Uworld NCLEX-RN TEST 2 Questions With 100% Correct Answers | Verified | Latest Update, Exams of Advanced Education

Download Uworld NCLEX-RN TEST 2 Questions With 100% Correct Answers | Verified | Latest Update and more Exams Advanced Education in PDF only on Docsity! Uworld NCLEX-RN TEST 2 Questions With 100% Correct Answers | Verified | Latest Update A nurse coworker is called into work from home to help care for an influx of clients being admitted after a bus accident. While assisting the coworker prepare for incoming clients, the nurse becomes concerned that the coworker may be under the influence of an impairing substance. Which action by the nurse is best? 1. Ask another coworker to observe the individual to confirm the suspicion 2. Confront the coworker about the concern and offer emotional support 3. Speak with the nursing supervisor about the concern 4. Telephone the appropriate regulatory agency and make a report - Correct Answer-3. A nurse is administering a rituximab infusion to a client with lymphoma in an oncology clinic. Which client symptom would be a priority to report to the health care provider? 1. Dizziness and sudden diarrhea 2. Nausea and onset of vomiting 3. New-onset tachypnea and dyspnea 4. Temperature of 101 F (38.3 C) - Correct Answer-3. The student nurse plans postmortem care for an Orthodox Jewish client hospitalized for the last week with heart failure who did not sign consents for any postmortem actions. Which statement by the student would require further education by the supervising nurse? 1. "I will allow the family to remain with the client at all times." 2. "I will call the next of kin before providing any postmortem care." 3. "I will prepare the client for transfer to the morgue for autopsy." 4. "I will provide a sheet to be placed over the client's face." - Correct Answer-3. The nurse is caring for a client with chronic pancreatitis. Which meal should the nurse recommend when assisting the client in selecting food items from a menu? 1. Baked tilapia with lemon wedge, sweet potatoes, and green peas 2. Cream of potato soup and roast beef sandwich on a croissant 3. Sautéed salmon, macaroni and cheese, string beans, and a biscuit 4. Shrimp enchiladas with tomato salsa, rice, cornbread, and refried beans - Correct Answer-1. The nurse is preparing to change the dressing of a client's subclavian central venous catheter using a chlorhexidine gluconate (CHG)-impregnated patch and transparent adhesive dressing. Place the procedural steps in the correct order. All options must be used. Apply CHG patch over catheter insertion site and cover with a sterile transparent dressing Cleanse the site with CHG for at least 30 seconds using friction; allow to air dry completely Discard the clean gloves, perform hand hygiene, and apply sterile gloves Perform hand hygiene, don face mask, place a mask on the client, and apply clean gloves Remove old dressing and CHG-impregnated patch; assess insertion site - Correct Answer-Perform hand hygiene, don face mask, place a mask on the client, and apply clean gloves Remove old dressing and CHG-impregnated patch; assess insertion site Discard the clean gloves, perform hand hygiene, and apply sterile gloves Cleanse the site with CHG for at least 30 seconds using friction; allow to air dry completely Apply CHG patch over catheter insertion site and cover with a sterile transparent dressing Four clients enter the pediatric emergency department at the same time. Which client should the nurse see first? 1. 2-week-old with tricuspid atresia who has dusky lips and nailbeds 2. 5-week-old with forceful vomiting after every feeding who is crying 3. The licensed practical nurse (LPN) leaves the client's report sheet in the cafeteria after lunch 4. The LPN tells the unlicensed assistive personnel (UAP) who is pregnant to not enter the room of a client with toxoplasmosis 5. The UAP tells a client that the hospital roommate will return to the room after receiving hemodialysis - Correct Answer-2, 3, 5 A nurse is screening clients for skin cancer. Which assessment would be most concerning? 1. Client with a blue and black, irregular papule on the hand 2. Client with a pearly, pink papule with ulceration on the ear 3. Client with a pink patch with silvery scales on the neck 4. Client with a red, scaly patch with rough edges on the forehead - Correct Answer-1 The nurse determines that a client with incontinence and limited mobility is at increased risk for skin breakdown and pressure injury. While caring for this client, which of the following nursing interventions are appropriate? Select all that apply. 1. Applying moisture barrier cream to the skin after performing perineal care 2. Providing a diet that is high in protein and contains adequate calories 3. Repositioning the client using a turn sheet every 2 hours 4. Restricting fluid intake to ≤2 L/day to reduce number of incontinent episodes 5. Using foam padding placed under the client's legs to elevate the heels - Correct Answer-1, 2, 3, 5 The client admitted to the psychiatric unit with severe anxiety is pacing rapidly in the room, crying, and hyperventilating. The client yells, "I can't believe you took my belongings! Where are you keeping them? This is so frustrating!" What is the appropriate response by the nurse? 