a prescription for a transfusion of packed red blood cells. 2. A nurse is caring for a client who requires wrist restraints. Which of the following actions should the nurse take? - Remove the restraints at least every 2 hours. 3. A nurse is assessing a client's vascular system. Which of the following techniques should the nurse use when evaluating the carotid arteries? - Auscultation of the arteries for bruits with the bell of the stethoscope. 4. After assessing a client, the nurse documents "1 pedal edema bilaterally.' This indicates that the nurse observed an indentation of which of the following depths after applying pressure? - 2 mm. 5. A nurse is assessing a client who is experiencing stress following a near fall out of bed. Which of the following physiological responses should the nurse expect due to the fight-or-flight response? - Increased blood pressure. 6. A nurse in an urgent-care center is caring for a 15-year-old client whose symptoms suggest a sexually transmitted infection (STI). The client's parent is unavailable, but the client's grandmother accompanied the client to the clinic. Which of the following actions should the nurse take? - Ask the adolescent to sign the consent form. 7. A nurse is collecting health history data from a client who is deaf and uses American Sign Language (ASL) to communicate. The nurse will be working with an ASL interpreter. Which of the following actions should the nurse take when working with the interpreter? - Pace speech to allow time for the interpreter to convey the words. 8. A nurse is employing a thorough, systematic method while obtaining objective data about a client. Through which of the following methods should the nurse collect this information? - Physical examination. 9. A nurse is assessing the pH of a client's gastric fluid to confirm the placement of an NG tube in the stomach. Which of the following pH values should the nurse expect? - 2 10. A nurse is caring for a client who requires fluid restriction and may drink only 1 oz of water with each oral medication. How many milliliters of water should the nurse document as intake for the 3 separate medications the client receives during a 12-hr night shift? - 90 11. A nurse is performing a physical assessment of a client. Which of the following actions should the nurse take to assess the client's tissue perfusion? - Perform a blanch test. 12. A nurse enters a client's room and finds the client sitting on the floor and leaning against the side of the bed. The client states she slipped while getting out of bed. Which of the following actions should the nurse take first? - Check the client for injuries. 13. A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding? - Sit at the bedside while feeding the client. 14. A nurse is caring for a client who requires a peripheral IV insertion. When choosing the site, which of the following sites should the nurse select? - Choose a vein that is soft on palpation. 15. A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2°C (102.6°F), a heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority? - Temperature. 16. A nurse is teaching a client who is postoperative about the importance of turning, coughing, and breathing deeply. Which of the following statements should the nurse identify as an indication that the client understands the instructions? - If I do this often, I won't get pneumonia. 17. A nurse is caring for a client who has chronic kidney disease. The kidneys regulate body fluids as well as assisting with which of the following functions? - Regulation of acid-base balance. 18. A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse prioritize when using the nursing process? - Obtain client information. 19. A nurse is teaching a client who has urinary incontinence about bladder retraining. Which of the following instructions should the nurse include? - Try to block the urge to urinate until the next scheduled time. 20. A nurse is evaluating a client's use of crutches. The nurse should identify that which of the following actions by the client indicates safe usage of this equipment? - The client has slightly flexed elbows when ambulating with the crutches.