How to Answer Kindly Help With Questions (Complete Guide)

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Kindly help with the best of the answers. Thank you in advance! 1. One week after an above the knee amputation (AKA) to the left leg, a male client seems upset and reports that his left foot feels “numb.” which action should the nurse implement? a. Assess the wound for signs of inflammation or drainage b. assess the right foot for signs of diminished circulation c. offer assurance that the numb feeling is temporary d. reinforce learning about the cause of this sensation 2. A client with end-stage renal disease (ESRD ) is refusing all treatment and requests that no life -saving me action should the nurse take? A. Initiate a review of the situation by the hospital’s ethics committee . B. Remind the client that new treatments are being developed daily. C. Facilitate a palliative care meeting with the client and healthcare provider D. Provide the healthcare provider with a copy of the client’s bill of rights. 3. A client who is admitted with palpitations. Chest discomfort and shortness of breath is anxious while reporting a history of a mitral stenosis related to rheumatic fever as a child. The cardiac monitor displays a supraventricular tachycardia (SVT) at a rate of 180 beats/minute. Vital signs include heart rate 156 beats/minute, respiration 22 breaths /minute, and blood pressure 100/84. Which intervention should the nurse implements first? a. Obtain emergency cart and give midazolam (versed) IV per protocol b. Prepare bedside cardiac defibrillator with synchronized cardio version c. Explain the importance of immediate synchronized cardioversion d. Call 12 lead electrocardiogram and cardiac isoenzymes. 4- A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Vital signs include: a. Bilateral diffuse wheezing b. temperature of 100. 5 c. Yellow expectorated sputum d. Shortness of breath 5. A male client with a history of heavy alcohol intake is admitted with acute pancreatitis. The client reports severe abdominal pain, radiating to the back. In positioning the client, which instruction should the nurse provide the unlicensed assistive personnel (UAP)? A. Tell client to deep breath and cough every 2 hours. B. Assist client to his side with his knees bent to his chest C. Maintain the client is a supine position D. Mobilize the client to stimulate peristalsis 6. The nurse planning group therapy for client in a substance abuse program. The focus of the group is “Risk factor hepatitis” What intervention should the nurse plan for the group? a. Include only clients who have hepatitis b. Summarize what the group talked about c. limit the group to no more than seven clients d. talk to client individually before the group 7. The nurse provides discharge teaching to a who was recently diagnosed with diabetes DM)receiving the the client expresses understanding about when , how, and why to take his prescribed medications at Which important for the nurse to implement ? A. Offer to consult with the pharmacist about resources for reduced price medications B. Review the purpose of medications prescribed for the client to take home with him C. Send a list of medications taken while hospitalized to the client’s healthcare provider D. Provide the client with a printed list of medications and a schedule for administration 8. The nurse is conducting an assessment of a female client with bipolar disorder, the client suddenly begins to take off her clothes and then throws them about the room. Which action should the nurse take client’s inappropriate behavior. A.Leave the client’s room so she can act out her. B. State it is unacceptable to undress during the interview D. Change to less anxiety -promoting questions 9. Client is receiving continuous ambulatory peritoneal dialysis since the arteriovenous graft in the right arm is no longer available to use for hemodialysis. The client has lost weight, has increasing peripheral edema, and has a serum albumin level of 1.5 g/ dL. Which intervention is the priority for the nurse to implement? a. Instruct the client to continue to follow the prescribed rigid fluid restriction amount b. evaluate pat and see of the AV graft for resumption of hemodialysis c. ensure the client receives frequent small meals containing complete proteins d. recommend the use of support stockings to enhance venous return 10. One week after an above the knee amputation (AKA) to the left leg, a male client seems upset and reports that his left foot feels “numb.” which action should the nurse implement? a. Assess the wound for signs of inflammation or drainage b. assess the right foot for signs of diminished circulation c. offer assurance that the numb feeling is temporary d. reinforce learning about the cause of this sensation 11. A client is recieving an 5% dextrose in Lactated Ringer’s solution at a rate of 100mL / hour The client tells the nurse ” I dont need to eat because I’m getting all the nutrition need through this IV needle. Which initial response is best for the nurse to provide this client ? A. This is called hypertonic , and is more concentrated than your