HIM EXAM 2 Testbank
A nurse assesses clients on a cardiac unit. Which clients should the nurse identify as at greatest risk for the development of acute pericarditis? (Select all that apply.)
A 36-year-old woman with systemic lupus erythematosus (SLE) A 42-year-old man recovering from coronary artery bypass graft surgery An 80-year-old man with a bacterial infection of the respiratory tract
A registered nurse (RN) cares for clients on a surgical unit. Which clients should the RN delegate to a licensed practical nurse (LPN)? (Select all that apply.)
A 43-year-old diagnosed with cancer after a lung biopsy 2 days ago An 88-year-old with esophageal cancer who is awaiting gastric tube placement
A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease?
A 45-year-old American Indian woman with diabetes mellitus
The nurse assesses clients who are at risk for diabetes which client is at greatest risk
A 48-year-old American Indian
A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation?
A 50-year-old who is post coronary artery bypass graft surgery
A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first?
A 52-year-old in a tripod position using accessory muscles to breathe
A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea?
A 55-year-old woman who is 50 pounds overweight
An emergency department nurse triages clients who present with chest discomfort. Which client should the nurse plan to assess first?
A 58-year-old male who describes his pain as intense stabbing that spreads across his chest
A nurse teaches clients at a community center about risks for dehydration. Which client is at greatest risk for dehydration?
A 76-year-old who is cognitively impaired
A nurse performs an admission assessment on a 75-year-old client with multiple chronic diseases. The clients blood pressure is 135/75 mm Hg and oxygen saturation is 94% on 2 liters per nasal cannula. The nurse assesses the clients rhythm on the cardiac monitor and observes the reading shown below: Which action should the nurse take first?
Ask the client what medications he or she takes.
I nurse is caring for a client with a nonhealing arterial ulcer the physician has inform the client about possibly needing to amputate the clients leg the client is crying and upset what actions by the nurse are best
Asked the client to describe his or her current emotions, assess the client for support systems and family, offered to stay with the client if he or she desires
A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown below: Which action should the nurse take first?
Assess airway, breathing, and level of consciousness.
Why is four hours post operative after Femino Pablito bypass the client reports throbbing leg pain on the affected side rated a seven out of 10 what action by the nurse takes priority
Assess distal pulses and skin color
A client with a known abdominal aortic aneurysm the nurse assesses the clients blood pressure at 82/40 what actions by the nurse are most important
Assess distal pulses every 10 minutes, notify the rapid response team, take vital signs every 10 minutes
A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. Which actions should the nurse take prior to the catheterization? (Select all that apply.)
Assess for allergies to iodine. Administer intravenous fluids. Assess blood urea nitrogen (BUN) and creatinine results.
An older adult is on cardiac monitoring after a myocardial infarction the client shows frequent dysrhythmias what action by the nurse is most appropriate
Assess for any hemodynamic affects of the rhythm
While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. Which action should the nurse take next?
Assess for symptoms of left-sided heart failure.
A nurse is evaluating a client who is being treated for dehydration which assessment results of the nurse correlate with a therapeutic response of the treatment plan
Decreased orthostatic lightheadedness and dizziness
A nurse is caring for a client who has the following laboratory results potassium at 3.4 magnesium 1.8 calcium 8.5 sodium 144. Which assessment should the nurse complete first
Depth of respirations
A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best?
Determine if the client can switch to a nasal cannula during the meal.
After teaching a young adult client who is newly diagnosed with type one diabetes the nurse assesses the clients understanding which statement made by the client indicates a correct understanding of the need for Eye examinations
Diabetes can cause blindness so I should see the opthalmogist just yearly
A client is being discharged on warfarin therapy what discharge instructions the nurse required to provide
Dietary restrictions, follow up laboratory monitoring, possible drug drug interactions, reason to take medication
A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect?
Disorientation and confusion
A client had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding by the nurse indicates a priority outcome for this client has been met?
Distal pulse on affected extremity 2+/4+
I nearest teaches the client about self monitoring of blood glucose levels which Steven should the nurse include in this clients teaching to prevent blood-borne infections
Do not share your monitoring equipment
A nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should the nurse include in this clients teaching?
Do not take this medication within 1 hour of taking an antacid.
A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled. Which question should the nurse ask first?
Do you experience shortness of breath with basic activities?
A nurse observes that a clients anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question should the nurse ask the client in response to this finding?
Do you have any chronic breathing problems?
Client is in the clinic a month after having an myocardial infarction the client reports sleeping well since moving into the guest bedroom what response by the nurse is best
Do you have any concerns about sexuality
A nurse assesses a client with chronic obstructive pulmonary disease. Which questions should the nurse ask to determine the clients activity tolerance? (Select all that apply.)
Do you have any difficulty sleeping? How long does it take to perform your morning routine? Have you lost any weight lately?
A nurse plans care for a client who is at high risk for a pulmonary infection. Which interventions should the nurse include in this clients plan of care? (Select all that apply.)
Encourage deep breathing and coughing. Ambulate the client three times each day. Provide a diet high in protein and vitamins.
A nurse assesses a client who is prescribed fluticasone (Flovent) and notes oral lesions. Which action should the nurse take?
Encourage oral rinsing after fluticasone administration.
After teaching a client with type two diabetes who is prescribed Starlix the nurse assesses the clients understanding which statement made by the client indicates a correct understanding of the prescribed therapy
I will take this medication immediately before I eat
After teaching a client who is prescribed salmeterol (Serevent), the nurse assesses the clients understanding. Which statement by the client indicates a need for additional teaching?
I will use the drug when I have an asthma attack.
After teaching a client who is being treated for dehydration a nurse assesses the client understanding which statement indicates the client correctly understood the teaching?
