New Comp

- Yellowing of the eyes - Abdominal pain - Increased bruising - Increased bleeding tendency - Insomnia (?) - Darkening of the urine from what i got from ATI - Yellowing of the eyes - blurred vision (ethambutol) - Abdominal pain - Increased bruising - Increased bleeding tendency

(Same client as prev card) The nurse is administering meds to the client and is monitoring the potential adverse effects of the meds. For each body system below, click to highlight the findings that indicate a serious adverse reaction. Head, Eyes, Ears, Nose, and Throat: - Yellowing of the eyes - Blurred vision - Dry eyes GI: - Abdominal pain - Hard stool Hematologic: - Increased bruising - Increased bleeding tendency - Insomnia Genitourinary: - Red/orange tint to urine - Darkening of the urine

"I will need to have a repeat Mantoux test in 4 weeks." "I can expect my contact lenses to turn red or orange." "I should notify my provider if I start taking new OTC or prescription medications." i think its: "I will need to have someone observe me when I take my medication." "I can expect my contact lenses to turn red or orange." "I should notify my provider if I start taking new OTC or prescription medications." u dont do repear mantoux test in 4 weeks. sputum cultures is 4 weeks

(same client as prev) The nurse is preparing the client for discharge. Select the 3 client statements that indicate an understanding of the teaching. "I will need to have a repeat Mantoux test in 4 weeks." "I will need to have someone observe me when I take my medication." "I will need to take my medications for a total of 6 weeks." "I can expect my contact lenses to turn red or orange." "I can continue my current alcohol intake." "I am no longer contagious." "I should notify my provider if I start taking new OTC or prescription medications."

D. Assault.

A charge nurse is observing a newly licensed nurse provide care for a client who is postoperative. The newly licensed nurse tells the client that she will insert a urinary catheter if the client will not void. Which of the following torts should the charge nurse identify as having occurred? A. Libel. B. Battery. C. Negligence. D. Assault.

"Information Technology will install a firewall to secure client information."

A charge nurse is teaching a newly licensed nurse about the facility's computerized documentation system. Which of the following information should the nurse include? "You will be asked to change your password once per year." "Documentation of sensitive material is performed by the charge nurse." "You will be given access to the medical records of every client in the facility." "Information Technology will install a firewall to secure client information."

Previous violent behavior

A charge nurse is teaching new staff members about factors that increase a client's risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence? A history of being in prison Male gender Experiencing delusions Previous violent behavior

A client who is 1 day postoperative following a vertebroplasty

A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge? A client who is receiving heparin for deep-vein thrombosis A client who has COPD and a respiratory rate of 44/min A client who has cancer and a sealed implant for radiation therapy A client who is 1 day postoperative following a vertebroplasty

B. Review the skill level and qualifications of each AP. D. Communicate appropriate tasks to the APS with specific expectations A. Monitor progress of task completion with each AP. C. Evaluate the APs' performance of each task.

A nurse has identified tasks to delegate to a group of assistive personnel (AP) after receiving change-of-shift report. Identify the sequence of steps the nurse should follow when delegating tasks to the APs. A. Monitor progress of task completion with each AP. B. Review the skill level and qualifications of each AP. C. Evaluate the APs' performance of each task. D. Communicate appropriate tasks to the APS with specific expectations

"The estimated blood loss was 250 milliliters."

A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report? "The estimated blood loss was 250 milliliters." "The client is a member of the board of directors." "There was a total of 10 sponges used during the procedure." "The client was intubated without complications."

Establish alternatives to verbal conversation

A nurse in contributing to the plan of care for a client who has multiple sclerosis. The nurse should recommend including which of the following interventions in the plan of care to assist the client in overcoming barriers related to this condition? Establish alternatives to verbal conversation. Provide the client with large-handled eating utensils. Use the numbers on a clock to describe the position of food on the client's plate. Touch the client's arm before beginning to speak.

Nontender, protruding abdomen Head circumference exceeds chest circumference - at 2 years old, chest circum becomes larger than head circum. they are equal at 1-2yr Palpable fontanels - posterior font closes at 2 months, anterior font closes at 18mo Natural loss of deciduous teeth - loss baby teeth at school ager (6yrs old)

A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect? Head circumference exceeds chest circumference Palpable fontanels Natural loss of deciduous teeth Nontender, protruding abdomen

b. Fever

A nurse is assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect? a. Drooling b. Fever c. Tinnitus d. Rhinorrhea

FHR baseline 170/min

A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider? Temperature 37.4° C (99.3° F) Early decelerations in the FHR FHR baseline 170/min Contractions lasting 80 seconds

D. Naloxone.

A nurse is assessing a client who received hydromorphone 4 mg IV 15 min ago. The client has a respiratory rate of 10/min. The nurse should prepare to administer which of the following medications? . A. Diazepam B. Acetaminophen. C. Ibuprofen. D. Naloxone.

