HESI- med surg
PT WITH OBESITY HIGH GLUCOSE LEVEL IS AT RISK FOR?
CARDIOVASCULAR DISEASE
A patient who has been taking B12 says he's fatigue. What lab to monitor?
CBC
PREOPERATIVE NURSING CARE
CONCERNS AND ANXIETY FOR SURGERY
Pt w/ dysrhythmias
Calciumof 7.2 (low)
A potential donor of corneal tissue for the eye bank has just died. The nurse enters the room prescribed antibiotic eye drops. What action should the nurse take next?
Secure eye shields over the closed after instilling the eyedrops.
What's Priority for a client with Multiple Scerolosis and has urinary rention?
Self cathetherization
When a nurse is caring for a client with acute hypothyroidism, which serum laboratory value requires immediate intervention?
Serum sodium 122 mEq/L.
EXAMPLES OF DASH DIE
peel fruits and vegetables
MID ABDOMEN BURNING PAIN
peptic ulcer
Suprapubic prostateomy concern?
urine leakage
Suprapubic prostatectomy. Three-way catheter. Which assessment?
urine leakage meatus
Lupus
use heavy sunblock Exacerbations of Fever
What should the nurse evaluate with a client that has ORIFSA? Select All
verify Monitor for manifestations of compartment syndrome
A client that had a CVA has visual impairment and has not be able to eat all of his food. What should the nurse instruct the family to do?
visual...
After administering dihydroergotamine (Migranal) 1 mg subcutaneously to a client with a severe migraine headache the nurse should explain that relief can be expected within what time frame?
15 minutes
Pt. DIAGNOSED RECENTLY W/ DM HAVE NOT BEEN ABLE TO CONTROL GLUCOSE LEVEL DURING 3 MONTH WHAT SHOULD BE DONE
I PUT CHECK FOR A1C LEVEL(OTHER SAY ASSESS FOR WHAT SHE HAVE BEEN EATING 3 DAYS AGO
A client returns from surgery following a hiatal hernia repair via Nissen fundoplication. Which position should the nurse implement for this client?
30 degreesemi-Fowler's to drop the diaphragm
Renal Failure
45% BUN
A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are temperature 101F, heart rate 128 beats/minute, respirations28 breaths/minute, and blood pressure 122/82. Which intervention is most important for the nurse to implement first
Administer PRN oral antipyretic
A male client with an external fixation device for a fractured left femur is complaining of left foot pain. Which intervention should the nurse implement first?
Administer PRN pain medication
The nurse learns in change of shift report that the x-ray report for a newly admitted client indicates consolidation in the left lower lung. What action should the nurse take?
Administer a PRN dose of a bronchodilator
INTESTINAL BOWEL OBSTRUCTION
90 degrees sitting
Which client has the highest risk for developing skin cancer?
A 65 year-old fair-skinned male who is a construction worker
During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?
A grandson and his new dog recently visited
A hospitalized client with chemotherapy-induced stomatitis complains of mouth pain. What is the best initial nursing action?
Administer a topical analgesic per PRN protocol
What is needed for a client that has traction applied and need repositioning?
A trapeze bar
What lab indicate a Diabetic is adhering to regiment?
A1C
MULTIPLE SCLEROSIS (MS)
ADMINISTER ANTIMEDICS/ PRN
FEMALE PATIENT HOW HAVE EPIGASTRIC PAIN FOR 3 DAYS HAVE BEEN TAKIN ANTACIDS AND NO RESOLVE ARRIVE TO HOSPITAL W/HR;128 BPM, BP110/70 WHAT IS THE MOST IMPORTANT INTERVENTION FINDING IN ASSESSMENT
ASSES FOR RADIATING JAW PAIN
NEW PATIENT DIAGNOSES WITH DM TYPE IS RECEIVING TEACHING IN WHICH GLUCOMETER WILL BE THE BEST
ASSES FOR VISUAL ACUITY AND ABILITY TO READ OR SOMETHING LIKE THAT
Patient had Atrial Fibrillation and then AED was used. One minute later, Patient sudden goes in to ventricular Tachycardia. What should the nurse do?
Administer Adenosine over 1-2 seconds IV
For Dysrhythmias
Administer Epinephrine
Flank pain and acute pyelonephritis. Priority nursing action.
Administer IV antibiotics.
A client has a pain of 8 out of 10 on the pain scale...?
Administer opioids and non pharmacological interventions
A male client reports to the nurse that he is experiencing GI distress from high dose of a corticosteroid and is planning to stop taking the medication. In response to the clients statement what nursing action is most important for the nurse to take?
Advice the client that the medication should be stopped gradually rather than abruptly.
Which action is most important for the nurse to implement to reduce the risk for deep vein thrombosis in a postoperative client?
Advise the client to perform leg exercises regularly
Pancreatitis: Which enzyme increases in 1st 24 hours
Amylase
Two days following abdominal surgery a client begins to complain of cramping abdominal pain, and the nurse's inspection of the abdomen indicates slight distention. Which action should the nurse implement first?
Auscultate abdomen quadrants
A male client who is 24hr post operative for an exploratory laparoctomy complains that he is starving because he has had no real food since before surgery. Prior to advancing his diet which intervention should the nurse implememt?
