V3 exit HESI
The nurses preparing a dose of 60 MCG of Leriparatide. The medication is labelled 750 MCG/2 .4 ML. how many ML should the nurse administer enter numerical value only if rounding is required, round to the nearest 10th.
0.2
A client who weighs 176 pounds receives a prescription for enoxaparin sodium 1.5 mg/kg/day subcutaneo: available in 120 mg/0.8 mL. prefilled syringe. How many mL. should the nurse administer?
0.8
an adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department with full thickness burns to all surfaces of both lower extremities. What percentage of body surface area should the nurse document In the electronic medical record?
36%
The charge nurse is planning for the shift and has a registered nurse (RN) and a practical nurse (PN) on the team. Which client should the charge nurse assign to the RN?
A 30-year-old depressed client who admits to suicide ideation. A client who is suicidal requires psychological assessment, therapeutic communication, and knowledge beyond the educational level of a practical nurse (PN).
The daughter of an older woman who has Parkinson's disease, calls the clinic and reports that her mother has been confused for the past week. Which action(s) should the nurse take? (Select all (hat apply.)
A Determine if the mother has recently experienced a fall. C Ask If the mother is experiencing any pain with urination. D Instruct the daughter to check her mother's temperature.
An older adult with a terminal lines is receiving hospice care and is having difficulty coping with feelings related to death and dying Which interventions) should the nurse include in This client's plan of care select all apply
A Encourage family to visit frequently. Teach client how to use guided Imagery. Encourage family to bring the diet old photographs
An older client admitted for observation following a fall while getting out of the bath tub becomes increasingly confused. Tho family arrives with the home medication list and tho clinton's healthcare power of attorney. When providing a report to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse Provide 1st?
A Increasing confusion of the client. The nurse should report the increase in the dient's confusion first. The change in the client's cognitive describes the current situation and the reason for contacting the healthcare provider.
The nurse is reviewing lab work and nurses' notes to determine which actions to take at this time. Which actions are appropriate for the nurse to take at this time? Select all that apply.
A Keep infant In warmer with bilirubin lights to maintain temperature of 97.6° B Inform the mother that the baby is stable enough to take out of the warmer D Explain to the mother that the baby's respiratory rate needs to be below 60 1 E Observe for signs of respiratory distress and monitor oxygenation by pulse c
A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus, and tells the nurse the quarter is supposed to fix her child's hernia. Which explanation should tho nurse provide
Acthis hernia as a normal variation that resolves without treatment
when conducting an admission assessment, the nurse notes that an adult female client has developed to new allergies since her last admission. The client describes herself as lactose intolerance and states that she is unable to eat eggs. Which interventions should the nurse implement? Select all that apply
Add egg allergy to dient's identification arm band. Atth dento describe her reaction to milk and eggs Enter new allergy Inform at on In the clients electronic medical record notify the dietary department of the client egg tolerance
Which environmental factor is most significant when planning care for a client with osteomalaysia?
Adequate sunlight
the nurse obtains a prescription to perform a straight catheterization, After inserting the cathotor, the nurse observes that the client has an immediate output of 500 ml. of clear yellow urine. Which action should the nurse implomontinext?
Allow the bladder to empty completely or up to 1 000 ml of urine.
The psychiatric nurse is caring for dints on an adolescent unit. Which client requires the nurse's immediate attontion?
An 18-year-old client with antisocial behaviour who is being yelled at by other clients.
At the end of a preoperative teaching session on pain managomont techniques, a client starts to cry and states, "I just know I can't handle all the pain." Which is the priority nursing problem for this client?
Anxiety.
A client with obstructive sleep apnea (OSA) ambulates in the hallway with the nurse prior to bedtime and then returns to bed. Which intervention is most important for the nurse to implement before leaving the client?
Apply the client's positive alrway pressure device.
A female client with Fibromyalgia ask the nurse to arrange for hospice care to help her manage the saviour, chronic pain. Which intervention should the nurse provide to address the clients problem?
Arrange an appointment with a pain specialist
What nursing intervention is particularly indicated for the second stage of labour?
Assisting the client to push effectively so that expulsion of the fetus can be achieved
The nurse is assigning care of a client with prostatitis to a practical nurse (PN). Which instruction should the nurse provide the PN regarding care of this client?
Avoid urinary catheterization.
