(Test Bank) Udpdated Nclex-Rn Ascencia

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Diagnostic Test Read the question, and then choose the most correct answer. Safe and Effective Care Environment — Management of Care 1. The nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which client task should the nurse delegate to the UAP? A. a client whose IV infiltrated and needs replacing B. a client on BiPAP who needs arterial blood gases (ABGs) drawn C. a client with mild dementia who needs assistance with her food tray D. a client who needs a wet-to-dry dressi ng change on an abdominal incision Number C is correct. Rationale: Assessing the IV site and inserting an IV is beyond the scope of practice for a UAP and should be performed only by the licensed nurse. Drawing ABGs should be performed by the licensed nurs e or respiratory therapist per facility policy. Assisting a client with a meal tray is within the scope of practice for a UAP. Dressing changes should be performed by the licensed nurse. UAPs may not provide direct nursing care or perform nursing intervent ions requiring specialized nursing knowledge, judgment, or skill. 2. A nurse is preparing a client scheduled for a right mastectomy. Which statement indicates the need for further intervention? A. The client refuses to sign the blood consent since she is a Jeho vah‘s Witness. B. The client identifies the right breast as the surgical site for a right mastectomy. C. The client signs the consent form with an X, which is witnessed by two licensed personnel. D. The client expresses doubt over her decision and asks the nurse to explain more about the procedure. Number 4 is correct. Rationale: Expressing doubt and asking further questions of the nurse indicates that the client may not be fully informed and should confer further with the health care provider. The nurse may clarify facts, but it is the health care provider‘s responsibility to give detailed information about the surgical procedure. The nurse is responsible for ensuring that the client has been adequately informed. A client may refuse to sign a blood consent due to religious beliefs prior to surgery. The client has correctly identified the surgical site, which is to be expected. The client who cannot write ma y sign with an X as long as it is witnessed by two people. 3. An external weather disaster has flooded the emergency department with several new clients. Which client should the nurse see first ? A. the client complaining of chest pain and nausea who is diaphoretic B. the client with a simple fracture of the radius from a fall on a staircase C. the client complaining of slight redness and itching at the IV site in his hand D. the client presenting with a sprained ankle from a tree branch falling on him Number 1 is correct. Rationale: Triage works on the principle that clients with the highest acuity have priority over clients with injuries or conditions that are not considered life -threatening. C hest pain, nausea, and diaphoresis indicate a possible myocardial infarction, which can be life - threatening and requires immediate intervention. Fractures and sprains are nonurgent and can wait for treatment. Redness and itching at an IV site indicates a n eed to assess the site and remove and replace the IV, but is not immediately life -threatening. 4. A nurse is working with an unlicensed assis tive personnel (UAP) to perform a bed bath on a client. The nurse notes the smell of alcohol on the UAP‘s breath. Which is the priority nursing action? A. Work closely with the UAP during the shift and observe for any signs of impairment. B. Complete the bed bath without comment. The unit is already short one staff member. C. Offer chewing gum to the UAP. Since she does not give medications, she can do her job as she does not appear impaired. D. Call for another nurse to complete the bath and immediately report the UAP to the charge nurse or unit manager. Number 4 is correct. Rationale: The professional nurse works under the framework of six ethical principles. Nonmaleficence emphasizes protecting the client from harm. Client safety is always a priority. Another nurse may step in and complete the bath, ensuring that the client is not left alone with impaired personnel. Options 1, 2, and 3 allow the impaired UAP to remain on duty, possibly causing harm to the client . The nurse also has an ethical and legal duty to report situations that may cause client danger. Failure to do so may result in disciplinary action by the board of nursing for the nurse involved, regardless of whether harm comes to the client. 5. The nurse has received report on the assigned night -shift clients. Which client should the nurse see first ? A. a mildly confused client due for a dressing change on a diabetic ulcer to the heel B. an elderly, stable client who just returned from an MRI to rule out a kidney mass C. a client whose IV pump has started beeping, indicating that the antibiotic has completed infusing D. a client complaining of sudden warmth and pain at an appendectomy incision site 48 hours after surgery Number 4 is correct. Rationale: Classic signs of localized infection include sudden warmth, redness, pain at the site, and swelling caused by the inflammatory process. This client should be assessed first due to the risk of infection following surgical procedures. Th e health care provider should be notified immediately so that lab work can be ordered