Auscultate bowel sound in all four quadrants
External Fixation Device- What should the nurse do first?
Assess for peripheral pulse at the foot
The nurse applies an automatic external defibrillator (AED) to a client who collapsed in an exam room at a community clinic. What action should the nurse take next?
Assess the client's oxygen saturation
The nurse is taking a client's blood pressure and observes carpal spasm after the sphygmomanometer cuff is inflated. What action should the nurse implement next
Assess the client's recent serum calcium level.
Pulmonary artery wedge pressure(SWAN GANZ)
Assess/monitor for dysrhythmias
An older adult woman with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. She is anxious and is complaining of a dry mouth. Which intervention should the nurse implement?
Assist her to an upright position
A fair-skinned female client who is an avid runner is diagnosed with malignant melanoma, which is located on the lateral surface of the lower leg. After wide margin resection, the nurse provides discharge teaching. it is most important for the nurse to emphasize the need to observe for changes in which characteristic?
Appearance of any moles
When preparing to apply a fentanyl (Duragesic) transdermal patch the nurse notes that the previously applied patch is intact on the clients upper back and the client denies pain. What action should the nurse take?
Apply a new patch in a different location after removing the original patch
A client is being seen at the clinic for Tinea Pedia. What question to ask
Are you taking the prescription Tolfnate
During preoperative teaching for a male client scheduled for repair of an inguinal hernia, the client tells the nurse that he has had several surgeries and understands the need to perform coughing and deep breathing exercises after surgery. How should the nurse respond?
Ask for demonstration of these exercises.
What intervention will the nurse implement when caring for a client with a pulmonary infection? Select All
Assess breathing, change in level of consciousness, monitor skin color
A male tells the clinic nurse that he is experiencing burning on urination, and assessment that he had sexual intercourse four days ago with a woman he casually met. Which action should the nurse implement?
Assess for perineal itching, erythemia, and excoriation
BONE CANCER TYPE IV
BONE CANCER TYPE IV
A client with pheocromocytoma reports the onset of a severe headache. The nurse observes that the client is very diaphoretic. Which assessment data should the nurse obtain first.
BP
A client is brought to the ED by ambulance in cardiac arrest with cardiopulmonary resuscitation (CPR) in progress.The client is intubated and is receiving 100% oxygen per self-inflating (ambu) bag. The nurse determines that the client is cyanotic, cold, and diaphoretic. Which assessment is most important for the nurse to obtain?
Breath sounds over bilateral lung field
Long-standing pulmonary infection. Assess for hypoxia. Select All That Apply.
Breathing patterns, Check mentation, color of skin and nailbeds
The nurse assesses the dressing of a client who has just returned from post-anesthesia and finds that the dressing is wet with a moderate amount of bright red bloody drainage. What action should the nurse take?
Call surgery and request that the surgeon see the wound prior to leaving the hospital
A client in the operating room received succinylcholine. The client is experiencing muscle rigidity and has an extremely high temperature. What action should the nurse implement?
Call the PACU nurse to prepare for prolonged ventilatory support
A client with a history of COPD has established a walking program. How do we know that walking is effective?
Cardiovascular improvement
Mechanical ventilator-asymmetry
Check for placement
An overweight, young adult made who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions should the nurse implement?(Select all that apply.)
Check his fingerstick glucose level Assess his skin temperature and moisture Measure his pulse and blood pressure
While taking routine vital signs at 0400 AM, the nurse notes that a client who had a total knee replacement the previous day has a heart rate of 126 beats/minute. What action should the nurse take first?
Check surgical drainage system and bandage for bleeding
Pt w/ Hysterectomy (sxto remove uterus)
Checkfor Hypo-tension (low BP) and check for increased bleeding
A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the post anasthesia unit. Before selecting which medication to administer, which action should the nurse implement?
Compare the client's pain scale rating with the prescribed dosing
While planning care for a client with carpal tunnel syndrome, the nurse identifies a collaborative problem of pain. what is the etiology of this problem
Compression of a nerve
A patient with Parkinson's. "Freezes." Pretends there is a crack on the floor and Carefully lifts leg and steps over.
Confirm that this is the correct and effective technique.
A client with type 2 diabetes mellitus is managed with metformin (Glucophage), an oral hypoglycemic agent. The primary health care provider prescribes ad additional medication injected exenatide (byetta). Which information is most important for the nurse to teach this client?
Consume additional sources of potassium
An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red and the client reports a burning sensation. What action should the nurse take?
Continue to monitor the fingers until color returns to normal
During a paracentesis, two liters of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed, and 50 ml of clear, straw-colored fluid drains within the first hour. What action should the nurse implement?
Continue to monitor the fluid output
A client who suffered an electrical injury on the left foot is admitted to the burn include in this client's plan of care?
Continuous cardiac monitoring
When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain?
Daily weight
Ten hours following thrombolysis for an ST elevation myocardial infarction (STEMI), a client is receiving a lidocaine infusion for isolated runs of ventricular tachycardia (VT). Which finding should the nurse document in the electronic medical record as a therapeutic response to the lidocaine infusion?
Decreased frequency of episodes of VT
Which change in lab values would indicate to the nurse that treatment for gout is successful?
