ATI RN Medical Surgical 2023 A

A nurse is providing teaching to a female client who has stress incontinence and a BMI of 32. Which of the following statements by the client indicates an understanding of the teaching? - "Taking my daily progesterone should improve my symptoms." - "A risk factor for my condition is obesity." - "I should limit my daily fluid intake." - "I will switch my morning cup of coffee to hot tea."

- "A risk factor for my condition is obesity." RATIONALE: Excess weight creates increased abdominal pressure that can result in stress incontinence.

A nurse is caring for a client who has terminal cancer. The client tells the nurse, "I wish I could stop these treatments. I am ready to die." Which of the following statements should the nurse make? - "Discontinuing with the treatments is your choice if it is your wish to do so." -"Your child is named as your health care surrogate. I will ask them if you can stop the treatments." -"I will call your spiritual advisor to come in, so you can discuss this with them." -"Next time you have an oncology appointment, you should ask the oncologist."

- "Discontinuing with the treatments is your choice if it is your wish to do so." RATIONALE: The nurse should recognize the client's right to refuse treatments and inform the client of this right. The nurse should advocate for the client and offer to contact the provider for the client.

A nurse is caring for a client in the emergency department (ED). The nurse is evaluating the client's understanding of discharge instructions. Which of the following client statements indicates an understanding of the teaching? - "Food that contain tyramine might trigger my headaches." - "I will keep a food and headache diary." - "I will place a cool cloth on my forehead when I experience a migraine." - "I will take the sumatriptan once every day." - "I should stay awake until my headache is gone."

- "Food that contain tyramine might trigger my headaches." RATIONALE: Tyramine-containing foods, such as aged cheeses, smoked sausage, pickles, and beer are common triggers for migraines. - "I will keep a food and headache diary." RATIONALE: The nurse should instruct the client to keep a food and headache diary to identify migraine triggers. - "I will place a cool cloth on my forehead when I experience a migraine." RATIONALE: The nurse should instruct the client to lie down, dim the light, and place a cool cloth on the forehead to relieve migraine pain.

A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement. Which of the following statements should the nurse make? - "Ginkgo biloba relieves nausea for people who have vertigo." - "Taking ginkgo biloba will help relieve your joint pain." - "Ginkgo biloba can cause an increased risk for bleeding." - "Taking ginkgo biloba decreases the risk of migraine headaches."

- "Ginkgo biloba can cause an increased risk for bleeding." RATIONALE: Ginkgo biloba increases blood flow and is effective in decreasing the pain associated with peripheral artery disease. The supplement also decreases platelet aggregation, which in turn, increases the risk for bleeding. Clients who have been prescribed antiplatelet medications, such as aspirin, should avoid taking ginkgo biloba without first speaking with their provider.

A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new prescription for metformin. Which of the following statements by the client indicates an understanding of the teaching? - "I will monitor my blood sugar carefully because the medication increases the secretion of insulin." - "I should take this medication with a meal." - "I can expect to gain weight while taking this medication." - "While taking this medication, I will experience flushing of my skin."

- "I should take this medication with a meal." RATIONALE: The client should take metformin with or immediately following meals to improve absorption and to minimize GI distress.

A nurse is providing discharge instructions to a client who has laryngeal cancer and is receiving radiation therapy. Which of the following statements by the client indicates an understanding of the teaching? - "I will wear a badge to measure how much radiation I am receiving." - "I will remove the markings on my skin after each radiation treatment." - "I will avoid direct exposure to the sun." - "I will rinse my mouth with a commercial mouthwash."

- "I will avoid direct exposure to the sun." RATIONALE: The client should avoid exposure of irradiated skin areas to the sun for at least 1 year after completing radiation therapy. Skin in the radiation path is especially sensitive to sun damage.

A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching? - "I will monitor my blood pressure while taking this medication." - "I should take a vitamin D supplement to increase the effectiveness of the medication." - "I should inform the provider if I experience an increased appetite while taking this medication." - "I will decrease the amount of protein in my diet while taking this medication."

- "I will monitor my blood pressure while taking this medication." RATIONALE: The client should montior their blood pressure while taking this medication because HTN is a common adverse effect and can lead to hypertensive encephalopathy.

The nurse is providing preoperative teaching for a client who is scheduled for a mastectomy. Which of the following statements should the nurse make? - "You should accept your body image before discharge." - "It is important for you to look at the incisional site when the dressings are removed." - "I will refer you to community resources that can provide support." - "The scar will remain red and raised for many years after surgery."

- "I will refer you to community resources that can provide support." RATIONALE: The nurse should provide the client with support resources, including community programs, to assist the client with acceptance of body changes.

A nurse is teaching a group of newly licensed nurses about pain management for older adult clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? - "Older adult clients might require up to 6 grams of acetaminophen over 24 hr for effective pain control." - "Ibuprofen can cause GI bleeding in older adult clients." - "Meperidine is the medication of choice for older adult clients experiencing severe pain." - "Older adult clients taking oxycodone are at risk for diarrhea."

- "Ibuprofen can cause GI bleeding in older adult clients." RATIONALE: A common adverse effect of ibuprofen is GI bleeding, and older adult clients have an increased risk GI toxicity and bleeding.

A nurse in the emergency department is assessing a client who has a detached retina. Which of the following should the nurse expect the client to report? - "It's like a curtain closed over my eye." - "This sharp pain in my eye started 2 hours ago." - "I've been having more and more difficulty seeing over the last few weeks." - "I seem to have more problems seeing different colors."

- "It's like a curtain closed over my eye." RATIONALE: A retinal detachment is the separation of the retina from the epithelium. It can occur because of trauma, cataract surgery, retinopathy, or uveitis. Clients who have retinal detachment typically report the sensation of a curtain being pulled over part of the visual field.

A nurse is caring for a client who has homonymous hemianopsia as a result of a stroke. To reduce the risk of falls when ambulating, the nurse should provide which of the following instructions to the client? - "Wear an eye patch over one eye." - "Make sure to have a staff member walk on your stronger side." - "Scan the environment by turning your head from side to side." - "Make sure to look at your feet while walking."

- "Scan the environment by turning your head from side to side." RATIONALE: Homonymous hemianopsia is the loss of the same visual field in both eyes. Turning their head from side to side helps enlarge a client's visual field. This technique is also useful for the client during mealtimes.