I will weigh myself each morning before I eat or drink
After teaching a client who is recovering from pancreas transplant Tatian the nurse assesses the clients understanding which statement made by the client indicates a need for additional education
If I develop an infection I should stop taking my corticosteroid
After teaching a client with congestive heart failure (CHF), the nurse assesses the clients understanding. Which client statements indicate a correct understanding of the teaching related to nutritional intake? (Select all that apply.)
Ill read the nutritional labels on food items for salt content. I will eat oatmeal for breakfast instead of ham and eggs. Substituting fresh vegetables for canned ones will lower my salt intake.
The nurse assesses the client using the device pictured below to deliver 50% O2:The nurse finds the mask fits snugly, the skin under the mask and straps is intact, and the flow rate of the oxygen is 3 L/min. What action by the nurse is best?
Immediately increase the flow rate.
A nurse assesses a clients respiratory status. Which information is of highest priority for the nurse to obtain?
Occupation and hobbies
A nurse cares for a client who has developed esophagitis after undergoing radiation therapy for lung cancer. Which diet selection should the nurse provide for this client?
Omelet, soft whole wheat bread
I nearest cares for a client was diagnosed with acute rejection two months after receiving a simultaneous pancreas kidney transplant the client states I was doing so well with my new organs and the thought of having to go back to living on hemodialysis and taking insulin is so depressing how should the nurse respond
One acute rejection episode does not mean that you will lose the new organs
Owners cares for a client who has type one diabetes the client asked is it OK for me to have an occasional glass of wine how should the nurse respond
One glass of wine is OK with a meal and is counted as two fat exchanges
A nurse cares for a female client who has a family history of cystic fibrosis. The client asks, Will my children have cystic fibrosis? How should the nurse respond?
Since you have a family history of cystic fibrosis, I would encourage you and your partner to be tested.
Client is in the preoperative holding area prior to an emergency coronary artery bypass graft the client is yelling at family members and tells the doctor to just get this over with when asked to sign the consent form what action by the nurse is best
Tell the client that anxiety is common and that you can help
A nurse is assessing clients on a MedSurg unit which clients are at increased risk for hypo phosphatetemia
The 36-year-old who is malnourished, a 42-year-old with uncontrolled diabetes, a 76-year-old who is prescribed antacids
A client with coronary artery disease Ask the nurse about taking fish oil supplements what response by the nurses best
The best source is fish but pills are ok too
A client received tissue plasminogen activator after a myocardial infarction and now is on an intravenous infusion of heparin the client spouse asks why the client needs this medication response by the nurse is best
The heparin keeps the artery from getting blocked again
After teaching a client with diabetes how to inject insulin the nurse assesses the clients understanding which statement made by the nurse indicates a need for additional teaching
The lower abdomen is the best location because it is closest to the pancreas
A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this clients teaching? (Select all that apply.)
Until your incision is healed, do not submerge your pacemaker. Only take showers. Report any pulse rates lower than your pacemaker settings. Do not lift your left arm above the level of your shoulder for 8 weeks.
A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention?
Upper extremity swelling is noted.
The nurse develops a plan of care for a patient who has a history of hypocalcemia what intervention should the nurse include in the clients care plan
Use a draw sheet to re-position the client strain all urine output and assessed for urinary stones
A nurse delegates care to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene for a client who has a vascular access device?
Use a plastic bag to cover the extremity with the device.
A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, I know a transplant is my last chance, but I dont want to become a vegetable. How should the nurse respond?
Would you like information about advance directives?
A nurse cares for an older adult client with heart failure. The client states, I dont know what to do. I dont want to be a burden to my daughter, but I cant do it alone. Maybe I should die. How should the nurse respond?
Would you like to talk more about this?
I nurse cares for a client with diabetes who is visually impaired the client asks can I ask my niece to pre-fill my syringes and then store them for later use when I need them how should the nurse respond
Yes prefilled syringe is can be stored for three weeks in the refrigerator in a vertical position with a needle pointing up
A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition should the nurse include in this clients teaching?
You should balance weight loss with consuming necessary nutrients.
A nurse teaches a client who is being discharged after a fixed centric occlusion for a mandibular fracture. Which statements should the nurse include in this clients teaching? (Select all that apply.)
You will need to cut the wires if you start vomiting. Eat six soft or liquid meals each day while recovering. Irrigate your mouth every 2 hours to prevent infection. Sleep in a semi-Fowlers position after the surgery.
The nurse is teaching a client with diabetes Molite us who asked why is it necessary to maintain my blood glucose levels no lower than about 60 how should the nurse respond
Your brain needs a constant supply of glucose because it cannot store it
After teaching a client who is recovering from a heart transplant to change positions slowly, the client asks, Why is this important? How should the nurse respond?
Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes.
A nurse cares for a client who tests positive for alpha1-antitrypsin (AAT) deficiency. The client asks, What does this mean? How should the nurse respond?
Your risk for chronic obstructive pulmonary disease is higher, especially if you smoke.
A nurse cares for a client who has a family history of diabetes the client states my father has type one diabetes well I develop this disease as well how should the nurse respond
Your risk of diabetes is higher than the general population but it may not occur
A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and feeling warm. For which complication of this therapy should the nurse assess this client?
infection
A nurse cares for a client who is experiencing epistaxis. Which action should the nurse take first?
initiate standard precautions
A client had an acute myocardial infarction what assessment finding indicates to the nurse that a significant complication has occurred
Poor peripheral pulses and cool skin
A client presents to the emergency department with an acute myocardial infarction at 3 PM the facility has 24 hour catheterization laboratory abilities to meet the joint commission core measures set by what time should a client have a percutaneous coronary intervention performed
1630 or 4:30 PM
A nursing student caring for a client removes the clients oxygen as prescribed. The client is now breathing what percentage of oxygen in the room air?
21%
A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for asphyxiation related to inspissated oral and nasopharyngeal secretions? (Select all that apply.)
