passpoint

The nurse is teaching an adolescent with type 1 diabetes about signs and symptoms of hypoglycemia. Which of the following statements by the client help the nurse determine that the teaching has been effective? Select all that apply.

"If my blood sugar is low, I may feel sweaty and anxious." "If my blood sugar is low, my heart rate will speed up." "If my blood sugar is low, my blood pressure will increase."

A client's spouse voices concern over the client not being able to cope with having had a permanent pacemaker implanted. Which statement by the nurse would best address this concern?

"It is important to discuss your spouse's feelings in case of anxiety or depression."

A client asks the nurse why epoetin alfa is administered during dialysis sessions. Which response by the nurse is accurate?

"The medication is a form of erythropoietin that stimulates red blood cell production."

The nurse at the clinic is assessing a toddler and notices retractions while the child is breathing. The parents state that they began to notice the retractions a few days ago and wondered if it was significant. What is the best response by the nurse?

"Your child is having difficulty breathing and we need to determine why."

A client with pneumonia has developed dyspnea, has a respiratory rate of 32 breaths/min, and is having difficulty expelling secretions. The nurse auscultates the lung fields and hears bronchial sounds in the lower left lobe. Which action should the nurse take first?

Apply oxygen

Four hours after a cast has been applied for a fractured ulna, the nurse assesses that the client's fingers are pale and cool and capillary refill is delayed for 4 seconds. How should the nurse interpret these findings?

Arterial blood supply to the fingers is decreased.

Which assessment finding should alert the nurse to suspect appendicitis in a male adolescent reporting severe abdominal pain?

Bowel sounds are heard twice in 2 minutes.

While assessing the incision of a client who had surgery 2 weeks ago, a nurse observes that the suture line has a shiny, light pink appearance. Which step should the nurse take next?

Continue to monitor the suture line, and document findings.

A nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first?

Cover the protruding internal organs with sterile gauze, moistened with sterile saline solution.

A nurse is caring for a client in a coma who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in intracranial pressure (ICP)?

Elevate the head of the bed 15 to 30 degrees.

Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence?

Establish a regular voiding schedule.

A client has just been diagnosed with pneumonia. What is the nurse's priority action?

Maintain airway clearance.

A client tells the nurse he is experiencing dyspnea. Which action by the nurse is most appropriate?

PLACE THE CLIENT IN HIGH FLOWERS POSITION

After a myocardial infarction, the hospitalized client is taught to move the legs while resting in bed. What is the expected outcome of this exercise?

Prevent thrombophlebitis and blood clot formation.

The client is experiencing parasympathetic responses to pain. What responses should the nurse assess the client for? Select all that apply.

bradycardia weakness

A nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?

call hcp asap

A client with acute renal failure has a serum potassium level of 6.5 mEq/L (6.5 mmol/L). The nurse should monitor the client for which potential complication?

cardiac arrest

The nurse is assessing a client with a known history of chronic heart failure. Which finding indicates poor perfusion to the tissues?

coool, pale extremeties

The public health nurse is teaching the parents of an 8-year-old client who is diagnosed with iron deficiency anemia. What education should the nurse include in the client's plan of care? Select all that apply.

encourage foods high in iron increase vitamin C to enhance iron absorption

The nurse is caring for an infant with severe diarrhea that has lasted 3 days. The child has poor skin turgor and dry mucous membranes. What is the priority nursing diagnosis for the nurse to use when planning care for this child?

fluid volume deficit

A client tells the nurse he is experiencing dyspnea. Which position will the nurse place the client in?

high fowlers

The nurse receives a change-of-shift report on the following four clients. Which client should the nurse assess first?

immobile client with a sudden onset of shortness of breath

Which mental status change may occur when a client with pneumonia is first experiencing hypoxia?