A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurse's priority? - Initiate oxygen at 2 L/min via nasal cannula - Apply firm pressure to the insertion site - Take the client's vital signs - Obtain a stat order for an aPTT

- Apply firm pressure to the insertion site RATIONALE: The greatest risk to the client is bleeding. Therefore, the priority intervention is for ythe nurse to apply firm pressure to the hematoma and stop the bleeding.

A nurse is providing teaching to a client who has cancer and a new prescription for opioid analgesic for pain management. Which of the following information should the nurse include in the teaching? - "It is an expected effect to sleep throughout the day when taking this medication." - "Your constipation will be lessened as you develop a tolerance to the medication." - "You should void every 4 hours to decrease the risk of urinary retention." - "If you experience ringing in your ears, your dose will need to be reduced."

- "You should void every 4 hours to decrease the risk of urinary retention." RATIONALE: The nurse should instruct the client to void at least every 4 hr to decrease the risk of urinary retention, which is an adverse effect of opioid analgesics.

A nurse is providing teaching to a client who has stage II cervical cancer and is scheduled for brachytherapy. Which of the following instructions should the nurse include? - "You will have an implant placed twice each month for the duration of the treatment." - "You should remain at least 6 feet away from others between treatments." - "You should expect to have blood in your urine for a few days after treatment." - "You will need to stay still in the bed during each treatment session."

- "You will need to stay still in the bed during each treatment session." RATIONALE: The nurse should instruct the client that they will need to remain on bed rest with very limited movement because excessive movement can cause the radioactive source to become dislodged.

A nurse is teaching a class about client rights. Which of the following instructions should the nurse include? - A client should sign an informed consent before receiving a placebo during a research trial. - A client cannot refuse to sign a consent form for a life-saving treatment. - A client who has a mental illness is unable to give informed consent. - An unemancipated minor needs guardian consent for substance use disorder treatment.

- A client should sign an informed consent before receiving a placebo during a research trial. RATIONALE: A nurse should ensure a client has provided informed consent before administering a placebo. Placebos should not be used outside of approved clinical research in which the client has consented to participate.

A nurse is assessing a group of clients for indications of role changes. The nurses should identify that which of the following clients is at risk for experiencing a role change? - A client who has type 1 diabetes mellitus and is starting to self-monitor blood glucose - A client who had a cholecystectomy and is starting on a modified-fat diet - A client who has Crohn's disease and is experiencing diarrhea 3 times a day - A client who has multiple sclerosis and is experiencing progressive difficulty ambulating

- A client who has multiple sclerosis and is experiencing progressive difficulty ambulating RATIONALE: The nurse should identify that progression of a neurologic disease such as multiple sclerosis can lead to a role change as the client becomes less independent.

A nurse is evaluating the plan of care for four clients after 2 days of hospitalization. The nurse should identify the need to revise the plan for which of the following clients? - A client who is taking potassium supplements, has a potassium level of 3.2 mEq/L (3.5 to 5 mEq/L), and reports constipation. - A client who has Alzheimer's Disease (AD), has a room near the nurse's station, and is agitated. - A client who is postoperative following abdominal surgery and reports feeling that something "popped" when they coughed. - A client who has conductive hearing loss, speaks softly, and is scheduled for a cerumen removal.

- A client who is postoperative following abdominal surgery and reports feeling that something "popped" when they coughed. RATIONALE: A feeling of something popping or loosening with coughing might indicate a wound dehiscence. This client will need to have revisions to the plan of care, which can include management of the dehiscence, prevention of evisceration, or possible surgical repair of an evisceration if one occurs.

A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate this risk, which of the following dietary alterations should the nurse recommend? - Add full-fat yogurt to the diet - Add cabbage to the diet - Replace butter with coconut oil - Replace shellfish with red meat

- Add cabbage to the diet RATIONALE: To help reduce the risk for colorectal cancer, the client should consume a diet that is high in fiber, low in fat, and low in refined carbohydrates. Brassica vegetables, such as cabbage, cauliflower, and broccoli, are high in fiber.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A new bag is not available when the current infusion is nearly completed. Which of the following actions should the nurse take? - Keep the line open with 0.9% sodium chloride until the new bag arrives - Administer dextrose 10% in water until the new bag arrives - Flush the line and cap the port until the new bag arrives - Decrease the infusion rate until the new bag arrives

- Administer dextrose 10% in water until the new bag arrives RATIONALE: TPN solutions have a high concentration of dextrose. Therefore, if a TPN solution is temporarily unavailable, the nurse should administer dextrose 10% to 20% in water to avoid a precipitous drop in the client's blood glucose level.

A nurse is caring for a client in the emergency department (ED). A nurse is caring for a client who has a migraine. Which of the following interventions should the nurse anticipate? (Select all that apply.) - Prepare the client for a lumbar puncture - Administer phenobarbital - Administer sumatriptan - Dim the lights in the client's room - Prepare to initiate fibrinolytic therapy - Place the client in seizure precautions

- Administer sumatriptan RATIONALE: The nurse should plan to administer a medication, such as sumatriptan, to produce cerebral artery vasoconstriction and relieve the client's manifestations. - Dim the lights in the client's room RATIONALE: The nurse should plan to dim the lights in the client's room to promote comfort because the client is experiencing photophobia.

A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After ensuring a patent airway, which of the following interventions is the priority? - Obtaining vital signs - Placing the client in Fowler's position - Administering epinephrine - Initiating an IV infusion of 0.9% sodium chloride

- Administering epinephrine RATIONALE: Evidence-based practice indicates that the priority intervention is for the nurse to administer epinephrine quickly to dilate the bronchioles and prevent circulatory shock.

A nurse is admitting a client who has active tuberculosis. Which of the following types of transmission precautions should the nurse initiate? - Airborne - Droplet - Contact - Protective environment

- Airborne RATIONALE: Airborne precautions are required for clients who have infections due to microorganisms that can remain suspended in air for lengthy periods of time, such as tuberculosis, measles, varicella, and disseminated varicella zoster.

A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following nonpharmacological interventions should the nurse suggest to the client to reduce pain? - Increase intake of foods containing calcium - Alternate application of heat and cold to the affected joints - Keep the affected extremities elevated - Limit movement of the affected joints

- Alternate application of heat and cold to the affected joints RATIONALE: The nurse should instruct the client to alternate heat and cold applications to decrease joint inflammation and pain. The application of cold can relieve joint swelling and the application of heat can decrease joint stiffness and pain.