.To start the client on oxygen as ordered, what should the nurse collect from the supply room? Select all that apply.
B Nasal cannula C Lamb's wool D Humidifier bottle F Sterile water G Flowmeter
An older client with a history of cataracts is recovering from intraocular lens implant (/OL) surgery to the left eye. During the post- procedure period, which intervention should the nurse implement?
C Provide an eye shield to be worn while sleeping.
When assessing a multi gravida on the first postpartum day, the nurse points a moderate amount of Lochia rubra, with the uterus from Kama and three finger Bretts above the umbilicus. What action should the nurse implement first?
Check for distended bladder
A male client is admitted for the removal of an internal fixation device that was insorted for a fractured ankle. During the client's admission history, he tells the nurse that he recently received vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which action(s) should the nurse take? (Select all that apply.)
Collect multiple site screening cultures for MRSA. Place the client on contact transmission precautions. Continue to monitor the client for signs of an infection.
The nurse is providing lifestyle change education for your client to slow the progression of coronary artery disease which statements made by the client should the nurse recognise as needing additional education select all that apply
Consume foods with saturated fats Eat more canned vegetables.
A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose?
Current diagnosis of hepatitis B.
The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include?
Ensure that the infant's crib mattress is firm.
A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness and fatigue. Which lab test should the nurse monitor?
Hemoglobin
A 46-year-old male client who had a myocardial infarction (MI) 24-hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behaviour, which client problem should the nurse include in the plan of care?
Ineffective coping related to denial.
What medication should the nurse suggest in the recommendations section of their SBAR report?
Inhaled cromolyn Intravenous dexamethasone Nebulized ipratroplum A pediatric client experiencing an acute asthma exacerbation in an emergency setting needs supplemental oxygen, a short-acting bronchodilator, a systemic glucocorticoid, and inhaled Ipratropium
What action should the school nurse implement to provide secondary prevention for school-aged children?
Initiate a hearing and vision screening program for first graders
.A client is being urgently transported to radiology for a Computerised Tomography (CT scan) after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the nurse to take?
Keen chest tube container below the site of Insertion
Which oral medication can the nurse safely cut in half?
Line in the middle
The nurse is teaching an older client about the prevention of osteoporosis. Which foods should the nurse recommend to the client to increase in the diet?
Low fat dairy products.
Which nursing Intervention is most important for the nurse to include in the plan of care for a client with alcohol withdrawal delirium?
Maintain a quite , non-stimulating environment.
Which intervention is most important for the nurse to include in the plan of care for your client who is 12 hours post thyroidectomy?
Maintain a semi flower position
A client with cancer develops tumour lysis syndrome following chemotherapy. Which nursing action has the highest priority in responding to the symptoms of this syndrome?
Maintain intravenous therapy
Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress
Measure BP, encourage the client to drink, dehydration, urine output, capillary refill
The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection? Reference Range White Blood Cell (WBC) [Reference Range: 5000-10,000/mm° (5-10 x 109/L)]
Moderate amount of foul-smelling lochia
Glucose level immediately after birth and then at 30 min, 1 hour, 2 hours, 4 hours, 8 and 12 hours and if symptoms suggest hypoglycemla. • Breastfeed Immediately once stable, then on demand. If unstable, may feed breast milk via orogastric tube. • If two feeding attempts fall to increase the glucose levels or if symptoms of hypoglycemia develop, apply dextrose (sugar) gel Inside the baby's cheek. • If the above are ineffective, IV glucose should be administered to maintain glucose levels above 45 mg/dL (2.5 mmol/L).
Monitor for Respiratory distress, contact respiratory therapy for ABG and oxygen therapy, blood glucose level, keep in warmer with Bilirubin lights, monitor temperature every 30 minutes, feed immediately
The nurse is caring for a client with a fractured femur. Following removal of traction and the application of a full-leg cast, which action should the nurse prioritize?
Neurovascular checks.
An unlicensed assistive personal lives the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UAP behavior place the action in the order from first on top to last on the bottom
Note date and time of the behaviour discuss the issue privately with the UAP plan for scheduled break times evaluate the UNP for signs of improvement
A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention(s) should the nurse implement? (Select all that apply.)
Note signs of swelling and edera. Report serum albumin and globulin levels, Monitor abdominal girth.
Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?
Observe insertion site.
A client is admitted to the hospital after experiencing a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding?