Decreased serum uric acid
Lady in the ER diagnosed with MI and states "oh I just Have a little indigestion, I'll be fine
Deficient knowledge
Client with CVA (stroke). Has only eaten half of their food. Family is concern about nutrition. What should the nurse tell the family?
Demonstrate the use of Visual Scanning.
A male client with asthma has bronchoconstriction and mucous production due to exercising. What should the nurse do?
Determine if the client is using an inhaler before exercising.
(Photo) The charge nurse observes a newly employed nurse gathering equipment to obtain a venous blood sample from a client's implanted port. The nurse has obtained the equipment seen in the photo. What actions should the charge nurse take? (Select all that apply)
Determine if the nurse has ever performed this skill Assist in obtaining the correct needle to access the port
A client with type 2 diabetes mellitus is admitted to the hospital for uncontrolled DM. Insulin therapy is initiated with initial dose of Humulin insulin at 8:00 at 16:00 the client complains of diaphoresis, rapid heart beat, and feeling shaky. What shouldthe nurse do first?
Determine the client current glucose level
Autonomic dysreflexia
Diaphoretic and headaches
While assessing a client with degenerative joint disease,the nurse observes Heberden's nodes, large prominences on the client's fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take?
Discuss approaches to the chronic pain control with the client
AV Graft has a bruit
Document the finding; bruit is normal
DISCHARGE FOR VENOUS ULCERS SELECT ALL APPLY?
ELEVATE THE FEET WHEN LAYING DOWN-CHECK BROWNISH SKIN AROUND THE ANKLES-VITAMINS or socks?
A client admitted to a surgical unit is being evaluated for an intestinal obstruction. The healthcare provider prescribes a nasogastric tube (NGT) to be inserted and placed to intermittent low wall suction. Which intervention should the nurse implement to facilitate proper tube placement?
Elevate head of bed 60 to 90 degrees
Paracentesis
Empty bladder completely before procedure
The health care provider prescribe a medication for an older adult client who is complaining of insomnia. And instructs the client to return in 2 weeks. The nurse should question which prescription?
Eszoplicone (Lunesta)10 mg orally at bed time
PT W/ OPEN ANGLE GLAUCOMA SELECT ALL THAT APPLY
FREQUENT EYE EXAM TO ASSES FOR VISSION, USE DROPS TO DIMINSH IOP, AVOID EXTRENOUS EXERCICES LIKE JOGGING OR RUNNING
Thetherapeutic effect of insulin in treating type 1 diabetes mellitus is based on which physiologic action?
Facilitates transport of glucose into the cell
A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117 mEq/L. Which nursing problem should the nurse include in this client's plan of care?
Fluid volume excess
A client who has a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse
Further decline in level of consciousness
A client who had a biliopancreatic diversion procedure (BOP) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse?
Gastroccult positive emesis
More than 30% of burns
Give fluid resuscitation
Esophageal varices & portal HTN
Give them stool softeners to prevent straining
A male client with heart failure (HF) calls the clinic andreports that he cannot put his shoes on because they aretoo tight. Which additional information should the nurseobtain?
Has his weight changed in the last several days?
The nurse is assessing a group of older adults. What factorin a male client's history puts him at greatest risk for developing colon cancer?
Has intestinal polyps
2-year old boy is having health assessment. Which further assessment by nurse?
He refuses to feed, but I make him eat meats
A client with eczema is using an over-the-counter (OTC) topical product with urea 10% OTC (Aqua Care Cream) to the affected skin areas. Which finding reflects the expected therapeutic response?
Healing with a return to normal skin appearance OR hydration of affected area
Which laboratory test result is most important for the nurse to report to the surgeon prior to a client's scheduled abdominal surgery?
Hemoglobin level of 13 grams
A female client is being treated for tuberculosis with rifampin (rifadin) Which statement indicates that futher teaching is needed?
I will take my usual contraceptive for birth control
Succinylcholine. High Temperature.
Ice Pack axillary
A client whose history includes IV drug abuse is admitted to the intensive care unit (ICU) with Kaposi's sarcoma associated with Acquired Immune Deficiency Syndrome (AIDS). Which intervention is most important for the nurse to include in the client's plan of care?
Identify signs of opportunistic infections
In planning care for a client with pneumonia, which nursing problem should the nurse identify as the priority?
Impaired gas exchange related to the effects of alveolar-capillary membrane changes
A client with cancer is receiving chemotherapy with a known vesicant. The client's IV has been in place for 72hours. The nurse determines that a new IV site cannot be obtained, and leaves the present IV in place. What is the greatest clinical risk related to this situation?
Impaired skin integrity
When teaching a client with osteoporosis to increase weight-bearing exercise, how should the nurse explain the purpose of this activity?
Increase bone strength
During an annual health check, the clinic nurse updates an adult female's health history. When discussing the woman's history of lactose intolerance, the client reports that it has been years since she last consumed dairy products. What dietary suggestions should the nurse recommend to help ensure that the client receives an adequate intake of calcium? Select all that apply:
Increase intakeof salmon, sardines, tofu, and leafy green vegetables Eat at least six servings of citrus fruits weekly Take a calcium supplement with vitamin D daily
A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened tenacious mucous, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care?