A nurse on a medical-surgical unit is reviewing the medical record of an older adult client who is receiving IV fluid therapy. Which of the following client information should indicate to the nurse that the client requires reevaluation of the IV therapy prescription? - Blood pressure - Prescribed medications - Oxygen saturation - BUN

- BUN RATIONALE: The client's Hct and BUN levels indicate dehydration and require an increase in the IV fluid infusion rate.

A nurse is assessing a client who has Graves' disease. Which of the following images should indicate to the nurse that the client has exophthalmos?

- Bulging eyeballs RATIONALE: The nurse should identify an outward protrusion of the eyes as exophthalmos, a common finding of Graves' disease. An overproduction of the thyroid hormone causes edema of the extraocular muscle and increases fatty tissue behind the eye, which results in the eyes protruding outward. Exophthalmos can cause the client to experience problems with vision, including focusing on objects, as well as pressure on the optic nerve.

A nurse is performing a dressing change for a client who is recovering from a hemicolectomy. When removing the dressing, the nurse notes that a large part of the bowel is protruding through the abdomen. Which of the following actions should the nurse take first? - Place the client in a supine position - Measure vital signs - Cover the wound with a sterile, saline-moistened dressing - Call for help

- Call for help RATIONALE: Evidence-based practice indicates that the nurse should first stay with the client and call for assistance. The client will require emergency surgery and is at risk for shock. Therefore, the nurse should obtain immediate assistance.

A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the following actions should the nurse take first? - Obtain the client's vital signs - Describe the blood transfusion procedure to the client - Check for the type and number of units of blood to administer - Initiate a peripheral IV

- Check for the type and number of units of blood to administer RATIONALE: According to evidence-based practice, the nurse should first confirm that the type and number of units of blood matches what is indicated in the client's medication administration record.

A nurse in an emergency department is assessing an older adult client who has a fractured wrist following a fall. During the assessment, the client states, "Last week I crashed my car because my vision suddenly became blurry." Which of the following actions is the nurse's priority? - Check the client's neurologic status - Document the client's statements - Prepare the client for a CT scan - Teach the client about using safety precautions for falls

- Check the client's neurologic status RATIONALE: The first action the nurse should take using the nursing process is to assess the client. Therefore, the nurse should first check the neurologic status of the client.

A nurse is caring for a client in the emergency department (ED). Drag one condition and one client finding to fill in each blank in the following sentences. 1) Following the administration of sumatriptan, the nurse should monitor for ____________ - Dehydration - Chest pain - Reflux 2) due to the risk of __________ - Peptic ulcer diease - Diuresis - Myocardial ischemia

- Chest pain - Myocardial ischemia RATIONALE: The nurse should monitor the client for chest pain because sumatriptan can cause coronary vasospasms.; Sumatriptan can cause coronary vasospasms, which can lead to myocardial ischemia.

A nurse is assessing a client who has had a suspected stroke. The nurse should place the priority on which of the following findings? - Dysphagia - Aphasia - Ataxia - Hemianopsia

- Dysphagia RATIONALE: Dysphagia indicates that this client is at greatest risk for aspiration due to impaired sensation and function within the oral cavity. Therefore, the nurse should place priority on this finding.

A nurse is assessing a client who has advanced lung cancer and is receiving palliative care. The client has just undergone thoracentesis. The nurse should expect a reduction in which of the following common manifestations of advanced cancer? - Dyspnea - Hemoptysis - Mucus production - Dysphagia

- Dyspnea RATIONALE: Thoracentesis, the removal of pleural fluid, can temporarily relieve hypoxia and thus ease the client's breathing and improve comfort.

The nurse is caring for the client. The nurse is caring for the client 1 hr following chest tube insertion. Click to highlight the findings in the nurses' note that indicate that the client's condition is improving. To deselect a finding, click on the finding again. - Client reports pain as 3 on a scale of 0 to 10. - Client reports SOB has decreased - Client reports nausea, awaiting prescription for nausea - Transfused 1 unit of packed RBCs, awaiting second unit - Wound dressing is dry and intact - Respiratory rate 24/min - Blood pressure 108/74 mmHg - Oxygen saturation 95% on 2 L/min via nasal cannula

- Client reports pain as 3 on a scale of 0 to 10. RATIONALE: The nurse should identify that the client's pain has decreased, indicating their condition is improving. - Client reports SOB has decreased RATIONALE: The nurse should identify that the client's SOB has decreased, indicating their condition is improving. - Wound dressing is dry and intact RATIONALE: The nurse should identify that a dry and intact wound dressing indicates the client's wound is no longer bleeding. - Respiratory rate 24/min - Blood pressure 108/74 mmHg - Oxygen saturation 95% on 2 L/min via nasal cannula RATIONALE: The nurse should identify that the client's vital signs have improved, indicating improved hemodynamic function.

A nurse is planning care for a client who is postoperative following a laparotomy and has a closed-suction drain. Which of the following actions should the nurse take to manage the drain? - Set the wall suction to 80 to 100 mmHg - Compress the drain reservoir after emptying - Allow the drainage to collect on a sterile gauze dressing - Position the drain below the bed to promote drainage

- Compress the drain reservoir after emptying RATIONALE: Compressing the reservoir creates a vacuum that draws fluid out of the wound, through the drain, and into the reservoir.

A nurse is caring for a client who has hypothyroidism. Which of the following manifestations should the nurse expect? - Constipation - Insomnia - Tachycardia - Diaphoresis

- Constipation RATIONALE: A client who has hypothyroidism can experience constipation due to the decrease in the client's metabolism, resulting in slow motility of the GI tract. The nurse should instruct the client to increase fiber and fluid intake to reduce the risk for constipation.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) and is NPO. When reviewing the chart, the nurse notes the following prescription: capillary blood glucose AC and HS. Which of the following actions should the nurse take? - Check the client's blood glucose according to facility mealtimes - Contact the provider to clarify the prescription - Request for meals to be provided for the client - Hold the prescription until client is no longer NPO

- Contact the provider to clarify the prescription RATIONALE: Mealtimes do not pertain to this client due to the NPO status. The nurse should monitor the client's glucose levels on a set schedule, either every 6 hr or per facility protocol. Thus, the prescription requires clarification.