A 24-year-old with a traumatic brain injury A 58-year-old at risk for aspiration following radiation therapy A 66-year-old who is a quadriplegic and has a sacral ulcer An 80-year-old who is aphasic after a cerebral vascular accident
A nurse assesses several clients who have a history of asthma. Which client should the nurse assess first?
A 27-year-old client with a heart rate of 120 beats/min
The nurse is assessing clients for fluid and electrolyte in balance is which client should the nurse assess first for potential hyponatremia
A 34-year-old on NPO status who is receiving intravenous D5W
A nurse assesses clients on a cardiac unit. Which client should the nurse identify as being at greatest risk for the development of left-sided heart failure?
A 36-year-old woman with aortic stenosis
Which statements by the client indicates good understanding of foot care in peripheral vascular disease
I will keep my feet dry especially between the toes, lotion is important to keep my feet smooth and soft, washing my feet in room temperature water is the best
I nurse assesses a client with diabetes and notes the client only responds to a sternal rub by moaning has capillary blood glucose of 33 and has an intravenous line that has infiltrated with 45% normal saline which action should the nurse take first
Administer 1 mg of intramuscular glucagon
A nurse assesses a client after administering isosorbide mononitrate (Imdur). The client reports a headache. Which action should the nurse take?
Administer PRN acetaminophen.
A nurse plans care for a client who has chronic obstructive pulmonary disease and thick, tenacious secretions. Which interventions should the nurse include in this clients plan of care? (Select all that apply.)
Ask the client to drink 2 liters of fluids daily. Add humidity to the prescribed oxygen. Use a vibrating positive expiratory pressure device.
A nurse cares for a client after radiation therapy for lung cancer. The client reports a sore throat. Which action should the nurse take first?
Ask the client to gargle with mouthwash containing lidocaine.
After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the clients understanding. Which statement indicates the client comprehends the teaching?
I will take this medication every morning to help prevent an acute attack.
A nurse is assessing a client who is recovering from a lung biopsy. Which assessment finding requires immediate action?
Absent breath sounds
A nurse is teaching a client about possible complications and hazards of home oxygen therapy. About which complications does the nurse plan to teach the client? (Select all that apply.)
Absorptive atelectasis Combustion Dried mucous membranes Toxicity
A nursing student studying acute coronary syndrome learns that the pain of a mile cardio infarction differs from stable angina in what ways select all that apply
Accompanied by shortness of breath, feelings of fear Exide he, no relief from taking nitroglycerin, pain occurs without known cause
A nurse is assessing a client with left-sided heart failure. For which clinical manifestations should the nurse assess? (Select all that apply.)
Pulmonary crackles Confusion, restlessness Cough that worsens at night
A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply.)
Administer oxygen to keep saturations greater than 94%. Administer prescribed albuterol (Proventil) inhaler.
A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. Which action should the nurse take?
Administer pain medication and encourage the client to take deep breaths.
After teaching a client who is malnourished and is being discharged a nurse assesses the clients understanding for which statement indicates the client correctly understood teaching to decrease risk for the development of metabolic Acidosis
I will eat three well-balanced meals and a snack daily
Enters cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations which action should the nurse take
Administration of intravenous IV insulin
A nursing student planning to teach clients about risk factors for coronary artery disease would include which topics
Advanced age, diabetes, ethnic background, smoking
The nurse is interested in providing community education and screening on hypertension. In order to reach a priority population to what target audience should the nurse provide this service
African-American churches
A nurse assesses a client who reports waking up feeling very tired, even after 8 hours of good sleep. Which action should the nurse take first?
Ask the client if he or she has ever been evaluated for sleep apnea.
A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment should the nurse complete prior to this procedure?
Allergies to iodine-based agents
A client is in the hospital after suffering a myocardial infarction and has bathrooms Privileges. The nurse assess the client to the bathroom I know it's the clients oxygen saturation to be 95% pulse at 88 bpm and respiratory rate at 16 breast minute after returning to bed what action by the nurse is best
Allow continued bathroom privileges
A nurse is caring for a client who is intubated and has an intra-aortic balloon pump the client is restless and agitated what action should the nurse perform first for comfort
Allow family members to stay at the bedside
A nurse is assessing clients on a medical surgical unit which adult client should the nurse identify as being at greatest risk for insensible water loss
Anxious client who has tachypnea
The client has a deep vein thrombosis what comfort measure it is the nurse delegate to the unlicensed assistive personnel
Apply a warm moist pack
A client has been bedridden for several days after major abdominal surgery what action does the nurse delegate to the unlicensed assistive personnel
Apply compression stockings, assist with ambulation, offer fluids frequently
A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first?
Apply oxygen by mask or nasal cannula.
A client is receiving oxygen at 4 liters per nasal cannula. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP)?
Apply water-soluble ointment to nares and lips.
What nonpharmacologic comfort measures should the nurse include in the plan of care for a client with severe varicose vein's
Applying elastic compression stockings, elevating the legs when sitting or lying,Reminding a client to do leg exercises
A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed?
Applying suction while inserting the catheter
A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.)
Applying water-soluble lip balm to the clients lips Reminding the client to cough and deep breathe often
A client had a from moral popliteal bypass graft with a synthetic graft what action by the nurse is most important to prevent wound infection
Appropriate hand hygiene before giving care
A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess the extent of the clients heart failure?
Are you able to walk upstairs without fatigue?
The nurse is working in the emergency department knows that which factors are commonly related to aneurysm formation select all that apply
Artherosclerosis, History of hypertension history of smoking
A nurse cares for a client with arthritis who reports frequent asthma attacks. Which action should the nurse take first?
Ask about medications the client is currently taking.
A nurse teaches a client who is prescribed a central vascular access device. Which statement should the nurse include in this clients teaching?
Ask all providers to vigorously clean the connections prior to accessing the device.