blood. B. Only a very small amount of the calories you need are provided by your IV. C. The IV does contain nutrients but eating is very important. D It is very imortant to keep eating. Why don’t you want to eat? 12. A client with a history of heavy alcohol intake is admitted with acute pancreatitis. The client reports severe abdominal pain radiating to the back. And positioning the client, which instruction should the nurse provide to the unlicensed assistive personnel (UAP) a. motivate the client to stimulate peristalsis b. maintain the client in a supine position c. assist the client to his side with his knees to his chest d. tell client to deep breathe and cough every two hours 13. following a left spontaneous pneumothorax, a chest tube is inserted into the client’s left lung pleural space. The nurse observes continuous bubbling in the water seal chamber and informs the health care provider that the client has a constant air leak. When transporting the client for a computerized tomography (CT) scan, which action should the nurse implement? a. Maintain the tube drainage device below the level of insertion b. clamp the tube in two places with blunt tipped hemostats c. milk the tube immediately prior to transporting from the unit d. reinforce the dressing around the chest tube’s exit site 14. A client with a history of chronic obstructive pulmonary disease is admitted with pneumonia. Vital science include: heart rate 122 beats/min, respiratory rate 28 breaths/min, and a blood pressure 170/90. Which assessment finding warrants the most immediate intervention by the nurse? a. Temperature of 100.5 F (38.1 C) b. bilateral diffused wheezing c. yellow expectorated sputum d. shortness of breath on exertion 15. The nurse is performing group therapy for a client in a substance abuse program. The focus of the group is “Risk factors for hepatitis.” What intervention should the nurse plan for the group? a. Summarize what the group talked about b. talk to the clients individually before the group session c. limit the group to no more than seven clients d. include only clients who have hepatitis. 16. The nurse is developing a food safety educational class for a group of parents Which type of food is most likely to pose a threat of food poisoning after being stored in a refrigerator at 40^ * F ( A^ + C) or below for more than two days ? A. Packaged of uncooked lamb chops B. Ground -up hamburger raw meat C. Opened package of hot dogs D. Opened package of deli sliced meat 17. A 36 weeks primigravida is admitted to labor and delivery with severe abdominal pain and bright red vaginal bleedingHer abdomen is rigid and tender touch The fetal heart rate (FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minuteWhat action should the nurse implement first? A Notify the healthcare provider from the client’s bedside B. Obtain written consent for an emergency cesarean section C. Draw a blood sample for stat hemoglobin and hematocrit D. Alert the neonatal team and prepare for neonatal resuscitation 18. A who is day following a mastectomy is preparing to leave the hospital Whenever the nurse attempts to conduct discharge teaching the client changes the subject and tries to the nurse a joke Which response is best for the nurse to provide ? A. You can discuss your future care with the home health nurse B I can tell that you are in denial about your physical condition C perhaps the best way to handle this trauma is the use of humor D Right now is important that you learn how to care for yourself 19. When the parents of a 6-year-old boy with a brain tumor are told that his condition is terminal, the mother shouts at the father, this is your fault, it never would have happened if we had sought treatment sooner. Which intervention is best for the nurse to implement? A Tell the parents that blaming each other will not change the situation B Refer the parents to the chaplain to provide grief counseling C Assure the parents that a terminal diagnosis was inevitable D Explain to the parent that anger is a common response to grief. 20. A client who is hypotensive is receiving dopamine, adrenergic agonist, Ivy at the rate of 8mcg / kg / min . Which intervention should the nurse implement well administering this ymedication ? a. Assess pupillary response to light hourly b. monitor serum potassium frequently . initiate seizure precautions 21. A seriously ill male mantis transferred to a health care facility in a different state. Included in his records are in advanced directive and a Physician Orders for Life Sustaining Treatment(POLST). However, The state to which he is transferred does not endorse POLST. The client lapses into a coma shortly after admission to the new facility. What action should the nurse take? A. Requested the new health care provider cosign the POLST document B. implement the client’s wishes as described in his advanced directive C. ask the clients family to make life sustaining treatment decisions D. attach an advance directive copy to the medical records prescription page 22. One week after an above-the-knee-amputation (AKA) of the left leg, a male client seems upset and reports that his left foot feels “numb”. What action should the nurse implement? A. Assess wound for signs of inflammation or drainage. B. Offer assurance that the numb feeling is temporary. C. Assess right foot for signs of diminished circulation. D. Reinforce learning about the cause of this sensation. 