1. A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure ulcer. Which of the following actions should the nurse take? - Use a 30 mL syringe 2. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take? - Remain with the client for the first 15 minutes of the infusion. 3. A nurse in an emergency department is assessing a client who has a detached retina. Which of the following should the nurse expect the client to report? - It's like a curtain closed over my eye. 4. A nurse is reviewing the laboratory results of a client who had a recent exposure to hepatitis C virus. Which of the following tests should the nurse identify as indicating the presence of hepatitis C antibodies? - Enzyme immunoassay (EIA) 5. A nurse is caring for a client who has active bleeding from peptic ulcer disease. Which of the following findings is an indication that the client is experiencing compensatory shock? - Increased heart rate 6. A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify that which of the following findings requires further screening? - Shellfish allergy 7. A nurse is providing teaching to a client who has a recent diagnosis of constipationpredominant irritable bowel syndrome. Which of the following instructions should the nurse include in the teaching? - Consume at least 30 g of fiber daily 8. A nurse is caring for a client who has type 1 diabetes mellitus and has had acute bronchitis for the past 3 days. Which of the following statements should the nurse include when instructing the client? - Take insulin even if you are unable to eat your regular diet. 9. A nurse is reviewing the laboratory report of a client who is receiving nonsurgical treatment for Cushing's disease. Which of the following laboratory findings should the nurse identify as a positive outcome of the treatment? - Decreased sodium 10. A nurse is reviewing the laboratory results of a client who has AIDS and is taking amphotericin B for a fungal infection. The nurse should identify that which of the following values is an indication of an adverse effect of the medication? - BUN 34 mg/dL 11. An older adult client is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration? - Urine specific gravity is 1.045 12. A nurse is caring for a client who has had a cerebrovascular accident. Which of the following findings indicates that the client has homonymous hemianopsia? - The client has to turn her head to see the entire visual field. 13. A nurse is assessing heart sounds of a client who reports substernal precordial pain. Identify which of the following sounds the nurse should document in the client's medical record by listening to audio clip. - Pericardial friction rub 14. A nurse is providing teaching to a client who has end-stage kidney disease and is waiting for a kidney transplant. Which of the following information should the nurse provide? - Hemodialysis is sometimes needed after surgery. 15. A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The nurse should postpone the testing and report to the provider which of the following findings? - Current medications 16. A nurse is assessing a client who is receiving morphine via a PCA pump. Which of the following findings indicates an adverse effect of the medication? - Urinary retention