1. "I understand that you are frustrated. I will give you some time to yourself to decompress." 2. "This is frustrating for me too. I wish I could give you your belongings right now, but I can't." 3. "Would you like to sit down so we can talk? Pacing like this will make you feel worse." 4. "Your belongings are locked in a safe place to ensure that they are protected while you are here." - Correct Answer-4 The nurse is caring for a client who is 2 days postoperative craniotomy with bone flap removal. The nurse notes clear wound drainage saturating the dressing over the incision. Which action by the nurse is most appropriate at this time? 1. Cleanse the incision site with saline and apply a new, sterile dressing 2. Mark the edges of the drainage on the dressing and continue to monitor 3. Notify the health care provider of the color and amount of drainage 4. Turn the client onto the nonoperative side using the log-rolling technique - Correct Answer-3 A nurse caring for a client following a right femoral angiogram is unable to palpate the right pedal pulse. What should the nurse do next? 1. Apply a heating pad to increase circulation 2. Call the health care provider 3. Document "0" for right pedal pulse strength 4. Obtain a Doppler ultrasound - Correct Answer-4 The following 4 clients are assigned to the emergency department nurse. Which client should the nurse see first? 1. Client in a motor vehicle collision whose head hit the steering wheel 2. Client who is 6 months pregnant and slipped and fell on icy stairs 3. Client who sustained a stab wound through the hand during a fight 4. Client with a 1-in (2.5 cm) leg laceration acquired during a soccer game - Correct Answer-1 What nursing intervention is most appropriate when caring for a client with impairment to cranial nerve II? 1. Ensure that the client has a mechanical soft diet 2. Raise the head of the bed to prevent aspiration 3. Use pen and paper to write instructions 4. Verbally explain nursing interventions in detail - Correct Answer-4. After assessing 4 clients in the pediatric emergency department, the nurse should alert the health care provider to see which client first? 1. 4-month-old who is lethargic with fever and vomiting 2. 2-year-old who is alert and calm with an occasional barking cough 3. 8-year-old with cola-colored urine and generalized edema 4. 15-year-old who is withdrawn and having painful urination - Correct Answer-1. A nurse is preparing to administer a unit of packed red blood cells to a critically ill client. Two nurses have performed the verification process, and the unit label indicates that it is in-date and unexpired. On inspection, the nurse notices a large air bubble at the top of the bag. What is the appropriate action by the nurse at this time? 1. Call the blood bank to verify the expiration date and the safety of the blood for administration 2. Call the health care provider for further instruction and file an incident report 3. Proceed with administration as any air will be caught by the drip chamber of the tubing 4. Return the blood to the blood bank, notify them that air is present, and obtain a new bag - Correct Answer-4. The nurse checks a client's blood pressure using an automatic, noninvasive machine. The nurse notes that the machine inflates for an unusually long amount of time, and the client reports intense pain in the arm with the cuff. The device suddenly stops inflation and displays an error message. Which action by the nurse is appropriate? 1. Place a soft washcloth under the cuff and repeat the measurement 2. Repeat the measurement after moving the cuff to the opposite arm 3. Repeat the measurement using a new cuff that is a size larger than the client needs 4. Send the machine for maintenance and repeat the measurement manually - Correct Answer-4 The clinic nurse is listening to voicemail messages in the office. Which client should the nurse call back first? 1. Client started on capsaicin cream 2 days ago reports sudden burning in the eyes 2. Client started on carbidopa-levodopa a day ago reports dizziness on standing 3. Client started on hydroxyzine 3 days ago reports urinary difficulty and hesitancy 4. Client started on phenytoin a week ago reports blistered lesions on the face and trunk - Correct Answer-4 The nurse responds to a neighbor's calls for help and finds the neighbor's infant is choking but still responsive. Which intervention is most appropriate at this time? 1. Call 911 and begin cardiopulmonary resuscitation 2. Perform 5 back slaps followed by 5 downward chest thrusts 3. Perform a finger sweep of the mouth to assess for foreign objects 4. Place the infant on the nurse's lap and perform abdominal thrusts - Correct Answer-2 The nurse is teaching a client about newly prescribed cyclosporine. Which client statement indicates a need for further teaching? 