46. A nurse is caring for a client admitted with a skull fracture. Which of the following assessment findings should
be of greatest concern to the nurse?
Glasgow coma scale score changes from 14 to 9
Bilateral pupil diameter changes from 4 to 2 mm
Pulse pressure changes from 30 to 20 mm Hg
WBC count changes from 9000 to 16,000 mm3
48. A nurse is caring for a client who is taking furosemide. The client has a potassium level of 3.1 mEq/L. Which of
the following should the nurse assess first?
49. A nurse is caring for a client who is scheduled for an abdominal paracentesis. The nurse should plan to take
which of the following actions?
P . 299 ati ms pdf 10.0
50. A nurse is caring for a client who is 6 hours postoperatively following a thyroidectomy. The client reports
tingling and numbness in the hands. The nurse should identify this as a sign of which of following electrolytes
51. A nurse is assessing a client 15 min after the start of a transfusion of 1 unit of packed RBC’s. Which of the
following findings is an indication of a hemolytic transfusion reaction?
Page 250 MS ATI PDF 10.0 under
acute hemolytic complications
Bradypnea-tachypnea ( RR > 20) it will produce
Bradycardia- tachycardia it will produce
Hypothermia- FEVER is a complication of a hemolytic reaction
A nurse in an emergency department is caring for a client who has sinus bradycardia. Which of the following
actions should the nurse take first?