B. Elevated Temperature C. Bradycardia D. Drowsiness 84. A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client? A. Speak directly into the client's impaired ear. B. Exaggerate lip movements. 71 C. Speak loudly. 40' D. Face the client when speaking 85. A nurse is collecting data on a client who has a diagnosis of myasthenia gravis. For which of the 72 following complications is most important for the nurse to monitor? 14 A. Diplopia B. Loss of bladder control C. Paresthesias D. Decreased respiratory effort. 86. A charge nurse on ped unit is making assignments for a nurse who has floated from labor and delivery unit. Which of the following clients is appropriate for charge nurse to assign. A. A preschooler with a hip spica cast who is being discharged today B. an infant scheduled for a surgical repair of ventricular septal defect tomorrow C. a toddler with a fractured femur who has been in Bryants for 5 days D. an adolescent who is 2 days post op following an appendectomy. 87. A nurse is changing the dressings for a client who has two Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice to use to decrease skin irritation. A. Abdominal Binder B. Montgomery straps C. Hypoallergenic tape D. Plastic tape 88. A nurse is assisting with care of a client who is in labor. Following spontaneous rupture of membranes, the nurse visualizes the umbilical cord protruding from the vagina and the fetal heart rate is 50/min. After calling for assistance and notifying the provider, which of the following is the priority action by the nurse? A. wrap the cord in a towel saturated with 0.9% sodium chloride. B. Apply oxygen via face mask. C. Place client in knee-chest position. D. increase IV fluid rate. 89. A nurse in a long-term facility is assisting with an educational program regarding common sites of health care associated infections for a group of newly hired assistive personnel. Which of the following sites should be included in the teaching (select all that apply) A. urinary tract B. surgical wound C. musculoskeletal system D. respiratory tract E. blood stream 90. A nurse is caring for a toddler who has laryngotracheobronchitis and is having difficulty breathing. Which of the following should be the first action of the nurse. A. Administer nebulized epinephrine (racemic epinephrine) B. Ensure adequate hydration C. Obtain an oxygen sat level D. Encourage parents to comfort the client. 91, A nurse is reinforcing teaching regarding foods containing complete protein to a client. Which of following should be included in teaching? A. Lentils B. Soybeans C. Broccoli