1. "I am going to a concert with my friends this weekend." 2. "I can use a hair removal cream for excess hair growth." 3. "I will need to check my blood pressure regularly at home." 4. "I will stop drinking grapefruit juice every morning." - Correct Answer-1 The clinic nurse is caring for a 76-year-old client who has heart failure and is experiencing sudden weight gain and orthopnea. Which question would be the most beneficial for the nurse to ask at this time? Click the exhibit button for additional information. Exhibit Daily Medications Digoxin: 0.125 mg by mouth, once daily Furosemide: 40 mg by mouth, once daily Sucralfate: 1 g by mouth, 4 times daily as needed for heartburn 1. "Are you continuing to exercise regularly?" 2. "Do you check your heart rate before taking your medications?" 3. "When are you taking each of your medications?" 4. "When was your most recent visit to the primary care clinic?" - Correct Answer-3. The home health nurse visits a client with inflammatory bowel disease who recently underwent a total colectomy with ileostomy creation. Which statement by the client indicates that the client understands ileostomy care? 1. "I can irrigate the stoma daily to help regulate stool drainage." 2. "I change the ostomy appliance and bag every morning." 3. "I cut the appliance opening slightly larger than my stoma." 4. "I restrict how much I drink to make the stool drainage less watery." - Correct Answer-3. A nurse is providing teaching to a client newly prescribed verapamil for chronic migraine headaches. Which statement by the client indicates the need for further teaching? 1. "I will avoid taking this medication with grapefruit or grapefruit juice." 2. "I will make sure my pulse is greater than 60 before I take this medicine." 3. "I will take this medication at the first sign of a migraine." 4. "I will take this medicine with plenty of water and increase my intake of fiber." - Correct Answer-3. The nurse assesses the heart sounds of a 77-year-old client with chronic heart failure. Which heart sound should the nurse document? Listen to the audio clip. (Headphones are required for best audio quality.) 1. Pericardial friction rub 2. S1, S2, no adventitious sounds 3. S3 extra heart sound 4. Systolic murmur - Correct Answer-3. The labor and delivery nurse is caring for a client whose unborn child has been diagnosed with anencephaly. Which of the following nursing actions are appropriate for supporting the client in preparation for birth? Select all that apply. 1. Avoid bringing up the newborn's prognosis to prevent upsetting the client 2. Discuss the newborn's expected appearance with the client 3. Educate the client that grieving cannot truly begin until one cries 4. Explore the client's preferences for social and spiritual support 5. Remind the client of the ability to conceive again in the future - Correct Answer-2, 4 A client is diagnosed with septic arthritis of the knee. What manifestations does the nurse expect to find? Select all that apply. 1. Fever 2. Joint swelling with effusion 3. Limited range of motion 4. Moderate to severe pain 5. Numbness in the extremity - Correct Answer-1, 2, 3, 4 The monitor tech on the telemetry unit notifies the charge nurse that there are no more client telemetry boxes available for new admissions. Which client should the charge nurse consider for discontinuation of telemetry monitoring? 1. Client awaiting pacemaker battery replacement with a heart rate of 72/min 2. Client on observation to rule out myocardial infarction who has no ST elevation 3. Client with chronic atrial fibrillation prescribed warfarin with an INR of 3.0 4. Client with second-degree type 2 heart block with a blood pressure of 126/78 mm Hg - Correct Answer-3 The nurse is reviewing health history information for a client who is being seen for a routine physical examination. Which of the following clinical findings indicate that the client is at risk for latex allergy? 1. Had an etonogestrel implant inserted 9 months ago for birth control 2. The client reports pain "all over" and rates the pain as 9 on a scale of 0-10. The client reports anxiety and is short of breath when walking to the bathroom. The client is also scratching the arms and reports itching. Auscultation of the client's lungs reveals crackles in the bilateral lower lobes. Notified the health care provider, prescriptions received. 1. Diphenhydramine 25 mg IV every 8 hours, PRN for itching 2. Furosemide 20 mg IV once, now 3. Lorazepam 1 mg IV once, now 4. Morphine 2-4 mg IV every 4 hours, PRN for pain - Correct Answer-2. A nurse assists a student nurse in formulating a care plan for a nonverbal hospice client who demonstrates restlessness and facial grimacing during repositioning. Which statements by the student nurse indicate a correct understanding of the goals of end-of- life care? Select all that apply. 