Increase the daily intake of oral fluids to liquefy secretions
InsulinProtocol (Big scenario that begins with insulin scale)
Increased insulin by 1unit/hr
The wife of a client with Parkinson's disease expresses concern because her husband has lost so much weight.Which teaching is best for the nurse to provide?
Invite friends over regularly to share in meal times
A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse?
Irregular apical pulse
An adult male client is admitted for pneumocystis carinil pneumonia (PCP) secondary to aids. While hospitalize he receives IV pentamidine isethionate therapy. In preparing this client for discharge what important aspect regarding his medication therapy should the nurse explain?
It will be necessary to continue prophylactic doses of IV or aerosol pentamine every month
A client is diagnosed with Pyelinephritis. What is priority?
Iv antibiotics
A client who took a camping vacation two weeks ago in a county with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week.Which finding is most important for the nurse report to the healthcare provider?
Jaundiced sclera
CKD lab to report?
K > 6.5
PATIENT THAT HAVE THE K= 6.7 WHAT MEDICATION PROVIDE
KAYELAXATE (TREATS HYPERKALEMIA
Following surgical repair of the bladder, a female client is being discharged from the hospital to home with an indwelling urinary catheter. Which instruction is most important for the nurse to provide to this client?
Keep the drainage bag lower than the level of the bladder
An adolescent is admitted to the hospital because of a suicide attempt with an overdose of acetaminophen (Tylenol). Which blood values are most important for the nurse to monitor during the first 72 hours following ingestion of this overdose?
LDH OR LD, SGOT OR ALT, SGPT OR AST
Finger stick glucose finding 50mg
LOC
MI
LOW Cardiac output
Acute Renal Failure Diet
LOW Protein & HIGH CARBS; low Na & K
What instruction should the nurse include in the discharge teaching plan of a client who had a cataract extraction today?
Light housekeeping is permitted but avoid heavy lifting
Following involvement in a motor vehicle collision, a middle aged adult client is admitted to the hospital with multiple facial fractures. The clients blood alcohol level is high on admission. Which PRN prescription should be administer if the clients begins to exhibit signs and symptoms of delirium tremens (DT s)?
Lorazepam (Ativan) 2mg IM
An adult woman with Grave's disease is admitted with severe dehydration is currently restless and refusing to eat. Which action is most important for the nurse to implement?
Maintain a patent intravenous site
A client who has a history of long-standing back pain treated with methadone (Dolophine), is admitted to the surgical unit following urological surgery. What modifications in the plan of care should the nurse make for this client's pain management during the postoperative period?
Maintain client's methadone, and medicate surgical pain based on pain rating
The drainage in the chest tube of a client with emphysema has changed from clear watery fluid. What action would be best for the nurse to take/
Maintain the current IV antibiotic schedule
The nurse is reviewing blood pressure readings for a group of client's on a medical unit. Which client is at the highest risk for complications related to hypertension?
Middle-aged African-American male who has a serum creatinine levelof 2.9 mg/dL
What information should the nurse include in the teaching plan of a client diagnosed with gastroesophageal reflux disease (GERD)?
Minimize symptoms by wearing loose, comfortable clothing
A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions?
Monitor urinary stream for decrease in output
Glasgow Coma Scale of 14
Monitorneuro status every 2 hrs
Pulmonary contusion due to crushing of chest from an accident
Most common penetrating wound
Mechanism/action of calcitonin
Moves calcium from the blood circulation into the bone
Patient had a thyroidectomy-which indicates a problem
Muscle twitching and jerking
Pancreatitis
NPO to Rest and prevent production of enzymes
The nurse reports that a client is at risk for a brain attack (stroke) finding?
Nuchal rigidity
How to turn a pt w/ enteral feeding and IV
Nurse must HOLD enteral feeding than restart the feeding after
RIGHT HIP FRACTURE
O2 sat level
A client is admitted with a sudden onset of right sided HF what should the nurse complete first?
Observe for peripheral edema
While assisting a female client to the toilet, the client begins to have a seizure and the nurse eases her to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?
Observe for prolonged periods of apnea
A client with a productive cough has obtained a sputum specimen for culture as instructed. What is the best initial nursing action?
Observe the color, consistency, and amount of sputum
A male client tells the clinic nurse that he is experiencing burning on urination, and assessment reveals that he had sexual intercourse four days ago with a woman he casually met. Which action should the nurse implement?
Obtain a specimen of urethral drainage for culture
A male adult comes to the urgent care clinic 5 days after being diagnose with influenza. He is short of breath, febrile, and coughing green colored sputum. Which intervention should the nurse implement first?
Obtain a sputum sample for culture
The nurse admits a client who has a medical diagnosis of bacterial meningitis to the unit. Which intervention has the highest priority in providing care for this client?
Obtain results of culture and sensitivity of CSF
A female client with possible acute renal failure (ARF) is admitted to the hospital and mannitol (Osmitrol) is prescribed as a fluid challenge. Prior to carrying out this prescription, whatintervention should the nurse implement?
Obtain vital signs and breath sounds
The nurse drops a sterile package of supplies on the floor in the operating room (OR) suite. The ... impervious wrapper. Which action should the nurse implement?
Open contents to sterile field package intact.
