Med surg
A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following manifestations of peritonitis?
Nausea and vomiting
A nurse is reviewing the transfer report on a Client. A nurse is preparing to receive a client from a residential care facility who is scheduled to arrive on the medical-surgical unit. The nurse has received the following transfer report by telephone from the nurse at the residential care facility. Click to highlight the statements in the transfer report that require action by the nurse prior to the client's arrival.
70-year old male with reports of mid-abdominal pain for 4 days, rating pain 7 on a 0 to 10 pain scale Upper abdomen distention present with decreased bowel sounds in lower abdomen Client reports nausea and started vomiting orange-brown emesis yesterday afternoon that has foul odor Last bowel movement 7 days ago
A nurse is caring for a newborn who is 4 hr old.
A clavicle fracture Moro reflex
A nurse is working with an emergency response team in caring for a group of people who may have been exposed to anthrax while doing farm work. Which of the following is the appropriate action for the nurse to take?
Administer antibiotic therapy.
A nurse is caring for an infant in the emergency department.
Assess pupillary reaction to light. Measure the infant's head circumference. Palpate fontanel level.
A nurse in the emergency room is assessing a client who was brought in following a seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next?
Assess the cranial nerves.
A nurse is caring for a client who has an elevated potassium level and is on a cardiac monitor. The nurse is aware that hyperkalemia may be associated with changes to the T-wave. On the graphic, point and click on the area of the electrocardiogram (ECG) that represents the T-wave.
BOX ON THE FAR RIGHT
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection?
Check the catheter tubing for kinks or twisting.
Place the client on supplemental oxygen Obtain a chest x - ray Request a prescription for dexamethasone
CORRECT
A nurse is caring for a 5-year-old child in the acute care setting. Which of the following assessment findings require additional action by the nurse? Click to highlight the assessment findings which require additional action by the nurse? To deselect a finding, click on the finding again.
Child uncooperative and agitated Child reports chest pain and joint pain as a 4 on the Faces Scale Nasal flaring and moderate subcostal and substernal retractions are noted Bilateral, moderate inspiratory and expiratory wheezes noted upon auscultation
A nurse is caring for a client who is at 32 weeks of gestation.
Collecting a urine specimen for culture and sensitivity is nonessential. Administer magnesium sulfate 4 g IV bolus is anticipated. Tell the client to lie in a supine position is contraindicated. Monitor blood pressure and respiratory status every 15 min is anticipated.
A nurse is caring for a child who is 2 hr postoperative following a tonsillectomy. Which of the following fluid items should the nurse offer the child at this time?
Crushed ice
A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?
pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg
A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?
Excessive thrombosis and bleeding
A nurse is caring for a client who has a pneumothorax.
Obtain ABGs is anticipated Prepare for insertion of a chest tube is anticipated Obtain intravenous access is anticipated Computed tomography ( CT ) of the chest is non - essential Pulmonary Function Tests ( PFTS ) are non - essential Thoracentesis is contraindicated
A nurse is providing dietary teaching to a client who has frequent kidney stones. Which of the following instructions should the nurse include in the teaching?
"Avoid eating tree nuts, such as almonds."
A parent calls a clinic and reports to a nurse that his 2-month-old infant is hungry more than usual but is projectile vomiting immediately after eating. Which of the following responses should the nurse make?
"Bring your baby in to the clinic today."
A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies?
"These tests help determine the degree of damage to the heart tissues."
A nurse is caring for a client in the emergency department (ED). Drag 1 condition and 1 client finding to fill in each blank in the following sentence.
Encephalopathy Ammonia
A nurse is caring for a client who is pregnant. Which of the following provider prescriptions should the nurse plan to implement? Select the 3 actions the nurse should plan to take.
Encourage the client to limit carbohydrate intake to 40% of their daily calories Anticipate a prescription for metformin Conduct a non-stress test twice per week
A nurse is caring for an 18-month-old toddler in the emergency department.
High dose intravenous immunoglobins (IVIG) Aspirin
A nurse is caring for a client who has cancer and is undergoing chemotherapy. Which of the following assessments indicates an improvement in the client's condition?
Oral health Bleeding episodes
A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip?
Pacemaker spikes before each QRS complex
A nurse is caring for a client who has a new diagnosis of lung cancer. For each potential provider's prescription at 4 weeks, click to specify if the prescription is anticipated, nonessential, or contraindicated for the client.
Place the client in a private room is anticipated Insert an indwelling urinary catheter is contraindicated Place the client on droplet precautions is nonessential Check the client's rectal temperature once daily is contraindicated Rinse the client's mouth with 0.9 % sodium chloride every 4 hr is anticipated
A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take?
Prevent aspiration.
A nurse is caring for an adolescent who has hemophilia A and is scheduled for wisdom teeth extractions. Prior to the procedure, the nurse should anticipate that the client will receive which of the following products?
Recombinant
?
Respiratory rate has improved Oxygen saturation has improved Oral intake has improved Lung sounds have not changed Heart rate has improved Dyspnea has not changed Blood pressure has improved
A nurse is reviewing laboratory values for a client who has systemic lupus erythematosus (SLE). Which of the following values should give the nurse the best indication of the client's renal function?
Serum creatinine
A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first?
Stop the infusion of blood.
A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support?
Talk with the client during wound care.