Serotonin syndrome Adverse effects of paroxetine

A nurse is caring for a client at a clinic. Adm 1 week ago: Client reports that manifestations of hopelessness and disinterest are lessened, but present. Sleep disturbance continues. Provider increased paroxetine to 30 mg daily. Return to clinic in 1 week. 2 weeks ago: Client with a history of generalized anxiety disorder and major depressive disorder. Client presents with increased hopelessness, disinterest, and a change in sleep and appetite over several months. Client is currently taking fluoxetine 20 mg daily for the past year. Fluoxetine discontinued and paroxetine 10 mg daily started. Return to clinic in 1 week. Complete the following sentence by using the lists of options. The client is at risk for developing Select... due to Select.... Mania Serotonin syndrome Psychosis Feelings of hopelessness Adverse effects of paroxetine Anxiety

D. Client experiences nightmares E. Witnessing their family's death, F. Caregiver reporting client acting differently than usual H. Smoking marijuana to clear their mind.

A nurse is caring for a client in a clinic, Nurses' Notes 0900: A 16-year-old client reports to the clinic with their caregiver. The client's caregiver informs the nurse that the client has "not been themselves lately." The client's parents and a sibling passed away from injuries sustained when a tornado moved through their town 1 month ago. They were the only survivor and witnessed their family's deaths. Select the 4 findings require immediate follow up A. BP 122/80 mmHg. B. Heart rate 99/min. C. Startles easy during thunderstorm. D. Client experiences nightmares. E. Witnessing their family's death. F. Caregiver reporting client acting differently than usual. G. Attends school regularly. H. Smoking marijuana to clear their mind.

Rheumatoid arthritis ESR

A nurse is caring for a client in an outpatient clinic. First office visit: Erythrocyte sedimentation rate (ESR) 21mm/hr (up to 20 mm/hr) Hct 36% (37-47) Hgb 12 g/dL (12-16) WBC count 6000/mm3 Uric acid 6.1 (2.7-7.3) 6mo follow up: Erythrocyte sedimentation rate (ESR) 22mm/hr (up to 20 mm/hr) Antinuclear antibodies positive Hct 35% (37-47) Hgb 11 g/dL (12-16) WBC count 4000/mm3 Uric acid 6.3 (2.7-7.3) Complete the following sentence by using the list of options. The client is at risk for developing ____ as evidenced by _____

C. Document the reaction in the medical record.

A nurse is caring for a client who has a prescription for 1 unit of packed RBCs. Five minutes after beginning the transfusion, the client becomes febrile with chills. After stopping the transfusion, which of the following actions should the nurse take? A. Administer epinephrine subcutaneously. B. Place the blood bag in a biohazard bag before discarding. C. Document the reaction in the medical record. D. Infuse 500 ml lactated Ringer's IV.

D. "Would you like to speak to a spiritual advisor?

A nurse is caring for a client who has cancer and is terminally ill. The client reports feeling depressed. Which of the following statements should the nurse make? A. "Do you need a prescription for an antianxiety medication?" B. "Do you need information on hospice care?" C. "Would you like to talk to a counselor about advance directives?" D. "Would you like to speak to a spiritual advisor?

Determine if the client's health care surrogate is aware of the risks and benefits of the procedure.

A nurse is caring for a client who is in a coma and is scheduled for a surgical procedure. Which of the following actions should the nurse take? Send the unsigned informed consent form to the facility's risk manager. Determine if the client's health care surrogate is aware of the risks and benefits of the procedure. Ensure that the client's family supports the provider's decision for surgery. Determine if the procedure is medically necessary for the client.

A. Maternal hypoglycemia.

A nurse is caring for a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia? A. Maternal hypoglycemia. B. Maternal fever. C. Chorioamnionitis. D. Fetal anemia.