PT ARRIVES TO CLINIC W/ NUCHAL RIGIDITY FEVER FOR 6 HOURS WHAT TO DO
PREPARE FOR ISOLATION PRECAUTIONS ( IPUT THIS ONE AND NO LUMBAR PUNCTURE
PT W/ HYPERTHYROIDISM DEVELOPING EXOSPHTALMUS:
PRESCRIBE TEAR EYE DROPS
Pt. W. RADIACTIVE THERAPY WHAT TO TEACH/ RECOMMEND TO
PROTECT THAT PART OF THE SKIN SPECIALLY FROM THE SUN
PATIENT W/ ML FELL AND WHEN RECEIVING THE NURSE HE HAVE 2 PROJECTILE VOMITS WHAT SHE DO
PROVIDE ANTIEMETICS PRN
PATIENT W/ ESOPHAEGAL VARICES HAVE NOT BE BLEEDING FOR 3 DAYS
PROVIDE LUKE WARM BROTH, ICE TEA AND LEMON POPSICLE
A client with acquired immunodeficiency syndrome(AIDS) has impaired gas exchange from a respiratory infection. Which assessment finding warrants immediate intervention by the nurse?
Pain when swallowing
A client who was discharged 8 months ago with cirrhosis and ascites is admitted with anorexia and recent hemoptysis. The client is drowsy but responds to verbal stimuli. The nurse programs a blood pressure monitor to take readings every 15 minutes,. Which assessment should the nurse implement first?
Palpate the abdomen for tenderness and rigidity
An older male client tells the nurse that he is losing sleep because he has to get up several times at night to go to the bathroom, that he has trouble starting his urinary stream, and that he does not feel like his bladder is ever completely empty. Which intervention should the nurse implement?
Palpate the bladder above the symphysis pubis
ARDS (acute respiratory distress syndrome)
Patient using abdominal muscles to breath
A male client with diabetes mellitus (DM) is transferred from the hospital to a rehabilitation facility following treatment for a stroke with resulting right hemiplegia. He tells the nurse that his feet are always uncomfortably cool at night, preventing him from falling asleep. Which action should the nurse implement.
Place warm blankets next to the client's feet
To prevent deep vein thrombosis following knee replacement surgery, an adult male client is receiving enoxaparin (Lovenox) subcutaneously daily. Which laboratory finding requires immediate action by the nurse?
Platelet count of 100,000/mm3 or 100x10??/ L (SI)
A client who is newly diagnosed with emphysema is being prepared for discharge. Which instruction is best for the nurse to provide the client to assist them with dyspnea self-management?
Practice inhaling through the nose and exhaling slowly
After a computer tomography (CT) scan with intravenous contrast medium, a client returns to the room complaining of shortness of breath and itching. Which intervention should the nurse implement?
Prepare a dose of epinephrine (Adrenalin)
A male client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning him, the wound dehiscences and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. What intervention should the nurse implement next?
Prepare the client to return to the operating room
While the home health nurse is making a home visit, a client with a history of seizures demonstrates tonic-clonic seizure activity. What action should the nurse implement first?
Protect the client's head with a pillow ???
Right cataract and lens implant. Which intervention should the nurse first?
Provide an eye shield to be worn while sleeping.
A male client in skeletal traction tells the nurse that he is frustrated because he needs help repositioning himself in bed. Which intervention should the nurse implement?
Provide an overhead trapeze to the bed for the client to use
Fluids are restricted to 1,500 ml daily for a male client with acute kidney injury (AKI). He is frustrated and complaining of constant thirst, and the nurse discovers that the family is providing the client with additional fluids.Which intervention should the nurse implement?
Provide the client with oral swabs to moisten his mouth
Injury to L4, T1
Pt c/o urinary retention
PT. W/ RISK OF DVT
ROM or leg exercises
A client with symptoms of influenza that started the previous day ask the clinic nurse about taking oseltamivir (Tamiflu) to treat the infection. Which response should the nurse provide?
Refer the client to the healthcare provider at the clinic to obtain a medication prescription
After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a client develops pontine myselinolysis. Which intervention should the nurse implement first?
Reorient client to his room
The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendations should the nurse encourage the client to follow?
Restrict protein intake by limiting meats and other high-protein foods
A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis skin test. The nurse's assessment of the test after 72 hours indicates 5mm of erythema without induration. What isthe best initial nursing action?
Review client's history for possible exposure to TB
An older adult woman is seen in the clinic 3 months following her diagnosis of type 2 diabetes mellitus (DM). She tells the nurse that she has had a difficult time keeping her blood sugar in control. The nurse reviews the client's current finger-stick and daily log of blood glucose levels. Which intervention is most important for the nurse to implement?
Review the client's glycosylated hemoglobin (A1c) level
Fifteen minutes after receiving sulfa athenozole . A male client report a burning sensation over his abdomen chest and groin. Which intervention is most important for the nurse to implement?
Review the clients list if drugs allergies
Which nursing diagnosis should be selected for a client who is receiving thrombolytic infusions for treatment of an acute myocardial infarction?
Risk for injury related to effects of thrombolysis
After 3 days of persistent epigastric pain, a female pt presents to the clinic. She has been taking oral antacids w/o relief. Her vital signs are HR 122 beats/min, respirations 16 breaths/min, O2 96% and BP 116/70. The nurse obtains a 12-lead ECG. Which assessment finding is most critical?