The nurse is working with a client who takes Lipitor the clients recent lab results include a blood urea nitrogen of 33 and a creatinine of 2.8 what action by the nurse is best
Ask if the client eats grapefruit
A client is on a dopamine infusion to get a peripheral line what action by the nurse takes priority for safety
Assess the IV site hourly
A client has intra-arterial blood pressure monitoring after a myocardial infarction the nurse notes the clients heart rate has increased from 88 210 bpm the blood pressure drop from one 2082 to 100/60 what action by the nurse is most appropriate
Assess the client for bleeding
I nurse is caring for a client on IV infusion of heparin what actions does this nurse include in the clients plan of care
Assess the client for bleeding, monitor the daily activated partial thromboplastin time results, use an IV pump for the infusion
A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. Which action should the nurse take next?
Assess the clients gag reflex before giving any food or water.
A nurse is caring for an older adult client who has a pulmonary infection. Which action should the nurse take first?
Assess the clients level of consciousness.
A client with a history of heart failure and hypertension is in the clinic for a follow up visit the client is on lisinopril and warfarin the client reports new onset cough what action by the nurse is most appropriate
Assess the clients lung sounds in oxygenation
An unlicensed assistive personnel (UAP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse takes priority?
Assess the clients lung sounds.
A nurse assesses an older adult client who has multiple chronic diseases. The clients heart rate is 48 beats/min. Which action should the nurse take first?
Assess the clients medications.
A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the clients face is puffy and the eyelids are swollen. What action by the nurse takes priority?
Assess the clients oxygen saturation.
A nurse is assessing a client with hypokalemia and Oates the clients hand grip strength has diminished since the previous assessment one hour ago which action should the nurse take first
Assess the clients respiratory rate rhythm and depth
A nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first?
Assess the clients respiratory status.
A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take?
Assess the color and temperature of the left leg.
A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin the client is adamant about refusing the job because it is dangerous what action by the nurse is best
Assess the reason behind the clients fear
A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the clients electrocardiogram. Which action should the nurse take next?
Assess vital signs and level of consciousness.
The client has hypertension and high risk factors for cardiovascular disease the client is overwhelmed with the recommended lifestyle changes what action by the nurse is best
Assist in finding one change the client can control
A nurse cares for a client who is scheduled for a total laryngectomy. Which action should the nurse take prior to surgery?
Assist the client to choose a communication method.
A nurse is caring for a client who had a coronary artery bypass graft in yesterday what actions does the nurse delegate to the unlicensed assistive personnel
Assist the client to the chair for meals into the bathroom, ensure the client wears sequential compression devices, take the record of a full set of vital signs per hospital protocol
A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention should the nurse include in this clients plan of care?
Assistance with activities of daily living
After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the clients understanding. Which client statement indicates a need for additional teaching?
I will have my teeth cleaned by my dentist in 2 weeks.
A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia should the nurse assess?
Atrial fibrillation
A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement should the nurse include in this clients teaching?
Avoid carrying your grandchild with the arm that has the central catheter.
A nurse teaches a client who has chronic obstructive pulmonary disease. Which statements related to nutrition should the nurse include in this clients teaching? (Select all that apply.)
Avoid drinking fluids just before and during meals. Rest before meals if you have dyspnea. Have about six small meals a day.
A nurse teaches a client recovering from a heart transplant who is prescribed cyclosporine (Sandimmune). Which statement should the nurse include in this clients discharge teaching?
Avoid large crowds and people who are sick.
A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification should the nurse suggest to avoid further slowing of the heart rate?
Avoid straining while having a bowel movement.
I nurse teaches a client with type two diabetes who is prescribed Glucotrol which statement should the nurse include in the clients teaching
Avoid taking nonsteroidal anti-inflammatory drugs
A nurse is teaching a client with heart failure who has been prescribed enalapril (Vasotec). Which statement should the nurse include in this clients teaching?
Avoid using salt substitutes.
The nurse is evaluating a three day diet history with a client who has an elevated lipid panel what meal selection indicates the client is managing this condition well with diet
Baked chicken breast broccoli and tomatoes
The client at risk for developing hyperkalemia states I love fruit and usually eat it every day but now I can't because of my high potassium level how should the nurse respond
Berries cherries apples and peaches are low in potassium
A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, Why will I need to take anticoagulants for the rest of my life? How should the nurse respond?
Blood clots form more easily in artificial replacement valves.
A nurse assesses a client who is prescribed a medication that inhibits angiotensin one from converting into angiotensin II a.k.a. ace in Hibbett her for what you expected therapeutic effect should the nurse assess
Blood pressure decreases from 180/72 to 144/50
The nurse assesses a client who is experiencing an acid-base imbalance the clients arterial blood gas values are a pH of 7.34, PA 02 88 MM HG, PAC 0238 MM HG and HCO3 of 19. Which assessment should the nurse perform first
Cardiac rate and rhythm
A nurse teaches a client who is prescribed an insulin pump which Steven should the nurse include in the clients discharge education
Change the needle every three days
A nurse responds to an IV pump alarm related to increased pressure. Which action should the nurse take first?
Check for kinking of the catheter.
A nurse administers medications to a client who has asthma. Which medication classification is paired correctly with its physiologic response to the medication?
Cholinergic antagonist Causes bronchodilation by inhibiting the parasympathetic nervous system
A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement should the nurse provide to the UAP related to this procedure?
Clean the skin and clip hairs if needed.
A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention?
Client has reduced breath sounds. Nurse calls physician immediately.
The nurse is caring for four clients which one should the nurse see first
Client who had a first dose of captopril (Capoten) and needs to use the bathroom
The nurses in charge of the coronary intensive care unit which client should the nurse see first
Client who is one day post coronary artery bypass graft blood pressure 180/100
A nurse is caring for four clients which client should the nurse assess first
Client who is one hour post angioplasty has tongue swelling and anxiety
A nurse is assessing clients on a MedSurg unit which client is at risk for hypokalemia
Client with pancreatitis who has continuous nasogastric suctioning
The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, Why do you want to know if I use cocaine? How should the nurse respond?
