NUR 2571 Professional Nursing II pn2 final, Exams of Nursing

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NUR 2571 Professional Nursing II pn

final

PN2 Final

The nurse assesses a client who has myasthenia gravis. Which clinical manifestation does the nurse expect to observe in this client? ✓ Muscle weakness that worsens with use and improves with test a client being treated for a spinal cord injury needs immediate ventilator support. The nurse realizes that this client's level of injury is most likely? ✓ C the nurse intends to participate in a health screening clinic and preparing teaching materials about colorectal cancer ✓ Personal history of Gl polyps the nurse is attempting to assess a coma patient's response to pain. Which technique does the nurse try first ✓ Speak the patient and call his/her name using a normal tone of voice

The step-down unity receives a new admission who has uncontrolled diabetes, polyuria, and blood pressure of 86/46 mm gh. Which staff member is assigned to care for the client? ✓ RN who has floated from the ICU A client is admitted to the emergency room with a respiratory rate of 6/min. Arterial blood gasses (ABGS) have been drawn and reveal to following values: pH 7.22, PaCO 68, HCO3 26, Pa02 74. Which of the following is an appropriate analysis these ABGS? ✓ Respiratory acidosis which of the following conditions should the nurse recognize as a type IV reaction? Allergic rhinitis ✓ Positive purified protein derivative (PPD) test A pre-operative wears a hearing aid and is extremely hard of hearing without it. what does the nurse do to help reduce this client's anxiety? ✓ Explain that it is hospital policy to remove a hearing aid until anesthesia is given the nurse is caring for the mechanically ventilated patients uses best practices to pre ventilator associated pneumonia. What action by the nurse should be questioned? ✓ Elevating the head of the bed nurse cares for a client who has Alzheimer's disease. which communication techniques would the nurse implement? ✓ Open-ended questions

Emergency medical services arrive to the emergency department with a client who has a cervical spinal cord injury. Which priority assessment does the emergency department nurse perform at this time? ✓ Respiratory status and airway patency a client newly diagnosed with Parkinson disease (PD) is being discharged. Which instructions is best for the nurse to provide to the client's spouse? ✓ Administer medications promptly on schedule to maintain therapeutic drug levels Which arterial blood gas (ABG) values are expected with hyperventilation? ✓ pH, 7.55; PaCO2, 32 mm Hg or ph 7.48 CO2 remain the same A nurse is planning care for a client who has acute dysphagia. Which of the following nursing interventions should be included in the p lan of care? ✓ Placing the client in at least semi fowlers position during meals A new nurse demonstrates their understanding of a proper physical assessment of an abdomen when the four techniques of examination are completed in which order? ✓ Inspect Auscultate Percuss Palpate A client is demonstrating signs of an anaphylactic reaction. Which of the following should the nurse do? (Select all that apply.)

✓ Maintain patent airway ✓ Place the client with feet and legs elevated head of bed down ✓ Begin administering ordered IV fluids in assessing a client's wound, which finding suggests to the nurse that the wound is healing? ✓ Granulation tissue is present when teaching intervention is most appropriate for the client with Parkinson's disease? ✓ Fall precautions in planning discharge for the client with Parkinson's disease, the nurse collaborates with the physical therapist for which outcome? ✓ Maintain physical strength and mobility The nurse is concerned that a client with a gastrostomy feeding tube is developing a complication. Which of the following are considered complications associated with this type of feeding tube? (Select all that apply.) ✓ Nausea ✓ Vomiting ✓ Abdominal distention ✓ Aspiration

In planning the nutritional needs for a client with late-stage Parkinson's disease the nurse includes which of the following? ✓ Record intake of diet and fluid daily which therapeutic intervention should be initiated first for the client in a hyperosmolar hyperglycemic state (HHS)? ✓ High dose insulin boluses A client suspected to have myasthenia gravis is scheduled for the edrophonium chloride test. Which prescribed medication does the nurse prepare to administer if complications of this test occur? ✓ Atropine sulfate nurse assess a patient with diabetes mellitus and notes that the patient only responds to a sternal rub by moaning. Has capillary blood glucose of 33 g/dl. And has an intravenous line that is infiltrated with 0.45% normal saline. Which action should the nurse take first? ✓ Administer 1 mg of intramuscular glucagon A client presented to ER with decrease level of consciousness, polydipsia, hyperthermia, dry mucous membranes. Blood glucose result was critical high of 600 mg/dl and serum Na- 155, K= 6, and no serum keton es. The nurse determines the physician will diagnosis this client with which of the following conditions? ✓ HHS The nurse is caring for a client who was recently diagnosed with type Il diabetes. The client is visibly upset about the diagnosis and states, "Now l'll never be able to keep my