and an appropriate course of treatment started. The client needing a dressing change is not as urgent as a client with infection. A stable client returning from MRI is no t the priority. The client with an IV pump beeping can be seen once the health care provider has been notified. The risk of infection and subsequent complications take priority over a beeping IV pump. 6. The nurse is working triage in the ED when four clients present at the same time. Which client should be seen first ? A. a 45-year-old female on oral contraceptives with unusually heavy menstrual bleeding B. a 24-year-old with a dog bite to the leg from the family dog who is current on rabies shots C. an irritable 4-month -old with a petechial rash, nuchal rigidity, and temperature of 103.4°F D. a 16-year-old football player with a twisted ankle who has no deformity and a pedal pulse Number 3 is correct. Rationale: Petechial rash, nuchal rigidity, and fever are signs of meningitis, which is a medical emergency, especially in an infant. The client with heavy menstrual bleeding is not as urgent as the infant. Dog bites from a known pet current on rabies shots are less urgent than bites from a dog with an unknown rabies status. A twisted ankle with a pedal pulse and no deformity is not life - threatening and can be seen after more urgent clients 7. .The nurse is caring for clients on a medical -surgical floor. Which tasks related to pain management can be delegated to unlicensed assistive personnel (UAP)? Select all that apply. A. assessing the pain level on a scale of 1 – 10 B. reminding clients to report pain immediately C. reporting facial grimacing in unresponsive clients D. asking clients directly, ―Are you having any pain right now?‖ E. giving acetaminophen (Tylenol) after the nurse obtains the medication but is interrupted to attend a code blue before she administers it Numbers 2, 3, and 4 are correct. Rationale: Asking clients if they currently have any pain and reminding clients to report pain are within the scope of practice for the UAP. The UAP may a lso report facial grimacing to the nurse, who can then assess the pain. Assessing pain using the pain scale should be done by the nurse, as assessment is a nursing action. No medications, even over -the-counter ones, may be given by anyone other than the li censed nurse. If the nurse is interrupted for an emergency, another nurse may administer the medication after assessing the client‘s pain and checking the chart for any allergies, if facility protocols permit this. The nurse is ultimately responsible for t he task that has been delegated. 8. A newly graduated nurse is working in the pediatric unit. Which client assignment is most appropriate for this nurse? A. a 2-year-old with hemophilia A who has suddenly become less responsive B. a 15-year-old with sickle cell disease complaining of lower right quadrant abdominal pain C. a 6-year-old who just had a tonsillectomy 2 hours earlier and is frequently swallowing D. a 12-year-old with newly diagnosed type 2 diabetes whose parents need teaching on insulin Number 2 is correct. Rationale: Clients with sickle cell disease commonly present with pain during a crisis. The newly graduated nurse is qualified to assess the client‘s pain and administer ordered pain medications. A clie nt with a clotting disorder and a decreased level of consciousness is an emergency situation due to possible intracerebral bleeding and is not appropriate for an inexperienced nurse. Swallowing after a tonsillectomy indicates possible bleeding and should b e assessed by the more experienced nurse. Client teaching is an important and more advanced skill that takes time to develop. Insulin is a high -alert drug, and incorrect information from the new nurse may cause harm to the client. 9. The nurse is preparing to transfer a client from the ICU to the floor. Which of the following ensures continuity of care for the client? Select all that apply. A. using approved abbreviations in documenting care B. providing report on the client using standard hand -off reports C. informing the receiving nurse of pending lab results and when they are expected D. informing the receiving nurse of any care that needs to be done, such as bathing E. telling the receiving nurse that the family is demanding and asks too Numbers 1, 2, 3, and 4 ar e correct. Rationale: Ensuring continuity of care is especially important when the client is being transferred to another area of the hospital. Options 1, 2, 3, and 4 are guidelines that ensure continuity of care. Addressing pending lab results, listing cl ient requests that the nurse was unable to do, and informing the receiving nurse of upcoming medications or glucose checks that will need to be done shortly after the client arrives make it easier for the receiving nurse to be sure that upcoming tests or m edications are not missed. Complaining about the family is unprofessional and takes the focus away from client needs. A smooth transition is essential to ensure that no orders are overlooked. The nurse should be prepared to answer questions from the receiv ing nurse if needed for clarification after the client is transferred. Many questions 10. A client has been admitted to the oncology unit and has a large amount of c ash, several credit cards, and several pieces of expensive -looking gold jewelry in her possession. Which action by the nurse is most appropriate? A. tell the client to hide