RN Adult Medical Surgical Online Practice 2019 B/
16. A nurse is teaching a family about the care of a parent who has a new diagnosis of Alzheimer's disease. Which
of the following information should the nurse include in the teaching?: Create complete outfits and allow the client to
select one each day
Rationale: The family should place completed outfits on hangers and allow the client to select which one to wear each
17. A nurse is caring for a client who has breast cancer and tells the nurse that they would like to have
acupuncture because it provides greater relief than pain medication. Which of the following statements should the
nurse make?: "I can speak to the provider about incorporating acupuncture into your treatment plan."
Rationale: The nurse should serve as an advocate for the client by acting on behalf of the client and offering to speak with
the provider. The client has the right to make choices and decisions about their treatment and the nurse should support
these decisions and assist the client to carry them out.
18. A nurse is caring for a client following extubation of an endotracheal tube
10 min ago. Which of the following findings should the nurse report to the provider immediately?: Stridor
Rationale: Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is
stridor. Stridor can indicate a narrowing airway or possible obstruction caused by edema or laryngeal spasms. The nurse
should report the finding immediately and implement an intervention.
19. A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago.The nurse should
identify which of the following findings as an indication of a myocardial infarction (MI)?: Troponin I 8 ng/mL
Rationale: Troponins are proteins present in skeletal and cardiac muscle that are involved with muscle contraction. The
elevation of either troponin T or troponin I is an indication of cardiac injury. The client's laboratory value is above the
expected reference range for troponin I, indicating an MI has occurred.
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