job as a teacher. I've heard that diabetes causes blindness." The best response by the nurse is: ✓ Controlling glucose and blood pressure reduces the risk for blindness A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following interventions by the nurse is best for preventing aspiration? ✓ Elevate the head of the client bed 30 - 45 degrees a nurse cares for a client with advanced Alzheimer's discase. the client's caregiver states. she is always wondering off what can I do to manage this restless behavior? How would the nurse respond? ✓ Encourage the client in scheduled activities throughout the day the registered nurse asks the nursing assistant why a cardiac patient's morning weight has not yet been done. The nursing assistant says, I'll get to it, what's the big deal? When deciding how to respond the nurse considers what information about weight? ✓ Weight is the most accurate noninvasive indicator of fluid status The nurse is assessing the patient who has started to complain of muscle cramps and paresthesia's in his hands and feet. The nurse notes a positive Chvostek sign upon assessment and knows this result is associated with which electrolyte disorder? ✓ Hypocalcemia a client is experiencing bleeding related to peptic ulcer disease (PUD). Which nursing intervention is the highest priority?

✓ Starting large-bore IV intravenous (IV) The nurse is discharging home a client at risk for venous thromboembolism on enoxaparin sodium. What instruction is a priority for the nurse to provide to this client? ✓ "Notify your health care provider if your stools appear tarry." A client is admitted with a diagnosis of Diabetic Ketoacidosis (DKA). Which arterial blood gas (ABG) lab value would the nurse expect to see with this client? ✓ pH: 7. PaCO2: 32 HCO3: client who has previously diagnosed with a urinary tract infection (UTI) and started on antibiotics returns to the clinic 3 days later with the same symptoms. When asked about the previous UTI and medication regimen. The client states I only took the first dose because after that, I felt better, how does the nurse respond? ✓ Not completing your medication can lead to return of your infection a patient presents to the emergency department reporting severe abdominal pain. On assessment, the nurse finds a barging, pulsating mass in the abdomen. What action by the nurse should take? ✓ Notify the provider immediately a client is receiving total parental nutrition (TPN) exhibits symptoms of congestive heart failure (CHF) and pulmonary edema. Which complication of T PN is the client most likely experiencing?

✓ Fluid volume overload Which medication will the nurse prepare to administer to the client who is experiencing status epilepticus? ✓ Lorazepam the nurse is providing discharge instruction to a client with glaucoma. Which activities does the nurse instruct the client to avoid? Select all that apply ✓ Bending over to tie shoes Blowing the nose frequent Lifting objects weighing more than 10 pounds (4.5 kg) a nurse witnesses a client with late-stage Alzheimer's disease eat breakfast afterword the client states, I am hungry and want breakfast," how would the nurse respond? ✓ see you are still hungry. I will get you some toast a patient has trigeminal neuralgia and has begun skipping meals and not brushing his teeth, and his family believes that the patient has become depressed. What action by the nurse is best? ✓ Ask the patient to explain feeling related to this disorder the medical-surgical unit has one negative-airflow room, which of these four clients who have just arrived on the unit should the charge nurse admit to this room? ✓ Client with possible pulmonary tuberculosis who currently has hemoptysis

