on the sterile basin while pouring the liquid © Placing the supplies on the sterile field end leaving a 41-inch perimeter Putting on sterile gloves after preparing the sterile flald A nurse is teaching a prenatal class about infection prevention at a community center, Which of the following statements by a client indicates an understanding of the teaching? © "Lean visit my nephew who has chickenpox 5 days after the sores have crusted." © "Lean clean my cat's litter box during my pregnancy.” ©. "Ishould take antibiotics when I have a virus.” ©. "Ishould wash my hands for 10 seconds with hot water after working in the garden.” A nurse is planning care for a group of clients and is working with one licensed practical nurse (LPN) and one assistive personnel (AP). Which of the following actions should the nurse take first to manage her time effectively? o* @ © © oe eee Olle Develop an hourly time frame for tasks. Schedule daily activities. Determine goals of the day. Delegate tasks to the AP. A nurse Is providing teaching to an adolescent who has peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching? a oac "L will decrease my daily protein intake to 15 grams per day." "Twill use ibuprofen as needed to control abdominal pain.” "will take sucralfate with meals three times per day," “I will avoid food and beverages that centain caffeine." A nurse is reviewing legal issues in health care with a group of newly licensed nurses. Which of the following recommendations should the nurse make? ee ee . coe e . Place copies of incident reports in clients' medical records. Overestimate clients’ acuity to prevent short staffing, Ensure that each client has a living will on file prior to treatment. Obtain personal professional liability insurance coverage. A nurse is working with a client who has an anxiety disorder and is in in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? eo 8 @ oo ef ee © eo 8 e © © © © © © © Oo 8 (“Let's talk about how you can change your response to stress." ©. "We should establish our roles in the initial session." (©. “Let me show yau simple relaxation exercises to manage stress.” "We should discuss resources to implement in your daily life." 7 C  A staff education nurse is evaluating a group of nurses during a new employee orientation on the use of proper body mechanics when following images indicates the appropriate use of ergonomic principles? ing. Which of the  86. C A nurse is caring for a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia? © Maternal fever © Fetal anemia © Maternal hypoglycemia © Chorioamnionitis 4 nurse is providing teaching to the parents of a newborn about newborn genetic screening. Which of the following statements should the nurse include in the teaching? ee . se . . . . . . © "This test should be performed efter your baby is 24 hours old.” © "“Anurse will draw blood from your baby’s inner elbow." Oo "Your baby will be given 2 ounces of water to drink prior to the test." "This test will be repeated when your baby is 2 months old." A nurse is caring for a client who asks for information regarding organ donation, Which of the following responses should the nurse make? . ‘1 eos . 2 © . 2° 0 . eo . . . © "Lcannot be a witness for your consent to donate." © “Your name cannot be removed once you are listed on the organ donor list.” © "Your desire to be an organ donor must be documented in writing.” Oo "You must be at least 21 years of age to become an organ donor." & C A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications? ©. Vomiting © Hypertension © Epigastric pain © Contractions sD A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching? (© Take magnesium hydroxide for indigestion. © Drink at least 3 L of fluid daily. } Eat g/kg of protein per day. Consume foods high in potassium. 6 C "The client might act seductively." "The client is overly concerned about minor details.” "The client exhibits impulsive dehavior.” "The client is exceptionally clingy to others.” 97. D expect? Cooo 10 Ritualistic behavior Suspicious of others Exhibits separation anxiety Preoccupied with aging . . . . Hold hand flat to perform percussions on the child. Perform the procedure twice a day. Administer a bronchodilator after the procedure. Perform the procedure prior to meals. . . A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder? A nurse is caring for a child who has cystic fibrosis and requires postural drainage, Which of the following actions should the nurse take? A nurse is completing an admission assessment for a client who has narcissistic personality disorder. Which of the following findings should the nurse A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine? ore oe @ e © Be e oe @ ee oe @ © © oe eo . © Heart rate 58/min © Fasting blood glucose 100 mg/dt. OQ. Hgb 14 g/d © WBC count 2,900/mm? 99. 