A nurse is caring for a client who has increased ICP and is receiving mannitol via continuous IV infusion. Which of the following findings should the nurse report to the provider as an adverse effect of this medication? - Decreased heart rate - Crackles heard on auscultation - Increased urinary output - Decreased deep tendon reflexes

- Crackles heard on auscultation RATIONALE: Mannitol is an osmotic diuretic that prevents the reabsorption of water in the kidneys, thus increasing urinary output. With the exception of the brain, mannitol can leave the vascular system at the capillary site, which can result in edema. The nurse should identify crackles as a manifestation of pulmonary edema and notify the provider. Other manifestations include dyspnea and decreased oxygen saturation.

A nurse is providing preoperative teaching for a client who is scheduled for an open cholecystectomy. Which of the following actions should the nurse take? - Teach the important of a clear liquid diet after discharge - Tell the client to remove the incisional adhesive strips 3 days after discharge - Demonstrate ways to deep breathe and cough - Instruct the client to maintain bed rest for 48 hr

- Demonstrate ways to deep breathe and cough RATIONALE: The nurse should demonstrate deep breathing and coughing exercises and explain the importance of splinting the incision to reduce the risk for respiratory complications.

A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following interventions should the nurse include in the plan? - Encourage the client to take deep breaths after the procedure - Assist the client to hold their arms up during the procedure - Instruct the client to remain NPO after midnight prior to the procedure - Keep the client on bed rest for 8 hr following the procedure

- Encourage the client to take deep breaths after the procedure RATIONALE: After a thoracentesis, the client should deep breath to reexpand the lung.

A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the following precautions should the nurse implement? - Place a padded tongue blade at the client's bedside - Keep the side rails lowered on the client's bed - Maintain the client's bed at hip level or above - Ensure that the patient has a patent IV

- Ensure that the patient has a patent IV RATIONALE: The nurse should ensure the client has IV access in the event that the client requires medication to stop seizure activity.

A nurse is caring for a client in the emergency department (ED). Select the 4 findings that require follow-up by the nurse. - Pain - Orientation - Expressive aphasia - Tingling of the lips - Blood pressure - Hand grasps - Visual disturbances

- Expressive aphasia RATIONALE: Expressive aphasia is a manifestation of a neurological event. Therefore, the nurse should follow-up on this finding. - Tingling of the lips RATIONALE: Tingling in the face is a manifestation of a neurological event. Therefore, the nurse should follow-up on this finding. - Hand grasps RATIONALE: The client's hand grasps are unequal, which could indicate a neurological deficit. Therefore, this finding requires follow-up by the nurse. - Visual disturbances RATIONALE: Visual disturbances are manifestations of a neurological event. Therefore, the nurse should follow-up on this finding.

A nurse is caring for a client who is 4 hr postoperative following an open reduction internal fixation of the right ankle. Which of the following assessment findings should the nurse report to the provider? - Extremity cool upon palpation - Serosanguineous drainage on the dressing - Capillary refill of 2 seconds - Client report of discomfort when moving toes

- Extremity cool upon palpation RATIONALE: The nurse should report indicators of reduced circulation, such as pallor, cool temperature, or paresthesia of the client's extremity. These findings can indicate that the client is at risk for developing acute compartment syndrome.

A nurse is providing education to a client who has tuberculosis (TB) and their family. Which of the following information should the nurse include in the teaching? - After 1 week of medication, TB is no longer communicable - Dispose of contaminated tissues in a paper bag - Airborne precautions are necessary in the home - Family members in the household should undergo TB testing

- Family members in the household should undergo TB testing RATIONALE: Family members who live in the same household with the client have been exposed to TB. Therefore, the nurse should recommend TB screening to foster early detection and treatment of TB.

A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the following instructions should the nurse include? - Flex the foot every hour when awake - Place a pillow under the knee when lying in bed - Lower the leg when sitting in a chair - Ensure the leg is abducted when resting in bed

- Flex the foot every hour when awake RATIONALE: The nurse should instruct the client to flex the foot every hour to reduce the risk for thromboembolism and promote venous return.

A nurse is preparing to present a program about prevention of atherosclerosis at a health fair. Which of the following recommendations should the nurse plan to include? (Select all that apply.) - Following a smoking cessation program - Maintain an appropriate weight - Eat a low-fat diet - Increase fluid intake - Decrease intake of complex carbohydrates

- Following a smoking cessation program RATIONALE: Smoking cessation is an important lifestyle modification to prevent athersclerosis. - Maintain an appropriate weight RATIONALE: Preventing obesity through diet and exercise can help to prevent atherosclerosis. - Eat a low-fat diet RATIONALE: Eating a low-fat diet decreases LDL cholesterol and can prevent atherosclerosis.

A nurse is caring for a client who has DKA. Which of the following findings should indicate to the nurse that the client's condition is improving? - Potassium 3.2 mEq/L (3.5 to 5 mEq/L) - pH 7.28 (7.35 to 7.45) - Glucose 272 mg/dL (74 to 106 mg/dL) - HCO3- 14 mEq/L (21 to 28 mEq/L)

- Glucose 272 mg/dL (74 to 106 mg/dL) RATIONALE: A glucose reading less than 300 mg/dL indicates improvement in the client's status.

A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit? - Heart rate 110/min - Blood pressure 138/90 mmHg - Urine specific gravity 1.001 (1.005 to 1.03) - BUN 8 mg/dL (10-20 md/dL)

- Heart rate 110/min RATIONALE: A client who has a 3-day history of vomiting and diarrhea is likely to have fluid volume deficit and an elevated heart rate.

The nurse is caring for the client. Complete the following sentence by using the list of options. 1) The client is most likely experiencing a _____________ - Traumatic brain injury - Hemothroax - Ruptured spleen 2) as evidenced by the client's ________ - Gastrointestinal findings - GCS score - Respiratory findings

- Hemothorax - Respiratory findings RATIONALE: The client has SOB, hypoxia, diminished breath sounds, and a decreased hematocrit. Therefore, the client is likely experiencing a hemothorax. The client has SOB, hypoxia, diminished breath sounds, and a decreased hematocrit. Therefore, the client is likely experiencing a hemothorax.