irritability

A primigravid client with diabetes at 39 weeks' gestation is seen in the high-risk clinic. The primary health care provider (HCP) estimates that the fetus weighs at least 10 lb (4,500 g). The client asks, "What causes the baby to be so large?" The nurse's response is based on the understanding that fetal macrosomia is usually related to which factor?

maternal hyperglycemia

When performing cardiopulmonary resuscitation (CPR), which finding indicates that external chest compressions are effective?

palpable pulse

To improve the oxygenation of a client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation, the nurse should place the client in which position?

prone

When assessing a client with cellulitis of the right leg, which finding should the nurse expect to observe?

red, swollen skin with inflammation spreading to surrounding tissues

A client with diabetes mellitus is admitted with hypoglycemia. Which information should the nurse include in the client teaching? Select all that apply.

"Hypoglycemia can result from excessive alcohol consumption." "Skipping meals can cause hypoglycemia." "Strenuous activity may result in hypoglycemia." "Symptoms of hypoglycemia include shakiness, confusion, and headache."

The nurse is providing information to the parents of a child newly diagnosed with juvenile arthritis. Which statements by the parents indicate understanding of the teaching? Select all that apply.

"I help my child perform daily range-of-motion exercises." "I give my child NSAIDs three times a day." "I apply heat pads to the joints when my child is having pain."

A teen client, who is one week postpartum, is concerned about the possibility of postpartum depression because she has a history of depression. Which comment by the client would indicate that she understood the nurse's teaching about the postpartum period and her risks for postpartum depression?

"If I'm feeling guilty or not capable of caring for the baby and am not sleeping or eating well, I need to contact the office."

A graduate nurse is explaining to the nurse mentor how to assess newborn jaundice and the effects of phototherapy in a dark skinned neonate. Which statement made by the graduate nurse would need clarification? Select all that apply.

"The neonate will be irritable from the elevated bilirubin in the system." "I will carefully record the neonate's intake as limiting fluids is helpful."

An unconscious client is brought to the emergency department following an opioid overdose. Physical assessment reveals pinpoint pupils, decreased muscle tone, pale skin, and shallow respirations with a rate of 8 breaths per minute. What is the nurse's best action?

Administer naloxone.

The nurse is caring for an 11-year-old client experiencing status epilepticus. When providing and delegating immediate nursing care, which nursing actions would be completed? Select all that apply.

Administer oxygen via nasal cannula. Pad side rails with cushions/pillows. Instruct the licensed practical/vocational nurse (LPN/VN) to obtain vital signs.

A nurse is preparing a client for cardiac catheterization. The nurse must provide which nursing intervention immediately when the client returns to their room after the procedure?

Assess the puncture site frequently for hematoma formation or bleeding.

The nurse is assisting a client from the bed to a chair when the client begins having a generalized seizure. Which action should the nurse take first?

Assist the client to a side-lying position on the floor.

A nurse is caring for a client who is 32 weeks gestation and being monitored in the antepartum unit for pre-eclampsia. The client suddenly reports continuous abdominal pain and vaginal bleeding. Which nursing interventions are priorities? Select all that apply.

Evaluate maternal vital signs. Auscultate fetal heart tones. Monitor the amount of vaginal bleeding. Monitor intake and output.

The nurse is caring for a client in early labor. The client reports sudden abdominal pain and is noted to have bright red bleeding. What would the nurse include in the client's plan of care? Select all that apply.

Examine the fetal heart monitoring tracing. Call the healthcare provider. Administer oxygen to the client.

A client in a general hospital is to undergo surgery in 2 days and is experiencing moderate anxiety about the procedure and its outcome. What should the nurse do to help the client reduce anxiety?

Explain the surgical procedure to the client and what happens before and after surgery.

A client is prescribed metoprolol 25 mg by mouth twice per day for an atrial arrhythmia. Which should the nurse assess to determine the effectiveness of this medication?

HR

A client is admitted with shortness of breath, a brain natriuretic peptide (BNP) level of 615 pg/mL, and pedal edema. Which actions should the nurse take next? Select all that apply

Initiate I.V. diuretic therapy. Give oxygen by mask.