A nurse assess a patient who experienced a spinal cord injury at the TS level 12 hours ago. Which manifestations would the nurse correlate the neurogenic shock? ✓ Decreased level of consciousness a client with asthma reports shortness of breath. Which of these findings does the nurse anticipate when assessing this client's chest? ✓ Expiratory wheezing not cleared by coughing Which action by the nurse is the most effective becoming exposed to the human immunodeficiency virus? ✓ Always use standard precautions with all clients in the workplace The nurse learns that the pathophysiology of Guillen-barre syndrome includes seg mental demyelination. The nurse understands that this causes what? ✓ Slowed nerve impulse transmission The nurse is reviewing the admission assessment of an elderly client with pneumonia. For which symptom of pneumonia. typical to older adults, does the nurse assess? ✓ Confusion a client is diagnosed as being obese. The nurse realizes that this client's body mass index (BMI) is most likely ✓ Above 30

when caring for a client who has the following blood gas results. Which of these interventions does the nurse plan to use to correct the acid base disturbance? PH 7:47. pCo2 37 mm hg. Hco 30 mEg/L. and p02 88 mm hg? ✓ Administering an antiemetic A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make? ✓ "Warfarin takes several days to work, so the IV heparin wil be used until the warfarin reaches a therapeutic level." A nurse is assessing a male client who has a new diagnosis of peripheral artery disease (PAD), Which of the following findings should the nurse expect to find on the affected extremity? (Select all that apply) ✓ Pain Paresthesia Pallor a nurse cares for a patient with a spinal cord injury. With which interdisciplinary team member would the nurse consult to assist the patient with activities of daily living? ✓ Occupational therapist The nurse assesses a client with pneumonia and notes no audible lung sounds on the left side and decreased lung expansion. What is the nurse's initial action? ✓ Assess oxygen sat and notify the health care provider

which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy? ✓ The nurse obtains a bedside commode before administering furosemide the wife of a client with Alzheimer's disease mentions to the home health nurse that, although she loves him, exhausted caring for her husband what does the nurse do to alleviate caregiver stress? ✓ Arranges for respite care The laboratory values of a client who has diabetes mellitus include fasting blood glucose level of 85 or 89 mg/dl and hemoglobin A1C of 6.9 or 7.2% What is the nurse's Interpretations of this findings? ✓ The client's glucose control for the past 24 hours has been good, but the overall control is poor A client receiving care for a spinal cord injury complains of a pounding headache, flushed skin, cardiac dysrhythmias and has a blood pressure of 220/125 mmHg. What is the first action? ✓ Check the bladder for distension. a nurse is caring for a patient who has just experienced a 90-s tonic colonic seizure. The patient's arterial blood gas values are PH 6.88, pa02 50 mm hg, paCo2 60 mm hg. And HCO3 22 mmo/L. What action would the nurse take first? ✓ Apply oxygen by mask or nasal cannula the nurse Is educating with heart failure on a new medication enalapril (Vasotec). How nurse angiotensin-converting (ACE) inhibitors work?

✓ They cause systemic vasodilation The nurse is preparing to transfuse a third unit of red blood cells to a client. Which laboratory result is the nurse most concerned about? ✓ Potassium level of 6. The nurse is reviewing the physician's order for a client newly admitted with a diagnosis Meniere's. what diet will most like be prescribed? ✓ Low sodium diet The nurse is caring fora client with type Il diabetes. Which of the following statements made by the client indicates understanding of predisposing factors for disease? ✓ Both my parents and grandparents had diabetes the nurse assesses a client who has Myasthenia Gravis, which clinical manifestation does the nurse expect to find in this client? ✓ Mild diplopia and unilateral ptosis a nurse is assessing a client with recent changes in hearing. After taking a medication history, which drugs does the nurse identify as possible cause of the client's hearing change? ✓ Loop diuretics the nurse is caring for a client who experiencing a seizure that has persisted for 5 minutes. What is the nurse's priority action?

✓ Establish a large-bore catheter and start 0.9% sodium chloride// a client is admitted with severe diarrhea. Arterial blood gas (ABG) results are PH 7.30, paCO235, HCO 18. The nurse concludes this client has which acid-base imbalance? ✓ Uncompensated metabolic acidosis a nurse assesses clients on a medical-surgical unit. Which clients would the nurse identify at risk for secondary seizures? ✓ 26 - year-old woman with a left temporal brain tumor 38-year-old male client in an alcohol withdraw program 42-year-old football player with a traumatic brain injury the nurse is proving discharge instructions to a client who has a new prescription for phenytoin (phenytoin). Which of the following information should the nurse include? ✓ Ensure you take the medication at the same time every day A client with macular degeneration would like to watch television. Where does the nurse place the television for best visualization of the screen? ✓ In the client's peripheral view. The nurse has admitted to the intermediate care unit a client who sustained a spinal cord injury at TI in a motor vehicle accident. Which nursing care activity can Ne nurse delegate to the unlicensed assistive person (UAP) working with this client? (Select all that apply.) ✓ Measure oxygen sat level every hour Provide mouth care