ST elevation in three leads
A client uses triamcinolone (Kenalog), a corticosteroid ointment, to manage pruritis caused by a chronic skin rash. The client calls the clinic nurse to report increased erythema with purulent exudate at the site. What action should the nurse implement?
Schedule an appointment for the client to see the healthcare provider
A client uses triamcinolone (kenalog), a corticosteroid ointment, to manage pruritis caused by a chronic skin rash. The client calls the clinic nurse to report increased erythema with purulent exudate at the site. What action should the nurse implement?
Schedule an appointment for the client to the healthcare provider.
The nurse assesses a client being treated for Herpes Zoster (shingles). Which assessments should the nurse include when evaluating the effectiveness of treatment?(Select all that apply)
Skin integrity Functional ability Pain scale
What is a concern for a client with Diabetes Insipidous?
Sodium level 185
A female client enters the clinic and insists on being seen. She is weak, nervous, and reports a racing heart beat and recent weight loss of 15 pounds. After ruling out substance withdrawal, the healthcare provider suspects hyperthyroidism and admits her for further testing. Which action should the nurse implement?
Space the client's care to provide periods of rest
Pt with V-fib
Start CPR; do not call code
The nurse positions a male client for a lumbar puncture by placing him in the side-lying position with his knees flexed and pulled toward his trunk. What action should the nurse implement next?
Support the client's head bent forward to the chest
Thyroid
T3 secretion / production
ABG (PH 7.25 PCO2 50 SODIUM 60
TACHY, CONFUSION, RESPIRATION
ADDISON DISEASE
TAKE CORTICOSTEROID MEDS
Pt WITH ALS WHAT TO DO TO PREVENT RESPIRATORY COMPLICATIONS
TEACH BREATHING TECNIQUES, USES SPIROMETER, AUSCULTATE FOR BREATH OR LUNG SOUNDS
Which instructions should the nurse include in the teaching plan of a client who is taking the diuretic spironolactone (Aldactone)?
Take the medication in the morning
The unlicensed assistive personnel (UAP) reports to the nurse that a client who was admitted with abdominal pain has just had a large black tarry stool. What intervention should the nurse implement first?
Test the stool for occult blood
HIV
The # of T-CELLS decrease and die
The nurse is assessing a client who has returned from surgery following a thoracotomy. Which finding indicates the client is experiencing adequate gas exchange?
The client demonstrates effective coughing and deep breathing exercises
The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic cholecystectomy under general anesthesia. Which finding warrants notification of the healthcare provider prior to proceeding with the scheduled procedure?
The client's blood pressure reading is 184/88 mm Hg
A male client is receiving pilocarpine hydrochloride (Isopto Carpine) ophthalmic drops for glaucoma. He calls the clinic and ask the nurse why he has difficulty seeing at night. What explanation should the nurse provide?
The eye drops slow pupil response to accommodate for darkness
The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client?
The xenograft is taken from nonhuman sources
Ineffective airway clearance
Thin secretions to remove easily
A cardiac catherterization of a client with heart disease indicates the following blockages: 95% proximal left anterior descending (LAD), 99% proximal circumflex, and ?% proximal right coronary artery (RCA). The client later asks the nurse "what does all this mean for me?" What information should the nurse provide?
Three main arteries have major blockages, with only 1 to5% of blood flow getting through to the heart muscle.
A young female client with seven children is having frequent morning headaches, dizziness, and blurred vision.Her blood pressure (BP) is 168/104 mmHg. The client reports that her husband recently lost his job and she is not sleeping well. After administering a STAT dose of an antihypertensive IV medication, which intervention is most important for the nurse to implement?
Use an automated BP machine to monitor for hypotension
What intervetion the nurse shoudl implement for a patient with Congestive Heart Failure?
Use bedside commode when needing to void
Patients BP is 60/40 (something like that) Nurse's action administer
Vasoconstrictor-a negative inotrope
A female client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions should the nurse implement?(Select all that apply.
Verify pedal pulses using a doppler pulse device Monitor left leg for pain, pallor, paresthesia, paralysis,pressure Evaluate the application of the splint to the left leg
An older female client with long term type 2 diabetes mellitus (DM) is seen in the doctor routine health assessment. To determine if the client is experiencing any long-term complications ofDM, which assessments should the nurse obtain? Select all that apply:
Visual acuity Serum creatinine and blood urea nitrogen (BUN) Sensation in feet and legs Skin condition of lower extremities
The nurse is monitoring drainainge of an abscess. What lab should the nurse monitor?
WBC
While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?
Weakened cough effort
A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider.