everything in her purse or a bag and put it in the closet B. offer to take her belongings to the charge nurse‘s office where they can be locked up C. suggest that the client put her valuables in a sock and place it in the bottom of the bedside table under some clothing D. inform the client of the hospital policy regarding valuables and suggest that she give them to a trusted family member or to security for safekeeping Number 4 is correct. Rationale: Most hospitals provide security to lock up client‘s valuables, along with a receipt or form for identification for claiming the items. All items placed i n security must be documented on the admission form and signed. The facility is not responsible for valuables left in the room by clients, and the nurse should be sure that the client is aware of this policy and understands it. Options 1 and 3 still leave the valuables subject to theft. Locking them up in the charge nurse‘s office is not an appropriate option, as this places the charge nurse in a position of responsibility. Many hospital admissions are unplanned, and the best advice the nurse can give a new client is to send home anything of value. 11. The nurse is caring for a 7 -year-old child who presents to the ED with multiple bruises, a fractured ankle, and cigarette burns on the arms. Which action by the nurse is most appropria te? A. ask the parents if they burned the child with cigarettes B. ask the client to tell you what happened to cause the bruising and burns C. inform the parents that they cannot leave with the child until they talk to the police D. notify the charge nurse immediately so that the suspected child abuse can be reported Number 4 is correct. Rationale: Any suspected cases of abuse and neglect must, by law, be reported to the authorities. The ED will have policies and procedures to guide staff on appropriate responses t o suspected child abuse cases. Option 1 assumes that the parents are responsible for the burns and may provoke a violent response. While it is appropriate to ask the client what happened, the nurse should be aware that many abused children are coached to say that they fell off a swing or had another type of accident when asked about their injur ies by authority figures. Option 3 is both presumptive and accusatory. Additionally, it may also provoke a violent response. The nurse must objectively assess the client and chart the findings, including descriptions of injuries. Child abuse cases require collaboration among nurses, physicians, social workers, police, and family services. The nurse should remain alert to verbal or nonverbal cues that the situation may intensify, and follow facility guidelines Safe and Effective Care Environment —Safety and Infection Control 12. Which precaution must a nurse take when checking the blood pressure of an HIV-positive client? A. wear gloves B. wear a gown C. use contact precauti ons D. wash hands Number 4 is correct. Rationale: Washing hands is sufficient since taking a client‘s blood pressure does not involve contact with blood or secretions. The other listed precautions would be appropriate if blood or secretions is involved. 13. The pediatric nurse is preparing a child with acute lymphocytic leukemia for discharge. The discharge plan should include all but which of the following statements? A. restrict naps to allow more complete rest at night B. increase intake of prote in, iron, and vitamin C to provide nutrients required for hemoglobin production C. keep a food diary to evaluate dietary intake D. restrict antacids, tetracyclines, and phosphorous salt Number 1 is correct. Rationale: Arranging rest periods throughout the day helps promote the client‘s ability to participate in an array of desired activities. Increasing intake of protein, iron, and vitamin C aids in hemoglobin production. Keeping a food diary helps document actual nutritional intake. Restricting antacids, tetracyclines, and phosphorous salts will avert absorption of iron. 14. The nurse teaches a group of fire fighters about the spread of tuberculosis (TB). Which statement by a fire fighter indicates the teaching has been effective? A. ―I could get TB if I come in contact with blood from an infected person.‖ B. ―I can share a cup of coffee with someone who is infected with TB.‖ C. ―I could get TB if I inhale infected droplets when an infected individual coughs.‖ D. ―I need to refrain from shaking hands with an infected person.‖ 15. After administering the annual Mantoux tuberculin skin test to employees, the nurse instructs the staff to return within how many hours aft er administration to have the results determined? A. 12 to 24 hours B. 24 to 48 hours C. 48 to 72 hours D. 72 to 84 hours 16. A client is diagnosed with Meniere‘s disease. Which nursing diagnosis would take priority for this client? A. risk for injury B. disturbed body image C. low self-esteem D. impaired skin integrity 17. While driving, the client forgets how to get home. Which lobe could be dysfunctional? A. temporal B. parietal C. occipital D. frontal 18. At the scene of an accident, which intervention applies to a client with a suspected neck injury? A. administer CPR B. keep the person warm C. do not move the client D. ask the client to state her name and birthday 19. Which treatment should be included in the immediate management of acute appendicitis? A. prevent fluid volume deficit B. administer antibiotic therapy C. reduce anxiety D. relieve pain 20. Medical management of a client with acute diverticulitis should include which treatment? A. increased fiber in diet B. administration of antibiotics C. pain medication administration D. liquid diet for 1 – 2 days 21. An enema is prescribed for a client with suspected appendicitis. The nurse should take which action? A. tell the client to lie on his left side B. explain the procedure to the client C. compile necessary equipment D. question the physician about the order Health Promotion and Maintenance 22. A 28-year-old client has just given birth. At one minute the baby appears healthy, with the exception of bluish hands. Which of the following would the nurse midwife pronounce? A. The Apgar score is 11. B. The Apgar score is 9. C. The Apgar score is 6. D. The Apgar score is 4. 