Problem 1: The nurse is planning care for a client with multiple sclerosis (MS) who has ataxia. Which of the following interventions should the nurse include in the client's plan of care? 1. Add thickener to thin liquids for the client. 2. Obtain a referral to a physical therapist for the client. 3. Face the client directly when speaking with the client. 4. Provide a board with pictures to help the client communicate needs.
Problem 2: The home-health nurse is assigned to visit the following clients who live within 3 miles (4.8 km) of one another. The nurse should first visit the client with 1. breast cancer who had a mastectomy 2 days ago and has had 25 mL of drainage from the closed-wound drainage system in the past 12 hours 2. lung cancer who received a dose of chemotherapy 2 weeks ago and has a temperature of 101.1° F (38.4° C) 3. chronic obstructive pulmonary disease (COPD) who is reporting expectorating large amounts of thick, yellow mucus 4. diabetes mellitus (type 1) who had a right below-the-knee amputation (BKA) and is reporting having right toe pain
Problem 3: The nurse has become aware of the following client situations. The nurse should first assess the client 1. who had a total abdominal hysterectomy (TAH) 1 day ago and is unable to void 7 hours after the indwelling urethral catheter was removed 2. who had a total knee replacement 24 hours ago, is restless, and has a petechial rash on the chest 3. with bacterial pneumonia who has bronchial breath sounds auscultated between the scapulae and a temperature of 103.3° F (39.6° C) 4. with hepatic cirrhosis who has an elevated aspartate aminotransferase (AST) level and respirations of 24
Problem 4: The nurse is planning care for a pediatric client being admitted with pertussis. Which of the following interventions should the nurse include in the client's plan of care? 1. Keep the client NPO. 2. Place a dehumidifier in the client's room. 3. Encourage the client to ambulate frequently. 4. Implement droplet precautions.