Clients who use cocaine are at risk for fatal dysrhythmias.
A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse need to assess before teaching this particular client? (Select all that apply.)
Cognition Dexterity Range of motion Vision
A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. Which action should the nurse take next?
Collect the nasal drainage on a piece of filter paper.
A nurse assesses a client who is recovering from a myocardial infarction. The clients pulmonary artery pressure reading is 25/12 mm Hg. Which action should the nurse take first?
Compare the results with previous pulmonary artery pressure readings.
After providing discharge teaching and nurse assesses the client understanding regarding increased risk of metabolic alkalosis which statement indicates the client needs additional teaching
I take sodium bicarbonate after every meal to prevent heartburn
A nurse is caring for a client who has a serum calcium level of 14 mg which provider order should the nurse implement first
Connect the client to a cardiac monitor
A nurse is caring for a client with a nonhealing arterial lower leg ulcer what action by the nurse is best
Consult with the Wound care nurse
While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. Which action should the nurse take first?
Contact the provider and prepare for intubation.
A nursing student is caring for a client who had a myocardial infarction the student is confused because the client states nothing is wrong and yet listens attentively while a student provides education and lifestyle changes and healthy menu choices what response by the faculty members best
Continue to educate the client on possible healthy changes
A nurse is assessing a client with peripheral artery disease Client states walking five blocks as possible without pain well question asked next by the nurse will give the best information
Could you walk further than that a few months ago
While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action should the nurse take first?
Cover the insertion site with sterile gauze.
A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the client maintain self-esteem? (Select all that apply.)
Create a communication system. Try loose-fitting shirts with collars. Wear fashionable scarves.
After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching?
I will avoid sources of strong electromagnetic fields.
A nurse is caring for an older adult client who is admitted with moderate dehydration which intervention should the nurse implement to prevent injury while in the hospital
Dangal the client on the bedside before ambulating
A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply.)
Decrease in cardiac output Increase in blood pressure Decrease in urine output
A nurse auscultates a harsh hollow sound over a clients trachea and larynx. Which action should the nurse take first?
Document the findings.
A nurse is teaching a client who has cystic fibrosis (CF). Which statement should the nurse include in this clients teaching?
Eat a well-balanced, nutritious diet.
I nurse is assessing a client who has an electrolyte imbalance related to renal failure for which potential complications of this electrolyte imbalance should the nurse assess
Electrocardio gram changes, paralytic ileus, skeletal muscle weakness
A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next?
Ensure an x-ray is completed to confirm placement.
A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client?
Ensure that everyone is clear of contact with the client and the bed.
A client has hemodynamic monitoring after myocardial infarction what safety precaution does the nurse implement for this client
Ensure the balloon does not remain wedged
The client presents to the emergency department with a severely lacerated artery what is the priority action for the nurse
Ensure the client has a patent airway
A nurse assesses a client who has a 15 year history of diabetes in notes decreased tactile sensation in both feet which action should the nurse take first
Examine the client's feet for signs of injury.
A home healthcare nurse is visiting an older client lives alone after being discharged from the hospital after a coronary artery bypass graft what finding in the home those clauses the nurse to consider additional referrals
Expired food in the fridge
A nurse teaches a client who is interested in smoking cessation. Which statements should the nurse include in this clients teaching? (Select all that apply.)
Find an activity that you enjoy and will keep your hands busy. Drink at least eight glasses of water each day. Make a list of reasons you want to stop smoking.
The nurse is caring for for hypertensive clients which drug laboratory value combination should the nurse report immediately to the healthcare provider
Furosemide/ potassium 2.1
A nurse teaches a client with heart failure about energy conservation. Which statement should the nurse include in this clients teaching?
Gather everything you need for a chore before you begin.
Client has presented to the emergency department with an acute myocardial infarction what action by the nurse is best to meet the joint commission square measure outcome
Give the client an aspirin
While assessing a clients peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding?
Grade 3 phlebitis at IV site
After teaching a client who is prescribed a restricted sodium diet a nurse assesses the client understanding which Food choice for lunch indicates the client correctly understood the teaching
Grilled chicken breast with glazed carrots
A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse expect?
Heart rate of 120 beats/min
A nurse evaluates laboratory results for a client with heart failure. Which results should the nurse expect? (Select all that apply.)
Hematocrit: 32.8% Serum sodium: 130 mEq/L Proteinuria Microalbuminuria
Anders cares for a client with diabetes who asks why do I need to administer more than one injections of insulin each day how should the nurse respond
Hey single dose of insulin each day would not match your blood insulin levels and your food intake patterns
A nurse assesses a client who has developed epistaxis. Which conditions in the clients history should the nurse identify as potential contributors to this problem? (Select all that apply.)
Hypertension Leukemia Cocaine use
I nursing student learns about modifiable risk factors for coronary artery disease which factors does this include
Hypertension, obesity, smoking, stress
A nurse is caring for clients with electrolyte in balance is on a MedSurg unit which clinical manifestations are correctly paired with the contributing electrolyte imbalance
Hypokalemia flaccid paralysis with respiratory depression, hyponatremia decreased level of consciousness
The client has peripheral arterial disease what statement by the client indicates misunderstanding about self management activities
I can use a heating pad on my legs if it's set on low
An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure?
I get short of breath when I climb stairs.
A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements should the nurse include in communications with the respiratory therapist prior to the tests? (Select all that apply.)
I held the clients morning bronchodilator medication. I advised the client not to smoke for 6 hours prior to the test. The client is alert and can follow your commands.
A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left- sided heart failure?
I must stop halfway up the stairs to catch my breath.
