54 a nurse is assessing a clients bowel sounds which

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54. A nurse is assessing a clients bowel sounds. Which of the following actions should the nurse take? a. Listen to the bowel sounds after performing abdominal palpation
(inspect, auscultate, percuss palpate) b. Auscultate for 2 min to determine if bowel sounds are absent (at least 5 minutes) c. Place the diaphragm of the steth over each quadrant d. Ask the client to cough upon auscultation (for lung assessment) 55. A nurse is delegating client care to an assistive personnel. Which of the following tasks should the nurse delegate? A. Evaluating healing of an incision- nursing process is RNs job B. Inserting a NG Tube- LVN can do this C. Performing a simple dressing change.- key word is SIMPLE so this should be it . D. Changing IV tubing.- LVN or RN can do t his 56. A nurse is screening several clients at a neighborhood health fair. Which of the following assessment findings is the priority for referral for further care? A. HR 105/min B. BMI 25 kg/m2 C. BP 148/92 D. Glucose 45mg/dl- can lead to coma and seizure and death if not corrected . 57. A nurse is assessing a client’s extraocular eye movements. Which of the following actions should the nurse take? A. Position the client 6.1m(20ft) away from the Snellen chart. B. Instruct the client to follow finger through the six cardinal position of gaze, C. Ask the client to cover her right eye during assessment of her left eye. D. Hold a finger 46cm (18inch) in front of the client’s eye. 58.A nurse is planning care for a client who has prescription of knee- length antibolic stockings. Which of the following actions should the nurse take? P . 224 ati funds A. Remove the client’s stockings at least once each shift.NOT THS ONE ati book says every 8 hours you remove and asses for redness warmth and tnederness B. Roll the top of the client’s stocking down to just below the knee.- you pull up the leg C. Seat the client in a chair for 30min prior to applying stockings
D. Measure the length of the client’s leg from the heel to gluteal fold.- book says measure length of leg and thigh circumference to pick the right size B right? Ryan naw I dont thin its B either … ati fund page 224 says pull stocking up the leg 59. A nurse is assessing a client’s oculomotor nerve functions. Which of the following actions should the nurse take? A. Check the client’s pupillary reaction to light B. Ask the client to read print from the Snellen chart C. Ask the client to identify diff scents D. Use cotton to touch the client’s cornea lightly. 60. A nurse is planning to perform ear irrigation on an adult client who has impacted cerumen. Wich fo the following should the nurse plan to take? A. Wear sterile gloves while performing irrigation B. Position the client with the affected side down following irrigation C. Use cool fluid to irrigate the ear canal. D. Pull the pinna downward during irrigation. 61. A nurse is preparing to administer gentamicin 2mg/kg via IV bolus to a client who weighs 220lb. How many mg should the nurse administer? 200mg 62. A nurse is caring for a client who reports a pain level of 5 on a scale from 0-10. The client informs the nurse that pain medication are not option for managing pain. Which of the following is an appropriate response by the nurse?

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