which of the following systemic disorders does not affect the eye and vision and does not require yearly eye examination by an ophthalmologist? ✓ Hepatitis A nurse is assessing a client who returned to the unit 4 hours ago after a partial colectomy. Which of the following findings should the nurse attend to first? ✓ Respiratory rate of 12 A client is diagnosed with glaucoma and is prescribed medication to treat it. The nurse knows that which of the following best explains the purpose of the medication? ✓ This medication lowers intraocular pressure. the nurse is teaching a client about dietary choices to prevent dumping syndrome after gastric bypass surgery. Which statement by the patient indicates a need for further teaching? ✓ I cannot drink alcohol at all the nurse is caring for a group of clients with electrolytes and blood chemistry abnormalities. Which client will the nurse see first?" ✓ The client has potassium of 6. a client with chronic obstructive pulmonary disease (COPD) has a prescription to adjust oxygen to maintain SpO2 between 90% and 92%. Which action can be delegated to unlicensed assistive personnel (UAP}? ✓ Adjust the position of oxygen tubing

A nurse is teaching a community group about preventing hearing loss. What Instruction is best? ✓ Always wear a bicycle helmet A client with systolic dysfunction has an ejection fraction of 38%. The nurse assesses for which physiologic change? ✓ Decrease in tissue perfusion a nurse cares for older adult clients in a long-term acute care facility. Which interventions would the nurse implement to prevent skin breakdown in these clients? ✓ Implement pressure-relieving devices when preparing to examine an ear with drainage. What does the nurse do first? ✓ Dans clean gloves the nurse picks up a unity red blood cells (PRBCS) at the blood bank. It is a busy day and the nurse is prioritizing tasks, they look at the clock and realize it is 1445. The nurse knows that this unit of PRBCS must be hung by what time? ✓ 1515 a client is newly diagnosed with sickle cell anemia. Which information does the nurse include in the client's discharge instructions? ✓ Be aware of the early symptoms of crisis

the nurse is performing an admission assessment on diet with morbid obesity. Which common complications of obesity does the nurse assess for? ✓ Metabolic syndrome the nurse is teaching a client with a newly diagnosed anemia a bout conserving energy. Which instructions would the nurse give to the client? (select all that apply) A. "Allow others to perform your care during periods of extreme fatigue." B. "Drink small quantities of protein shakes and nutritional supplements daily. C. "Provide yourself with 4- 6 small meals" D. " stop the activity when SOB are present" A patient has been diagnosed with Guillen-barre' syndrome. The nurse is teaching the patient and family about the condition. Which statement by the family indicates a need for additional teaching? ✓ He'll never be able to walk again A nurse is teaching a group of nursing students about dissecting abdominal aortic aneurysm. Which of the following statements should the nurse include in the teaching? ✓ It is a medical emergency requiring immediate treatment An elementary school teacher has been informed that her student's brother has absence seizures. The teacher is fearful that her student may have the same types of seizures and unsure what to expect. Which signs does the school nurse advise the teacher to look for? ✓ Brief loss of consciousness that may appear as daydreaming or blank starring

which is the most effective way for a college student to minimize the risk for bacterial meningitis? ✓ Getting the meningitis polysaccharide vaccine the nurse is working with a client who has severe rheumatoid arthritis in her hands. The client states that she is frustrated at mealtime because it is difficult for her to manage. What is the nurse's best response? ✓ Let's see if the occupational therapist can provide you with some utensils that are easier for you to use." which statements by a client with chronic obstructive pulmonary disease (COPD) and a 10 - pound (4.5 kg) weight loss indicates the need for additional follow-up instruction? ✓ should consume plenty of fluids with my meal The home health nurse is checking in on a client with dementia and the client's spouse. The spouse confides to the nurse. "I am so tired and worn out" what is the nurse's best response? ✓ Make sure you take some time off and take care of yourself the patient is receiving intermittent feedings of a specified amount at specified times through a feeding tube. Which type of feeding is the patient receiving? ✓ Bolus feeding tube the nurse is caring for a client post-spinal cord injury. What interventions will the nurse provide to minimize the risk of autonomic dyslexia? ✓ Minimize moving the client to prevent further injury