23. The client‘s first day of her last period was January 24. Which of the following should the nurse tell the client is her expected date of delivery? A. September 30 B. October 31 C. November 15 D. December 1 24. The nurse is discussing concerns the parent has wit h his 3 - year-old. The parent identifies limitations in the child‘s activities. Select all that should be of concern to the nurse. A. unable to work simple toys B. unable to understand simple instructions C. unable to say first and last name D. unable to name any colors or numbers 25. The nurse is providing education at a senior center. Which of the following measures will the nurse say is most effective in attaining normal blood pressure in a client with hypertension? A. eating red meat daily B. increasing potassium and calciu m intake C. increasing fluid intake D. decreasing sodium intake 26. A 9-month -old child is registered to attend a local childcare clinic. Upon initial intake, the nurse discovers the child has received the first and second dose of the hepatitis B vaccine. What is the best course of action for the nurse to recommend to the parents? A. no action; a third dose of the vaccine is not recommended B. immediately inoculate the child given the high risk of not having a third vaccine C. wait until the child is 12 months to give the vaccine D. schedule the child for the third vaccine at the earliest convenience 27. The nurse is teaching a smoking cessation program. He will state that which of the following benefits of quitting appear within one year? A. risk of coronary heart disease is the same as that of a nonsmoker B. carbon monoxide level in blood drops to normal C. risk of dying from lung cancer is about half that of a smoker‘s D. risk of having a stroke is reduced to that of a nonsmoker‘s 28. The nurse is preparing a community educational presentation. The topic is the leading causes of death for people ages 12 – 19. The nurse knows that which of the following should be presented? A. unintentional injuries B. cancer C. homicide D. suicide 29. The nurse identifies a client‘s learning preference as visual. Which of the follow ing would be appropriate when teaching the client about insulin injection? A. an audiotape B. an orange, an insulin syringe, an alcohol wipe, and a bottle of sterile saline C. classroom discussion D. an instructional pamphlet Psychosocial Integrity 30. The nurse is carin g for a client with end-stage kidney disease and multiple organ failure. Which action by the nurse indicates an understanding of end-of- life care? Select all that apply. A. The nurse explains signs and symptoms that indicate death is near. B. The nurse explains to the client and family what to expect during the final phase of the illness. C. Cultural beliefs are acknowledged, but priority is placed on life- lengthening treatment options. D. The nurse avoids talking to the client about impending death to avoid upsetting him and the family. E. The nurse asks the client and family what their goals and wishes are regarding care, pain management, and emergency resuscitation. 31. The nurse is talking in the lounge with other nurses about grief and loss. The nurse understands which to be true regarding grief and loss? Select all that apply. A. The process of grief is detrimental to physical and emotional health. B. Age, gender, and culture are a few factors that influence the grieving process. C. The nurse must explore his own feelings about death before he may effectively help others. D. The nurse should discourage expression of grief and loss because it may upset other clients nearby. E. The nurse can help the family develop ways to relieve loneliness and depression following the death of a loved on e. 32. The nurse has assessed the assigned group of clients. Which client would the nurse identify as being at the greatest risk for alterations in sensory perception? A. a client in a halo vest following an automobile accident B. a child with severe autism who is having a tonsillectomy C. a teenager who broke her leg during cheerleader practice D. a schoolteacher who was hospitalized for shortness of breath 33. The nurse is working in a mental health facility that uses group therapy with the clients. The nurse understands whi ch to be correct regarding group therapy? A. The termination stage begins with the initial group meeting. B. Members‘ feelings about their accomplishments are explored in the working stage. C. During the working stage, members may be unclear about the purpose of the group. D. Group roles and responsibilities are established in the working stage of group therapy. 