1. "I can observe the client's agitation as an indicator of the client's pain level." 2. "I should ask the family to leave the client alone if the client becomes restless." 3. "I should continue to explain interventions I am performing even though the client is unresponsive." 4. "I will ask the family if they would like to hold the client's hand while I administer pain medication." 5. "Managing pain rather than treating disease is the priority goal for this client." - Correct Answer-1, 3, 4, 5 The clinic nurse instructs a female client on how to collect a clean-catch urine specimen for culture and sensitivity. Which of the following client statements indicate that teaching has been effective? Select all that apply. 1. "l will be very careful not to touch the inside or rim of the container." 2. "I will begin to urinate before passing the container into the stream for collection." 3. "I will carefully cap the container and repeat the process later if I cannot fill it." 4. "I will cleanse the area with single-use antiseptic wipes prior to urinating." 5. "I will have to collect the specimen when I first urinate tomorrow morning." - Correct Answer-1, 2, 4 The nurse reviews self-care strategies for a client with overflow urinary incontinence. Which client statement indicates a need for further teaching? 1. "I should increase the amount of fiber in my diet so that I do not become constipated." 2. "I should leave my desk every 2 hours to walk around a bit and to use the bathroom." 3. "I will decrease my fluid intake to 6 glasses each day and avoid drinking fluids after 7 PM." 4. "I will use my hand to apply pressure over my lower abdomen when I urinate." - Correct Answer-3. The nurse is caring for a client with non-Hodgkin lymphoma who is starting chemotherapy. What assessment findings alert the nurse that the client is developing the potential complication of tumor lysis syndrome? 1. Facial and upper body edema 2. Generalized edema and hyponatremia 3. Hyperkalemia and hyperuricemia 4. Hypotension and elevated lactic acid - Correct Answer-3. The nurse on a medical-surgical unit prepares scheduled daily medications for a client and places them in a pill cup. After receiving the pill cup, the client states, "I take a whole tablet of metoprolol at home. Why did you cut this one in half?" What is the best response by the nurse? 1. "Do you know how many milligrams of metoprolol you normally take at home every day?" 2. "Show me which pill you're talking about so I can verify your prescriptions again." 3. "This is the same dose you received the past 3 days in the hospital, so we know it's safe to take." 4. "Your health care provider has prescribed a half-dose of metoprolol while you're in the hospital." - Correct Answer-2. The nurse assesses a client who is intubated and mechanically ventilated after a cerebrovascular accident. Which assessment finding is most important for the nurse to report to the health care provider? 1. Flaccid right hand and arm 2. Impaired gag reflex when suctioning 3. Presence of urinary incontinence 4. Rigid flexion of arms at the elbows - Correct Answer-4. The nurse is preparing to discharge a client 4 days after colostomy placement. Which of the following findings are concerning and require further investigation? Select all that apply. 1. Areas of excoriation are noted on the skin surrounding the stoma. 2. No bowel sounds are present and the client reports nausea. 3. The client states, "I will call home health to come empty the pouch." 4. The client states, "There is a little gas in the colostomy bag." 5. The stoma is red, edematous, and smaller than the previous day. - Correct Answer-1, 2, 3 The emergency department nurse is caring for a client with diabetic ketoacidosis. Which new prescription should the nurse implement first? Click on the exhibit button for more information. Exhibit Laboratory resultsSerum glucose451 mg/dL (25 mmol/L)Serum pH6.9PaO291 mm Hg (12.1 kPa)PaCO227 mm Hg (3.6 mmol/L)HCO312 mEq/L (12 mmol/L) 1. Administer 50 mEq sodium bicarbonate IVP 2. Give 1 L bolus of 0.9% sodium chloride IV 3. Initiate a continuous infusion of regular insulin 4. Insert and maintain an indwelling urinary catheter - Correct Answer-2. The nurse provides discharge teaching for family members of a client going home following a suicide attempt. Which of the following instructions are appropriate for the nurse to include? Select all that apply. 1. 3. "My child ate a large container of chocolate ice cream in one evening." 4. "My child frequently leaves the table during meals to go to the bathroom." 5. "The dentist informed me that my child's tooth enamel is wearing away." - Correct Answer-3, 4, 5 The nurse is admitting a client with a seizure disorder and delegates preparation of the client's room to the student nurse. Which of the following actions by the student nurse indicate a correct understanding of seizure precautions? Select all that apply. 