A nurse is caring for a client who has chronic glomerulonephritis with oliguria. Which of the following findings should the nurse identify as a manifestation of chronic glomerulonephritis? - Metabolic alkalosis - Hyperkalemia - Increased hemoglobin - Hypophosphatemia

- Hyperkalemia RATIONALE: The nurse should identify that a client who has chronic glomerulonephritis can experience hyperkalemia as a result of kidney failure. Kidney failure results in decreased excretion of potassium.

A nurse is caring for a client who has a potassium level of 3 mEq/L (3.5 to 5 mEq/L). Which of the following assessment findings should the nurse expect? - Positive Trousseau's sign - 4+ deep tendon reflexes - Deep respirations - Hypoactive bowel sounds

- Hypoactive bowel sounds RATIONALE: Hypokalemia decreases smooth muscle contraction in the GI tract leading to decreased peristalsis.

A nurse in an emergency department is caring for a client who has full-thickness burns over 20% of their total body surface area. After ensuring a patent airway and administering oxygen, which of the following items should the nurse prepare to administer first? - IV fluids - Analgesia - Antibiotics - Tetanus toxoid

- IV fluids RATIONALE: After establishing that the client's airway is secure and administering oxygen, evidence-based practice indicates that the nurse should prepare to administer IV fluids to provide circulatory support.

A nurse is providing discharge instructions to a client following an upper GI series with barium contrast. Which of the following information should the nurse provide? - Increase fluid intake - Take an over-the-counter antidiarrheal medication - Expect black, tarry stools - Follow a low-fiber diet

- Increase fluid intake RATIONALE: Increasing fluid intake will help to prevent constipation. Therefore, the nurse should instruct the client to increase fluid intake to facilitate the elimination of the barium used during the test.

A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. Which of the following assessment findings is the nurse's priority? - Temperature 38.4 (101.1 F) - Increased respiratory secretions - Fluid intake of 200 mL in the prior 8 hr - Limited ROM

- Increased respiratory secretions RATIONALE: Using the airway, breathing, circulation approach to client care, the nurse should determine that the priority assessment finding is increased respiratory secretions. Clients who have ALD may experience respiratory muscle weakness and dysphagia, and excessive respiratory secretions can impair the ability to clear the airway, which increases the client's risk for aspiration.

A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive cough. Which of the following actions should the nurse take first? - Obtain a sputum sample - Administer antipyretics - Provide hand hygiene education - Initiate airborne precautions

- Initiate airborne precautions RATIONALE: The client is exhibiting manifestations of tuberculosis. The greatest risk in this client situation is for other people in the facility to acquire an airborne disease from this client. Therefore, the first action the nurse should take is to initiate airborne precuations.

A nurse is caring for a client who is postoperative following abdominal surgery. A nurse is caring for a client who is postoperative. Which of the following actions should the nurse take? (Select all that apply.) - Ask the client to rate their pain on a 0 to 10 pain scale - Instruct the client to splint the abdomen with a pillow for coughing - Plan to ambulate the client as soon as possible - Apply oxygen via a face mask - Report urinary output to the provider

- Instruct the client to splint the abdomen with a pillow for coughing RATIONALE: It is important for the client to turn, cough, and deep breathe to reduce the risk for respiratory complications. The nurse should instruct the client to splint the incision while performing these actions to reduce the risk of complications to the surgical incision. - Plan to ambulate the client as soon as possible RATIONALE: The nurse should plan to ambulate the client as soon as possible to promote ventilation and decrease the risk of thrombosis.. - Report urinary output to the provider RATIONALE: The client should produce at least 30 mL of urine per hour. Therefore, the nurse should report this finding to the provider. - Ask the client to rate their pain on a 0 to 10 pain scale RATIONALE: The nurse should have the client rate their pain prior to and following the administration of pain medication to evaluate its effectiveness.

A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? - Insert a padded tongue blade - Apply oxygen - Restrain the client - Loosen restrictive clothing

- Loosen restrictive clothing RATIONALE: The nurse should loosen tight, restrictive clothing to prevent injury and suffocation.

A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction? - Anorexia and jaundice - Bronchospasm and urticaria - HTN and bounding pulse - Low back pain and apprehension

- Low back pain and apprehension RATIONALE: Hemolytic transfusion reactions result from the infusion of incompatible blood products and create a systemic inflammatory response. Manifestations include low back pain, hypotension, tachycardia, and apprehension.

A nurse is caring for a client in the emergency department (ED). Complete the following sentence by using the list of options. 1) The nurse should identify that the client is most likely experiencing __________ - Migraine - Stroke - Meningitis 2) and the nurse should address the client's __________ - Blood pressure - Pain - Neurological status

- Migraine - Pain RATIONALE: The client is exhibiting manifestations of a migraine. The client presented initially with neurological manifestations of flashing lights, aphasia, unilateral weakness, and numbness of the lips. These findings are consistent with the first phase, or the aura phase of a migraine. These changes resolved after an hour and were followed by throbbing pain with nausea and vomiting. The client reports pain as a 7 on a scale of 0 to 10, which indicates significant discomfort. The nurse should address the client's pain level to promote comfort.

A nurse is creating a plan of care for a client who has neutropenia as a result of chemotherapy. Which of the following interventions should the nurse include in the plan? - Monitor the client's temperature every 4 hr - Insert an indwelling catheter for the client - Request the client's bathroom be cleaned 3 times each week - Place a box of latex gloves just outside the client's room

- Monitor the client's temperature every 4 hr RATIONALE: The nurse should monitor the temperature of a client who has neutropenia every 4 hours because the client's reduced amount of leukocytes greatly increases the client's risk for infection.

A nurse is providing discharge teaching to a client who is postoperative following a modified radical mastectomy. Which of the following instructions should the nurse include? - Flex the affected arm when ambulating - Numbness can occur along the inside of the affected arm - Begin ROM exercises 1 day after surgery - Dress in clothing that fits snugly

- Numbness can occur along the inside of the affected arm RATIONALE: The nurse should instruct the client that numbness can occur near the incision and along the inside of the affected arm due to nerve injury.

A nurse is caring for a client who has portal HTN. The client is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first? - Check laboratory values for recent hemoglobin and hematocrit levels - Establish a peripheral IV line for possible transfusion - Call the laboratory to obtain a stat platelet count - Obtain vital signs

- Obtain vital signs RATIONALE: The first action the nurse should take using the nursing process is to assess the client's vital signs. A client who has portal HTN can develop esophageal varices, which are fragile and can rupture, resulting in large amounts of blood loss and shock. Obtaining vital signs provides information about the client's condition that can contribute to decision making.