34. The nurse is caring for a client who is having surgery the next morning. The client says, ―I‘m really scared about surgery. I‘ve never been put to sleep before and I‘m afraid I might not wake up.‖ Which response by the nurse is the most therapeutic? A. ―Why are you worried about such a minor procedure?‖ B. ―We can call the doctor and cancel the surgery if you would prefer.‖ C. ―It‘s normal to be afraid of something new like surgery. Tell me how you feel.‖ D. ―Don‘t worry, you have a really good doctor and he will see to it that nothing goes wrong.‖ 35. The nurse is caring for a client who has just been diagnosed with ovarian cancer. The nurse is using silence as an effective therapeutic response. How is silence an effective therapeutic response? A. It is not therapeutic; it implies that the nurse is not listening. B. It encourages the client to keep her feelings to herself. C. It allows the client time to think and reflect and lead the conversation. D. It allows the nurse to think about other tasks she needs to tackle to provide efficient care to all of her clients. 36. The nurse is caring for a client with schizophrenia who is having active hallucinations. The nurse implements which actions to manage the client during the episode? Select all that apply. A. administers medications as ordered B. uses gentle touch to reassure the client C. tells the client that others see or hear what he does D. distracts the client by placing him in the dayroom with others E. asks the client if he hears voices telling him to harm himself or others F. goes along with what the client says to decrease the risk of increasing the client‘s anxiety 37. The nurse is admitting a client with schizophrenia. The client is extremely socially withdraw n, is unable to perform activities of daily living, has an inappropriate affect, and has grimacing mannerisms. The nurse understands that this client is experiencing which type of schizophrenia? A. residual schizophrenia B. paranoid schizophrenia C. catatonic schiz ophrenia D. disorganized schizophrenia E. undifferentiated schizophrenia 38. The nurse is precepting a new nurse in the psychiatric unit. The nurse is discussing interventions for schizophrenia. Which statement by the student nurse indicates an understanding of man agement of schizophrenia? Select all that apply. A. ―I should be warm and friendly to put the client at ease.‖ B. ―I can reassure the client that he is in a safe environment.‖ C. ―Puzzles or word games are good activities to engage in.‖ D. ―I can help the client use art or writing to express his feelings.‖ E. ―I won‘t tell the client when I‘m leaving him so he won‘t get upset.‖ 39. The mental health nurse is caring for a client with Cluster B personality disorder. The nurse would expect the client to exhibit which behaviors? Select all that apply. A. suspicious of others, magical thinking, eccentric behavior, paranoia, relationship deficits B. preoccupation with rules and details, hoarding, ritualistic behavior, extremely devoted to work C. easily bored, poor and shallow interpersonal relationships, enjoys being the center of attention D. impulsivity, unpredictable behavior, extreme mood shifts, easily angered, playing people against each other E. suspicious and untrusting of others, argumentative, controlling of others, thoughts of grandiosi ty Physiological Integrity —Basic Care and Comfort 40. The nurse is preparing to receive an 18 -month -old client from surgery who had repair of a congenital hip deformity. What type of traction does the nurse anticipate setting up for the client? 41. The nurse is caring for a client whose lab results show triglycerides of 380 and cholesterol level of 240. Which foods would the nurse educate the client about including in his diet when he is discharged? Select all that apply. A. wheat toast with sugar -free jelly B. grilled salmon seasoned with herbs C. an egg-white omelet with vegetables D. natural honey from a local farmer‘s market E. plain grilled steak prepared with pepper only 42. The nurse is preparing to discharge a client who was treated for tuberculosis. Which guidelines for home management should the nurse include in his discharge teaching? Select all that apply. A. The client may resume his normal activities. B. The family should maintain respiratory isolation at home. C. The medication regimen should be followed diligently as presc ribed. D. The client may return to work when three sputum cultures are negative. E. The nurse should educate the client about the medication and possible side effects and their management. 43. The nurse is discharging a client who was prescribed prednisone. The nurs e tells the client that one of the side effects may be impaired sleep. The client says, ―I already have a hard time sleeping. What can I do to help with that?