the nurse is assessing a client with a cardiac infection. Which symptoms support the diagnosis of Infective endocarditis instead of pericarditis or rheumatic carditis? ✓ Splinter hemorrhages In planning discharge for the client with Parkin son's disease, the nurse collaborates with the physical therapist for which outcome? ✓ Maintaining physical strength and mobility the nurse is assessing a patient after bariatric surgery. The patient has increased back pain, is restless, has heart rate of 126/minute, and has only 15 ML of urine output for the past hour, what does the nurse suspect? ✓ anastomotic leak when the nurse assess a patient after abdominal surgery, assessment reveals diminished, hypoactive bowel sounds. What is the nurse's best action? ✓ Document the finding and continue to monitor the nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer? ✓ A rigid, board like abdomen The nurse is teaching a class of unlicensed assistive personnel (UAP), about turning and repositioning clients in a long-term care setting. Which client requires extreme caution and is at greatest risk for a skin tear?

✓ An 85-year-old client with breathing problems receiving dally doses of prednisone A nurse who is applying eyedrops to a client holds pressure against the corner of the eye nearest the nose after instilling the drops. The client asks what the nurse is doing. What response ✓ This prevents systemic absorption nurse is caring for a client with the meningitis. Which laboratory values would the nurse monitor to identify potential complications of the disorder? Select all that apply ✓ Clotting factors Sodium Levels Assessment findings reveal that a client admitted to the hospital has a contact type 1 hypersensitivity (immediate) to latex. Which preventive nursing intervention is best in planning care for this client? ✓ Communicate the need for avoidance therapy to the health care team Which finding indicate that a patient may have hypervolemia (select all that apply) ✓ Increased Bounding pulse Elevated blood pressure Skin pale and cool touch Which findings indicate that the patient may have hypervolemia? Select all that apply ✓ Increased, bounding pulse Jugular venous distention Presence of crackles Elevated blood pressure

A student nurse is learning about blood transfusion compatibilities. What information does this include? Select all that apply ✓ Donor blood type A can donate to recipient blood type AB Donor blood type O can donate to anyone After teaching a client who is diagnosed with new-onset status epilepticus and prescribed phenytoin (Dilantin). The nurse assess the client's understanding. Which statement by the client indicates a correct understanding of the teaching? ✓ Even when my seizures stop, I will continue to take this drug Isoniazid (INH) and rifampin (rifadin) have been prescribed for a client with tuberculosis (TB). A nurse reviews the medical record of the client. Which of the following noted in the client's history order for these medications? ✓ Hepatitis B A client has hypokalemia. Which question by the nurse obtains the most information on a possible cause? ✓ Do you take diuretic or use laxatives? After the unlicensed assistive personnel (UAP) tells the nurse that an older patient will not eat dinner. The nurse enters the patient's room to assess the situation. Which factors likely to the patient s lack of food to eat (select all that apply) ✓ An emesis basin in on the bedside table the volume of the television is loud the food is cold Housekeeping staff is in the room disinfecting the bathroom The client's roommates has two adults and three children visiting

what is the priority nursing intervention when planning meals for a client who is malnourished? Provide the client with high-calorie, high-protein food ✓ Determine the client's food preferences a nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question would the nurse ask? ✓ Do you live in crowded residence? a nurse is preparing a teaching plan for a client with migraine headaches who is receiving a beta blocker daily to help manage this disorder, which instruction would be appropriate to relay to this client? ✓ "Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches." a client with a history of bronchitis for a greater than 20 years is hospitalized. What this clients' history s potential complication? ✓ Right-side heart failure the nurse is assessing a client in an outpatient clinic. Which client statement alerts the nurse to possible left-sided heart failure? ✓ I have to stop halfway up the stairs to catch my breath and l'm out not urinating as much The nurse is caring for a client being discharged after treatment for acute diverticulitis. Prior to discharge the nurse should instruct the client to avoid which of the following foods in the diet? ✓ Poppy seeds, strawberries, cucumbers

