[Verified Answer]: An immune-compromised client is being…

An immune-compromised client is being treated for a leg wound infection which has minimal redness and is unchanged since admission. The client’s temperature has increased to 99.9°F (37.7°C). What should be the nurse’s next action? A. Document the findings B. Assess the white blood cell count C. Deliver acetaminophen 650 mg orally D. Elevate the leg on 2 pillows 88. The nurse realizes that twice the dose of furosemide was delivered to an older adult with dementia. Which vital sign assessment should the nurse perform first? A. Oxygen saturation B. Respiratory rate C. Heart rate. D. Blood pressure 89. The nurse is caring for a client with metabolic acidosis. Which finding needs immediate attention? A. Respiratory rate of 28 breath per minute B. Client reports palpitations C. Client reports feeling of nausea D. Hypoactive bowel sounds 79. A client with a history of clot formation is experiencing sudden pain in the left great toe. What should the nurse do next? A. Determine circulation, movement, and sensation (CMS) to the feet. B. Offer pain medication. C. Assess the popliteal and dorsalis pedis pulses. D. Elevate the left foot 80. The nurse is caring for a client on extended bedrest. Which action (s) should the nurse take when getting the client out of bed for the first time? Select all that apply. A. Medicate for pain B. Request additional assistance. C. Obtain orthostatic blood pressure readings D. Apply a gait belt E. Raise the head of the bed F. Deliver additional IV fluids 81. The school nurse is assessing a child with a newly placed immobilizer on the right arm for a hairline fracture. The nurse notes that the fingers are slightly cooler than those on the left hand. What should the nurse do next? A. Nothing, this is normal B. Ask the child if the immobilizer feels tight C. Assess the fingertips on each hand for blanching. D. Assess the radial pulse in the right wrist. 82. A client in the Emergency has been hydrated with normal saline over the last hour for hypovolemia. Assessment changes now include a rapid bounding pulse and shortness of breath. What action should the nurse delegate to the unlicensed assistive personnel? A. Raise the head of bed B. Apply oxygen C. Stop IV fluids. D. Obtain blood pressure. 83. A client has been treated with a diuretic for fluid overload and shortness of breath. After voiding 960 mL clear yellow urine over an hour, the client says she feels funny. What should the nurse do next? A. Reassess the oxygen saturation reading. B. Administer an additional dose of the diuretic. C. Assess the blood pressure. D. Obtain a serum potassium level.