102 D weey, A nurse Is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include In the teaching? «0 8 © © © oe “Limit your child's potassium intake while she is taking this medication." "You can add the medication to a half-cup of your child's favorite juice. “Repeat the dose if your child vomits within 1 hour after taking the medication." “Have your child drink a small glass of water after swallowing the mecication.” 101 A nclude? o 8 © © © © © © © © © 8 * oe © © © A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse oe “This type of seizure can be mistaken for daydreaming.” "This type of seizure lasts 30 to 60 seconds." "The child usually has an aura prior to onset." "This type of seizure has a gradual onset.” OOOO 12B A nurse is reviewing assessment data from several clients. For which of the following clients should the nurse recommend referral to a dietitian? Oo (> An older adult client who has a BMI of 24 © Aclient who hes a nonhealing leg ulcer © An older adult client whe has presbyopia A client who has an albumin level of 3.7 g/dL C A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration? ° © Sitting in 2 high-Fowler's position during the feeding A history of gastroesophageal reflux disease Receiving a high osmolarity formula A residual of 65 mL 1 hr postprandial A nurse is caring for a client who is in labor and has received an epidural. Which of the following actions should the nurse take? o ¢ © © © © © © © © © & ee heh OhhlUhrthlUlh hl hlUr hl Ul hl eo e ° Decrease the maintenance infusion rate of IV fluid. Have protamine sulfate available at the bedside. Reposition the client side-to-side each hour. OCO0O Monitor the client for hypertension. 110 B 4 nurse is building a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take during the orientation phase of the relationship? eo 8 © © © © 8 eo © © © © 0 © © © © © © © © © © © Determine previous coping skills used by the client. Establish the responsibilities of the nurse and client. Facilitate the client's problem-solving skills. Assist the client in expressing alternative behaviors, 111.D A nurse Is providing dietary teaching to a client who has a new diagnosis of Irritable bowel syndrome. Which of the following recommendations should the nurse include? (© Increase intake of foods high in gluten. © Increase intake of milk products (© Sweeten foods with fructose corn syrup. © Consume food high in bran fiber. e A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings requires follow up care? Acclient who received a Mantoux test 48 hr ago and has an induration A client who is scheduled for a colonoscopy and is taxing sodium phosphate A client who is taking warfarin and has an INR of 1.8 Acclient who Is taking bumetanide and has a potassium level of 3.6 mEq/L 112'C 113 B A nurse is caring for a client who is 2 hr postoperative following a cardiac catheterization. Which of the fallowing is the priority assessment finding? (© Report of burning sensation at the insertion site Absence of pedal pulse in the affected extremity Urinary output 25 mL/hr Oxygen saturation 91% 114. A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? © 0 © © © © © © © © © ot ew 8 ee «© oe eo « @ © Hold hand flat to perform percussions on the child. ©. Perform the procedure twice a day. © Perform the procedure prior to meals. © Administer a bronchodilator after the procedure, 115A A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include? ©. Metallic taste in mouth O Dry cough Increased urinary frequency © Excessive sweating 120 A oe & nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder? “The client exhibits impulsive behavior." "The client might act seductively," "The client is exceptionally clingy to others." "The client is overly concerned about minor details.” 121. C A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration? eo © © © @ © oe eo se @ A residual of 65 mL 1 hr postprandial Sitting in @ high-Fowler's position during the feeding A history of gastroesophageal reflux disease Receiving a high osmolarity formula . . . A nurse is caring for a client following a cardiac catheterization through the left groin. Which of the following actions should the nurse take? se 0 © © © © © © © © © oO ee ell ltl el tll ltl lhl tll ll © Monitor the dorsalis pedis pulse every 15 min. © Keep the client NPO for 24 hr. © Place the client in Fowler's position. © Maintain strict bedrest for the first 12 hr.  A nurse is reviewing the medical record of a client who has a prescription for intermittent heat therapy for a foot injury. Which of the following findings should the nurse identify 2s a contraindication for heat therapy? e ce @ © @ ee 8 oe eo se © © @ oe ew we © Peripheral neuropathy © Osteoarthritis © Abdominal aortic aneurysm OQ Phlebitis 124. € es A nurse in an emergency department is caring for a toddler who has burns following a house fire. Which of the following actions should the nurse take first? . . . . ° ° . ° ° . ° * © Calculate fluid replacement based on vital signs and urinary output. © Determine the location and depth of the burns. Check the mouth for soot and smoky breath. oO Administer antibiotics prophylactically to prevent sepsis, 12D A nurse is caring for a client following a stroke. The client has right-sided weakness and facial drooping. Which of the following nursing actions is the priority? © Perform range-of-motion exercises to the client's extremities. © Place the client's right hand in a supination position, © Change the client's position every 2 hr. ©} Maintain NPO status for the client. 