A client is transported to the emergency department with an acute respiratory infection. Vital signs are T 102 degrees F (38.8 degrees C), P 110 bpm, R 32 breaths/min. Circumoral cyanosis is noted, and the oxygen saturation is 86%. What should be the immediate actions by the nurse caring for this client? Select all that apply.

Initiate oxygen at 6 L/min via nasal cannula. Place the client in high Fowler's position.

The nurse is caring for a client admitted with severe blood pressure 80/40 hypotension and positive blood cultures for Escherichia coli. What are the priority interventions for this client? Select all that apply.

Maintain intravenous fluids and vasopressors. Administer ceftriaxone.

A client returns from a laryngectomy and begins to cough violently, dislodging the tracheostomy tube. What is the priority action of the nurse?

Mask ventilate the client and prepare for orotracheal intubation when the healthcare provider arrives.

The nurse is caring for a client with urinary calculi of unknown origin. Which interventions would be appropriate for this client? Select all that apply.

Medicate for pain. Strain urine.

A client had an appendectomy 2 days ago and is now presenting with purulent drainage, pain in the mid-incision, and a temperature of 101.3°F (38.5°C). What would be the most appropriate action by the nurse?

Notify the surgeon as soon as possible.

A client with diverticulitis has developed peritonitis following diverticular rupture. When assessing the client, what should the nurse do? Select all that apply.

Percuss the abdomen to note tympany. Percuss the liver to note lack of dullness. Monitor the vital signs for fever. Auscultate bowel sounds to note frequency.

A client has chest pain rated at 8 on a 10-point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and troponin levels are elevated. What should the nurse do first?

Reduce pain and myocardial oxygen demand.

The nurse is receiving a client in the operating room for a right leg amputation. Which steps will the nurse follow during the timeout procedure? Select all that apply.

Review the surgical site marking of the right leg. Note preparation for the removal of the limb disposal. Assess the completed surgical consent. Confirm the client's name band.

Which nursing measure would be most effective in helping the client cough and deep breathe after a cholecystectomy?

Teach the client to use a folded blanket or pillow to splint the incision.

The nurse is caring for a child with cystic fibrosis who is admitted to the floor with an upper respiratory tract infection. The child has labored breathing and a congested, nonproductive cough. What is the immediate priority for the nurse?

airway

A client's face, neck, and chest have been burned in a fire 1 hour ago. What is the nurse's priority assessment at this time?

airway obstruction

A client has undergone a left hemicolectomy for bowel cancer. Which combination of activities is most effective in preventing the occurrence of postoperative pneumonia in this client?

coughing, breathing deeply, frequent repositioning, and using an incentive spirometer

A nurse encourages a client to increase fluid intake, based on which laboratory test results? Select all that apply.

increased serum creatinine level increased blood-urea-nitrogen (BUN) level

Which nursing diagnosis is the most appropriate for a preschool child with epiglottitis?

ineffective airway clearance related to laryngospasm

The nurse is caring for a child hospitalized with epiglottitis. What will the nurse assign as the highest priority nursing diagnosis?

ineffective airway clearance related to swelling of the epiglottis

The parent of a newborn has supplemented breastfeeding with water to prevent hyperbilirubinemia and the need for phototherapy. What assessment findings might the nurse expect to see in this 3-day-old breastfed newborn? Select all that apply.

jaundice hyponatremia weight loss

Which nursing intervention is the highest priority during the first 24 hours postoperatively for the client who had a total laryngectomy due to cancer of the larynx?

keep airway open

A child, age 4, with a recent history of nausea, vomiting, and diarrhea is admitted to the pediatric unit with a diagnosis of gastroenteritis. During the physical examination, the nurse detects tenting. This finding supports a nursing diagnosis of

deficient fluid volume related to dehydration.

