• Wheezing is often associated with asthma- assess breathing patterns and learn about any precipitating factors that caused the onset of the wheezing
• A male client with limited mobility is discharged with home health services. When the home health nurse arrives, the client asks what he does for the swelling in his leg. Which should the nurse implement?
• -instruct the client to flex both of his feet several times a day
• A client at an outpatient clinic submits a clean-catch midstream urine specimen for routine urinalysis. In later review of the client’s medical record, which data indicates to the nurse that the specimen collection should be repeated?
• -the urine specimen shows multiple organisms in low colony counts
Rationale: *often indicates that a contaminated specimen was obtained
• During the admission assessment of a terminally ill male client, the client states that he is an agnostic. What is the best nursing action in response to this statement?
• -document the statement in the client’s spiritual assessment
• The nurse observes a newly admitted older adult female take short stems and walk very slowly while pushing a walker in front of her. What action should the nurse take in response to these observations?
• -complete a full fall risk assessment of the client
• The nurse notes that a client has cyanosis of the toes and fingertips. Which vital signs should the nurse obtain first?
• -respiratory rate
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