Prepu: Chapter 73: (Beta) Next Generation - NGN

The nurse is caring for a 24-year-old female client with a right tibial fracture treated with a cast 2 hours ago. The client now reports unrelenting pain, rated as 7/10, despite taking oxycodone, and decreased sensation in the right foot. A nursing assessment reveals the right foot is cooler and paler than the left foot, with delayed capillary refill and a weak pulse. Complete the following sentence by choosing from the lists of options.

Based on the nursing assessment, the priority action the nurse should take is to notify the orthopedic health care provider immediately and prepare the client for bivalving of the cast

A client is receiving enteral therapy following gastric surgery. To maintain fluid balance and minimize any gastrointestinal symptoms such as cramping, diarrhea, and/or nausea, the nurse should follow appropriate enteral therapy protocols. For each intervention, click to specify if the action should be included in the plan of care to improve outcomes for fluid balance or improvement of gastrointestinal symptoms. If the action should not be included in the plan of care for either outcome, note as not indicated. Each intervention may be included for more than 1 outcome.

Fluid Balance: Administer fluids at room temperature. Maintain semi-Fowler position during and following feeding for at least 1 hour. Monitor water intake used to flush tubing. Monitor daily weights. Gastrointestinal: Administer fluids at room temperature. Maintain semi-Fowler position during and following feeding for at least 1 hour. Monitor water intake used to flush tubing. Monitor bowel sounds. Not Indicated: Increase the rate of enteral fluids. Administer bolus feeding.

The nurse on a telemetry unit is caring for a 54-year-old male client, admitted with chest pain, who has an arteriovenous (AV) fistula in the left arm for hemodialysis secondary to chronic kidney disease. For each intervention, click to specify if the intervention is indicated or contraindicated for this client.

Indicated: Auscultate for a bruit over AV fistula every 8 hours Assess for redness, swelling, and drainage at AV fistula site. Palpate for a thrill over the AV fistula every 8 hours. Contraindicated: Take blood pressure readings in the left arm. Use AV fistula site to draw blood. Wrap the AV fistula site in the left arm with a compression dressing.

A nurse is caring for a team of clients, each with an orthopedic injury. Click to indicate which interventions are included in a plan of care between the different orthopedic repairs. For each intervention, click to specify if the action is taken for clients with an internal fixaction device and/or with an external fixation device. Each intervention may support more than 1 type of device.

Internal Fixation Device: Administer nonopioid analgesics as needed. Administer prescribed antibiotic. Provide assistance with physical therapy. Encourage isometric and muscle-setting exercises. Encourage performance of activities of daily living. Bear weight as determined by the surgeon. External Fixation Device: Administer nonopioid analgesics as needed. Administer prescribed antibiotic. Complete pin care per prescribed guidelines. Provide assistance with physical therapy. Encourage isometric and muscle-setting exercises. Encourage performance of activities of daily living.

The nurse collects data related to cultural beliefs as part of the comprehensive assessment process for a client admitted for the treatment of newly diagnosed type 2 diabetes mellitus (DM). The nurse is asking about cultural beliefs. Complete the table of cultural beliefs by choosing the best question from each list of options.

"How do you usually respond when asked a question?" "How close do you stand to a family member when asking a question?" "What is your role in your family?"

The nurse is preparing to administer medication to a client who has been diagnosed with glaucoma. Which information should the nurse include related to client teaching for each of the identified medications? Complete the following table by choosing from the list of options.

"Use safety measures in dim lighting." "It can cause hypotension." "Have your electrolyte levels monitored."

The nurse is collaborating with the health care provider on a plan of care for a 54-year-old male client with osteomyelitis of the left femur secondary to uncontrolled type 1 diabetes. Click to highlight the prescriptions for care that the nurse should anticipate for this client.

*Perform neurovascular checks of lower extremities every 8 hours. *Administer IV antibiotic based on culture and sensitivity report. *Administer ibuprofen 400 mg orally three times daily, as needed for pain. *Make referral to dietitian to discuss nutrition for healing and blood glucose control. *Provide education on self-blood glucose monitoring and insulin administration.

The emergency nurse is preparing to triage a group of four clients who have presented to the emergency department (ED) and arrived at the same time. For each client, determine based on the system of triage if the client requires immediate intervention or can wait to be seen.