Mantoux test & Chest x-ray

A nurse is caring for a client who presents to the ED...Day 1: Client reports, "I have a cough." Hx present illness: 38 y/o clients presents to ED w/ a 4-day hx cough, often productive. Reports fatigue, night sweats, and a low-grade fever. Reports "blood-tinged sputum." Also reports "I used to weigh 167 lbs. Now I weigh 162." Reports a decreased appetite along w/ the 2.26 kg weight loss over the last week. Client states they have been trying to stay hydrated. Fam hx: Child has asthma. All other members healthy. Social hx: Heavy alcohol use (4-5 drinks/day), denies tobacco/illicit drug use. Recently traveled to visit their fam in South Africa and stayed for 3 wks. Exhibit 2: Temp: 38.1 C (100.5 F). BP 112/88 mm Hg. HR 98/min. RR 24/min. O2 Sat 98% on RA Drag words form the choices to fill in each blank in the sentence: "To further evaluate the client, the nurse anticipates the client will need _____ and _____. A nasopharyngeal swab A Mantoux test A pulmonary function test Blood cultures A chest x-ray

Sputum characteristics Weight Travel History Temperature cough?

A nurse is caring for a client who presents to the ED...Day 1: Client reports, "I have a cough." Hx present illness: 38 y/o clients presents to ED w/ a 4-day hx cough, often productive. Reports fatigue, night sweats, and a low-grade fever. Reports "blood-tinged sputum." Also reports "I used to weigh 167 lbs. Now I weigh 162." Reports a decreased appetite along w/ the 2.26 kg weight loss over the last week. Client states they have been trying to stay hydrated. Fam hx: Child has asthma. All other members healthy. Social hx: Heavy alcohol use (4-5 drinks/day), denies tobacco/illicit drug use. Recently traveled to visit their fam in South Africa and stayed for 3 wks. Exhibit 2: Temp: 38.1 C (100.5 F). BP 112/88 mm Hg. HR 98/min. RR 24/min. O2 Sat 98% on RA Which of the following findings indicate the need for further eval? SATA Report of cough BP Sputum characteristics Weight Travel History Temperature Heart Rate Oxygen sat

B. Check the client for indications of bleeding.

A nurse is caring for a client who received 50,000 units. Which of the following actions should the nurse take first? A. Complete an incident report. B. Check the client for indications of bleeding. C. Monitor the client's aPTT levels D. Notify the risk manager.

- Document the client's refusal in the medical record

A nurse is caring for a client who refuses a blood transfusion. Which of the following actions should the nurse take? - Notify risk management about the client's refusal - Document the client's refusal in the medical record - Inform the client that the transfusion is mandatory - Suggest that the client explore alternative therapies

C. Determine if the client has thoughts about self-harm.

A nurse is caring for a client whose partner died in a fire that destroyed their home. Which of the following actions should the nurse take first? A. Empower the client to feel that he is in charge of his life. B. Find the client a temporary shelter where he can feel safe. C. Determine if the client has thoughts about self-harm. D. Review the client's available social support system

- mastitis - cracked nipple

A nurse is caring for a postpartum client in an outpatient setting. Nurses' Notes Discharge from acute care facility note 2 days postpartum: Client discharged to home with newborn. Fundus firm, midline, and measures two finger breadths below umbilicus. Lochia scant rubra. Episiotomy site well approximated. Mild labial edema present. Voiding without difficulty. Breastfeeding newborn every 2 to 3 hr. Denies any pain with breastfeeding, nipples intact. Reports increased firmness in breasts. Complete the following sentence by using the lists of options. The client is at high risk for developing ???? as evidenced by the client's ??? - endometritis - mastitis - perineal hematoma - large for gestational age newborn - group b streptococcus - cracked nipple

d. using an albuterol inhaler

A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage? a. Take pancrealipase b. complete oral hygiene c. eat a meal d. using an albuterol inhaler

a. speak in a normal voice at a natural pace

A nurse is caring for client who speaks a different language than the nurse and is using an interpreter. Which of the following actions should the nurse take when working with the interpreter? a. speak in a normal voice at a natural pace b. use gestures when speaking with the client c. pause in the middle of sentences d. direct statements to the interpreter

A. 7.5%

A nurse is discussing weight loss with a client who is concerned about losing 6.8 kg (15 lb) from an original weight of 90.7 kg (200 lb). The nurse should identify the weight loss as which of the following total percentages? A. 7.5% B. 8.1% C. 13.3% D. 15%

A. Increased hemoglobin level

A nurse is evaluating the laboratory values of a client who is receiving epoetin alfa. Which of the following findings indicates a therapeutic response to the medication? A. Increased hemoglobin level B. Increased platelet count C. Increased neutrophil count D. Increased erythrocyte sedimentation rate

