Reduction Risk

A client has burn injuries sustained from an electrical current. What are the interventions to follow until the client is transferred to the primary healthcare center

Leave the adherent clothing in place Wrap the client in a dry clean sheet Remove as much burned clothing as possible

A nurse is assessing a client with a history of marijuana use. Which long-term effects are associated with marijuana?

Lung cancer Emphysema Heart disease

A client with ascites is scheduled to have a paracentesis. What should the nurse include in the plan of care

Instruct the client to urinate before the procedure

The nurse is assessing a client's equilibrium to test his or her cerebellar function. The nurse finds that the client sways with his or her eyes closed. How should the nurse document this observation

Positive Romberg's sign

What instruction would the nurse be most likely to give a client with reduced sensory perception to prevent injury from scalding

Use a bath thermometer

A registered nurse writes a care plan for a client undergoing a renal scan. Which of the following interventions should the nurse include

Administering furosemide after initial imaging Inserting the peripheral intravenous (IV) catheter to give the radioisotope

A client is brought to the emergency department with chest pain. The client asks why an electrocardiogram (ECG) has been prescribed. What does the nurse explain that the ECG will do

Aid in detecting heart damage

The nurse is reviewing the laboratory reports of a group of elderly clients. Which client has an age-related impairment in thirst mechanism

167

When providing care for a client with a nasogastric (NG) tube, the nurse should take measures to prevent what serious complication

Aspiration Pneumonia

A nurse identifies premature ventricular complexes (PVCs) on a client's cardiac monitor. What does the nurse conclude that these complexes are a sign of

Cardiac irritability

A nurse is caring for a client with a T-tube after an open cholecystectomy. What specific action should the nurse include in the plan of care

Check the color of the stool

Which dietary changes does the nurse suggest for a client who has diarrhea associated with human immunodeficiency virus (HIV disease)? Select all that apply

Eat much less roughage Drink plenty of fluids between meals

Which instruction would be most beneficial for an aging African-American client with hypertension

Have a annual urinalysis

The nurse is caring for a client with Parkinson disease. Which is a priority nursing concern

Risk for injury related to gait disturbances

An older adult client who complains of difficulty breathing after a surgery is found to have decreased vital capacity on spirometry. Which nursing intervention should be performed in this situation

Teach them to cough and deep breath

After a 5-year-old child's tonsillectomy, the nurse notes that the child swallows frequently. What should the nurse conclude about the child's behavior

The child is bleeding from the surgical site

The registered nurse is teaching a nursing student about bulimia nervosa in adolescents. Which statement made by the nursing student indicates effective learning

The client experiences recurrent episodes of binge eating

As a nursing priority, the nurse avoids active external rewarming with heating devices because it is contraindicated due to rapid vasodilation. From which condition is the client suffering

The client is suffering from severe hypothermia

A client in the emergency department is diagnosed with atrial fibrillation. Initially the primary healthcare provider instructs the client to perform the Valsalva maneuver by holding the breath and bearing down. What should the nurse include in an explanation of how this may convert atrial fibrillation to a normal sinus rhythm

The vagus nerve is stimulated

What does the nurse instruct a client to do while performing McMurray's test

To flex, rotate, and extend the knees

A client has a tentative diagnosis of Hodgkin disease. How does the nurse expect the diagnosis to be confirmed

Lymph node biopsy

A client who had several episodes of chest pain is scheduled for an exercise electrocardiogram (ECG). Which explanation should the nurse include when teaching the client about this procedure

This is a noninvasive test to check your heart's response to physical activity

Which concentration of a client's serum calcium level will stimulate the release of parathyroid hormone

8.5 mg/dL (0.47 mmol/L

After reviewing the testosterone levels of four female clients, the nurse discovers an abnormal finding in one of the clients. Which client's finding is abnormal

90

A client is diagnosed with cancer of the stomach and is scheduled for a partial gastrectomy. The teaching on postoperative care provided by the nurse should cover what topic

Gastric suction

A registered nurse teaches a nursing student about routines followed during a physical examination to help ensure that important findings are not missed. Which statement by the nursing student indicates ineffective learning

I'll perform painful procedures at the beginning of the examination

Which instruction given by the nurse ensures good healing in a client recovering after surgical removal of the pituitary gland by endoscopic transnasal approach

Increase high-fiber food intake

A male client reports dysuria, nocturia, and difficulty starting the urinary stream. A cystoscopy and biopsy of the prostate gland have been scheduled. After the procedure the client reports an inability to void. Which action should the nurse take

Palpate above the pubic symphysis.