The nurse is teaching a client with chronic obstructive pulmonary disease who has been prescribed continuous oxygen therapy at home. Which statement indicates the client correctly understands the teaching?
I plan to use cotton balls to cushion the oxygen tubing on my ears.
After teaching a client has diabetes and proliferative right no path the Nero Kathy and peripheral neuropath he nurse assesses the clients understanding which statement made by the client indicates a correct understanding of the teaching
I should look into swimming or water aerobics to get my exercise
A nurse assists with the insertion of a central vascular access device. Which actions should the nurse ensure are completed to prevent a catheter-related bloodstream infection? (Select all that apply.)
Include a review for the need of the device each day in the clients plan of care. Remind the provider to perform hand hygiene prior to starting the procedure. Ask everyone in the room to wear a surgical mask during the procedure.
A nurse cares for a client with a 40-year smoking history who is experiencing distended neck veins and dependent edema. Which physiologic process should the nurse correlate with this clients history and clinical manifestations?
Increased pulmonary pressure creating a higher workload on the right side of the heart
The nurse assesses a client who is admitted for treatment of fluid overload which manifestation should the nurse expect to find (select all that apply)
Increased pulse rate, distended neck veins, skeletal muscle weakness
And emergency department nurse assesses a client with keto acidosis which clinical manifestation should the nurse correlate with this condition
Increased rate and depth of respiration
A nurse assesses a client with diabetes Molite us who is limited with an acid-base imbalance the clients arterial blood gas values are pH of 7.36, PaO2 98mm hg, PaCo2 33 mm hg, HCO3 18. Which manifestation should the nurse identify as an example of the clients compensation mechanism
Increased rate and depth of respirations
A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention should the nurse suggest to the management team to make the biggest impact on decreasing complications?
Initiate a dedicated team to insert access devices.
A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention should the nurse be prepared to implement while this client waits for surgery?
Initiation of an external pacemaker
After administering newly prescribed captopril (Capoten) to a client with heart failure, the nurse implements interventions to decrease complications. Which priority intervention should the nurse implement for this client?
Instruct the client to ask for assistance when rising from bed.
A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that goals for a priority diagnosis are being met?
Intact skin behind the ears
A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that he no longer enjoys going out with his friends. How should the nurse respond?
Share any thoughts and feelings that cause you to limit social activities.
The provider request the nearest start an infusion of an initropic agent on a client. How does the nurse explain the action of these drugs to the client and spouse
It increases the force of the heart contractions
A student nurse asks what essential hypertension is what response by the RN is best
It is hypertension with no specific cause
The nurse is caring for a client who is prescribed a long-acting beta2 agonist. The client states, The medication is too expensive to use every day. I only use my inhaler when I have an attack. How should the nurse respond?
It is important to use this type of inhaler every day. Lets identify potential community services to help you.
The nurse is caring for a client with lung cancer who states, I dont want any pain medication because I am afraid Ill become addicted. How should the nurse respond?
It is unlikely you will become addicted when taking medicine for pain.
A nurse cares for a client who is prescribed an intravenous prostacyclin agent. Which actions should the nurse take to ensure the clients safety while on this medication? (Select all that apply.)
Keep an intravenous line dedicated strictly to the infusion. Ensure that there is always a backup drug cassette available. Use strict aseptic technique when using the drug delivery system.
A nurse cares for a client who has a pleural chest tube. Which action should the nurse take to ensure safe use of this equipment?
Keep padded clamps at the bedside for use if the drainage system is interrupted.
A nurse cares for a client who is infected with Burkholderia cepacia. Which action should the nurse take first when admitting this client to a pulmonary care unit?
Keep the client isolated from other clients with cystic fibrosis.
A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance for which manifestation of this acid-base imbalance should the nurse assess
Kussmaul respiration's
A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next?
Level of consciousness
The nurse is reviewing a lipid panel of a mail client who has artherosclerosis which finding is most concerning
Low density lipoprotein cholesterol 122 mg
A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies that the client has a 60pack-year smoking history. Which action is most important for the nurse to take when interviewing this client?
Maintain a nonjudgmental attitude to avoid causing the client to feel guilty.
A client any cardiac step down unit reports severe crushing chest pain accompanied by nausea and vomiting what action by the nurse takes priority
Maintain a patent airway
I nearest teaches the client who is diagnosed with diabetes Molite us which statement should the nurse include in the clients plan of care to delay the onset of microvascular and macrovascular complications
Maintain tight glycemic control and prevent hyperglycemia
A nurse cares for a client who has packing inserted for posterior nasal bleeding. Which action should the nurse take first?
Make sure the string is taped to the clients cheek.
A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement should the nurse include in this clients teaching?
Make sure you clean the humidifier to prevent infection.
A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best?
Measure and compare cuff pressures.
The nurse is assessing an obese client in the clinic for a follow up after an episode of deep clean thrombosis the client has lost 20 pounds since the last visit what action by the nurse is best
Measure for new compression stockings
A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care services. Which priority information should be communicated to the home health nurse upon discharge?
Medication reconciliation
I nurse assesses a client who is prescribed Lasix for hypertension for which acid-base imbalance to the nurse assess to prevent complications of this therapy
Metabolic alkalosis
A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse?
Mid-sternal chest pain
A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. Which statement should the nurse include in this clients teaching?
Minimize or abstain from caffeine.
A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms what responses best by the nurse
Most people with hypertension do not have symptoms
A nurse assesses a client who is 6 hours post-surgery for a nasal fracture and has nasal packing in place. Which actions should the nurse take? (Select all that apply.)
Observe for clear drainage. Assess for signs of bleeding. Watch the client for frequent swallowing. Ask the client to open his or her mouth.
An older client with peripheral vascular disease explaining the daily for Cara Jean to the family practice clinic nurse what statement by the client may indicate a barrier to proper footcare
My handshake when I try to do things requiring coordination
A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right-sided heart failure?