The nurse is caring for the client. Drag words from the choices below to fill in each blank in the following sentence. 1) The nurse should first address the client's _________ - Peripheral pulses - Temperature - Oxygenation - Pain - Blood pressure 2) followed by the client's ________ - Peripheral pulses - Temperature - Oxygenation - Pain - Blood pressure

- Oxygenation - Blood pressure RATIONALE: Using the airway, breathing, circulation priority framework, the nurse should first address the client's oxygenation, followed by the client's blood pressure. The client's oxygenation is below the expected reference range and is the top priority. The nurse should then address the client's circulation because the client's blood pressure is below the expected reference range.

A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the following results should the nurse expect? - PaCO2 56 mmHg (35 to 45 mmHg) - pH 7.50 (7.35 to 7.45) - HCO3- 18 mEq/L (21 to 28 mEq/L) - PaO2 130 mmHg (80 to 100 mmHg)

- PaCO2 56 mmHg (35 to 45 mmHg) RATIONALE: A client who has COPD retains PaCO2 due to the weakening and collapse of the alveolar sacs, which decreases the area in the lungs for gas exchange and causes the PaCO2 to increase above the expected reference range.

A nurse in the emergency department is caring for a client. Drag 1 condition and 1 client finding to fill in each blank in the following sentence. 1) The client is experiencing manifestations of ___________ - A cerebral vascular accident (CVA) - Cardiogenic shock - Pancreatitis - Paralytic ileus - Adult respiratory distress syndrome (ARDS) 2) as evidenced by the __________ - Oxygen saturation - Blood pressure - Platelet levels - Urine output - Amylase and lipase

- Pancreatitis RATIONALE: The client's laboratory results and physical assessment indicate that the client is experiencing manifestations of pancreatitis. Clients who have pancreatitis experience and increase in pancreatic enzymes, amylase, and lipase. - Amylase and lipase RATIONALE: The client's laboratory results and physical assessment indicate that the client is experiencing manifestations of pancreatitis. Clients who have pancreatitis experience and increase in pancreatic enzymes, amylase, and lipase.

A nurse is caring for a client. Drag 1 condition and 1 client finding to fill in each blank in the following sentence. 1) The client is experiencing manifestations of _________ - Myxedema coma - Hemorrhage - Pneumonia - Dysrhythmias - Peritonitis 2) due to _________ - Thyroid level - X-ray results - Oxygen saturation - Potassium level - Platelet count

- Peritonitis RATIONALE: The client is experiencing manifestations of peritonitis, such as abdominal pain, cloudy dialysate, and an elevated white blood cell count. - X-ray results RATIONALE: The client's abdominal x-ray shows fluid in the abdomen along with inflammation, both of which are indications of peritonitis.

A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take? - Maintain adduction of the client's legs - Encourage ROM of the hip up to a 120 degree angle - Place a pillow between the client's legs - Keep the client's hip internally rotated

- Place a pillow between the client's legs RATIONALE: The nurse should place a pillow between the client's legs to prevent hip dislocation.

A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take? - Flush the line before administering antibiotics - Position the client in Trendelenburg to obtain measurements - Have the client bear down when readings are obtained - Place a pressure bag around the flush solution

- Place a pressure bag around the flush solution RATIONALE: The nurse should place a pressure bag around the flush solution of 0.9% sodium chloride because the pressure from an artery is greater than that of the line.

The nurse is caring for the client. The nurse is caring for the client following the placement of a chest tube for a hemothorax. Which of the following actions should the nurse take? (Select all that apply.) - Monitor drainage every 30 minutes for the first hour - Strip the drainage tubing to ensure it is patent - Place the client in high-Fowler's position - Palpate the chest tube insertion site for subcutaneous emphysema - Ensure that all chest tube connections are securely attached - Place two rubber-tipped hemostats in the client's room - Ensure there is a continuous bubbling in the water seal chamber

- Place the client in high-Fowler's position RATIONALE: The nurse should place the client in high-Fowler's position to promote drainage of the hemothorax. - Place two rubber-tipped hemostats in the client's room RATIONALE: The nurse should place two rubber-tipped hemostats in the client's room to use in case of an emergency, such as a chest tube dislodgement. - Palpate the chest tube insertion site for subcutaneous emphysema RATIONALE: The nurse should palpate the chest tube insertion site for subcutaneous emphysema because this is a manifestation of an air leak. - Ensure that all chest tube connections are securely attached RATIONALE: The nurse should ensure that all connections between the chest tube and drainage system are secure and intact to reduce the risk of a tension pneumothorax.

A nurse is caring for a client who has a leg cast and is returning to demonstrate on the proper use of crutches while climbing stairs. Identify the sequence the client should follow when demonstrating crutch use. - Brings the crutches and the affected leg up to the stair - Places body weight on the crutches - Shifts weight from the crutches to the unaffected leg - Advances the unaffected leg onto the stair

- Places body weight on the crutches - Advances the unaffected leg onto the stair - Shifts weight from the crutches to the unaffected leg - Brings the crutches and the affected leg up to the stair

A nurse in a provider's office is assessing a client who has HTN and takes propranolol. Which of the following assessment findings should indicate to the nurse that the client is experiencing an adverse reaction to this medication? - Report of a night cough - Report of tinnitus - Report of excessive tearing - Report of increased salivation

- Report of a night cough RATIONALE: The nurse should recognize that a night cough is an early indication of heart failure and report this adverse reaction to the provider.

A nurse is caring for a client who is brought to the emergency department following an oil fire. Drag words from the choices below to fill in each blank in the following sentence. 1) During the emergent phase of burn care, the client is at risk for developing ____________ - Hypovolemia - Respiratory failure - Hyperthermia - Hypokalemia - Curling's ulcer 2) and __________________ - Hypovolemia - Respiratory failure - Hyperthermia - Hypokalemia - Curling's ulcer

- Respiratory failure - Hypovolemia RATIONALE: Plasma volume is lost immediately during a burn injury, which can lead to a lack of perfusion to all body organs. Hypovolemia is indicated by the client's blood pressure declining and heart rate increasing. If fluid resuscitation is not initiated successfully, hypovolemic shock can occur. The initial priority following a burn injury is to assess and protect the airway. The client has burns to the face and chest, which will compromise respiratory function, placing them at risk for respiratory failure. The client's respiratory function is decompensating as edema to the airway increases. Continued decompression might indicate the need for the client to be intubated.

