Question

1. A nurse is assessing a client whose therapy has included bed rest for several weeks. Which of the following findings should the nurse identify as the priority?
   1. Musculoskeletal weakness
   2. Loss of appetite
   3. Increase heart rate during physical activity
   4. Left lower extremity tenderness
2. A nurse is assessing a client’s ability to balance. Which of the following actions is appropriate when the nurse conducts a Romberg test?
   1. Ask the client to extend her arms in front of her body.
   2. Ask the client to walk in a straight line heel to toe.
   3. Have the client stand with her feet together.
   4. Have the client place her hands on her hips
3. A nurse is caring for a client who has a tracheostomy collar. As the nurse is performing tracheal suctioning, the client’s heart rate and oxygen saturation decrease. Which of the following actions should the nurse take?
   1. Elevate the head of the bed.
   2. Remove the inner cannula.
   3. Irrigate the stoma.
   4. Discontinue suctioning.
4. A nurse is caring for a client who has a new diagnosis of terminal cancer. Which of the following interventions is the priority?
   1. Teach the client to use progressive relaxation techniques.
   2. Help the client to find a local support group.
   3. Discuss the client’s prior coping mechanisms.
   4. Develop a list of goals with the client.
5. A staff nurse is teaching a newly hired nurse how to complete an informed consent document for a client. The staff nurse should include that the nurse’s signature on the form confirms which of the following requirements? (SATA)
   1. The client was not coerced.
   2. The client does not have a mental health condition.
   3. The client signed in the nurse’s presence.
   4. The client speaks the same language as the nurse.
   5. The client has legal authority to do so.

Answer 1

Answer:- 1 A musculoskelatol weak ness due to muscles spasm.

Answer :- 3 D discontinued, stop the auction

Answer :- 4 C the discuss clients prior copy mechanism