A client who sustained trauma to the chest as a result of an injury has chest tubes inserted and is attached to a closed chest drainage system. When caring for this client, what should the nurse do

Palpate the area around the tubes for crepitus

A client with a distal femoral shaft fracture is at risk for developing a fat embolus. The nurse knows to watch for what distinguishing sign that is unique to a fat embolus

Petechiae

An infant has noncommunicating hydrocephalus, and a ventriculoperitoneal shunt is inserted. What should the nurse do when caring for the infant during the initial postoperative period

Place the infant flat with the head on the unaffected side

The nurse observes the following pattern on a client's electrocardiogram (ECG) strip. What dysrhythmia does the nurse identify?

Premature ventricular complex

A nurse is caring for a client who had a kidney transplant. Which test is most important for the nurse to monitor to determine whether a client's newly transplanted kidney is working effectivelySerum creatinineSerum creatinine

Serum creatinine

What is most important for a nurse to monitor after a client has an endarterectomy in a lower extremity

Skin color

Which diagnostic study is used to determine a client's bone density

Standard x-ray

A pregnant woman continues consuming alcohol during pregnancy. Which teratogenic effects might be seen in the fetus or neonate

Still birth spontanios abortion Intellectual disabilities

The electronic fetal monitor displays contractions every 2 minutes and lasting 95 seconds. What is the nurse's highest priority intervention at this time

Stop the Pitocin (oxytocin) infusion

Why does the nurse teach the parents of a young child with type 1 diabetes how to test the child's urine at home during periods of stress or illness, even though blood glucose testing is being done four times a day

Urine should be tested for acetone during illness and when the blood glucose level is increased

What are the considerations for bariatric surgery in an adolescent

Attainment of physical maturity Failed attempt at weight loss for at least six months Ability to give informed consent to surgical treatment

A nurse performs preoperative teaching for a client who is to have cataract surgery. Which is most important for the nurse to include concerning what the client should do after surgery

Avoid bending from the waist

A client is admitted to the hospital with an altered level of consciousness. When assessing this client the nurse understands that level of consciousness extends along a continuum. Place the following words that describe level of consciousness in order from the most alert to the least alert

1. Alert 2. Confused 3. Lethargic 4. Obtunded

After a partial gastrectomy is performed, a client is returned from the postanesthesia care unit to the surgical unit with an intravenous (IV) solution infusing and a nasogastric tube in place. The nurse identifies that there is no nasogastric drainage for 30 minutes. There is a prescription for instillation of the nasogastric tube as needed. What should the nurse instill, and what is the procedure that follows

30 mL of normal saline, then continue the suction

A client who was in an automobile accident is admitted to the hospital with multiple injuries. Approximately 14 hours after admission, the client begins to experience signs and symptoms of withdrawal from alcohol. Which signs and symptoms should the nurse connect to alcohol withdrawal

Anxiety Diaphroresis Psychomotor agitation

To determine the status of a client's carotid pulse, where should the nurse palpate The options were Below the mandible the lateral neck region near the clavicle at the anterior neck lateral to the trachea

At the anterior neck, lateral to the trachea Correct answer not what it says on googleLaboratory EHS: Saxton Question of the Week - Elsevier Health www3.us.elsevierhealth.com/cgi-bin/Mosby/CDOnline/Saxton/Question?17 Question of the Week. To determine the status of a client's carotid pulse, the nurse should palpate: In the lateral neck region; Immediately below the mandible

