Page 2052 - Saunders Comprehensive Review For NCLEX-RN

present?
1. Fluid is clear and tests negative for glucose.
2. Fluid is grossly bloody in appearance and has a pH of 6.
3. Fluid clumps together on the dressing and has a pH of 7.
4. Fluid separates into concentric rings and tests positive for glucose.
708. A client with a spinal cord injury is prone to experiencing autonomic
dysreflexia. The nurse should include which measures in the plan of care to
minimize the risk of occurrence? Select all that apply.
1. Keeping the linens wrinkle-free under the client

2. Preventing unnecessary pressure on the lower limbs

3. Limiting bladder catheterization to once every 12 hours

4. Turning and repositioning the client at least every 2 hours

5. Ensuring that the client has a bowel movement at least once a
week
709. The nurse is evaluating the neurological signs of a client in spinal shock
following spinal cord injury. Which observation indicates that spinal shock
persists?
1. Hyperreflexia
2. Positive reflexes
3. Flaccid paralysis
4. Reflex emptying of the bladder
710. The nurse is caring for a client who begins to experience seizure activity
while in bed. Which actions should the nurse take? Select all that apply.
1. Loosening restrictive clothing.

2. Restraining the client’s limbs.

3. Removing the pillow and raising padded side rails.

4. Positioning the client to the side, if possible, with the head

flexed forward.
5. Keeping the curtain around the client and the room door
open so when help arrives they can quickly enter to assist.
711. The nurse is assigned to care for a client with complete right-sided
hemiparesis from a stroke (brain attack). Which characteristics are associated
with this condition? Select all that apply.
1. The client is aphasic.
2. The client has weakness on the right side of the body.

3. The client has complete bilateral paralysis of the arms and

legs.
4. The client has weakness on the right side of the face and
tongue.

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