Requires Immediate Intervention: 46-year-old male client who presents with suspected broken leg as a result of motor vehicle crash (MVC) 22-year-old female client who presents with left quadrant abdominal pain and moderate vaginal bleeding with clots 52-year-old female client who presents with severe back pain of recent onset Can Wait to Be Seen: 25-year-old male client who presents with a small laceration on the left upper arm

The community health nurse is assessing the risk factors for osteoporosis in a female client at a health fair. For each assessment finding, click to specify if the finding is a risk factor for osteoporosis or is not a risk factor for osteoporosis.

Risk Factor for Osteoporosis: 66 years of age Asian heritage postmenopausal status takes fluticasone inhaler for asthma Not a Risk Factor for Osteoporosis: large frame Nonsmoker alcohol intake of 3 drinks/week walks 2 miles, 3 days/week

The nurse plans care for a client who is diagnosed with atopic dermatitis. For each teaching point, click to specify if the instruction addresses skin hydration or itchy skin. Each teaching point may address more than 1 condition.

Skin Hydration: Use an emollient containing glycerol on the skin after bathing. Itchy Skin: Use an emollient containing glycerol on the skin after bathing. Take short showers using a mild soap for cleansing. Wear cotton fabric. Wash clothes using a mild detergent. Take an antihistamine before bed.

The nurse provides care for a client, with a history of atherosclerosis, who is hospitalized for the initiation of pharmacotherapy for the treatment of hypothyroidism. Complete the following sentence by choosing from the lists of options.

The client is at highest risk for developing cardiac dysfunction as evidenced by angina

The nurse provides care for a client who is critically ill due to a diagnosis of pneumonia and is at risk for developing shock. Assessment data reveals a white blood cell (WBC) count of 15 × 103 cells/mm3 (15 × 109/l) (normal: 4.5 to 10.5 × 103 cells/mm3 (4.5 to 10.5 × 109/l), a temperature of 102.2°F (39°C), and warm, flushed skin. Complete the following sentence by choosing from the lists of options.

The client is at the highest risk for developing septic shock as evidenced by altered mentation

The nurse in the oncology clinic is caring for a 42-year-old female client receiving chemotherapy with fludarabine for acute myeloid leukemia who has developed petechiae, epistaxis, and ecchymosis. Complete the following sentence by choosing from the lists of options.

The nurse anticipates that the client has developed hemorrhage and that the laboratory results will reveal thrombocytopenia

A nurse is assessing an older adult client who has returned for a follow-up visit after receiving medications related to the diagnosis of hypertension. The nurse prepares to evaluate the client's blood pressure. Drag words from the choices below to fill in each blank in the following sentence.

The nurse will ask the client to sit quietly for 5 minutes as to obtain an accurate measurement

The nurse is providing education to a 65-year-old female client with pneumococcal pneumonia being discharged from the health clinic on oral antibiotics. The client is a nonsmoker, takes levothyroxine for Hashimoto disease, and is otherwise in good health. For each client statement, click to specify if the finding indicates understanding or the need for reinforcement of the teaching.

Understanding: "I should get the PPSV23 this year because I got the PCV13 last year." "Sleeping with a humidifier can help loosen secretions." "I will seek medical attention if my cough worsens." "I will rest and avoid overexertion." Requires Reinforcement of Teaching: "I will take the antibiotics until the secretions clear up." "I will drink 1 liter of fluid each day." "A persistent or recurring fever is normal after starting antibiotics." "I will perform deep-breathing exercises once per day."

The nurse provides care for a client who is diagnosed with shock and who is at risk for multiple organ dysfunction syndrome (MODS). Complete the following sentence by choosing from the lists of options. Based on the first organ system that is typically affected by MODS, the nurse prioritizes monitoring the client for symptoms of

acute lung injury (ALI) as evidenced by shortness of breath

A nurse is assessing a client who is experiencing significant stress due to septicemia. Drag words from the choices below to fill in each blank in the following sentence.

administer oxygen therapy, monitor temperature, and obtain the lactate level

A 47-year-old male client presented to the medical unit and the health care team suspects tuberculosis (TB). The nurse is admitting the client to a reverse isolation room. QuantiFERON testing and chest x-ray are pending. Urinalysis results are negative. No other testing was performed prior to admission to isolation. The client denies any chest pain, shortness of breath (SOB), or respiratory difficulty. The client presents with productive yellow sputum. Complete the following sentence by choosing from the lists of options.

airborne precautions to prevent exposure and sputum to collect specimens for additional testing.