Persistent coughing while drinking
.The nurse is planning to assess a client's oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client has bilateral below-the-knee amputations and radial pulses that are weak and thready. Which action should the nurse take?
Place the oximeter clip on the earlobe to obtain the oxygen saturation reading.
.A client with pancreatitis complains of severe epigastric pain, so the nurse administers a prescribed narcotic analgesic. Ten minutes later, the client insists on sitting up and leaning forward. Which intervention should the nurse implement?
Position bedside table so the client can lean across It.
The nurse on a pediatric unit observes a distraught mother in the hallway scolding her three-year-old son for beating his fans. What in shell action should the nurse take?
Provide disposable training parents while calming the mother
The client is an 81-year-old female who is in the hospital for treatment of a blood clot. She has a history of Type 2 diabetes mellitus and takes metformin. She is active at home and performs activities of dally living Independently but has required assistance from her son for the last couple of weeks due to weakness and fatigue. Review H and P, and nurse's note. Complete the diagram by dragging from the choices area to specify which condition the client Is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the clients progress
Provide skin care, secure the call Bell saw it is within reach, functional in continents, skin integrity, mobility
Five days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspects that the client may have had a pulmonary embolus. Which action should the nurse take first?
Provide supplemental oxygen
The nurse is preparing a 50 mL dose of 50% Dextrose IV for a client with insulin shock. How should the nurse administer the medication?
Push the undiluted Dextrose slowly through the currently infusing IV.
A client who is newly diagnosed with type two diabetes mellitus receives a prescription for metformin 500 mg po twice Daily. which information should the nurse include in these clients teaching plan select all that apply
Recognize signs and symptoms of hypoglycemia. Report persistent polyuria to the healthcare provider. Take metformin with the morning and evening meal.
The nurse is performing a routine assessment of an IV site for a client receiving both IV fluids and medications through the line. The cliont reports tenderness when the nurse touches the arm above the site. Which finding should the nurse expect which will require immediate intervention?
Red streak tracking the vein
the nurse caring for a client on the first day postoperative for a descending aortic aneurysm repair. Which assessment should the nurse prioritise reporting to the healthcare provider?
Reference Range Potassium (Réference Range: 3.5 to.5 mEg/L (3.5 to 5 mmol.)) B Electrocardiogram ST segment elevation.
The nurse is preparing a 4-day-old infant with a sorum bilirubin level of 19 mg/di (325 Mcmol/L) for discharge from the hospital. When teaching the parents about home phototherapy, which instruction should the nurse include in the discharge teaching plan? Reference Range Total Bilirubin (Reference Rango: Newborn:0.1 to 10.5 mg/dL (1.7 to 180 McmolL)) sow ailaiator
Reposition the infant every 2 hours.
The client Is a 49-year-old who reports flu-like symptoms Including fever and chest congestion for 4 days. He came to the emergency department (ED) last night when he was having more difficulty breathing. He has a history of one-half pack a day cigarette smoking for 20 years. He has no significant medical or surgical history.
Respiratory oxygen saturation 90% respiratory rate 28 BPM Neurological anxious restless Cardiovascular BP 145/89 MMHG heart rate 101 BPM
A client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) donning gloves and a gown to assist the client. Which action should the nurse take?
Review the need for the UAP to wear a face mask while in close contact with the client.
The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection indicate to the nurse that the client understands the prescribed diet?
Roasted turkey, canned vegetables.
What other medications would the nurse expect the surgeon to prescribe along with Martin? Select all that apply
Senna Naloxone Ibuprofen Docusate sodium
A client is receiving lactulose for signs of hepatic encephalopathy. To evaluate the client's therapeutic response to this medication, which assessment should the nurse obtain?
Serum electrolytes.
An adult client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the healthcare provider? Blood alcohol Level (Referenco Rango: O to 10 9 mmol/L (0% to 0.05%)) Lithium [Reference Range: 0.8 to 1.2 mEg/L or 0.8 to 1.2 mmoiL)
Serum lithium level of 1.6 mEg/L (1.6 mmolL).
Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD)?
Serum potassium, calcium, and phosphorus.
