The nurse performs a physical assessment on a client and observes the client demonstrate palmar flexion while obtaining the blood pressure. The nurse should take which action?A. Obtain the blood pressure on the client's calfB. Request an order for a magnesium levelC. Assess the client's orthostatic blood pressureD. Obtain capillary blood glucose (CBG)

The nurse assesses distended neck veins in a client sitting in a chair to eat. What intervention is the nurse's priority?*1 pointa. Document the observation in the chart.b. Measure urine specific gravity and volume.c. Assess the pulse and blood pressure.d. Assess the client's deep tendon reflexes.

A client has been diagnosed with overhydration and is confused. Which intervention does the nurse include in the client's plan of care to relieve the confusion?*1 pointa. Measuring intake and output every shiftb. Slowing the IV flow rate to 50 mL/hrc. Administering diuretic agents as prescribedd. Placing the client in Trendelenburg position

The nurse enters a client's room who is found on the ground. The nurse should perform which initial action?A. Assess the client’s level of consciousnessB. Examine the client for injuriesC. Call the rapid response team (RRT)D. Palpate the client’s carotid pulse

62) A nurse is caring for a client who is in the progressive stage of shock. Which findingshould the nurse expect?(a) Blood pressures change from 129/78 (95) to 89/45 (60)(b) Blood pressures change from 95/55 (68) to 90/52 (65)(c) Blood pressures change from 100/50 (67) to 90/45 (60)(d) Blood pressure reading is undetectable

The nurse is assessing fluid balance in the client with heart failure. Which of these strategies will the nurse employ?*1 pointa. Ask the client how much fluid was consumed yesterday.b. Place an indwelling catheter to measure urine output.c. Auscultate the lungs for adventitious sounds.d. Weigh the client daily, at the same time.