A nurse is assessing a client following the completion of hemodialysis. Which of the following findings is the nurse's priority to report to the provider? - Temperature 37.2 C (99 F) - Blood pressure 100/70 mmHg - Weight loss - Restlessness

- Restlessness RATIONALE: Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding to report to the provider is restlessness, which can be an indication the client is experiencing disequilibrium syndrome. Disequilibrium syndrome is caused by the rapid removal of electrolytes from the client's blood and can lead to dysrhythmias or seizures. Other manifestations include nausea, vomiting, fatigue, and headache.

A nurse is providing follow-up care for a client who sustained a compound fracture 3 weeks ago. The nurse should recognize that an expected finding for which of the following laboratory values is a manifestation of osteomyelitis and should be reported to the provider? - Sedimentation rate - Hematocrit - Calcium - Acid phosphatase

- Sedimentation rate RATIONALE: An increased sedimentation rate occurs when a client has any type of inflammatory process, such as osteomyelitis.

A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions should the nurse anticipate taking? - Administer an antihistamine - Slow the infusion rate - Give the client a corticosteroid - Elevate the client's lower extremities

- Slow the infusion rate RATIONALE: Dyspnea, restlessness, and the onset of crackles during a blood transfusion are manifestations of circulatory overload. The nurse should slow or stop the infusion to improve the client's ability to breath, place the client in an upright position, and notify the provider. The provider might prescribe a diuretic to alleviate the fluid overload.

A nurse is assessing a client who had extracorporeal shock wave lithotripsy (ESWL) 6 hr ago. Which of the following findings should the nurse expect? - Stone fragments in the urine - Fever - Decreased urine output - Bruising on the lower abdomen

- Stone fragments in the urine RATIONALE: ESWL is an effort to break the calculi so that the fragments pass down the ureter, into the bladder, and through the urethra during voiding. Following the procedure, the nurse should strain the client's urine to confirm the passage of stones.

A nurse is providing discharge teaching to a client who has a gastric ulcer a new prescription for omeprazole. The nurse should instruct the client that the medication provides relief by which of the following actions? - Neutralizing gastric acid - Reducing the growth of ulcer-causing bacteria - Coating the stomach lining - Suppressing gastric acid production

- Suppressing gastric acid production RATIONALE: Omeprazole is a proton pump inhibitor. It relieves manifestations of gastric ulcers by suppressing gastric acid production.

A nurse is planning care to decrease psychosocial health issues for a client who is starting dialysis treatments for chronic kidney disease. Which of the following intervention should the nurse include in the plan? - Remind the client that dialysis treatments are not difficult to incorporate into daily - Inform the client that dialysis will result in a cure - Tell a client that it is possible to return to similar previous levels of activity - Begin health promotion teaching during the first dialysis treatment

- Tell a client that it is possible to return to similar previous levels of activity RATIONALE: The nurse should help the client develop realistic goals and activities to have a productive life.

A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the nurse's priority? - Moderate serosanguineous drainage on the dressing - Calcium 9.5 mg/dL (9 to 10.5 mg/dL) - Temperature 38.9 C (102 F) - Decreased bowel sounds

- Temperature 38.9 C (102 F) RATIONALE: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is an elevated temperature. An elevated temperature is a manifestation of excessive thyroid hormone release, or thyroid storm, due to an increase in metabolic rate. The nurse should report this finding immediately to provider because it can lead to seizures and coma.

A nurse is caring for a client who had a nephrostomy tube inserted 12 hr ago. Which of the following findings indicates a potential complication? - The client's urinary output has increased - The client reports back pain - The client's urine is red tinged - The client's tube requires irrigation

- The client reports back pain RATIONALE: The nurse should notify the provider if the client reports back pain, which can indicate that the nephrostomy tube is dislodged or clogged.

A nurse is assessing a client while suctioning the client's tracheostomy tube. Which of the following findings should indicate to the nurse the client is experiencing hypoxia? - The client starts to cough - The client's heart rate increases - The client is diaphoretic - The client's blood pressure decreases

- The client's heart rate increases RATIONALE: Hypoxia related to suctioning can cause the client's heart rate to increase. If this occurs, the nurse should discontinue the suctioning and manually oxygenate the client with 100% oxygen. The nurse should instruct the client to take 3 or 4 deep breaths prior to suctioning to reduce the risk for hypoxia.

A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following findings indicates that the client is experiencing a complication? - The client reports that the sequential compression devices (SCDs) are uncomfortable - The client reports pain at the surgical site as 4 on a scale of 0 to 10. - The client's surgical site dressing has required changing twice in 2 hr due to drainage - The client needs assistance with a walker when ambulating in the room

- The client's surgical site dressing has required changing twice in 2 hr due to drainage RATIONALE: Frequent dressing changing after surgery may indicate poor clotting and increased bleeding.

A nurse is caring for a client who is having a seizure. Which of the following interventions is the nurse's priority? - Loosen the clothing around the client's neck - Check the client's pupillary response - Turn the client to the side - Move furniture away from the client

- Turn the client to the side RATIONALE: The greatest risk to this client is hypoxia from an impaired airway. Therefore, the priority intervention the nurse should take is to place the client in a side-lying position to prevent aspiration.

A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure injury, Which of the following actions should the nurse take? - Apply a wet-to-dry gauze dressing - Irrigate with hydrogen peroxide solution - Use a 30-mL syringe - Attach a 24-gauge angiocatheter to the syringe

- Use a 30-mL syringe RATIONALE: The nurse should use a 30-mL to 60-mL syringe with an 18- or 19-gauge catheter to deliver the ideal pressure of 8 pounds per square inch (psi) when irrigating a wound. To maintain healthy granulation tissue, the wound irrigation should be delivered at between 4 and 15 psi.

A nurse is providing teaching for a female client who has recurrent urinary tract infections. Which of the following information should the nurse include in the teaching? - Take tub baths daily - Drink at least 1 L of fluid daily - Wear underwear made of nylon - Void before and after intercourse

- Void before and after intercourse RATIONALE: The nurse should instruct the client to empty her bladder before and after intercourse, which flushes bacteria out of the urinary tract and prevents the occurrence of infection.