23. An adult with pneumonia is diaphoretic, tachycardia, and confused. The cardiac monitor indicates sinus tachycardia with frequent premature multifocal ventricular beats. Arterial blood gas (ABG ) findings are : pH 7.26, PaCO2 66 mmHgl HCO3 23 mEq/L (22 mmol/L). Which intervention is most important for the nurse to include in this client’s plan of care ? A. Obtain a 12 lead electrocardiogram (ECG) daily B. Assess for apical -radial pulse deficit with vital signs C. Monitor the respiratory rate and depth continuously D. Maintain a patent IV catheter for antibiotic therapy 24. The nurse wants to use roleplaying as a teaching techniqueWhich group is most likely to benefit from this teaching method? A. Older adults who are preparing to retire from the workforce B. Newly pregnant women who are attending a well – baby seminar C. Men who are willing to admit that they have a drinking problem D. Adolescents who are learning to abstain from recreational drug use 25. The nurse is preparing 0800 medications to clients on a medical unit. The dietary department is about to deliver the breakfast trays to the clients. which medication can the nurse administer after breakfast? A Furosemide to a client with a potassium level of mEq or mmol(SI B Sucralfate to a client with peptic ulcer disease C 70/30 insulin 15 units to a client with type 2 diabetes D. Levothyroxine to a client with hypothyroidism 26. Following surgery, a client reports severe incisional pain when attempting to moveWhich action should the nurse take first? A. Review preoperative teaching about pain after surgery B. Offer to administer a prescribed analgesic medication C. Explain the need to turn and consequences of immobility D. Assess the client’s level of anxiety related to the pain 27. A 15-years old male client is currently diagnosed with type 1 diabetes mellitus . He tells the nurse that he is having difficulty adhering to his meal plan when he is with his friends . What nursing intervention is best for the nurse to implement ? A Recommend that he avoid fast food restaurant until he is familiar with his prescribed diet B. Assist him in identifying popular fast foods that are within his meal plan for diabetes C. encourage him to find activities to do with his friends that do not involve eating D. advise him to take his own food with him when going to fast food restaurant with his friend 28. When the parents of 6 years old boy with brain tumor are told that his condition is terminal. The mother shouted at the father . This is all your faults it never would have happened if we had sought treatment earlier. Which intervention is best for the nurse to implement ? A. Assure the parents that a terminal diagnosis was inevitable . B. reference the parent to the chaplain to provide grief counseling C. explain to the parents that anger is a common response to grief D. tell the parents blaming each other will not change the situation 29. A client with bladder cancer had surgical placement of a ureteroilcostomy (beal condult) yesterday. Which postoperative assessment finding should the nurse report to the HCP immediately. A. red edematous stomach appearance b. liquid brown drainage from stoma c. stomal output of 40ml in the last hour d. mucous strings floating in the drainage. 30. A 3 year old boy with a congenital heart defect is brought to the clinic by his mother because he has a fever and an earache. During the assessment the moter ask why her child is at the 5th percentile for weight and height A: Does you child seem mentally slower than his peers also B: His smaller size is probably due to the heart disease C: You should not worry about the growth table. They are only average for children D: Haven’t you been feeding him according to the recommended daily allowance for children? 31. A client with peptic ulcer disease receives a prescription for intermittent suction via a Salem sump nasogastric tube(NGT)… obtaining coffee-ground gastric contents, the nurse clamps the NGT because the client must leave the unit for diagnostic studies. Upon return to the unit the client complains of nausea. Which action should the nurse implement first? A. Provide oral suction using a Yankauer tip. B. Administer a prescribed antiemetic agent. C. Irrigate the NGT with sterile normal saline. D. Connect the NGT to low intermittent suction. 32. A client with end -stage renal disease (ESRD) is refusing all treatment and requests that no life-saving action should the nurse take? A. Initiate a review of the situation by the hospital’s ethics committee . B. Remind the client that new treatments are being developed daily . C. Facilitate a palliative care meeting with the client and healthcare provider . D. Provide the healthcare provider with a copy of the client’s bill of rights. 