A. Neonatal Infant Pain Scale (NIPS)

A nurse is giving an intramuscular injection to a newborn who was delivered at 38 weeks of gestation. Which of the following pain scales should the nurse use to assess the newborn's pain? A. Neonatal Infant Pain Scale (NIPS) B. FACES pain rating scale C. Premature infant Pain Profile (PIPP) D. visual analog scale (VAS)

D. "I think the baby should be sleeping through the night by now"

A nurse is making an initial postpartum home visit. Which of the following client statements should the nurse identify as a manifestation of increased risk for child abuse? A. "I try to respond to the baby quickly so she doesn't cry very long." B. "I have several friends who come by to help out with the baby." C. "I want to meet other parents to see if they are going through the same things." D. "I think the baby should be sleeping through the night by now"

D. Uses the TPN IV tubing to administer the client's next dose of antibiotics

A nurse is observing a newly licensed nurse who is administering total parenteral nutrition (TPN) to a client. Which of the following actions by the newly licensed nurse indicates a need for the nurse to intervene? A. Schedules a bag and tubing change for 24 hr after the start of the infusion B. Gradually increases the TPN infusion rate each hr until the prescribed rate is achieved C. Plans for a check of the client's fingerstick glucose level every 6 hr D. Uses the TPN IV tubing to administer the client's next dose of antibiotics

sclera

A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client's body should the nurse observe to assess for jaundice? sclera palms of the hands shoulders face

Measure and compare abdominal girth daily.

A nurse is planning care for a client who is returning to the unit following open gastric bypass surgery. Which of the following interventions should the nurse include in the client's plan of care? Measure and compare abdominal girth daily. Ambulate the client 48 hr after the procedure. Provide a soft diet on the first postoperative day. Provide 60 mL (2 oz) of fluid intake every 5 min.

a. Give the dose over 60 min

A nurse is planning to administer vancomycin IV to a client. Which of the following actions should the nurse take to reduce the risk of an adverse reaction to the vancomycin? a. Give the dose over 60 min b. Administer the medication undiluted c. Obtain trough level 30 min after the medication infusion d. Inject 1% lidocaine prior to each dose

Place a wedge under one of the client's hips.

A nurse is positioning a client for a cesarean birth. To prevent a compromise in placental blood flow during the intraoperative period, which of the following actions should the nurse take? A. Insert a pillow under the client's knees. B. Position the client in reverse Trendelenburg. C. Assist the client into the lithotomy position. D. Place a wedge under one of the client's hips.

2 tablets

A nurse is preparing to administer levothyroxine 50 micrograms to a client. Available is levothyroxine 0.025 mg/tablet. How many tablets should the nurse administer per dose?

A. Use a syringe to allow the medications to flow by gravity.

A nurse is preparing to administer three medications to a client who is receiving continuous enteral feeding through an NG tube. Which of the following actions is appropriate for the nurse to take? A. Use a syringe to allow the medications to flow by gravity. B. Flush the NG tube with 5 mL water. C. Dissolve the medications together. D. Add medication directly to enteral feeding.

b. Wear gloves to apply the patch to the client's skin

A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take? a. Shave hairy areas of skin prior to application​ b. Wear gloves to apply the patch to the client's skin c. Apply the patch within 1 hr of removing it from the protective pouch d. Remove the previous patch and place it in a tissue

"You should remove your child's pressure dressing tomorrow"

A nurse is providing discharge teaching for the guardian of a school age child following a cardiac catheterization. Which of the following instructions should the nurse include in the teaching? "You should give your child a clear liquid diet for 24 hr." "Your child should stay out of school for 7 days following the procedure" "You should remove your child's pressure dressing tomorrow" Your child can take a tub bath this evening."

"I will need to keep my hand elevated above my heart for several days."

A nurse is providing discharge teaching to a client who is postoperative following surgery for carpal tunnel syndrome. Which of the following statements by the client indicates an understanding of the teaching? "| should not use my affected hand for 4 to 6 weeks." "I will need to keep my hand elevated above my heart for several days." "| should expect numbness and tingling in my hand." "I can apply heat for the first 24 hours to minimize the pain in my hand."

"I will use this test to monitor how well I control my blood glucose levels."

A nurse is providing teaching to a client who has diabetes mellitus about the glycosylated hemoglobin blood test. Which of the following statements by the client indicates an understanding of this test? "I will use the results of this test daily to modify my insulin dosage." "I will need to fast prior to taking this test." "I will need to drink a glucose solution to get an accurate result." "I will use this test to monitor how well I control my blood glucose levels."