The nurse suspects metastasis in a client with stage I seminoma that has just undergone biopsy. Which test is most appropriate for detecting the spread of cells in this client

Computed tomography

Within 4 to 6 hours after a client has a myocardial infarction, the nurse expects which blood level to increase

Creatine kinase-MB band (CK-MB)

A client with the diagnosis of ulcerative colitis has surgery for the creation of an ileostomy. Postoperatively, for which potential life-threatening complication should the nurse assess the clien

Electrolyte imbalances

What action should be included in the nursing care of an infant with increased intracranial pressure

Elevating the head higher than the hips

A client returns to the unit fully awake after a bronchoscopy and biopsy. Which action is priority

Evaluate the presence of a gag reflex

A school-aged child admitted to the hospital with a diagnosis of status asthmaticus appears to be improving. What is the most objective way for the nurse to evaluate the child's response to therapy

Evaluating the child's peak expiratory flow rate

Although the nurse is unable to identify any obvious signs or symptoms of bleeding, a client repeatedly has tested positive for occult blood in the stool. Which laboratory result is a concern considering this client's history

Hemoglobin level 8.5 g/dL (85 mmol/L)

A blood transfusion of packed cells has been prescribed for a client. The transfusion started 5 minutes ago, and the client is complaining of chest pain, nausea, difficulty breathing, and chills. The blood pressure has dropped from 140/88 to 110/60 mm Hg, temperature is 99.2° F (37.3° C), and the client seems less alert. What should the nurse suspect

Hemolytic reaction

A client complains of difficulty breathing. The nurse auscultates wheezing in the anterior bilateral upper lobes. What could be the possible reason for this sound?

High velocity airflow through an obstructed airway

A nurse is teaching a group of healthcare workers about the prevention of human immunodeficiency virus (HIV) transmission by healthcare workers. Which statements made by a healthcare worker indicate the need for the further teaching

I should never re-use equipment used in invasive procedures If I am infected with HIV, I am restricted from practice of non-exposure-prone procedures

The primary healthcare provider is preparing to instill medication into the pleural space via thoracentesis. Which interventions does the nurse consider to be appropriate when performing a thoracentesis

Verify breath sounds Encourage deep breaths Ensure a chest x-ray is performed after the procedure.

While assessing a knee injury, the nurse asks the client to flex the knee to 30 degrees, pulling the tibia forward while the femur is stabilized. Which test is the nurse performing

Lachman's test

Two days after delivery a client has a temperature of 101° F (38.3° C), general malaise, anorexia, and chills. Which clinical finding does the nurse expect to identify on the client's laboratory report

Increased white blood cell (WBC) count

Early in the ninth month of pregnancy a client experiences painless vaginal bleeding and is admitted to the hospital. What should the client's plan of care include

Placing the client in the semi-Fowler position to increase cervical pressure

The nurse identifies a decrease in serum sodium when reviewing the laboratory reports of an older client with diarrhea. A decrease in which additional electrolyte is a cause for the greatest concern for this client

Potassium

The primary health care provider prescribes fludrocortisone to a client with adrenal gland hypofunction. What does the nurse instruct the client about this medication

Regularly monitor blood pressure

Which body system should the nurse focus on when assessing a client with suspected Goodpasture's syndrome

Renal

What should the nurse monitor for when caring for a postoperative client who presents with 180 mL of urine in the urinary drainage bag from the past 8 hours

Renal Failure

The nurse is caring for a client with hyperplasia of pituitary tissue. What would be the most appropriate goals of management? Select all that apply

To alleviate headache To eliminate visual disturbances To return hormone levels to normal

After gastric surgery a client has a nasogastric tube in place. What should the nurse do when caring for this client

Monitor for signs of electrolyte imbalance

A client with peripheral arterial insufficiency is scheduled for surgery. On admission, the client complains of discomfort and aches in the legs and feet. How should the nurse position the client's feet and legs

Place them dependent to the torso

A client with a rigid and painful abdomen is diagnosed with a perforated peptic ulcer. A nasogastric tube is inserted, and surgery is scheduled. Before surgery, the nurse should place the client in what position

Semi-Fowler

In her 37th week of gestation, a client with type 1 diabetes has undergone an amniocentesis to determine fetal lung maturity. The lecithin/sphingomyelin ratio is 2:1, phosphatidylglycerol is present, and creatinine is 2 mg/dL (180 mcmol/L). What conclusion should the nurse draw from this information

The new born should be free of respiratory problems

The nurse is placing a short peripheral venous catheter. What would be the best nursing practice for client safety and quality of care?