33. An adult woman who has a history of inferior myocardial infarction, esophageal reflux, and type 1 diabetes mellitus (DM) is admitted to the telemetry unit for sudden onset of dizziness with palpitations and burning sensation in her chest. Which intervention should the nurse implement first? A. Review the client’s last meal choice B. Administer an oral antacid C. Assess blood glucose level D. Evaluate telemetry cardiac rhythm. 34. Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)? a- Reduce risks factors for infection b- Administer high flow oxygen during sleep c- Limit fluid intake to reduce secretions d- Use diaphragmatic breathing to achieve better exhalation 35. A family member accompanies a client with schizophrenia to the mental health unit. The family member describes to the nurse the client experienced a prolonged psychotic episode that lasted for 3 days. Which action should the nurse implement first? a) Review the list of medications taken at home b) assess if warning signs were observed c) explore possible triggers to the episode d) verify nutrition and hydration status 36. An older client is admitted to the cardiac stepdown unit following coronary artery bypass surgery(CABG) . Which postoperative nursing intervention is most beneficial to prevent respiratory complications? A. Provide ice or liquid’s win declines passes flatus B. note areas of atelectasis on the delete chest X rays C. promote full diaphragmatic excursion by messaging the back D. assist to a chair the day after surgery when condition is stable 37. The nurse is providing breastfeeding teaching to a new mother. which infant action should the nurse emphasize indicates readiness to feed a) crying when undisturbed b) showing hand to mouth movements (c) following movements with eye (D) spitting up clear mucus 38. An older client preparing to transition from every rehabilitation facility to home is receiving discharge instruction from the nurse which action ashould the nurse take while providing the discharge instruction A) stand behind the client to avoid intimidation B) turn on the overhead light while giving instruction C) provide handout written at a 12 grade reading level D) use background music to promote relaxation 39. A male adult is admitted because of an acetaminophen overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client’s discharge plan? A. Avoid exposure to large crowds B. Do not take any over-the-counter medications C. Call the crisis hotline if feeling lonely D. Eat a high carbohydrate, low fat, low protein diet 40. A client with a liver abscess develops septic shock. A sepsis resuscitation bundle protocol is initiated and the client receives a bolus of IV fluids. Which parameter should the nurse monitor to assess effectiveness of the fluid bolus? A. Oxygen saturation B. Blood culture. C White blood cells D. Mean anterior pressure. 41. A male client with ulcerative colitis received a prescription for a corticosteroid last month, but because of the side effect he stopped taking the medication 6 year ago. Which finding warrants immediate intervention by the nurse? A. Fluid retention B. Anxiety and restlessness. C hypotension and fever, D. Increased blood glucose. 42. The nurse is preparing to gavage feed a premature infant through an orogastric tube. During insertion of the tube, the infant’s heart rate drops to 60 beats/minute. Which action should the nurse take? A. Continue the insertion since this is a typical response . B. Insert the feeding tube into the infant’s nasal passage . C. Pause and monitor for a continued drop of the heart rate . D. Postpone the feeding until the infant’s vital signs and stable. 43. The nurse is assessing a client’s arteriovenous (AV) fistula. Which finding provides evidence of its normal function? A. Ecchymotic area B. Enlarged vein C. Pulselessness D. Redness 44. A young adult male client has a diagnosis of epididymitis and a positive culture for Escherichia coli. Which information should the nurse include in the teaching plan? A. Avoid penile contact with the rectal area B. Epididymitis is a pre-cancerous condition C. Obtain an annual prostate digital exam D. Surgical intervention is often indicated 45. The drainage in the chest tube of a client with emphysema has changed from viscous green to clear watery fluid. Which action is best for the nurse to take? A. Obtain a specimen of the drainage for culture B. “Milk” the tube to remove any clots C. Maintain the current IV antibiotic schedule D. Schedule a portable chest x-ray per PRN protocol 46. A client is being treated for acute kidney injury. On examination, the client has a weight gain of 4.4 lbs (2kg) in 24 hours and exhibits changes in mental status. Which intervention should the nurse implement? A. Monitor daily sodium intake B. Assess for dependent pitting edema C. Record usual eating patterns D. Obtain serum creatine levels daily 47. A client with eczema is applying 10% urea cream onto the affected skin areas. Which finding reflects the expected therapeutic response? A. Reduced pain in eczematous areas :B. Decreased weeping of ulcerations in affected areas C. Healing with a return to normal skin appearance D. Hydration of affected dry skin areas 48. The nurse is caring for a client in the post-anesthesia care unit (PACU) who underwent a Thoracotomy two hours ago. The nurse observes the following vital signs: heart rate 140 beats/minute, respirations 26 breaths/minute, and blood pressure 140/90 mmHg. Which intervention is most important for the nurse to implement? A. Administer IV fluid bolus as prescribed by the healthcare provider B. Medicate for pain and monitor vital signs according to protocol C. Encourage the client to splint the incision with a pillow to cough and deep breathe D. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter 49. A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis skin test. The nurse’s assessment of the test after 72 hours indicates 5mm of erythema without induration. What is the best initial nursing action? A. Review client’s history for possible exposure to TB B. Instruct the client to return for a repeat test in 1 week C. Refer client to a healthcare provider for isoniazid (INH) therapy D. Document negative results in the client’s medical record 50. The nurse admits a client who has a medical diagnosis of bacterial meningitis to the unit. Which intervention has the highest priority in providing care for this client? A. Administer initial dose of broad-spectrum antibiotic B. Instruct the client to force fluids hourly C. Obtain results of culture and sensitivity of CSF D. Assess the client for symptoms of hyponatremia 52. After an inservice about cectronic health record (EHR) Security and safeguarding client information, the nurse obseves a colleague going home eith printed copies of client inomation in a uniform pocket. Which action should the nurse take? A) File incident report with the specific hiring facility B)wam the colleague that their actions are unprofessional C)Comment anonymously about the action on a staff discussion board E) Communicate the colleague’s actions to the unit charge nurse 53. A new mother on the postpartum unit runs out of the room screaming that her newborn infant’s crib is empty and the baby is missing. What action should the nurse take first? A. activate the lockdown procedure B. determine if the newborn is in the nursery C. Ask the mother if any visitors were expected to arrive D. Match ID bands of all infants and mothers on the unit. 54. A new nurse preparing to irrigate an intravenous catheter is attaching a 24-gauge needle. Which action should the charge nurse implement ? A. Direct the nurse to change the IV tubing. B. Instruct the nurse to remove the needle. C. Prompt the nurse to apply providone to the site. D. Suggest the nurse use a 20-gauge needle. 55. A young adult male client has a diagnosis of epididymitis and a positive culture for Escherichia coli . Which information should the nurse include in the teaching plan ? A. Avoid penile contact with the rectal area B. Epididymitis is a pre cancerous condition C. Obtain an annual prostate digital exam D. Surgical intervention is often indicated. 56. A client with eczema is applying 10% urea cream onto the affected skin areas. Which finding reflects the expected therapeutic response ? A. Reduced pain in eczematous areas B. Decreased weeping of ulcerations in affected areas C. Healing with a return to normal skin appearance D. Hydration of affected dry skin areas 57. The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a Thoracotomy two hours ago. The nurse observes the following vital signs: heart rate 140 beats/minute, respirations 26 breaths /minute , and blood pressure 140/90 mmHg. Which intervention is most important for the nurse to implement? A. Administer IV fluid bolus as prescribed by the healthcare provider B. Medicate for pain and monitor vital signs according to protocol C. Encourage the client to splint the incision with a pillow to cough and deep breathe D. Apply oxygen at 10 L via a non-rebreather mask and monitor pulse oximeter 58. A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture . His right foot is cool, with palpable pedal pulses . Lungs are coarse with diminished bibasilar breath sounds . Vital signs are temperature 101F , heart rate 128 beats /minute , respirations 28 breaths / minute, and blood pressure 122/82 . Which intervention is most important for the nurse to implement first? A. Obtain oxygen saturation level B. Encourage incentive spirometry C. Assess lower extremity circulation D. Administer PRN oral antipyretic 59. A nurse is caring for a client with Diabetes Insipidus (DI). Which data warrants the most immediate intervention by the nurse? A. Serum sodium of 185 mEq/ L B. Dry skin with inelastic turgor C. Apical rate of 110 beats minute s / m D. Polyuria and excessive thirst. 60. A 48-year-old female client who has been treated for metastasized breast cancer for the past year is told by her healthcare provider that chemotherapy is not producing the desired remission The next morning the client is crying and asks the nurse Who will care for my children ? Which response is best for the nurse to provide? A. What would you like to see happen with your children? B. your husband will have to be there for your children C Try to think about getting well Someone will care for your children. D. Have you talked to your family about who will be responsible for your children? 