A client will undergo abdominal surgery. The nurse provides preoperative education regarding the importance of diaphragmatic breathing exercises to prevent postoperative complications. Drag words from the choices below to fill in each blank in the following sentence.

atelectasis, pneumonia, and bronchospasm

A nurse is reviewing the history of a client who has been admitted for a pressure injury. Click to highlight the findings that are risk factors associated with pressure injuries. A 74-year-old female client is admitted from the emergency department. The client arrived by ambulance. The client's adult son, the primary caregiver, accompanied the client. The client is bedridden due to a right-sided stroke sustained 6 months ago. The client lives with the adult son and the son's spouse. The family has 24-hour home care. The client is incontinent of urine and feces. Care is provided by home health assistants, who bath, feed, and provide companionship when the family is not available. The client is alertbut confused with time and place. The client refuses to eat most meals but will drink a high-calorie milkshake daily. The reason for the ambulance is that the client attempted to get out of bed and fell.

bedridden due to a right-sided stroke confused with time and place incontinent of urine and feces

A nurse is caring for a client. After review of the laboratory assessment, the nurse identifies that the potassium level is 6.2 mEq/l (6.2 mmol/l). Select the mechanism of action from each of the following medications.

calcium antagonizes the potassium in the heart alkalizes the plasma shifts potassium into the cells removal of potassium out out of the body

The office nurse is reviewing an 80-year-old female client's reports related to the onset of a severe headache, rated at 9 out of 10 on the pain scale, with recent onset. The client denies any visual changes. During a prior visit to the office a few months ago, the client had reported a ground-level fall as a result of falling off a chair and hitting the back of their head. The client had been taken to the emergency department, where imaging was performed with negative results. Complete the following sentence by choosing from the lists of options.

chronic subdural hematoma stroke and that computed tomography (CT) imaging of the brain

The nurse should determine the adult client's learning readiness by assessing

cultural identification personal values physical status emotions

The nurse assesses a client who is diagnosed with human immunodeficiency virus (HIV) for adverse reactions associated with the prescribed medication, abacavir. Drag words from the choices below to fill in each blank in the following sentence.

dyspnea, sore throat, cough

The nurse monitors a male client for symptoms of urethral strictures following a transurethral resection of the prostate (TURP) for the treatment of prostate cancer. Drag words from the choices below to fill in each blank in the following sentence.

dysuria, a weak urinary stream, straining

A nurse is caring for a client who was admitted with pain, tenderness, and rigidity of the upper right abdomen, suggesting a gall bladder issue. The client has also been experiencing nausea and vomiting for the past 3 days. The admitting service is planning for tests to be conducted in the morning. Complete the table of diagnostics by choosing from the list of implications for testing.

Cholesterol is elevated in biliary obstruction. It is used to visualize calculi in the gallbladder. The radioactive dye allows for visualization of the biliary tract.

The nurse plans care for a client who is newly diagnosed with Alzheimer disease (AD). For each nursing action, click to specify if the intervention is appropriate to address cognitive function, physical safety, or independence in self-care.

Cognitive Function: Ensure adequate lighting. Remove clutter from the environment. Use a bed alarm. Physical Safety: Limit environmental stimuli. Provide clear and simple explanations. Prominently display a clock. Independence in Self-Care: Initiate a referral with occupational therapy (OT). Allow the client to make simple choices with activities of daily living (ADLs). Provide adaptive equipment.

The nurse provides care for a 28-year-old female client experiencing an initial outbreak of herpes simplex virus 2 (HSV-2). Drag words from the choices below to fill in each blank in the following sentence.

Complications associated with HSV-2 applicable to the client's teaching plan developed by the nurse include neonatal transmission aseptic meningitis severe emotional stress

The nurse monitors a client for side effects associated with furosemide, which is newly prescribed for the treatment of heart failure. Complete the following sentence by choosing from the lists of options.

Due to the client's high risk for developing hypokalemia as a result of the prescribed medication, the nurse focuses on monitoring the client for ventricular arrhythmia

The community health nurse is preparing a teaching plan for a middle-aged client with hypertension, hypercholesterolemia, and obesity. For each of the health teachings provided by the nurse, click to specify whether the information is focused on health promotion or health maintenance.

Health Promotion Activities: Exercise for 45 minutes at least three times per week. Avoid cigarette smoking and alcohol use. Practice stress reduction techniques such as yoga or meditation. Health Maintenance Activities: Take medications as prescribed. Adhere to scheduled laboratory tests such as lipid profile, basic metabolic panel, and glucose tests.