My shoes fit really tight lately.
A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client should alert the nurse to the presence of edema?
My shoes fit tighter by the end of the day.
A client is taking warfarin and asked the nurse if taking St. John's wort is acceptable what response by the nurse is best
No it may interfere with the warfarin
A nurse is teaching a larger female client about alcohol intake and how it affects hypertension the client asks if drinking two beers at night is an acceptable intake what answer by the nurse is best
No women should only have one beer a day as a general rule
A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. Which action should the nurse take next?
Notify the Rapid Response Team.
A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The clients health history includes a previous myocardial infarction and pacemaker implantation. Which action should the nurse take?
Notify the health care provider before scheduling the MRI.
The nurse is caring for a client with a chest tube after coronary artery bypass graft the drainage low significantly what action by the nurse is most important
Notify the provider immediately
A client is receiving an infusion of Activase for an injured arterial clot the client begins to mumble and is disoriented what action by the nurse takes priority
Notify the rapid response team
The nurse is caring for a client with a deep vein thrombosis what nursing assessment indicates a priority outcome has been met
Oxygen saturation of 98%
A nursing student is caring for a client with an abdominal aneurysm what action by the student requires a registered nurse to intervene
Palpate the abdomen and four quadrants
Student nurse is assessing the peripheral vascular system of an older adult what action by the student would cause the faculty member to intervene
Palpating both carotid artery's at the same time
The nearest wants to provide community service that helps need the goals of healthy people 2020 related to the cardiovascular disease and stroke what activity would best meet this goal
Participate in blood-pressure screenings at the mall
The nurse is preparing to change a client sternal dressing what action by the nurse is most important
Perform hand hygiene
A nurse prepares to insert a peripheral venous catheter in an older adult client. Which action should the nurse take to protect the clients skin during this procedure?
Place a washcloth between the skin and tourniquet.
A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, which action should the nurse take to relieve pain?
Place warm compresses on the site.
A nurse prepares a client for a pharmacologic stress echocardiogram. Which actions should the nurse take when preparing this client for the procedure? (Select all that apply.)
Prepare for continuous blood pressure and pulse monitoring. Give the client nothing by mouth 3 to 6 hours before the procedure. Explain to the client that dobutamine will simulate exercise for this examination.
A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pulse of 0.5 what action by the nurse is most appropriate
Prepare to administer a fluid bolus
A nurse cares for a client who has a serum potassium of 7.5 and is exhibiting cardiovascular changes which prescription should the nurse implement first
Prepare to administer dextrose 20% and 10 units of regular insulin via IV push
A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next?
Prepare to assist with chest tube insertion.
A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse expect to find?
Pulse decreased from 100 beats/min to 80 beats/min
The client has an inter-arterial blood pressure monitoring line dinners know it's bright red blood on the clients sheets what action should the nurse performed first
Put on a pair of gloves
The nurse is preparing for a client for us in moral Pablo bypass operation what actions does the nurse delegate to the unlicensed assistive personnel
Raising the side rails on the bed, recording baseline vital signs
A nurse teaches a client who is at risk for mild hypernatremia which Steven should the nurse include in the clients teaching
Read food labels to determine sodium content
A nurse is planning interventions that regulate acid-base balance Do you ensure the pH of a clients blood remains within the normal range which abnormal physiologic functions may occur if the client experiences an acid base in balance
Reduction in the function of hormones, fluid and electrolyte imbalance is, increase in the effectiveness of many drugs
A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?
Report of headache and stiff neck
A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client with congestive heart failure. Which instructions should the nurse provide to the UAP when delegating care for this client? (Select all that apply.)
Reposition the client every 2 hours. Accurately record intake and output. Use the same scale to weigh the client each morning.
A nurse cares for a client who is prescribed Actos. After six months of therapy a client reports that his urine has become darker since starting this medication what action should the nurse take
Review the clients liver function study results
After teaching a client to increase dietary potassium intake and nurse assesses the client understanding which dietary meal selection indicates the client correctly understands the teaching
Sausage one slice of whole wheat toast half cup of raisins and a glass of milk
A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this clients concerns?
Schedule periods of exercise and rest during the day.
I nurse reviews laboratory results for a client with diabetes Molite us who presents with Polleria authority and a blood glucose of 560 which laboratory results should the nurse correlate with the clients polyuria
Serum Osmolarity 375
A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release for which potential complication should the nurse assess
Serum potassium level of 5.4, blood osmolarity of 250
A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply.)
Serum potassium of 2.9 mEq/L Expanding groin hematoma Rhythm changes on the cardiac monitor
A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess for as the expected therapeutic response?
Short period of asystole
A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side of the neck. Which nonpharmacologic comfort measure should the nurse implement?
Sit the client up with a pillow to lean forward on.
A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention?
Slurred speech and confusion
A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this clients teaching? (Select all that apply.)
Smoking cessation Stress reduction and management Adverse effects of medications
A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement should the nurse include in this clients teaching?
Smoking while taking this medication will increase your risk of a stroke.
A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition?
Speech alterations
A registered nurse (RN) delegates client care to an experienced licensed practical nurse (LPN). Which standards should guide the RN when delegating aspects of IV therapy to the LPN? (Select all that apply.)
State Nurse Practice Act The facilitys Policies and Procedures manual
A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the clients pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate?
Stay with the client and have someone else call the provider immediately.
Client is receiving an infusion of tissue plasminogen activator the nurse assesses a client to be diss oriented to person place and time what action by the nurse is best
Stop the infusion and call the provider
A nurse assesses a clients peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next?
Stop the infusion of intravenous fluids.