1. Ensures that suction equipment is present and operable 2. Ensures that supplemental oxygen and a bag valve mask are present 3. Places an oral airway at the head of the bed 4. Places padding on the side rails of the bed 5. Tapes a padded tongue blade at the head of the bed - Correct Answer-1, 2, 4 The nurse has provided teaching to the parents of a 6-month-old child who is being discharged with a new prescription for a liquid iron supplement. Which statements by a parent indicate a need for additional instruction? Select all that apply. 1. "Our child might become constipated while taking this medication." 2. "Our child's stools might become black and tarry." 3. "We can give the dose with milk to prevent stomach irritation." 4. "We will administer the dose into the back of our child's cheek." 5. "We will administer the dose with meals to increase absorption." - Correct Answer-3, 5 A nurse in the intensive care unit is responding to a low-pressure limit mechanical ventilator alarm. The nurse will assess for which conditions that can trigger a low- pressure alarm? Select all that apply. 1. Client has pulled out endotracheal tube 2. Client is coughing or gagging 3. Endotracheal tube cuff is leaking 4. Secretions are built up in endotracheal tube 5. Ventilator tubing is disconnected - Correct Answer-1, 3, 5 The nurse is reviewing home instructions with a client who just underwent cataract surgery with intraocular lens implantation. Which of the following client statements indicate appropriate understanding of the teaching? Select all that apply. 1. "I am concerned because my vision is still blurry." 2. "I can expect a lot of pain in the next few days." 3. "I need to wear an eye patch at night." 4. "I should avoid sexual intercourse until I'm healed." 5. "I will increase my fluid intake and take docusate daily." - Correct Answer-3, 4, 5 The nurse working in a gastrointestinal clinic is reviewing the list of walk-in clients. Which client should the nurse see first? 1. Client reporting constipation since having a barium enema 3 days ago 2. Client reporting moderate flatulence after a resolved bowel obstruction 3. Client with irritable bowel syndrome reporting 3 or 4 loose stools a day for the past 3 days 4. Client with ulcerative colitis reporting 2 or 3 loose, bloody stools a day - Correct Answer- 1. The staff nurse is preparing a presentation about strategies to reduce horizontal violence. The nurse educator is reviewing the presentation beforehand. Which recommendation included in the presentation indicates a need for further teaching? 1. Creating a behavior code of conduct outlining communication 2. Creating a suggestion box for anonymously reporting bullying 3. Providing consistent education regarding bullying 4. Working toward diversification of staff age and gender - Correct Answer-4. Using SBAR (Situation, Background, Assessment, Recommendation/Request) to communicate with the health care provider, which statement should the nurse include to describe the situation? 1. "I'm calling about the client in 711 who has low blood pressure and is symptomatic." 2. "The client has a limited code status and requests no intubation or compressions." 3. "The client was admitted for acute respiratory failure and intubated on September 16." 4. "The client's blood pressure was 97/45 mm Hg an hour ago and is now 88/40 mm Hg." - Correct Answer-1. An unconscious 22-year-old client is brought to the emergency department after being hit in the head by a steel rod. The nurse should monitor for which assessment findings that are most characteristic of markedly increased intracranial pressure with impending brainstem herniation? 1. Bradycardia and widening pulse pressure 2. Irregular respirations and hypothermia 3. Sluggish pupil response and otorrhea 4. Sudden increase in alertness and hypertension - Correct Answer-1. The nurse reinforces teaching for a client newly diagnosed with primary open-angle glaucoma. Which of the following client statements indicate that teaching has been effective? Select all that apply. 1. "After a few months of using the eye drops, my vision will be near normal." 2. "I need to keep all follow-up appointments with my health care provider." 3. "I will check with my health care provider before using allergy or cold medications." 4. "I will need to use prescribed eye drops for the rest of my life." 5. "If I see colored halos around lights, I should notify my health care provider." - Correct Answer-2, 3, 4, 5 Four clients enter the emergency department at the same time. Which client should the nurse alert the health care provider to see first? 1. 6-year-old who is crying and reports a headache after hitting the head 2. 17-year-old who cannot raise arm above head after a football injury 3. 