The nurse plans care for a client who is newly diagnosed with peripheral artery disease (PAD). For each nursing action, click to specify if the intervention is appropriate to increase the arterial blood supply to the client's extremities or to promote vasodilation and prevent vascular compression.

Increase Arterial Blood Supply to the Extremities: Keep legs in a dependent position. Increase in physical activity each day. Promote Vasodilation and Prevent Vascular Compression: Wear warm clothing in the winter. Do not use of bicotine products. Avoid crossing the legs.

The nurse monitors the laboratory data for several clients who are diagnosed with hypoproliferative anemias. For each laboratory data, click to specify if the finding indicates microcytic anemia or megaloblastic anemia.

Microcytic Anemia: decreased mean corpuscular volume (MCV) decreased reticulocytes increased total iron-binding capacity (TIBC) Megaloblastic Anemia: increased mean corpuscular volume (MCV) decreased vitamin B12 decreased folate

The nurse plans care for a client who was admitted for the treatment of a gastrointestinal (GI) bleed due to cirrhosis of the liver. Complete the table of nursing concerns by choosing from the list of options.

Monitor the client for symptoms of anxiety. Perform range-of-motion exercises every 4 hours. Keep the environment warm and draft free.

The nurse has documented an assessment on a 45-year-old male client on the third postoperative day following an open abdominal appendectomy. Click to highlight the assessment findings that will require follow up. Client has 3 in (7.6 cm) right lower abdominal incision. Proximal 2 in (5 cm) of incision edges are red and well-approximated. Distal portion of incision has separated and has yellow drainage on dressing. Bulb drain has serosanguinous drainage and clumps of yellow pus.Oxygen saturation on room air 97%. Blood pressure, 112/60 mm Hg; heart rate, 102 beats/min; respiratory rate, 22 breaths/min; temperature, 101.2°F (38.4°C) orally.Denies chills. Bowel sounds hypoactive in all 4 quadrants. . Client reports passing flatus, no Abdomen firm and slightly distendedbowel movement. Lungs clear to auscultation bilaterally. Client reports incisional pain level of 3/10red blood cell count 4.2 million/mcl (4.2 x 10¹²/l)thirty (30) minutes following oxycodone 5 mg orally. Reports an increased, but tolerable, level of pain while performing cough and deep-breathing exercises while splinting incision. Reports minimal pain on abdominal palpation. White blood count 12.9 x 103 cells/mm3 (12.9 x 109 /l), , hemoglobin 14 g/dl (140 g/l), blood glucose level 130 mg/dl (7.21 mmol/l).

has separated and has yellow drainage on dressing. clumps of yellow pus. 102 beats/min; respiratory rate, 22 breaths/min; temperature, 101.2°F (38.4°C) orally. White blood count 12.9 x 103 cells/mm3 (12.9 x 109 /l) blood glucose level 130 mg/dl (7.21 mmol/l).

A nurse is assessing a client who is experiencing significant stress due to septicemia. Drag words from the choices below to fill in each blank in the following sentence.

obtain the lactate level, administer oxygen therapy, and monitor temperature

The nurse assesses a client who has a nasogastric tube for long-term nutritional needs for complications associated with the medical device. Complete the following sentence by choosing from the lists of options.

purulent nasal drainage , a finding indicative of rhinosinusitis

The nurse is assessing a 78-year-old female client admitted with a stroke of recent onset within 2 hours of admission. Vital signs: blood pressure, 150/90 mm Hg; pulse rate, 112 beats/min; respiratory rate, 20 breaths/min; temperature, 100.4°F (38.0°C); pulse oximetry reading, 96% on room air. Audible murmur heard upon auscultation. Client is awake but somewhat lethargic and cannot respond to questions. Exhibiting neurologic deficits and impaired mobility of the left side of the body. The client is being evaluated for tissue plasminogen activator (t-PA) therapy. For each assessment parameter, indicate whether the result indicates that t-PA can be utilized.

t-PA Therapy Indicated: blood pressure reading computed tomograph confirmation of ischemic stroke NIH Stroke Scale/Score (NIHSS) result of 17 t-PA Therapy Not Indicated: international normalized ratio (INR) result of 2.0 heart murmur

The nurse provides care for a client who is prescribed bladder retraining following urinary catheterization. Complete the following sentence by choosing from the lists of options. The nurse should first ask the client to

urinate bladder scan