After administering 40 mEq of potassium chloride a nurse evaluates the clients response. Which manifestations indicate that the treatment is improving the clients condition
Strong productive cough and active bowel sounds
The nurse is caring for a client who is experiencing moderate metabolic alkalosis which action should the nurse take
Teach the client fall prevention measures
A nurse prepares a client for coronary artery bypass graft surgery. The client states, I am afraid I might die. How should the nurse respond?
Tell me more about your concerns about the surgery.
A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that apply.)
The client does not allow smoking in the house. Electrical cords are in good working order. Flammable liquids are stored in the garage.
A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met?
The client has joined a book club that meets at the library.
After teaching a client how to perform diaphragmatic breathing, the nurse assesses the clients understanding. Which action demonstrates that the client correctly understands the teaching?
The client places his or her hands on his or her abdomen.
A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern?
The clients left lower extremity is cool to the touch.
A nurse cares for a client who has a chest tube. When would this client be at highest risk for developing a pneumothorax?
When the tube becomes disconnected from the drainage system
A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action?
The trachea is deviated toward the opposite side of the neck.
A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How should the nurse respond?
This is normal after surgery. What types of food do you like to eat?
A client is one day post operative after coronary artery bypass graft what nonpharmacologic comfort measures does the nurse include when caring for this patient select all that apply
This is the client into a position of comfort and dad, provide complementary therapies such as music, remind the client to split the incision when coughing
A nurse is caring for a client who has sleep apnea and is prescribed modafinil (Provigil). The client asks, How will this medication help me? How should the nurse respond?
This medication will promote daytime wakefulness.
A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure should the nurse assess? (Select all that apply.)
Thrombophlebitis Pulmonary embolism Cardiac tamponade
A nurse reviews a clients laboratory results. Which findings should alert the nurse to the possibility of atherosclerosis? (Select all that apply.)
Total cholesterol: 280 mg/dL Triglycerides: 200 mg/dL Low-density lipoprotein cholesterol: 160 mg/dL
A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select all that apply.)
Tracheal deviation Sudden onset of shortness of breath
A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the nurses immediate intervention? (Select all that apply.)
Tracheal deviation Sudden onset of shortness of breath Drainage greater than 70 mL/hr Disconnection at Y site
A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should the nurse take prior to the initiation of cardioversion?
Turn off oxygen therapy.
A student nurse is providing tracheostomy care. What action by the student requires intervention by the instructor?
Tying a square knot at the back of the neck
A nurse prepares to administer a blood transfusion to a client, and checks the blood label with a second registered nurse using the International Society of Blood Transfusion (ISBT) universal bar-coding system to ensure the right blood for the right client. Which components must be present on the blood label in bar code and in eye-readable format? (Select all that apply.)
Unique facility identifier Lot number related to the donor ABO group and Rh type of the donor
A nurse cares for a client who has advanced cardiac disease and states, I am having trouble sleeping at night. How should the nurse respond?
Use pillows to elevate your head and chest while you are sleeping.
A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention should the nurse complete prior to the procedure?
Validate that informed consent has been given by the client.
A nurse assesses a clients electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How should the nurse interpret this observation?
Ventricular and atrial depolarizations are initiated from different sites.
A nurse assesses a client who is prescribed varenicline (Chantix) for smoking cessation. Which manifestations should the nurse identify as adverse effects of this medication? (Select all that apply.)
Visual hallucinations Impaired judgment
The nurse teaches a client with type one diabetes which statement should the nurse include in the clients teaching to decrease the clients insulin needs
Walk at a moderate pace for 1 mile daily
A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this clients medication administration record to prevent a common complication of this condition?
Warfarin (Coumadin)
A nurse teaches a client who has a history of heart failure. Which statement should the nurse include in this clients discharge teaching?
Weigh yourself daily while wearing the same amount of clothing.
A nurse cares for a client with right-sided heart failure. The client asks, Why do I need to weigh myself every day? How should the nurse respond?
Weight is the best indication that you are gaining or losing fluid.
A nurse cares for a client who is recovering from a myocardial infarction. The client states, I will need to stop eating so much chili to keep that indigestion pain from returning. How should the nurse respond?
What do you understand about what happened to you?
While obtaining a clients health history, the client states, I am allergic to avocados. Which responses by the nurse are best? (Select all that apply.)
What response do you have when you eat avocados? I will document this in your record so all of your providers will know. Have you ever been treated for this allergic reaction?
A nurse is providing care after auscultating clients breath sounds. Which assessment finding is correctly matched to the nurses primary intervention?
Wheezes are heard in central areas. The nurse administers an inhaled bronchodilator.
After teaching a client who is prescribed voice rest therapy for vocal cord polyps, a nurse assesses the clients understanding. Which statement indicates the client needs further teaching?
When I speak, I will whisper rather than use a normal tone of voice.
A nurse is assessing a client who has suffered a nasal fracture. Which assessment should the nurse perform first?
airway patency
A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert the nurse to the possibility that the clients stenosis has progressed?
dyspnea on exertion
A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?
ensure informed consent is on the chart
An emergency room nurse assesses a female client. Which assessment findings should alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.)
fatigue despite adequate rest indigestion shortness of breath
A nurse assesses a client with pericarditis. Which assessment finding should the nurse expect to find?
friction rub at the left lower sternal border
A nurse assesses a client who has a peripherally inserted central catheter (PICC). For which complications should the nurse assess? (Select all that apply.)
phlebitis thrombophlebitis
A nurse assesses a client who has a radial artery catheter. Which assessment should the nurse complete first?
presence of an ulnar pulse
A nurse cares for a client with infective endocarditis. Which infection control precautions should the nurse use?
standard precautions
A nurse assesses a client who has facial trauma. Which assessment findings require immediate intervention? (Select all that apply.)
stridor Ecchymosis behind the ear
A nurse teaches a client who has open vocal cord paralysis. Which technique should the nurse teach the client to prevent aspiration?
tuck the chin down when swallowing.