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92. Which finding should raise the greatest concern for a nurse who is performing an ENT examination? a. A painful ulcerated mucosal area inside the cheek for 1 day. b. Stippled gingival margins that adhere firmly to the teeth. c. A number of small yellowish-white and raised lesions on the buccal mucosa. d. An ulceration under the tongue that has been present for the last three weeks. 93. During a home visit, the nurse should evaluate the adequacy of a client's treatment for COPD by assessing for which primary symptom? a. Dyspnea b. Tachycardia. c. Unilateral diminished breath sounds. d. Edema of the ankles. 94. The community health nurse is working in a multi-ethnic health center. In what situation should the nurse intervene? a. An Asian-American mother reports using cupping to treat infection, resulting in a pattern of red round marks on her toddler's back. b. A Hispanic pregnant client who is often late for appointments, arrives late for today's appointment. c. A Native-American who is being interviewed will not make direct eye contact when asked about violence in the home. d. An African-American infant who is spitting up milk has lost 6 ounces since last week's clinic visit. 16 95. When assessing a male client who is receiving a unit of packed red blood cells (PRBCs), the nurse notes that the infusion was started 30 minutes ago, and 50 ml of blood is left to be infused. The client's vital signs are within normal limits. He reports feeling "out of breath" but denies any other complaints. What action should the nurse take at this time? a. Administer a PRN prescription for diphenhydramine (Benadryl). b. Start the normal saline attached to the Y- tubing at the same rate. c. Decrease the intravenous flow rate of the PRBC transfusion. d. Ask the respiratory therapist to administer PRN albuterol (Ventolin.). 96. The nurse observes that a client has received 250 ml of 0.9% normal saline through the IV line in the last hour. The client is now tachypneic, and has a pulse rate of 120 beats/minute, with a pulse volume of +4. In addition to reporting the assessment findings to the healthcare provider, what action should the nurse implement? a. Discontinue the IV and apply pressure at the site. b. Decrease the saline to a keep-open rate. c. Increase the rate of the current IV solution. d. Change the IV fluid to 0.45% normal saline at the same rate. 97. A client who participates in a health maintenance organization (HMO) needs a bone marrow transplant for treatment of breast cancer. The client tells the nurse that she is concerned that her HMO may deny her claim. What action by the nurse best addresses the client's need at this time? a. Have the client's healthcare provider write a letter to the HMO explaining the need for the transplant. b. Help the client place a call to the HMO to seek information about limitations of coverage. c. Encourage the client to call a lawyer so that a lawsuit can be filed against the HMO if necessary. d. Have the social worker call the state board of insurance to register a complaint against the HMO. 98. The charge nurse observes that a client with a nasogastric tube applied to low intermittent suction is drinking a glass of water immediately after the unlicensed assistive personnel a. Remove the glass of water and speak to the UAP. b. Discuss the incident with the UAP at the end of the day. c. Write an incident report and notify the healthcare provider. d. Remind the client of the potential for electrolyte imbalance