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The nurse is completing a focused assessment addressing a patient’s immune function.  What should the nurse prioritize in the physical assessment?    

The nurse is assessing a client with hypoxemia of unknown cause.  Which of the following assessment findings directly relate to the perfusion of oxygen and presence of circulating oxygen in the body? Select All That Apply 1.  PaO2 of 88mmHg 2.  B.P.  120/80 3.  Hemoglobin of 13.0 g/dL 4.  SpO2  97% 5.  NA  140 mEq/L

The nurse is teaching a patient/client about the inhaler:   Combination med salmeterol/fluticasone.    Which statements by the patient indicate a correct understanding of this medication?  SELECT ALL THAT APPLY         “I will be sure to rinse my mouth with water after each dose.”         “I need to use this inhaler whenever I feel short of breath.”         “This medication is taken twice every day, every 12 hours.”                 “I can take this inhaler if I get short of breath while exercising.”          “I will call my healthcare provider if I notice white patches inside my mouth.”

 Which nursing intervention is the highest priority during the first twenty-four (24)  hours postoperatively for the client who had a total laryngectomy due to cancer of the larynx?                                            

A client reports that he has received the Bacilli- Calmette- Guerin (BCG) vaccination.  Which of the following is the best method to determine the client’s  tuberculosis (TB) status?              

The nurse observes a constant bubbling in the water-seal column of a water-seal chest drainage system.   The nurse’s best priority intervention would be to:                                                                                       

A nurse is caring for a client with a pulmonary embolism who is receiving IV fluids.  Which finding by the nurse primarily supports the nurse’s assessment that the IV has infiltrated?    

The nurse caring for a patient with impaired immunity knows when her patient’s white blood cell count is 20,000 cell/mm 3, the assessment finding requiring priority intervention is:     

 A client who has severe rheumatoid arthritis has been receiving maintenance therapy of prednisolone: 10mg/day for the past six (6) weeks. A priority patient teaching point for the nurse to stress with this client  is to instruct the client to immediately report symptoms of:              

Which of the following individuals has the highest priority for receiving seasonal influenza vaccination?