An 11-year-old is admitted for treatment of an asthma attack. Which finding indicates immediate intervention is needed?

intercostal retractions

Immediately after surgery to create an ileostomy, which goal has the highest priority?

maintaining fluid and electrolyte balance

A client is diagnosed with acetaminophen poisoning. Which signs would the nurse expect to assess 12 to 24 hours after ingestion? Select all that apply.

nausea and vomiting sweating diarrhea irritability

The nurse assesses the client's burned right arm and notes increasing edema, absence of a radial pulse, and decreased sensation in the fingers. The nurse should:

notify the health care provider immediately.

A nurse is monitoring a client for manifestations of cardiac tamponade. Which findings would support this diagnosis? Select all that apply.

restlessness muffled heart sounds distended neck veins

A client has had surgery for a deviated nasal septum. The client has returned from the postanesthesia care unit. What should the nurse do first?

Assess respiratory status.

Which finding would indicate bowel functioning is returning after anesthesia and surgery for a client with a nasogastric tube?

Auscultation indicates bowel sounds in all four quadrants.

The nurse is completing an initial assessment of a client admitted with chronic kidney disease. Which finding indicates the client has fluid volume excess?

weight gain

When preparing the teaching plan for the mother of a child with asthma, what information should the nurse include as a sign to alert the mother that her child is having an asthma attack?

wheezing on expiration

A nurse is caring for a newborn exposed to drugs while in utero. Which behaviors will the nurse expect the newborn to exhibit? Select all that apply.

tachypnea with excessive secretions sensitive gag reflex hyperactivity and increased muscle tone

When teaching the parents of a 1-year-old child who is scheduled for placement of tympanostomy tubes, which explanation should the nurse include as the purpose for these tubes?

They allow ventilation and drainage of the middle ear.

A client asks the nurse, "Why can't the doctor tell me exactly how much of my leg they are going to take off? Don't you think I should know that?" The nurse responds, knowing that the final decision on the level of amputation depends primarily on:

the adequacy of the blood supply to the tissues.

A client is admitted to the emergency department with sudden onset of chest pain. Which prescriptions should the nurse implement immediately? Select all that apply.

Provide oxygen. Administer nitroglycerin. Administer aspirin. Administer morphine.

A nurse is assessing a client who is postoperative and unable to verbally answer questions. Which non-verbal behavior(s) should the nurse interpret as the client having pain Select all that apply.

clenching restlessness grimacing

A client is admitted to the emergency department with crushing chest injuries sustained in a car accident. Which sign indicates a possible pneumothorax?

diminished or absent breath sounds on the affected side

A client fell and broke an arm and had a cast applied. Which of these statements by the client indicates an immediate risk for compartment syndrome?

i cant wiggle my fingers

A client is in the first hour of her recovery after a vaginal birth. During an assessment, the lochia is moderate, bright red, and is trickling from the vagina. The nurse locates the fundus at the umbilicus; it is firm and midline with no palpable bladder. The client's vital signs remain at their baseline. Based on this information, the nurse would implement which action?

Report the findings to the health care provider (HCP).

The nurse is planning care for a client with a spinal injury who is to remain on complete bedrest. What should the nurse do to prevent the development of pressure ulcers? Select all that apply.

Turn the client every 2 hours. Monitor the serum albumin. Request a prescription for a pressure mattress. Inspect the skin for redness.

A client is admitted to the emergency department with a headache, weakness, and slight confusion. The physician diagnoses carbon monoxide poisoning. What should the nurse do first?

Administer 100% oxygen by mask.

The nurse is assessing a client experiencing a sickle cell crisis who continues to rate the pain at 10 on a scale of 1 to 10. Which is true about pain?

Expression and perception of pain vary widely from person to person.

