Module 9:

A client is tested for HIV with the use of an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. The nurse should provide which information to the client about the test?

test will be confirmed with western blot

A nurse is assessing a postoperative client on an hourly basis. The nurse notes that the client's urine output for the past hour was 25 mL. On the basis of this finding, the nurse should take which action first?

Check the client's overall intake and output record

A nurse is providing post-procedure instructions to a client returning home after arthroscopy of the shoulder. The nurse should provide the client with which information?

report to HCP if fever, redness occur

Blood is drawn from a male client with suspected uric acid calculi for a serum uric acid determination. Which value does the nurse recognize as a normal uric acid level?

4.4

A client without a history of respiratory disease has a pulse oximeter in place after surgery. The nurse monitors the pulse oximeter readings to ensure that oxygen saturation remains above which value?

95%

A nurse is caring for a client who has just regained bowel sounds after undergoing surgery. The health care provider has prescribed a clear liquid diet for the client. Which item does the nurse ensure is available in the client's room before allowing the client to drink?

suction equipment

A nurse is assessing the chest tube drainage system of a postoperative client who has undergone a right upper lobectomy. The closed drainage system contains 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant, and the client appears dyspneic. On the basis of these findings, what should the nurse assess first?

the chest tube connections

A CD4+ lymphocyte count is performed on a client who is infected with HIV. The results of the test indicate a CD4+ count of 450 cells per cubic millimeter of blood. The nurse interprets this test result as indicating which?

the need for antiretroviral therapy

A nurse has a prescription to collect a 24-hour urine specimen from a client. Which measure should the nurse take during this procedure?

asking the client to void

A nurse receives a telephone call from a nurse on the post-anesthesia care unit, who reports that a client is being transferred to the surgical unit. What should the nurse plan to do first on arrival of the client?

assess patency of airway

A client who has undergone renal biopsy complains of pain, radiating to the front of the abdomen, at the biopsy site. For which finding should the nurse assess the client?

bleeding

A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. Which action should the nurse take first?

check for kinks in the drainage system

A nurse administers scopolamine as prescribed to a client. For which side effect of this medication does the nurse monitor the client?

complaints of dry mouth

A client has just returned to the nursing unit after computerized tomography (CT) with contrast medium. Which action should the nurse plan to take as part of routine after-care for this client?

encourage fluid intake

A nurse is preparing a client for transfer to the operating room. Which action should the take in the care of this client at this time

ensure the client has voided

A client has just undergone lumbar puncture. Into which position does the nurse assist the client after the procedure?

flat

A client who underwent preadmission testing 1 week before surgery had blood drawn for several serum laboratory studies. Which abnormal laboratory results should the nurse report to the surgeon's office? Select all that apply.

hemoglobin hematocrit

A client in the postanesthesia care unit has an as-needed prescription for ondansetron. Which occurrence would prompt the nurse to administer this medication to the client?

nausea and vomiting

A client recovering from surgery has a large abdominal wound. Which food, high in vitamin C, should the nurse encourage the client to eat as a means of promoting wound healing?

oranges

A client has been scheduled for magnetic resonance imaging (MRI). For which condition, a contraindication to MRI, does the nurse check the client's medical history?

pacemaker insertion

A client has undergone renal angiography by way of the right femoral artery. The nurse determines that the client is experiencing a complication of the procedure on noting which finding?

pallor and coolness of right leg

A client has just undergone a renal biopsy. Which intervention should the nurse include in the post-procedure plan of care?

periodically testing urine for occult blood

A nurse is preparing a client for intravenous pyelography (IVP). Which action by the nurse is most important?

question pt about allergies to shellfish

A nurse is assessing a client who has a closed chest tube drainage system. The nurse notes constant bubbling in the water seal chamber. What actions should the nurse take? (Select all that apply).

Assess the system for an external air leak Document assessment findings, actions taken, and client response

A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is restless and the pulse rate is increased. As the nurse continues the assessment, the client begins to vomit a copious amount of bright-red blood. The nurse should take which immediate action?

Notify the surgeon

A nurse is preparing for intershift report when an unlicensed assistive personnel (UAP) pulls an emergency call light in a client's room. Upon answering the light, the nurse finds a client who returned from surgery earlier in the day experiencing tachycardia and tachypnea. The client's blood pressure is 88/60 mm Hg. Which action should the nurse take first?

Place the client in a modified Trendelenburg position

A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody secretions. Which action should the nurse take first?

Check the degree of suction being applied

A client who has undergone abdominal surgery calls the nurse and reports that she just felt "something give way" in the abdominal incision. The nurse checks the incision and notes the presence of wound dehiscence. The nurse should take which immediate action?

Cover the abdominal wound with a sterile dressing moistened with sterile saline solution

A nurse is helping a client with a closed chest tube drainage system get out of bed and into a chair. During the transfer, the chest tube is caught on the leg of the chair and dislodged from the insertion site. What is the immediate nursing action?

Cover the insertion site with a sterile occlusive dressing

A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets about to take which action?

administering oxygen by way of nasal cannula

A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse hears a wheeze. The nurse tries to remove the suction catheter from the client's trachea but is unable to do so. Which action should the nurse take first?

Disconnect the suction source from the catheter

A client reports for a scheduled electroencephalogram (EEG). Which statement by the client indicates a need for additional preparation for the test?

I didn't shampoo my hair

A nurse is getting a client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which action should the nurse take first?

Lower the head of the bed slowly until the dizziness is relieved