61. What instruction should the nurse include in the teaching plan for the family of a school -aged child with AIDS? A Obtain an injection of penicillin G 1000 units weekly B Keep the child away from other children and begin a home school program C. Avoid exposure to chickenpox D. Obtain a booster for all immunizations as soon as possible . 62. A client with hepatitis A is complaining of weakness and chronic fatigue Which intervention is most important for the nurse to implement ? A.Place belongings within the client’s reach so that bed rest can be maintained B. Provide liberal fluids for hydration and excretion of metabolic waste products C. Ensure the client has scheduled rest periods every 4 to 6 hours during the day D. Encourage dietary selections that are high in essential vitamins and iron 63. A 48-year-old female client who has been treated for metastasized breast cancer for the past year is told by her healthcare provider that chemotherapy is not producing the desired remission The next morning the client is crying and asks the nurse Who will care for my children ? A. Which response is best for the nurse to provide ? What would you like to see happen with your children ? B. Your husband will have to be there for your childrent C Try to think about getting well Someone will care for your children . D. Have you talked to your family about who will be responsible for your children? 64. Which structures other than the skin are considered to be the first line of defense in humans ? A. Macrophages and cytokines B. Thymus gland , bone marrow , and pancreas C. Lung epithelium , gastric mucosa , and tears. D. Interferon , T cells , and neutrophils . 65. Despite repeated instructions , an 80-year -old client with Parkinson’s disease is unable to instill ophthalmic medication without assistance because of hand tremors What action is best for the nurse to take ? A. Determine if a family member is available and willing to instill the medication B. Continue to reinforce the instructions to enhance the client’s self-confidence. C. Document the client’s inability to instill the medication without assistance . D. Obtain a prescription for a visiting nurse to instill the medication twice a day 66. A client who is one year post kidney transplant is showing early signs of chronic rejection The client asks the nurse what to expect chronic rejection occurs What is the best response by the nurse? A. We will take good care of you and get you through this, so don’t you worry about that B. You will be placed on renal dialysis until the rejection process is clearly reversed. C ” You will go back on the transplant list and we will continue to monitor kidney function D ” Your immunosuppressant medications will be increased until the symptoms have subsided .” 67. A client is recieving an 5% dextrose in Lactated Ringer’s solution at a rate of 100mL / hour The client tells the nurse ” I dont need to eat because I’m getting all the nutrition need through this IV needle. Which initial response is best for the nurse to provide this client ? A. This is called hypertonic , and is more concentrated than your blood. B. Only a very small amount of the calories you need are provided by your IV. C. The IV does contain nutrients but eating is very important. D. It is very imortant to keep eating. Why don’t you want to eat? 68. the nurse is conducting an admission assessment of a female with bipolar disorder , the client suddenly begins to take off her clothes and throw them about the room Which action should nurse take first? A. State is unacceptable to undress during the interview B. Change to less anxiety-promoting questions C. ignore the inappropriate behavior C. Leave the room so she can act out her anxiety 69. the nurse is conducting an admission assessment of a female with bipolar disorder, the client suddenly begins to take off her clothes and throw them around the room Which action should the nurse take? A. State is unacceptable to undress during the interview B. Change to less anxiety C. promoting questions ignore the inappropriate behavior D. Leave the room so she can act out her anxiety 70. The nurse administers naloxone to a client with opioid-induced respiratory depression. One hour inter, nursing assessment reveals that the client has a spiratory rate of 4 breaths/minute, oxygen saturation of 75%, and is unable to be aroused. Which action should the nurse implement? A. Administer a second dose of naloxone. B Prepare to assist with chest tube insertion. C Determine Glasgow Coma Scale score D Initiate cardiopulmonary resuscitation (CPR). 71. While completing an admission assessment for a client with fatigue, weakness, and unexplained weight loss, the nurse notes scleral jaundice. Which finding during percussion of the abdomen should the nurse document indicating heptomegaly? A. A dull percussion tone outside the costal margins. B. Areas of tympany within the liver region C. A hollow sound over the lower abdomen D. Tympany noted boarding the margins of the liver

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