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.

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.

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 is preparing to administer a prescribed medication to a client. The nurse should take which initial action?A. Verify the client's full name and date of birthB. Ask about any medication allergiesC. Review the client's vital signsD. Review medications and potential interactions

What intervention is most important to teach the client about identifying the onset of dehydration?*1 pointa. Measuring abdominal girthb. Converting ounces to millilitersc. Obtaining and charting daily weightd. Selecting food items with high water content

All the following are important considerations when a patient is to consult doctor, except;Question 18Select one:a.previous illness experienceb.previous doctor patient relationshipc.whether the patient has fed or notd.consultation coste.availability of doctor