Yellow sclera
What would indicate a sign of dementia in a client with AIDS?
a change in writing
Ulcer that is venous
abnormal/ irregular vein function
Tylenol Over Dose (Bun & Creat. High)
acetylcysteineMucomyst(an antagonist)
If a patient is in F-vib what medication to give?
adenosine
A client with Gullian Barre is not blinking. What intervention to implement?
administer lubricant
Pt has increased abdominalgirth Pos-op surgery
call MD
Patient had a mechanical valve replacement. What does nurse teach patient?
antibiotics before dental procedures
Meloma observe for what?
appearance
A client tells the nurse that her biopsy results indicate that the cancer cells are well differentiated How should the nurse respond?
ask the client in the healthcare provider has giving her any information about the classification of her cancer
After taking orlistat (Xenical) for one week a femel a client tells the home health nurse that she is experiencing increasingly frequent oily stools and flatus. What action should the nurse take?
ask the client to describe her dietary intake history for the last several days
Nurse to administer meds thru Central Triple LumenCatheterand notices no IV infusing.
aspirate for blood
Phenochrocytoma with HA
assess BP
Two days after an abscess of the chin was drained the client returns to the clinic with fever chills and a maculopapular rash with pruritis. The client has taken an oral antibiotic and cleansed the wound today with provide iodine (Betadine) solution. Which intervention should the nurse implement first?
assess airway patency and oxygen saturation
PT AFTER TTO OF SOMETHING AND WANTS TO EAT
assess for bowel movements
SLE
assess for hematuria
PT WITH AN EXTERNAL DEVICE COMPLAINING OF PAIN:
assess peripheral pulses
A client is discharged with a prescription for warfarin ( Coumadin). What discharge instructions should the nurse emphasize to the client?
avoid going barefoot especially outside
Antibiotic resistant organism area major infection control problems. To help minimize the emergence of resistant bacteria what instruction should the nurse provide to the clients?
avoid using antibiotics when suffering from coldsor the flu
Strip w/ asystole
begin CPR
CARPO TONIC SYNDROME
brace on both wrists
A client with hypertension who has been taking labetalol for two weeks, reports a five pound (2.2 kg) weight gain. Which follow up assessment is most important for the nurse to obtain?
breath sounds
A client diagnose with stable angina secondary to ischemic heart disease has a prescription for sublingual (SL) nitroglycerin (NTG). The nurse should tell the client to follow which instructions if chest pain is not relieved after taking 3 NTG tables 5 min apart?
call 911 pain is unrelieved and chew a tablet of aspirin 325mg
The nurse reports that a client is at risk for a brain attack(stroke) based on which assessment finding?
carotid bruit
Carpal Spasm w/ BP check
check calcium levels
The nurse is monitoring the glucose q4h of an adult woman admitted with DKA. Two hours after receiving 10 units of regular insulin for glucose of 255, the client is perspiring and complaining of shakiness. What intervention should the nurse implement?
check capillary glucose level
PT ARRIVE TO PACU POSTOP MOANING WHAT TO DO
check pulse, RR, BP
DM patients
check shoes
What should be included in the teaching for a client with Diabetes Mellitus with an ulcer?
check shoes before putting them on
PT VOMITING BLOOD LIKE THE PICTURE SAME AS HEMATENSIS
check vitals
How to check for Carbon monoxide poisoning
cherry mouth or tongue
A client subjective data includes dysuria, urgency, and urinary frequency. What action should the nurse implement next?
collect a clean catch specimen
The nurse is obtaining a client's fingerstick glucose level.After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take?
collect the blood sample
PT W/ A EXPRESSIVE APHASIA IS ANGER WHAT SHOULD DO THE NURSE:
communicate with picture boards
Septic Shock(possible negative question -in septic shock, massive vasodilation occurs)
constriction happens
Anaphylactic shock
constriction of airway
MRSA intervetions?
contact precaution, culture & sensitivity, monitor WBCs
Twenty minutes after the nurse starts a secondary IV infusion of cafepime (maxipime) 2 grams using an infusion pump to deliver the dose in one hour, the client reports feeling nauseated. What action should the nurse implement?
continue the infusion and administer a prn antiemetic prescription
When caring for a client with nephrotic syndrome which assessment is most important for the nurse to obtain?
daily weight
A young adult male who has had type 2 diabetes mellitus (DM) is admitted to the intensive care unit with hyperglycemic nonketotic symdrome (HHNS). A sliding scale protocol for an isotonic IV solution with regular insulin is prescribed based on the results of a continuous blood glucose monitoring device that is attached to the clients central venous catheter. When the clients respirations become labored and his lungs sound indicate crackles what action should the nurse take?
decrease infusion rate to address fluid overload
When planning care for a client newly diagnosed with open angle glaucoma, the nurse identifies a priority nursing diagnosis of, "visual sensory/perceptual alterations." This diagnosis is based on which etiology?
decreased peripheral vision
What intervention should be donefor post op cataract extraction?
deep breathing
A picture ofV-FIb What action do you take
defib
PT WITH A BRONCHOSCOPY AND DRINK A GLASS OF JUICE
delay procedure 6 hours
A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included in preparing this client for this treatment?
describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider
Cholecystitis
diet, weight program
The chest x-ray for a client who is admitted for pneumonia shows pleural effusion with decreased air flow in the entire left upper lobe. What breath sounds that verify the x-ray findings should the nurse document after auscultation of the left upper lobe?
diminished breath sounds
The nurse administer donepezil hydrochloride (Aricept) to a client with Alzheimers disease as an intervention for which client problem?
disturbed though processes
What should the nurse do after reading the results of a TB test that read 5mm?
document the findings
A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cell. When notifying the healthcare provider what information should the nurse provide first using the SBAR communication process?
explain specific reason for urgent notification
BNP
furosimide lasix
Burns: Debridement/ hydrotherapy
give narcotics before
A client with Addison's disease started taking hydrocortisone in a divided daily dose last week. It is most important for the nurse to monitor which serum laboratory value?
glucose
PT W/ SIADH:
hard candy for thirst
An elderly post operative female client is receiving morphine sulfate via a PCA pump. Which assessment finding should prompt a nurse to administer the prescribed PRN medication naloxone?
her respiratory rate is 7 breath/minute
NURSE IS TEACHING THE WIFE IF A PATIENT DIAGNOSED W/ SEIZURE WHAT TO DO
how to position him
S/S of shock
hypotension, thready pulse
The nurse is caring for a client with a lower left lobe pulmonary abscess. Which position should the nurse instruct the client to maintain?
left lateral
RA
impaired peripheral mobility relate to join pain.