Night when he was having more difficulty breathing. He has a history of one half back a day cigarette smoking for 20 years. He has no significant medical or surgical history
The client should take a 1 to 2 minute break from the facemask each hour 2 I should put gauze under the elastic straps over the earlobe I can adjust Da oxygen level on the flow metre to keep the client oxygen saturation greater than 94% one, I should clean the face mask once per shift I should please The mask first over the nose under cover the mouth one The mask should cover only the mouth and leave the nose open for expiration2
A client with description of prescription for *do not resuscitate* (DNR) begins to manifest signs of Impending death. After notifying the family of the counts status, what priority action should the nurse implement?
The client's need for medication should be determined.
What are the 3 most Important goals that would help the nurse evaluate the treatment of this client at discharge?
The dient will remain free of skin breakdown The client will maintaln oxygen saturation of 96% without supplemental ox The client will be afebrile for 24 hours The most important goals for a client with hypoxia related to pneumonia to achieve by discharge are to remain free of skin breakdown related to the devices that deliver oxygen, to wean the oxygen off and maintain appropriate oxygen saturation levels, and to be afebrile.
Whilo caring for a toddler receiving oxygen via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement?
Use a water soluble lubricant on affected oral and nasal mucosa.
A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?
Withhold this dose.
.while making rounds, charge nurse notices that a young adult client with asthma who was admitted Esther day he sitting on the side of the bed and loaning over the bedside table the client is currently receiving oxygen at 2 L per minute via Nasal Cannula the client please wheezing and is Pursed-lip Breathing. which intervention should the nurse implement?
administer a nebuliser treatment
During the conversation with the client, the nurse documents a statement by the client about wishing she had died in the crash. Choose the most likely options for the information missing from the statement by selecting from the list of options provided.
client represents suicidal Ideation and should be followed up with an assessment of risk factors for sulcide
The nurse is caring for your client with the sexually transmitted infection syphilis. The client reports having sex with someone who had many partners. Which response should the nurse provide?
remain non judgemental and assure the client of confidentiality
The client is a 26-year-old female who was in a car accident 6 months ago that killed her mother, husband, and 2-year-old son. She and her father were the only survivors of the crash. She is seeking care for depression
she only gets 2-3 hours of sleep due to nightmares about the crash . She feels that she is "jumpy" after the accident, especially when she is in the car. I feel so sad that I can't seem to feel anything at all.
A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?
Measure urinary output every hour.
The charge nurse places if all precautions sign on the clients door. What side-effects of morphine could contribute to this client's wall risk select all that apply
Morphine is a central nervous system depressant and causes vessel dilation. Common side effects are orthostatic hypotension and sedation, which increases the client's risk of falls. Urinary retention may give the client a sense of bladder fullness and urgency to use the restroom.
The nurse is discussing the clients pain management with a student nurse. Choose the most likely options for the information missing from the statements by selecting from the list of options provided
Morphine is pure opioid agonist and it activates my receptors and is used to relieve acute postop pain
The client Is a 49-year old who reports flu-like symptoms including fever and chest congestion for 4 days. He came to the emergency department (ED) last night when he was having more difficulty breathing. He has a history of one-half pack a day cigarette smoking for 20 years. He has no significant medical or surgical history. What 2 orders should the nurse complete first?
Place the client on a cardiorespiratory monitor Start oxygen 3 L vla nasal cannula
The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?
Practice using muscle relaxation techniques.
A male client admitted with chronic pulmonary obstruction disease (COPD) exacerbation is receiving assisted ventilation with continuous positive airway pressure (PAP). His vital signs are: temperature 98.8 °F (37.1 °C), heart rate 118 beats/minute, respirations 46 breaths/minute, blood pressure 176/92 mmH. While completing the pulmonary assessment, his oxygen saturation reading is 78% and he is difficult to arouse. Which action should the nurse implement?
Prepare for rapid sequence Intubation.
Day 1 1800: The client Is a female neonate born at 37 weeks of gestation to a G 2 P 1 mother, who was diagnosed with gestational dlabetes. Following a spontaneous vaginal birth, she received Apgar scores of 7 at 1 min and 8 at 5 min. The client weighs 4036.97 g (8 Ibs. 9 oz) and appears pink with acrocyanosis and a moderate amount of subcutaneous fat. She is noted to be slightly jittery at 30 min of age. Axillary temperature 96° F (35.6° C), pulse 140, respiratory rate 80. Blood glucose 35 mg/dL (1.9 mmol/L), bilirubin level 7 mg/dL (119.73 umol/L). Fontanelles soft, Mongolian spot noted on lower back, Ballard maturity rating 37 weeks.