‖ Which recommendations should the nurse make? Select all that apply. A. avoid alcohol late in the evening B. keep the bedroom dark and quiet C. maintain the same consistent sleep schedule D. eat a large, heavy meal at dinner to help promote sleep E. read or do another quiet, noncomputer activity before bed F. do a vigorous exercise routine after work to help him become tired 44. The nurse is caring for a client who has a nasogastric tube for medication administration and tube feedings. How should the nurse care for the tube during her shift? Select all that apply. A. flush tube every 4 hours with hot water to maintain patency B. allow the feeding and tubing to hang until empty, up to 48 hours C. maintain the head of bed in a high-Fowler‘s position during feedings D. check residuals and replace them unless the amount is greater than 300 mL E. check under the adhesive tape on the nose daily to assess for skin breakdown F. assess the bowel sounds before feeding, and feed at half the rate if bowel sounds are absent 45. The nurse is teaching a group of nursing students about proper client positioning. Which statement by a student nurse indicates an understanding of proper positioning? A. A client receiving an enema should be placed on the right side in the Sims‘ position. B. A client with a below -the-knee amputation should be positioned with the affected limb elevated at a 45 - degree angle. C. Clients with pulmo nary edema should be positioned upright with the legs dangling over the side of the bed. D. Clients with a craniotomy should be positioned with the head of bed at a 20-degree angle with the head in a neutral, midline position. 46. The nurse is caring for a client with deep vein thrombosis (DVT). Which should be included in the plan of care? A. bed rest with the affected extremity elevated B. bed rest with the bed in reverse Trendelenburg C. walking slowly in the hall with assistance to prevent pneumonia D. sitting up in the chair for all meals and during visitation time 47. The nurse is assessing a six -month -old infant at the clinic. When the nurse strokes from the heel of the foot upward toward the ball, the infant exhibits no movement. Which action is the priority for the nurse? A. take the infant‘s vital signs B. order a neurology consult C. examine the infant‘s nose and ears D. ask how much formula the infant consumes daily 48. The nurse is caring for a client with COPD who complains of poor quality of sleep. Which question should the nurse a sk next? A. ―Does your partner snore heavily?‖ B. ―Do you get exercise during the day?‖ C. ―How many pillows do you sleep on?‖ D. ―Do you eat large meals right before bed?‖ 49. The nurse is teaching infant CPR to a group of newly graduated nurses hired to work in the lab or and delivery unit. The nurse understands that proper technique with infants includes which action? Select all that apply. A. The femoral artery is checked for a pulse following each cycle of CPR. B. Chest compression depth should be approximately 1.5 inches, or 4 cm. C. A single rescuer should use three fingers on the dominant hand to do compressions. D. Rest the infant facedown on the forearm with the hand supporting the head and jaw. E. If arrest is witnessed the emergency response system should be activated before beginning CPR. 50. The nurse is caring for a comatose client with a Salem sump tube. Which action by the nurse is correct regarding care of this client? A. clamp the air vent during tube feedings B. place the client on the left side in a high-Fowler‘s position C. assess the position of the Salem sump before each feeding D. infuse bolus feedings with a pump or by gently plunging into the stomach 51. The nurse is teaching a client diagnosed with gastroesophageal reflux disease (GERD) about dietary measures to manage symptoms. Whi ch food does the nurse advise the client to avoid? A. bananas B. tomatoes C. white bread D. grilled salmon E. steel -cut oatmeal 52. The nurse is caring for a client with sternal wires following a coronary artery bypass graft (CABG). The client complains of severe pain when coughing and deep breathing. What nonpharmacological measures can the nurse take to increase client comfort? Select all that apply. A. apply hot packs to the sternum B. give morphine PRN for pain before client coughs C. suggest using audio books or relaxing music as a distraction D. teach the client how to use a pillow to splint the chest when coughing E. encourage the client to engage in prayer, meditation, or other activities F. properly position the head of the bed to minimize pressure on the sternum 53. 5The nurse is caring for a client who is sedated and on the ventilator in ICU. The family expresses concern about controlling the client‘s pain when he cannot speak. The nurse explains that assessing pain in a nonverbal client involves watching for which of the following signs ? Select all that apply. A. grabbing at the bed rails B. biting the ventilator tubing C. facial grimacing D. stiffness or rigidity of the body E. decreased urinary output F. increased blood pressure and heart rate as shown on the cardiac monitor 54. The clinic nurse is seeing a pregnant client who is expecting her first child. She complains of morning sickness and nasal stuffiness. The nurse recommends interventions to minimize discomfort from her symptoms. Which should the nurse recommend? Select all that apply. A. take ginger pills to alleviate nausea B. drink a full glass of water at each meal C. use a humidifier to help with congestion D. eat dry crackers before getting out of bed in the morning E. eat three regular meals each day to provide needed nutrients F. use an over-the-counter nasal spray such as a saline - based spray 55. The nurse is caring for a client who refuses to get out of bed. He tells the nurse, ―I‘m too tired to get up. I‘m sick. I‘m supposed to rest in the hospital.‖ For which complications of immobility does the nurse understand that the client is at risk? Select all that apply. A. decreased appetite B. urinary tract infection C. orthostatic hypotension