124 D 129.A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? (Select all that apply.) j. Have suction equipment available for use. k. Feed the client thickened liquids. l. Place food on the unaffected side of the client’s mouth. m. Assign an assistive personnel to feed the client slowly. n. Teach the client to swallow with her neck flexed. 130.A nurse is caring for a client who has global aphasia (both receptive and expressive.). Which of the following should the nurse include in the client’s plan of care? (Select all that apply.) o. Speak to the client at a slower rate. p. Assist the client to use flash cards with pictures. q. Speak to the client in a loud voice. r. Complete sentences that the client cannot finish. s. Give instructions one step at a time. 131.A nurse is assessing a client who has experienced a left- hemispheric stroke. Which of the following is an expected finding? t. Impulse control difficulty q. Suture removal kit 136.A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risks for complications? (Select all that apply.) r. Dyspnea s. Localized bloody drainage on the dressing t. Fever u. Hypotension v. Report of pain at the puncture site 137.A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client’s room? (Select all that apply.) a. Oxygen b. Sterile water c. Enclosed hemostat clamps d. Indwelling urinary catheter e. Occlusive dressing 138.A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first? f. Obtain a chest x-ray g. Apply sterile gauze to the insertion site. h. Place tape around the insertion site. i. Assess respiratory status. 139.A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? (Select all that apply.) j. Continuous bubbling in the water seal chamber k. Gentle constant bubbling in the suction control chamber l. Rise and fall in the level of water in the water seal chamber with inspiration and expiration m. Exposed sutures without dressing n. Drainage system upright at chest level 140.A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse instruct the client to do? o. Lie on it left side. p. Use the incentive spirometer. q. Cough at regular intervals. r. Perform the Valsalva maneuver. 141.A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? (Select all that apply.) s. Encourage the client to cough every 2 hours. t. Check the continuous bubbling in the suction chamber. u. Strip the drainage tubing every 4 hours. v. Clamp the tube once a day. w. Obtain a chestx-ray. 142.A nurse is orientation a newly licensed nurse who is caring for a client who is receiving mechanical ventilation and is receiving mechanical ventilation and is on pressure support d. “It delivers a preset ventilatory rate and tidal volume to the client.” 143.A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? (Select all that apply.) e. Confu si o n f.Pale skin g. Bradycardia h. Hypotension i. Elevation blood pressure. 144.A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching? j. Apply a vest restraint if self-extubation is attempted. k. Monitor ventilator settings ever 8 hours. l. Document tube placement in centimeters at the angle of jaw. m. Assess breath sounds every 1 to 2 hours. 145.A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? n. Nonrebreather mask o. Venturi mask p. Nasal cannula q. Simple face mask 146.A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following modes of ventilation that increase the effort of the client’s respiratory muscles should the nurse include in the plan of care? (Select all that apply.) r. Assist-control s. Synchronized intermittent mandatory ventilation t. Continuous positive airway pressure u. Pressure support ventilation v. Independent lung ventilation 146.A nurse is monitoring a group of clients for increased risk for developing pneumonia. Which of the following clients should the nurse expect to be at risk? (Select all that apply.) a. Client who has dysphagia b. Client who has AIDS c. Client who was vaccinated for pneumococcus and influenza 6 months ago d. Client who is postoperative and received local anesthesia. e. Client who has a closed head injury and is receiving ventilation f. Client who has myasthenia gravis 148.A nurse in a clinic is caring for a client whose partner states the client woke up this morning, did not recognize him, and did not know where she was. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nurse’s priority?