Proactive lactation management, strategies, support, and follow-up for late-preterm infants and some early term infants are important components that affect breastfeeding success. Prophylactic phototherapy is often used in preterm infants to prevent a significant increase in serum bilirubin levels. It is also recommended that healthy late-preterm and term infants (23S weeks of gestation) receive follow-up care and assessment of bilirubin within 3 days of discharge. Late preterm infants of a diabetic mother need to be monitored more closely. Parents are taught to evaluate the number of voids and evidence of adequate breastfeeding after the infant is home. Notify the primary care practitioner if there are indications the infant is not feeding well, is difficult to arouse for feedings, or is not voiding and stooling adequately. Seeing the obstetrician at 8 weeks is contraindicated, as most postpartum visits are between 4 and 6 wecks. ACOG recommends that postpartum care be an ongoing process in which each woman's individual needs determine the services and support she receives. Early follow-up is warranted for women who experienced complications such as hypertensive disorders of pregnancy, those with chronic health conditions, women at high risk for depression, and breastfeeding mothers who are experiencing feeding problems,
À male client reports to the on-call clinic nurse that he took tadalafil 10 mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina, but denies experiencing any current or recent chest pain. Which action should he nurse take?
Reassure the client that skin flushing is a common side effect of the medication.
when assessing the surgical nursing of a client who had abdominal surgery the previous day, the nurse observes that a small amount of dryness is present on the dressing and the owns him on bank suction device is empty with the plug open. How should the nurse respond?
Recompress the wound suction device and secure the plug.
A preschool-aged child who is being treated for Streptococcal pharyngitis returns to the clinic for signs of scarlet fever. Which assessment finding provides the earliest Indication to the nurse that the child is experiencing a reaction to the toxins that are created by the Streptococcus bacteria?
Red bumps across chest.
The nurse is auscultating a client's lung sounds. Which description should the nurse use to document this sound? (Please listen to the audio file to select the option that applies.)
Stridor
The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom. The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action?
Start two large bore IV catheters and review Inclusion criteria for IV Abrinolytic therapy.
Click to highlight the notes that demonstrate a positive outcome. Day 2 0630: Vitals have remained stable throughout the night. Oxygen 98% on nasal canal. Mother to breastfeed in nursery on demand. Able to tolerate breastmilk. Glucose after feeding was 60 mg/dL (3.3 mmol/L), temp 97.8° F (36.6° C) when returned to warmer and Bili light. Chest x-ray and echocardiogram results were normal. Calcium and magnesium within normal llmits, Direct bilirubin 5 mg/dI(5 umol/L), Discharge teaching Initlated, with goal of discharging infant and mother on day 3.
Studies confirm the importance of maintaining serum glucose levels above 45 mg/dL (25 mmol/1) in hyper insulinemic infants with hypoglycemia to prevent serious neurologic sequel. Blood glucose levels continue to improve. Direct bilirubin improved. Other signs of improvement include a normal temperature for at least 8 hours, improved respiratory status with no signs of respiratory distress syndrome and feedings are well tolerated.
The nurse is reviewing the possible complications that can occur for an infant of a diabetic mother. Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided.
The nurse recognizes that the infant of a diabetic mother is at risk for hyperbilirubinemia, respiratory distress syndrome, and cardiomyopathy
A clients oxygen saturation remains 85-90% after 15 minutes of oxygen therapy. Drag from the choices below to fill In each blank in the following sentence
the nurse should place the client in a a semi fowlers position to promote lung expansion
A child with peripheral edema who weighs 44 pounds receives a prescription for furosemide 2 mg/kg intravenous The vial is labeled, "10 mg/mL." How many mL should the nurse administer? (Enter numeric value only.)
4
A client receives a prescription for norepinephrine 3 mcg/min intravenously (IV). The IV bag is contains noreninanbrine dextrose 5% in water (D,W) 1,000 mL. How many mL/hour should the nurse program the infusion pump? only.) 45
45
Dopamino 5 mog/kg/minute IV is prosorbed for a cliont who woighs 132 pounds. The pharmacy dispensos: of 0.9% normal saline with dopamine 1800 mg. Tho nurse should program the infusion pump to deliver ix numone va ve only. If rounding is recured, round to the nearest fourth.