40-year-old with a first-degree burn and singed beard from a campfire 3. Encourage visits and social media contact from a 16-year-old's peers 4. Have a 10-year-old participate in care by keeping track of oral fluid intake with the nurse 5. Remind the parent of a 2-month-old to respond quickly to the infant's cries - Correct Answer-1, 3, 4, 5 A pregnant client in the third trimester completes an intake form for a clinic visit. The nurse understands that which signs and symptoms warrant further investigation? Select all that apply. 1. Copious amounts of watery, clear vaginal discharge 2. Dysuria and right flank pain 3. Ear fullness and nasal stuffiness 4. Headache and blurred vision 5. Yellowish discharge from both nipples - Correct Answer-1, 2, 4 The nurse is reinforcing education to a client prescribed methadone for management of chronic pain. Which of the following client statements indicate a correct understanding? Select all that apply. 1. "I should not consume alcohol while taking this medication." 2. "I will stand up slowly when getting out of a bed or a chair." 3. "If my pain is not managed with one tablet, I can take an additional tablet." 4. "My family should learn to use the naloxone auto-injector in case I am oversedated." 5. "This medication can cause problems with my heart, so I will need regular checkups." - Correct Answer-1, 2, 4, 5 The nurse is reinforcing education about good sleep hygiene to a client with chronic insomnia. Which instructions should the nurse include? Select all that apply. 1. "Avoid caffeine-containing beverages for at least 4 hours before bedtime." 2. "Drink a glass of red wine before you go to bed." 3. "If you are still awake 20 minutes after going to bed, get out of bed and read a book." 4. "Prepare the bedroom environment by making it dark, quiet, and cool." 5. "Watch television in bed until you feel tired enough to fall asleep." - Correct Answer-1, 3, 4 The nurse is teaching a group of clients about the use of complementary and alternative therapies. Which client statement indicates that further teaching is needed? 1. Client on apixaban who states, "I think I will try acupuncture for my arthritis." 2. Client on atorvastatin who states, "I have been taking garlic to help with my cholesterol." 3. Client with lupus who states, "I see a massage therapist for my muscle pain and stiffness." 4. Postpartum client who states, "I found a biofeedback coach for pelvic muscle training." - Correct Answer-1. The clinic nurse is discussing injury prevention with the parent of a 6-month-old infant. Which statements by the parent indicate that teaching has been effective? Select all that apply. 1. "I can switch to a front-facing car seat as my baby is in the 99th percentile for height." 2. "I do not need a childproof gate by the stairs as my baby cannot walk yet." 3. "I should place safety locks on the cabinets under the bathroom and kitchen sinks." 4. "I use the restraining belt on the changing table if I leave the room to get more supplies." 5. "I will need to move sharp or breakable objects onto high shelves, out of reach." - Correct Answer-3, 5 The nurse receives report on a client with chronic atrial fibrillation who had an episode of torsades de pointes during the night. The client spontaneously converted back to the baseline rhythm of atrial fibrillation and is now stable. Which information should the nurse immediately report to the health care provider? 1. Client is scheduled to receive a dose of sotalol this morning 2. Client is scheduled to receive a dose of warfarin this afternoon 3. Client's magnesium level is 2.2 mEq/L (1.1 mmol/L) 4. Client's potassium level is 4.5 mEq/L (4.5 mmol/L) - Correct Answer-1. The nurse is caring for a client in labor at 37 weeks gestation and notes a baseline fetal heart rate of 180 beats per minute. Which interventions should the nurse perform? Select all that apply. 1. Measure maternal blood pressure 2. Reassess fetal heart rate in an hour 3. Reduce IV fluid rate 4. Review medication administration record 5. Take maternal temperature - Correct Answer-1, 4, 5 Which of the following methods would the nurse use to collect a urine sample for culture and sensitivity testing in a 16-month-old client? 1. Apply a urine collection bag to the perineum 2. Aspirate a specimen from an indwelling catheter collection bag 3. Insert a sterile intermittent urinary catheter 4. Place cotton balls inside the diaper - Correct Answer-3. The nurse is caring for a client diagnosed with acute pericarditis. Which assessment finding would cause the nurse to immediately contact the health care provider? 1. Chest pain, worse when in supine position 2. Muffled heart sounds and narrow pulse pressure 3. Pericardial friction rub on auscultation 4. ST-segment elevation on all ECG leads - Correct Answer-2. The charge nurse is rounding on clients in restraints. Which of the following situations would require immediate intervention by the nurse? 1. Client in a belt restraint in the semi-Fowler position 2. Client in mitten restraints in the side-lying position 3. Client in soft wrist restraints in the supine position 4.