NUR 320 FINAL

The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for?

Burr holes

Agency policies are important to achieve culturally competent care. When reviewing a hospital's current policy framework, what action has the most potential to improve the overall level of culture competence?

Creating greater flexibility in visiting hours

Which instruction should a nurse provide a client with a history of rheumatic fever before the client has any dental work done?

To take prophylactic antibiotics

A community health nurse is organizing community training on healthy behavior change. Which action will the nurse focus on when using the transtheoretical model of change as guidance for the teaching?

Motivation of Individuals

The nurse is working with a colleague who has a delayed hypersensitivity (type IV) allergic reaction to latex. Which statement describes the clinical manifestations of this reaction?

Symptoms are localized to the area of exposure, usually the back of the hands.

The nurse assesses a patient for a possible pulmonary embolism. What frequent sign of pulmonary embolus does the nurse anticipate finding on assessment?

Tachypnea

During the physical assessment of a client with hypertension, what would the nurse expect to be the most obvious finding?

Sustained increase of either one or both systolic or diastolic measurements.

Early signs of hypervolemia

increased breathing effort and weight gain.

The nurse is assessing several clients. Which client does the nurse determine is most likely to have Hodgkin lymphoma?

The client with enlarged lymph nodes in the neck.

The nurse is assessing a client who had an ileostomy created three days ago for the treatment of irritable bowel disease. The nurse observes that the client's stoma is bright red and there are scant amounts of blood on the stoma. What is the nurse's best action?

Document these expected assessment findings

The nurse is assessing a client with acute coronary syndrome (ACS). The nurse includes a careful history in the assessment, especially with regard to signs and symptoms. What signs and symptoms are suggestive of ACS? Select all that apply.

Dyspnea, unusual fatigue, syncope

The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process?

Elevated BP

What is a characteristic of the intrarenal category of acute renal failure?

Increased BUN

A client hospitalized for treatment of hypertension is being prepared for discharge. Which teaching topic should the nurse should be sure to cover?

Maintaining a low-sodium diet

The nurse is creating a plan of care for a client with acute coronary syndrome. What nursing action should be included in the client's care plan?

Administer supplementary Oxygen, as needed.

A client with a history of chronic renal failure receives hemodialysis treatments three times per week through an arteriovenous (AV) fistula in the left arm. Which intervention should the nurse include in the care plan?

Assess the AV fistula for a bruit and thrill.

Which intervention should the nurse implement when caring for the client who complains of phantom limb pain two months after amputation?

Reassure the client that phantom pain is common.

A nurse is caring for a client with acute myeloid leukemia who is preparing to undergo induction therapy. In preparing a plan of care for this client, the nurse should assign the highest priority to which nursing diagnosis?

Risk for infection