After suctioning the patient with an endotracheal tube, which assessment finding indicates to the nurse that the intervention was effective?
increase in breathe sounds
colon cancer or renal injury?
kaylexate med
CHEST TUBE W/ A DRAINAGE CHANGING FROM CLEAR TOGREEN
keep IV fluids
PT WITH LEFT LEF ULCER
keep leg elevated as tolerated
A client has 40% of burns. Which fluid is needed during the acute phase?
lactated ringers
BMI
large waist circumfirence with central fat
WHEN BP IS HIGH
lasix
TRACHESTOMY CARE
leave old ties on until new ones can be secured
How to prevent a renal calculi?
limit tea and chocolate
A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the health care provider?
low back pain and hypotension
What is a diet for Osteomalacia?
milk and cereal
Pheochromocytoma
monitor BP
DESCRIBE PAIN NEUROPATHY
nervous system
CALCULO
o.75
A client presents with the s/s of Diabetes type 2 and feeling shaky. What is the nurse priority?
obtain glucose level
A client is who is diagnose with schizophrenia receives a prescription for a atypical antipsychotic drug aripipazole (Abilify). Which assessment should the nurse perform to monitor foran adrenergic receptor antagonist side effect that commonly occurs atypical antipsychotic agents?
obtain the client fingerstick glucose levels
FOR ANEMIA WHAT DOESN'T HAVE IRON, WHICH FOODS ARE NOT RICH IN IRON?
orange
In caring for a clientwith diabetes insipidus who is receiving an antidiuretic hormone intranasally which serum lab test is most important for the nurse to monitor?
osmolality
A male client with Herpes zoster (shingles) on his thorax tells the nurse that he is having difficulty sleeping. What is the probable etiology of this problem?
pain
Pt has angina
pain radiates to left arm
Shingles Select all the apply
pain-ability-skin integrity
A client has a positive guaic stool. What lab to review?
platelets
An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection (UTI) Prescriptions for intravenous antibiotics and insulin infusion are initiated. Which serum laboratory value warrants the most immediate intervention by the nurse?
potassium of 2.5 meq/l
STERNAL TRACTION COMPLAINS OF PAIN
prn pain meds
The nurse observes an increase number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). What is the best initial nursing action?
provide additional oral fluid intake 3L of water a day is needed
How should a client with COPD breath?
pursed lips
PARKINSON PT WALKING
reassure stepping on crackles is not harmful
A client who had a myocardial infarction is admitted to the coronary critical care unit (CCU) with a nitroglycerin drip infusing. The clients last blood pressure measurements was 78/36.What action should the nurse implement?
reduce the rate of the nitroglycerin infusion
A client complains of pain in the right calf. What is the nurse's priority?
remain in bed
Levothyroxine (Synthroid)
report palpitations and SOB
What should the HCP order for a client with Hypothyroidism who has depression and can not sleep?
request PRN
acute agn diet
restict Na
What to teach a client with acute glumoronepheritis
restict sodium
When explaining dietary guidelines to a client with acute glomerulonephritis (AGN) which instruction should the nurse include in the dietary teaching ?
restrict sodium intake
PT WITH OSTEOMALCIA
risk for injury
OSTEOARTHRITIS
risk for injury related to joint pain
A patient has been taking Kenalog (corticosteroid) with increase redness.
schedule an appt
A client just returned after having a TURP and has clot. What should the nurse do?
slowly irrigate
Client works as a data desk job with Raynaud's syndrome. What to do to prevent wrist injury?
space heater
What should a client with Ulcerative Colitis report?
stool with fatty streaks
A client with a chronic kidney disease is treated on hemodialysis. During the 1 treatment clients blood pressure drops from 150/90 to 80/30 Which action should the nurse take first?
stop dialysis treatment
A client who is receiving packed red blood cells develops nausea and vomiting. What action should the nurse take first?
stop the infusion of blood
ALLOPRINOL FOR GOUT
take meds always
Shingles
teach patient about phantom pain
UAP
test stool for occult blood
A client who is taking and oral dose of tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline
toasted wheat bread and jelly
The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this diagnosis?
upper mid abdominal gnawing and burning pain
Which assessment finding indicates to the nurse that the muscarinic agent bethanechol (Urecholine) is effective for a client diagnose with urinary retention?
urinary output equal to intake
A client is discharged on Prednisolone. What should the patient report?
weight gain
A glucagon emergency kit is prescribed for a client with type 1 diabetes mellitus. When should the nurse instruct the client to take the glucagon?
when recognized signs of severe hypoglycemia occur