A nurse is reviewing the laboratory results of a client who has a history of aplastic anemia. Which of the following findings indicates that the client is experiencing pancytopenia? - RBC count 6.3 million/mm3 (4.7 to 6.1 million/mm3 male) - WBC count 2,000/mm3 (5000 to 10,000/mm3) - Platelets 450,000/mm3 (150,000 to 400,000/mm3) - Potassium 3.3 mEq/L (43.5 to 5 mEq/L)

- WBC count 2,000/mm3 (5000 to 10,000/mm3) RATIONALE: A decreased WBC, or leukopenia, is a manifestation of pancytopenia. Pancytopenia occurs when there is a decreased RBC count, decreased WBC count, and decreased platelets.

A nurse is planning care for a client who is undergoing brachytherapy via a sealed vaginal implant to treat endometrial cancer. Which of the following actions should the nurse include in the client's plan of care? - Collect and place the client's urine or feces in a biohazard bag - Limit the client's ambulation to their own room - Wear a lead apron while providing care to the client - Limit each visit to 1 hr per day

- Wear a lead apron while providing care to the client RATIONALE: The nurse should wear a lead apron when providing direct care to provide protection from the radiation source and not turn their back toward the client, because the apron only shields the front of the body. The nurse should also wear a dosimeter film badge to measure radiation exposure.

A nurse has received report on a client who is being admitted to the emergency department. Select the 3 findings that require follow-up by the nurse. - GCS score - Wound drainage - Oxygen saturation - Pain level - Temperature

- Wound drainage RATIONALE: The nurse should apply a pressure dressing to control bleeding. - Oxygen saturation RATIONALE: The client has an oxygen saturation that is less than the expected reference level, indicating hypoxia. The nurse should plan to increase the client's supplemental oxygen. - Pain level RATIONALE: The nurse should follow-up on the client's pain level.

A nurse is caring for a client who is postoperative. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress. Actions To Take: - Begin antimicrobial therapy - Initiate a fluid challenge - Apply pneumatic compression - Insert a large gauge IV - Repeat troponin level Potential Complication: - Deep vein thrombosis - Surgical site infection - Hypovolemia - Acute myocardial infarction Parameter To Monitor: - Blood pressure - Cardiac rhythm - Urine output - Temperature - Swelling of the lower extremities

Actions To Take: - Initiate a fluid challenge - Insert a large gauge IV Potential Complication: - Hypovolemia Parameter To Monitor: - Blood pressure - Urine output RATIONALE: The nurse should insert a large-gauge IV and initiate a fluid challenge because the client is most likely experiencing hypovolemia as evidenced by the client's restlessness, tachycardia, hypotension, decreased pulses, cool extremities, and decreased urine output. The nurse should monitor the client's urine output and blood pressure to evaluate the effectiveness of the treatment.

The nurse is caring for the client. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client. - Place the client in Trendelenburg position - Cover the client with a cooling blanket - Transfuse packed RBCs - Prepare the client for chest tube insertion - Initiate NPO status

Anticipated: - Transfuse packed RBCs RATIONALE: The client's increased heart rate and decreased blood pressure indicate decreased circulating blood volume due to trauma. Therefore, the nurse should anticipate transfusing packed RBCs. - Prepare the client for chest tube insertion RATIONALE: The client has manifestations of a hemothorax. Therefore, a chest tube is indicated. - Initiate NPO status RATIONALE: The client might require a surgical procedure. Therefore, the nurse should anticipate initiating NPO status. Contraindicated: - Place the client in Trendelenburg position RATIONALE: Due to clinical manifestations of hypovolemia, the nurse should position the client flat or place their HOB no more than 30 degrees to promote venous return to the heart. - Cover the client with a cooling blanket RATIONALE: The client's temperature is below the expected reference range, which is a manifestation of hypothermia. Therefore, covering the client with a cooling blanket is contraindicated.

A nurse is caring for a client in the emergency department (ED). For each finding below, click to specify if the finding is consistent with migraine, stroke, or meningitis. - Family history - Aphasia - Numbess - Hand grasps - Visual changes

Hand Grasps: - Migraine - Stroke - Meningitis RATIONALE: Unilateral weakness can occur due to neurological vascular changes and inflammation that can be present with migraine, stroke, and meningitis. Numbness: - Migraine - Stroke RATIONALE: Numbness and tingling of the lips and tongue can occur with migraines due to neurological vascular changes and inflammation that can be present. Numbness can also occur with middle cerebral artery strokes. Aphasia: - Migraine - Stroke RATIONALE: Aphasia can occur due to neurological vascular changes and inflammation that can be present with a migraine and a stroke. Visual Changes: - Migraine - Stroke - Meningitis RATIONALE: Visual changes can occur with migraine, stroke, and meningitis due to neurovascular changes and inflammation that can be present. Family History - Migraine - Stroke RATIONALE: Family history is a risk factor associated with migraine and stroke.

A nurse is caring for a client who is receiving dialysis treatment. For each potential nursing intervention, click to specify if the intervention is indicated or not indicated. - Notify the provider immediately - Place the client in Trendelenburg position. - Perform a 12-lead ECG. - Obtain the client's blood glucose level - Administer a 0.9% sodium chloride 200 mL IV bolus. - Apply oxygen at 2 L/min via nasal cannula.

Indicated: - Place the client in Trendelenburg position. RATIONALE: The client should be placed in the Trendelenburg position to increase blood flow to the heart, improving cardiac output and organ perfusion. - Administer a 0.9% sodium chloride 200 mL IV bolus. RATIONALE: The nurse should administer 200 mL of 0.9% sodium chloride IV bolus to increase fluid volume and the client's blood pressure. - Apply oxygen at 2 L/min via nasal cannula. RATIONALE: The nurse should administer oxygen at 2 L/min via nasal cannula to increase the amount of oxygen carried in the blood. - Notify the provider immediately RATIONALE: The nurse should notify the provider immediately as part of the nurse's role to provide an update on the client's condition. Not Indicated: - Perform a 12-lead ECG. RATIONALE: The client is not reporting chest pain; therefore, a 12-lead ECG is not indicated at this time. - Obtain the client's blood glucose level RATIONALE: There is no indication that the client is experiencing hypoglycemia; therefore, obtaining a blood glucose level is not indicated.