a nurse is caring a client who is being admitted for an acute exacerbation of ulcerative colitis which of the following is the highest priority for the nurse? ✓ Review the client's electrolyte values Which neurologic disorder is most likely to require hourly sensory assessments of a patient? ✓ Gallian syndrome The nurse is caring for a client who was started on total parenteral nutrition (TPN) two days previously. The client reports increased thirst, dry mouth, and voiding frequently, which is the nurse's most appropriate action? ✓ Assess the client's blood sugar the nurse intends to participate in health screening clinic and is preparing teaching materials about colorectal cancer. ✓ Personal history of GL polyps the nurse is teaching a group of adults in the community about the 2015-2010 dietary guidelines for Americans. Which does the nurse emphasize as a dietary suggested in these guidelines for Americans? What does the nurse emphasize as dietary strategy suggested in these guidelines? ✓ Adults should focus on variety and nutrient density and not calories which statement by a client with chronic obstructive pulmonary disease (CO PD) and a 10 pounds (4.5 kg) weights loss indicates the need for additional follow-up instruction?

✓ I should consume plenty of fluids with meal the nurse is assessing a client with recent changes in hearing. After taking drugs does the nurse identify as possible causes of the client's hearing change? ✓ Furosemide (Lasix) the patient's chart indicates a sensorineural hearing loss. What assessment question does the nurse ask to determine the possible cause? ✓ Have you been exposed to loud noises? The nurse is caring for a client who was recently diagnosed with type Il diabetes. The client is visibly upset about the diagnosis and states, "Now Pll never be able to keep my jab as a teacher. I've heard that diabetes causes blindness." The best response by the nurse is: ✓ Controlling glucose and blood pressure reduces the risk for blindness the nurse assess a client who has myasthenia gravis. Which clinical manifestation does the nurse expect to observe in this client? ✓ Muscle weakness that worsens with use and improves with test the home health nurse visits a client with heart failure who has gained5 pounds (2.3 kg) in the past 3 days. The client states, "I feel so tired and short of breath." Which action does the nurse take first? ✓ Auscultate the client's posterior breath sounds

the nurse is caring for a client following a gastric resection and is monitoring the client closely for signs of symptoms is indicative of dumping syndrome ✓ Abdominal cramping and right lower quadrant pain the client with heart failure has been prescribed intravenous nitroglycerin and furosemide for pulmonary edema. Which is the priority nursing intervention? ✓ Monitor the client's blood pressure The nurse administering potassium to a patient carefully monitors the infusion because of the risk for which condition? ✓ Cardiac dysrhythmia the nurse is overseeing a nursing student who is administering medications to a group of clients receiving treatment for pulmonary embolism. The nurse recognizes the student understands safety and administration of anticoagulant therapy when the student makes which of these statements? ✓ Therapy with warfarin (coumadin)is effective when the INR is between 2 and 3 A client who is receiving combination Antiretroviral therapy (CART: formerly HAART) tells the nurse," the doctor said that my viral load is reduced. What does this mean?" what is the nurse response? ✓ The medications are working well right to suppress the viral load The nurse is caring for a client to have immunotherapy due to severe allergies. Knowing that is being exposed to a known allergen, what intervention does the nurse. This allergy treatment?

✓ Stay with the client and ensure that emergency equipment in the room A nurse assess a client with diabetes mellitus who has admitted with an acid-base- imbalance. The client's arterial blood gas values are PH 7.36, pacO2 33, HCO3 18. Which manifestations does the nurse identify as an example of the client's acid-base compensation mechanism? ✓ Increased rate and depth of respirations A patient admitted for pneumonia has been tachypneic for several days. When the nurse starts an iv to give fluids, the patient questions this action, saying " I have been drinking tons of water. How am I dehydrated? The nurse best is? ✓ Breathing so quickly can be de hydrating A client is diagnosed with glaucoma and is prescribed medication to treat it. The nurse knows that which of the following best explains the purpose of medication? ✓ This medication lowers intraocular pressure a client is complaining of dizziness, unliteral ringing in ear, feeling of pressure or fullness in the ear, and unilateral hearing loss. Which would the nurse suspect experiencing ✓ Meniere's disease the nurse has admitted to the intermediate care unit a client who is sustained a spinal cord injury at TL in a motor vehicle accident. Which nursing care activity can the nurse delegate to the unlicensed assistive person this client? ✓ Measure oxygen saturation level every hour