The nurse should choose a distal site The nurse should not use the arm on the side of a mastectomy. The nurse should choose a vein of appropriate length and width to fit the catheter's size

A nurse is caring for a 9-month-old infant who has been admitted to the pediatric unit with a tentative diagnosis of meningitis. A lumbar puncture is performed. What does the nurse explain to the parents is the primary reason this procedure is performed

To determine the causative agent

A client with painful swelling of a distal joint of the ring finger is found to be in the early stages of rheumatoid arthritis (RA). A test for the rheumatoid factor is negative. The client asks about the reliability of the test, stating, "I don't think the result is accurate. I have been diagnosed with RA, and I am in so much pain." How should the nurse respond

tests often are negative in the early stages of the disease

What care should be provided to a client who is scheduled to undergo surgery for hyperaldosteronism

Administer spironolactone

A client with type 1 diabetes has an above-the-knee amputation because of severe lower extremity arterial disease. What is the nurse's primary responsibility two days after surgery when preparing the client to eat dinner

Checking the client's serum glucose level

The nurse assesses the vaginal pH of four clients in the obstetrics unit. Which client has normal pH?

Client A with pH of 4.2

The parents of a toddler with a right ventriculoperitoneal (VP) shunt for the treatment of hydrocephalus are taught about postoperative positioning. The nurse concludes that they understand the teaching when they state that they will place the infant in what position

Flat on the left side with the head and back supported

What principle must a nurse consider when caring for a client with a closed wound drainage system

Fluids flow from an area of higher pressure to one of lower pressure

A nurse is caring for a preschooler in the immediate postoperative period after a tonsillectomy. What should the nurse encourage the parents to offer the child

Ginger ale

During a yearly physical examination a complete blood count (CBC) is performed to determine a client's hematologic status. Which laboratory result will the nurse check

Hemoglobin (Hb)

When checking a newborn's reflexes, the nurse is unable to elicit one specific reflex response. This is not uncommon in neonates born vaginally in the breech presentation. How should the nurse attempt to elicit this response

Holding the infant in the upright position while pressing the feet flat on the crib mattress

While assessing a client's range of motion, the nurse explains adduction to the nursing student. Which statement made by the nursing student indicates effective learning

I will ask the client to move his or her arm towards the body

A client at 26 weeks' gestation arrives at the clinic for her scheduled examination. Her blood pressure is 150/86 mm Hg. She tells the nurse that she has gained 5 lb (2.3 kg) in the last 2 weeks. What is the priority nursing action

Testing the client's urine for albumin

Six hours after a femoropopliteal bypass graft, the client's blood pressure becomes severely elevated. What is the primary reason the nurse notifies the surgeon

The client's intraarterial pressure may compromise the graft's viability

A pregnant woman was exposed to a teratogenic drug during her first trimester. Which nursing interventions would be beneficial to the client? Select all that apply

The woman should be referred for evaluation The woman should be educated about the risks of drug-induced malformations The woman should be assured that the risk is minimal if the malformation is minor

A client is admitted with the diagnosis of possible myocardial infarction, and a series of diagnostic tests are prescribed. Which blood level should the nurse expect will increase first if this client has had a myocardial infarction

Troponin T (cTnT)

A 7-year-old child loses consciousness a few days after a traumatic head injury that resulted in a subdural hematoma. While assessing extraocular movements, the nurse notes that the child is displaying the oculocephalic reflex. What does the nurse conclude about the presence of the oculocephalic reflex in an unconscious child

Expected