Swelling of the face

A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching? Swelling of the face Bleeding gums Urinary frequency Faintness upon rising

A. "You might experience altered taste sensations."

A nurse is providing teaching to a client who is to begin external radiation therapy for cancer. Which of the following information should the nurse include? A. "You might experience altered taste sensations." B. "Use rubbing alcohol to remove the ink markings." C. "Wear a binder over the radiation site." D. "Wash your skin thoroughly with a washcloth after each treatment."

"I should use a soft-bristle toothbrush to clean my teeth after meals."

A nurse is providing teaching to a client who is undergoing radiation therapy and has stomatitis. Which of the following responses by the client indicates an understanding of the teaching? "I should use a soft bristle toothbrush to clean my teeth after meals." "I should limit my intake of diary products to prevent nausea." "I should gargle with an alcohol-based mouthwash to kill germs." "I should moisten my lips with lemon-glycerin swabs."

your child can return to school once the legions have crusted over

A nurse is providing teaching to the parents of a child who has varicella. Which of the following instructions should the nurse include in the teaching? your child can return to school after a negative title result your child can return to school once the fever has subsided your child can return to school once the legions have crusted over your child can return to school 24-hours after beginning antibiotics

A client who has a hip fracture and a new onset of tachypnea

A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first? A client who has epidural analgesia and weakness in the lower extremities A client who has a hip fracture and a new onset of tachypnea A client who has sinus arrhythmia and is receiving cardiac monitoring A client who has diabetes mellitus and an HbA1c of 6.8%

A. INR

A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the client's daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin? A. INR B. Fibrinogen level C. aPTT D. Platelet count

C. Ensure that all area rugs are rubber-backed. **think its A. Place a handrail in the entryway of the house.

A nurse is reviewing home recommendations with a client who is postoperative following knee surgery. Which of the following recommendations should the nurse make? A. Place a handrail in the entryway of the house. B. Place a towel on the floor outside of the shower. C. Ensure that all area rugs are rubber-backed. D. Wear slippers with cloth soles

A client who is taking warfarin and has an INR of 1.8

A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings requires follow-up care? A client who is taking bumetanide and has a potassium level of 3.6 mEq/L A client who is scheduled for a colonoscopy and is taking sodium phosphate A client who is taking warfarin and has an INR of 1.8 A client who received a Mantoux test 48 hr ago and has an induration

C. "You should administer the medication after breakfast"

A nurse is teaching a parent of a school-age child who is to begin a daily dose of methylphenidate. Which of the following should the nurse include in the teaching? A. "You should administer the medication at bedtime." B. "Your child should avoid foods containing tyramine." C. "You should administer the medication after breakfast" D. "Your child should avoid excess sodium intake."

"I can visit my nephew who has chickenpox 5 days after the sores have crusted."

A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching? "| should take antibiotics when | have a virus." "I can visit my nephew who has chickenpox 5 days after the sores have crusted." "I can clean my cat's litter box during my pregnancy." "I should wash my hands for 10 seconds with hot water after working in the garden."

A. Have the child take a tub bath each morning

A nurse is teaching the parents of a school-age child who is newly diagnosed with juvenile idiopathic arthritis. Which of the following interventions should the nurse include in the teaching? A. Have the child take a tub bath each morning B. Apply splints to the child's extremities during the day. C. Encourage the child to take naps during the day. D. Keep the child on bedrest as long as pain persists.

Facilitate discussion until all parties agree.

A nurse manager is preparing to meet with a group of staff nurses who are experiencing conflict. Which of the following mediation strategies should the nurse manager plan to implement to resolve the conflict? Establish demands from each party that allow for negotiations. Direct anyone who becomes angry to leave the room. Determine who is at fault in the situation. Facilitate discussion until all parties agree.

Document the client's condition every 15 min

A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include? Remove the client's restraint every 4 hr. Attach the restraint to the bed's side rails Request a PRN restraint prescription for clients who are aggressive. Document the client's condition every 15 min.

c. Recommend to the provider a list of clients for early discharge.

