PNU 133 Honan PrepU Clinical Decision Making / Clinical Judgment

The nurse is giving discharge instructions to the client following a bladder ultrasound. Which statement by the client indicates the client understands the instructions?

"I can resume my usual activities without restriction."

The nurse is caring for a client is scheduled for chemotherapy followed by autologous stem cell transplant. Which of the following statements by the client indicates a need for further teaching?

"I hope they find a bone marrow donor who matches."

A nurse is preparing a client for a scheduled adenosine stress test. Which statement made by the client indicates a need for further education?

"My family is bringing me a cup of coffee to drink before the test."

The nurse is reviewing the potassium level of a patient with kidney disease. The results of the test are 6.5 mEq/L, and the nurse observes peaked T waves on the ECG. What priority intervention does the nurse anticipate the physician will order to reduce the potassium level?

Administration of sodium polystyrene sulfonate [Kayexalate])

A client arrives at the ED with an exacerbation of left-sided heart failure and reports shortness of breath. Which is the priority nursing intervention?

Assess oxygen saturation

A client with achalasia recently underwent pneumatic dilation. The nurse intervenes after the procedure by

Assessing lung sounds

A client in the emergency department states, "I have always taken a morning walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though." Based on this statement, which priority assessment should the nurse complete?

Attempt to palpate the dorsalis pedis and posterior tibial pulses.

The nurse is caring for a client with an elevated blood pressure and no previous history of hypertension. At 0900, the blood pressure was 158/90 mm Hg. At 0930, the blood pressure is 142/82 mm Hg. The nurse is most correct when relating the fall in blood pressure to which structure?

Baroreceptors

A client comes to the clinic for evaluation because of complaints of dizziness and difficulty walking. Further assessment reveals a staggering gait, marked muscle incoordination, and nystagmus. A brain tumor is suspected. Based on the client's assessment findings, the nurse would suspect that the tumor is located in which area of the brain?

Cerebellum

A nurse is providing care to a client experiencing symptoms associated with terminal illness. Which of the following would be most appropriate to use as a means for managing the client's symptoms?

Client's goals

The client is admitted to the hospital with a diagnosis of acute glomerulonephritis. Which clinical manifestation would the nurse expect to find?

Cola-colored urine

Which value does the nurse recognize as the best clinical measure of renal function?

Creatinine clearance

A son brings his father into the clinic, stating that his father's color has changed to bluish around the mouth. The father is confused, with a respiratory rate of 28 breaths per minute and scattered crackles throughout. The son states this condition just occurred within the last hour. Which of the following factors indicates that the client's condition has lasted for more than 1 hour?

Cyanosis

Which is a late sign of hypoxia?

Cyanosis

The nurse is assessing a client who is stating gastrointestinal upset and a feeling of bloating. Which type of meal would the nurse anticipate causing these types of symptoms?

Hamburger and French fries

Which feature(s) indicates a carpopedal spasm in a client with hypoparathyroidism?

Hand flexing inward

A client with acromegaly has been given the option of a surgical approach or a medical approach. The client decides to have a surgical procedure to remove the pituitary gland. What does the nurse understand this surgical procedure is called?

Hypophysectomy

A nurse is helping a patient with her morning bath. The patient complains of having dry eyes. The nurse knows that the eyelids contain multiple glands that protect the eye. Which of the following eyelid glands should the nurse first assess?

Lacrimal

The nurse recognizes which statement as accurately reflecting a risk factor for breast cancer?

Mother affected by cancer before 60 years of age

The nurse has medicated a postoperative client who reported nausea. Which medication would the nurse document as having been given?

Ondansetron

The nurse is caring for a client with dysphagia. Which intervention would be contraindicated while caring for this client?

Placing food on the affected side of the mouth

During the skin assessment of a client, the nurse observes a skin lesion that is elevated, round, and filled with serum. Identify the type of lesion.

Vesicle

The nurse notes that the client demonstrates generalized pallor and recognizes that this finding may be indicative of

anemia

What is a harsh grating sound caused by abrasion of the pericardial surfaces during the cardiac cycle?

friction rub

When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?

Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix.

The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient?

Semi-Fowler's

Which is an effect of aging on upper and lower urinary tract function?

Susceptibility to develop hypernatremia

Which information should be included in the teaching plan for a client receiving glargine, which is "peakless" basal insulin?

Do not mix with other insulins.

A nurse is performing an otoscopic examination on a client. Which finding would the nurse document as abnormal?

External auditory canal erythema

After completing a skin assessment of an older adult patient, the nurse documents evidence of lentigines, which indicate which of the following?

Freckles

The nurse identifies a potential collaborative problem of electrolyte imbalance for a client with severe acute pancreatitis. Which assessment finding alerts the nurse to an electrolyte imbalance associated with acute pancreatitis?

Muscle twitching and finger numbness

A client with nausea and vomiting is to receive an antiemetic that inhibits the vomiting center in the brain. Which of the following would the nurse expect the physician to order most likely?

Prochlorperazine (Compazine)

A client is admitted to the hospital with systolic left-sided heart failure. The nurse knows to look for which assessment finding for this client?

Pulmonary congestion

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?

Reinforcing dressings or applying pressure if bleeding is frank

The nurse is aware, when caring for patients with renal disease, that which substance made in the glomeruli directly controls blood pressure?

Renin

The nurse is instructing the client who was newly diagnosed with peptic ulcers. Which of the following diagnostic studies would the nurse anticipate reviewing with the client?

Serum antibodies for H. pylori

A nurse is in the cafeteria at work. A fellow worker at another table suddenly stands up, leans forward with hands crossed at the neck, and makes gasping noises. The nurse first

Stands behind the worker, who has hands across the neck

The nurse observes a patient in the progressive stage of shock with blood in the nasogastric tube and when connected to suction. What does the nurse understand could be occurring with this patient?

The patient has developed a stress ulcer that is bleeding.

A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs, the nurse notes edema, brown pigmentation in the gaiter area, pedal pulses, and a few irregularly shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with peripheral circulation. Which of the following does the nurse suspect?

Venous insufficiency

The nurse recognizes which change of the GI system is an age-related change?

weakened gag reflex