A nurse is caring or a client who has experienced frontal lobe damage in a car accident. Which psychosocial behaviors are indications of this damage? Select all that apply.

a change in personality overt sexual behavior difficulty controlling temper fewer spontaneous facial expression

A client is admitted to the emergency department with crushing chest injuries sustained in a car accident. The nurse is assessing the client's respiratory status. Which sign indicates a possible complication that the nurse should report to the health care provider immediately?

absent breath sounds on the affected side

The nurse is caring for an older adult who has been bedridden for an extended period. Which symptom indicates that the client has hypoxia?

confusion

A client is diagnosed with left-sided heart failure. Which treatment should the nurse anticipate being prescribed to reduce this client's excess fluid?

diuretics

A nurse is caring for a client with lower extremity peripheral vascular disease. Which pulse will be the priority assessment for this client?

dorsalis pedis

The nurse enters the client's room as the client, who is sitting in a chair, begins to have a seizure. The nurse should first:

ease the client to the floor.

A child is admitted to the emergency department with dyspnea related to bronchospasms. The nurse should place the client in which position?

high fowlers

A client who has had a bowel resection comes to the health center 7 days postoperatively for removal of the staples. As the nurse is cleansing the incision, the client reports of mid-incision pain. After removing three staples, the nurse observes that the incision is separating. What is the nurse's priority action?

Stop the staple removal, cover the incision, and report the findings to the physician

A 5-year-old child returns to the pediatric unit following a cardiac catheterization using the right femoral vein. The child has a thick elastoplast dressing. Which assessment finding requires immediate intervention?

The pedal pulse of the right leg is not detectable.

When developing a care plan for a client who has recently suffered a stroke, a nurse includes the nursing diagnosis Risk for imbalanced body temperature. What is the rationale for this diagnosis?

The stroke may have impacted the body's thermoregulation centers.

A client with neutropenia has an absolute neutrophil count (ANC) of 900 (0.9 × 109/L). The nurse teaches the client to prevent which risk of neutropenia?

infection

A neonate returns from the operating room after surgical repair of a tracheoesophageal fistula and esophageal atresia. What is the nurse's priority intervention?

maintaining nasogastric tube patency

During assessment of an adolescent who has sustained a recent thoracic spinal injury, the nurse auscultates the adolescent's abdomen. The nurse explains to the parents that this is necessary because clients with spinal cord injury often develop which problem?

paralytic ileus

The mother of a child with tetralogy of Fallot asks the nurse why her child has clubbed fingers. The nurse bases the response on the understanding that clubbing is due to which factor?

peripheral hypoxia

A client with epilepsy is having a seizure. During the active seizure phase, the nurse should

place the client on their side, remove dangerous objects, and protect their head.

A child has been diagnosed with type 1 diabetes mellitus. Which signs and symptoms would the nurse manage with this diagnosis? Select all that apply.

polyuria weakness weight loss postprandial nausea

A client who has been hospitalized for treatment of a pneumothorax is ready for discharge. Which outcomes indicate that the client has adequate respiratory function? Select all that apply.

respiratory rate of 12 to 20 breaths per minute breath sounds present and equal in all lobes oxygen saturation on room air is 95%.

The nurse is caring for a group of postoperative clients. The client with what characteristics will the nurse assess as at highest risk for deep vein thrombosis?

the client who will be immobile during and shortly after surgery

Which client with burns will most likely require an endotracheal or tracheostomy tube? A client who has:

thermal burns to the head, face, and airway resulting in hypoxia.

A client is postoperative following resection of a lower lobe of the lung and presents with a large amount of respiratory secretions. The nurse should include which actions during care? Select all that apply.

turning and positioning every 2 hours administering bronchodilators providing oxygen via humidified mask

A client is admitted with a 45% partial and full thickness burn. Which finding would alert the nurse that the client has a deficiency in fluid volume during the first 24 hours?

urine output of less than 30 mL/hr

A client is receiving chemotherapy for treatment of acute lymphocytic leukemia. During discharge preparation, which topic is most important for the nurse to discuss with the client and caregivers?

ways to prevent infection