A nurse manager on an interprofessional team is creating a disaster plan. The nurse should include in the plan that which of the following actions is the responsibility of the unit nurse during a disaster? a. Act as a spokesperson to provide information to the media. b. Determine the need for additional providers. c. Recommend to the provider a list of clients for early discharge. d. Determine which clients should be transported for a higher level of care

B. First-degree AV block

A nurse on a telemetry unit is assessing a client who is receiving continuous cardiac monitoring. The client's heart rate is 69/min and the PR interval is 0.24 seconds. The nurse should interpret this finding as which of the following cardiac rhythms? A. Atrial fibrillation B. First-degree AV block C. Premature ventricular contraction D. Sinus bradycardia

Anorexia Nervosa - Provide a structured meal environment - Focus on the client's underlying feelings dysphoria of and lack of control - Behavior 15 min after meals - Cardiac function with ECG * Are we sure about behavior 15 min?- would that be bulimia?-blasta

Also on Pt.1 A nurse is caring for a recently admitted 18-year-old client. Nurses' Notes 1000: Client admitted to behavioral health unit for prolonged weight loss and refusal to eat. Client collapsed at school. The client's parents were called. They contacted the primary care provider, who arranged for a direct admission. Weight 37.2 kg (82 Ib) Height 157.5 cm (62 inches) BMI 15

Client transferred to step-down unit from ICU for continued care following a myocardial infarction 2 days ago. Oriented to room. Client reports a chronic productive cough due to COPD. States they are short of air. Also states that ambulating to the bathroom has resulted in chest pain rated 3 on a 0 to 10 Pain Scale. client appears anxious and reports a fear of dying

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again. Client transferred to step-down unit from ICU for continued care following a myocardial infarction 2 days ago. Oriented to room. Client reports a chronic productive cough due to COPD. States they are short of air. Also states that ambulating to the bathroom has resulted in chest pain rated 3 on a 0 to 10 Pain Scale. client appears anxious and reports a fear of dying

-placental abruption -hypertension

Drag one condition and 1 client finding to fill in each blank in the follow sentence The client is at risk for developing ??? due to ??? Condition: oligohydramnios placental abruption choreoammonites placenta previa spontaneous abortion Findings: fundal measurement hypertension vomiting hyperreflexia temperature

Report burning in chest to provider - IND Reinforce dressing around the tube as needed if it loosens - IND Maintain water level at 2cm - CONT Strip the tubing twice daily to ensure patency - CONT Clamp chest tube when client ambulates - CONT

For each potential nursing action, click to specify if the action is indicated or not indicated for the client.

Encourage naps during the day when client is tired - IND Encourage a regular sleep-awake schedule - IND Encourage high calorie finger foods - NOT Advise client to notify provider if pregnant - NOT Instruct client to avoid foods that have been fermented or aged - NOT Advise client to rise slowly from sitting position - IND Encourage client to sleep until later in the morning - NOT

For each potential nursing intervention, click to specify if the intervention is indicated or not indicated.

MISSING #18

MISSING #18

MISSING #36

MISSING #36

Urine Specific Gravity

NGN Vitals: BP: 126/94 HR: 85 RR: 20 Temp: 99.7F Diagnostic results: Urine Specific Gravity 1.035 Albumin 4/5 Prealbumin 25 POTASSIUM 4.2 a nurse is reviewing the medical record of a client which of the following findings should the nurse report to the provider Urine Specific Gravity Temperature Prealbumin Bowel sounds

Pain level - worsening Anxiety level - worsening Temperature - worsening Heart rate - worsening Spo2 - worsening Respiratory Rate - worsening

Pain level: 3/10 to 5/10 Anxiety level: Less anxious to anxious and pacing in room For each finding click to specify a defining indicates an improvement in or a worsening of the client's condition Pain level Anxiety level Temperature Heart rate Spo2 Respiratory Rate

Anticipated: Isoniazid, Airborne precautions, Pyrazinamide, Ethambutol, Rifampin Contraindicated: Monthly TB skin test for 1 year, Contact precautions,

Same as prev. cards. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client. Potential Prescriptions: Isoniazid Airborne precautions Contact precautions Pyrazinamide Ethambutol Monthly TB skin test for 1 year Rifampin

The client is at highest risk for developing Preeclampsia as evidence by the client's Urinalysis and Pain manage

The client is at highest risk for developing ??? as evidence by the client's ??? and ????

- 2L via nasal canula - hydralazine

The nurse continues to care for the client who is at 30 weeks of gestation Complete the following sentence by using the lists of options. Based on the client findings, the nurse should first administer ??? and then prepare to administer ???

