NUR 2571 Professional Nursing II PN2 Exam 2 Question: A client with bacterial pneumonia becomes increasingly restless and confused. Temperature is 100 F, and pulse, blood pressure, and respirations are increased since the last assessment 6 hours ago. Which action should the nurse take first? Answer: assess oxygen saturation Question: Which of the following would the nurse most likely assess in a client diagnosed with right -sided heart failure? Answer: distended neck veins Question: A client with an acute exacerbation of chronic obstructive pulmonary disease (COPD) is admitted to the hospital. How can the nurse best position the client to improve gas exchange Answer: Sitting up at the bedside or in a chair and leaning slightly forward Question: A client receiving a heparin infusion is demonstrating signs of acute bleeding. Which of the following should the nurse anticipate the provider to prescribe for this client? Answer: Protamine sulfate Question: A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. Which action should the nurse take? Answer: Administer pain medication and encourage the client to take deep breaths Question: A nurse is caring for a client who has heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should be a priority for the nurse to take? Answer: check the clients vital signs and heart rhythm Question: which of the following statement should the nurse teach a client who is receiving warfarin sodium? Answer: International normalized ratio (INR) is used to assess its effectiveness. Question: A client comes into the emergency department with acute shortness of breath and a cough that produces pink, frothy sputum. Admission assessment reveals crackles and wheezes, a blood pressure of 85/46 mm Hg, a heart rate of 122 beats/ minutes, and a respira tory rate of 38 breaths/minutes. The client's medical history included diabetes mellitus (DM), hypertension (HTN), and heart failure. Which of the following disorders should the nurse suspect? Answer: Pulmonary edema
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