Supplement feeding with sterile water = CON Dress in only diaper = IND Cover newborn's eyes with a shield = IND Apply lotion to skin every 4 hr = CON Breastfeed every 2-3 hr = IND

The nurse is preparing the infant for phototherapy. For each nursing action, click to specify if the action is indicated or contraindicated for the newborn. Supplement feeding with sterile water Dress in only diaper Cover newborn's eyes with a shield Apply lotion to skin every 4 hr Breastfeed every 2-3 hr

N95 Negative flow

The nurse reviews the client's test results (same client). Exhibit 1: Screenings: Mantoux test: results pending (nurse will read the results in 48 hr) Exhibit 2: Diagnostic Results: Chest x-ray: Caseation lesions to bilat upper lungs Exhibit 3: History and physical: see previous card Exhibit 4: VS: see previous card Exhibit 5: Lab Results: Sputum culture: positive for M. tuberculosis Complete the following sentence by using the list of options: The nurse should wear ____ and place ____.

- lithium toxicity - seizure activity

The nurse understands that the patient has likely developed ??? and will need to be monitored for ??? - lithium toxicity - UTI - metabolic syndrome - neuroleptic malignant syndrome - blood glucose - seizure activity - symptoms of infection - temperature over 39.4C (103F)

lower extremity assessment weight assessment blood pressure nausea DTR

Vital signs 1000 Temp: 99.3F HR: 90 RR: 20 BP: 148/94 O2: 95% RA Select the 5 findings that require follow-up by the nurse. lower extremity assessment fatal heart tracing weight assessment blood pressure nausea respiratory assessment fundal height DTR

b. Wear flat or low heeled shoes d. wear loose fitting clothing f. you should avoid fried foods

Which of the following statements should the nurse include in the client's teaching? Select all that apply . a. Take hot showers to help relieve itching b. Wear flat or low heeled shoes c. you can douche twice weekly d. wear loose fitting clothing e. try using an abdominal support belt f. you should avoid fried foods g. eat two large meals a day

A client who has left shoulder pain and S-T elevation on a 12-lead ECG

a nurse in the emergency department is receiving report on a group of clients which of the following clients should the nurse assess first? A client who has left shoulder pain and S-T elevation on a 12-lead ECG A client who has Clostridium difficile and a temperature of 38.6°C(101.5°A) A client who has orthostatic hypotension and 44 pitting edema in the lower extremities A client who has a complete femur fracture and reports a pain level of 7 on a scale from 0 to 10

Frothy, pink sputum

a nurse is assessing a client who has left-sided heart failure. which of the following findings should the nurse identify as a manifestation of pulmonary congestion? Frothy, pink sputum weight gain bradypnea jugular vein distention

Negative clonus

a nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion for which of the following therapeutics should the nurse monitor for the client? Flushed face Negative clonus Pulse rate 100/min BP 150/92 mm Hg

Perform postmortem care

a nurse is assigning tasks to an assistive personnel. which of the following tasks should then there's a sign to the AP? - Perform postmortem care - Suction a new tracheostomy - Change a dressing on an implanted central venous access device - Remove an NG tube

sternum

a nurse is assisting the skin turgor of an older adult client. in which of the following areas should the nurse lift the skin? neck abdomen shoulder sternum

- difficulty sleeping - frequent headaches - bp 169/91

a nurse is caring for a client in the outpatient mental health clinic highlight THE FINDINGS: client states "im feeling much better.* They report less fatigue, even though they have difficulty sleeping, client reports they are not sad anymore but are experiencing more frequent headaches. Client continues to deny any suicidal ideation Vital Signs bp 169/91 Heart rate 78/mm respiratory rate 18/min

Flush the tube with 0.9% sodium chloride.

a nurse is caring for a client who has an NG tube with intermittent suction. which of the following actions should the nurse take? Flush the tube with 0.9% sodium chloride. Replace the NG tube every 24 hr. Increase the suction pressure as tolerated. Position the Client supine in bed.

raised facial rash

a nurse is caring for a client who has systemic lupus erythematosus. Which of the following client findings should the nurse expect? hemangiomas raised facial rash psoriasis Kaposi's sarcoma lesions

it must be frustrating for you to be here

a nurse is caring for a client who is recovering from a cerebral vascular accident in a rehabilitation facility. The client tells the nurse, "I am sick of being in here and I want to go home." Which of the following responses should the nurse make? it must be frustrating for you to be here you should call your partner to discuss this you are making progress in your treatment plan it would be best to discuss your feelings with your provider

Inspect the client's mouth every 8 hours

a nurse is creating a plan of care for a client who has cancer and is experiencing immunosuppression. which of the following intervention should the nurse include in the plan of care? Monitor the client's vital sings every 12 hours rotate Healthcare staff caring for the client Inspect the client's mouth every 8 hours Provide fresh fruit with the client's meals

B. Limit use of nicotine gum to 6 months

a nurse is disgusting treatment options with a client who is experiencing nicotine withdrawal. which of the following information should the nurse include in the teaching? A. Substitute tobacco use with an electronic cigarettee B. Limit use of nicotine gum to 6 months C. Use progressively larger nicotine patches D. Use up to 40 nicotine leverages per day

Instruct the client to empty her bladder prior to the procedure

a nurse is planning care for a client was scheduled to have a paracentesis. which of the following actions should the nurse include in the plan of care? Position the client over an overbed table prior to the procedure. Administer 1 L dextrose 5% in water IV bolus prior to the procedure. Initiate NPO status 4 hr prior to the procedure. Instruct the client to empty her bladder prior to the procedure

A. Measure the arm circumference above the insertion site daily.

a nurse is planning care for a client who is scheduled to receive a peripherally inserted central catheter in the arm. Which of the following interventions is appropriate for the nurse to include in the plan of care? A. Measure the arm circumference above the insertion site daily. B. Administer sedation C. Schedule an MRI post procedure to verify placement D. Use gauze to secure an arm board to the involved extremity

A. Doxorubicin hydrochloride

a nurse is preparing to administer an IV medication to a client and accidentally punctures the IV bag causing the medication to leak on the counter. which of the following medications require the nurse to follow facility procedures in the safe handling of a biohazardous material spill? A. Doxorubicin hydrochloride B. Ampicillin Sodium C. Metronidazole D. Phenytoin

D. I will position my baby at a 45-degree angle in the car seat.

a nurse is providing discharges about car safety to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? A. I can turn my baby's car seat around when she weighs 15 pounds. B. I can place my baby in the front seat with the airbag turned off. C. I will place my baby in a forward-facing car seat in my back seat. D. I will position my baby at a 45-degree angle in the car seat.

A. "I will wipe my nose instead of blowing it"

a nurse is providing teaching to a cleint who has thrombocytopenia following chemotherapy. which of the following statements indicates an understanding of the teaching? A. "I will wipe my nose instead of blowing it" B. "I will remove my shoes when I'm inside my house" C. "I will floss between my teeth every time I brush" D. "I will use an enema to manage my constipation"

C. Presence of a productive cough

a nurse is suctioning the airway of a client who is receiving mechanical ventilation via an endotracheal tube. which of the following findings should the nurse identify as an indication that the suctioning has been effective? A. Thinning of mucous secretions B. Decreased peak inspiratory pressure C. Presence of a productive cough D. Flattening of the artificial airway cuff

- Complete activities for one client before moving to the next client.

a nurse on a medical surgical unit is planning care for assigned clients. Which of the following actions should the nurse plan to take to demonstrate effective time management? - Complete activities for one client before moving to the next client. - Document assessment findings and interventions after providing care for a group of clients. - Gather supplies for a client's dressing change after removing the old dressing. - Delay cleaning personal work area until the end of the shift.

I should visually monitor the client continuously when in mechanical restraints

a nurse on a mental health unit is teaching a newly licensed nurse about the use of mechanical restraints which of the following statements by the newly licensed nurse indicates an understanding of the teaching? I should ask the provider to write a prescription for mechanical restraints as needed. I should visually monitor the client continuously when in mechanical restraints I should assess the client's skin integrity every 8 hours while in mechanical restraints I should expect the provider to evaluate the client within a houfs of restraint application

monitor blood pressure prepare for amniocentesis encourage bed rest assess DTR

click to specify which of the following actions the nurse should anticipate including in the client's plan of care. SATA monitor blood pressure initiate contact precautions prepare for amniocentesis apply internal fetal monitor decrease lighting in the client's room check urinary output encourage bed rest assess DTR

missing #79

missing #79

physical activity recommendations blood pressure management relaxation techniques smoking cessation program nitroglycerin self-administration meal planning ideas

the nurse is developing a plan of care with a cardiac rehabilitation team. which of the following topics should the nurse recommend the team plan to address with the client? SATA potential pacemaker placement physical activity recommendations blood pressure management relaxation techniques cardioversion therapy smoking cessation program nitroglycerin self-administration meal planning ideas

you should avoid salt in your food prior to eating you should aim to consume fish at least twice a week you should where a medical alert bracelet or necklace you should keep your nitroglycerin with you at all times

the nurse is providing teaching to the client about self-care. select the 4 statements the nurse should include in the teaching. you should avoid salt in your food prior to eating you should aim to consume fish at least twice a week you should where a medical alert bracelet or necklace you should keep your nitroglycerin with you at all times you should take ibuprofen If you experience mild pain