5.6 mL
The nurse is working on an infectious disease unit. Which Client should sign it to arun with negative Er flow, while requiring personnel to use a particle at respirator mask, and requiring stuff to observe year war, as well as standard precautions?
A client with a positive mantoux and sputum cultures results positive for AFB.
Which situation indicates a need for the nurse to discuss the use of mitten restraints with the healthcare provider?
A disoriented client removed the mesh wrapped IV line for the second time.
A nurse who took drugs from the unit for personal use was temporarily released from duty. After completion of mandatory counselling, the impaired nurse has asked nursing administration to allow return to work. When the nurse administrator approaches the charge nurse with the impaired nurse's request, which action is best for the charge nurse to take?
Allow the impaired nurse to return to work and monitor medication administration.
The nurse receives shift report about a male client with obsessive-compulsive disorder. The nurse completes morning rounds and approaches the client while he is repeatedly washing the top of the same table. Which intervention should the nurse implement?
Allow time for the behavior and then redirect the client to other activities.
After receiving report, the nurse can most safely plan to assess which client last?
An adult client with no postoperative dralnage in the Jackson-Pratt drain with the bulb compressed.
After the examination by the physician, the client was diagnosed with depression and post-traumatic stress disorder. The physician wrote orders for medication that need to be filled. The nurse speaks with the client again to educate her about her diagnosis and medication. How can the nurse build a therapeutic relationship with the client?
B The nurse can communicate acceptance of the client as she is. C The nurse can be open, honest, and sincere. D The nurse can establish a meaningful connection
The nurse is planning care for a client who admits having suicidal thoughts. Which client behaviour indicates the highest risk for the client acting on these suicidal thoughts?
Begins to show signs of Improvement in affect.
The nurse observes an unlicensed assistive personnel (UP) who is preparing to provide personal care for a client who requires contact precautions. The UP has applied a gown and gloves and secured the tops of the gloves over the gown sleeves. What action should the nurse take?
Confirm that the gown is tied securely at the neck and waist.
an adult woman who was recently diagnosed with type two diabetes mellitus is seen in the clinic for laboratory tests . The client's height is 5 feet 2 inches 152.5 centimetres and weight is 165 pounds 74.8 KG her recent laboratory findings or described above . in planning nutrition teaching for this client , which diet modifications should the nurse recommended ? select all that apply
Decrease processed carbohydrate in diet, eliminate alcohol intake except for special locations, increased dietary fibre such as whole grains
A client is being discharged with a prescription for warfarin. Which instruction should the nurse provide this client regarding diet?
Eat approximately the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent. -The warfarin dose is prescribed and adjusted based on the client's normal consumption of foods containingvitamin K (an essential clotting factor that counteracts the effects of warfarin), so the client should eat a consistent amount of vitamin K food sources on a daily basis.
The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond?
Encourage the parents to allow the child to continue attending swimming lessons with supervision
A client is receiving continuous ambulatory peritoneal dialysis since the arteryVenous graft in the right of is no longer available to use were haemodialysis the client has lost weight, has increasing peripheral Edema, and has a serum albumin level of 1.5 GB deal which intervention is the priority for the nurse to implement?
Ensure the client receives frequent small meals containing complete proteins
A male client with a brain tumor is scheduled for a biopsy in the morning. During the admission procedure, the client has a tonic-clonic seizure that lasts 50 seconds. Following the seizure, the client is lethargic and confused and his wife tells the nurse that her husband has never had a seizure before and has always been alert and communicative. Which action should the nurse take?
Explain the postictal state that usually follows selzures.
An adult fomale cont tolls the nurse that though sho is afrald her abusive boyfriend might one day kill her, she keeps hoping that he Will change. Which action should the nurse lake first?
Explore client's readiness to discuss the situation
An adult male client reports that he recently experienced an episode of chest pressure and breathlessness when he was jogging. The client expresses concern because both of his parents had heart disease and his father had diabetes. He lives with his male partner, is a vegetarian, and tax at an alone which maintains his BP at 130/ 70 MMHG. Which risk factors should the nurse explore further with the client? Select all that apply
Family health history. History of hypertension.
What would be some effective strategies that the nurse could use to decrease the client's risk of suicide in the future? Select all that apply.
Help the client enlist the help of friends and family. Refer the client for cognitive behavioural therapy. Have the client sign a no-suicide contract.
When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)?
If the clients has an elevated blood pressure.
A 6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy. Which pre-operative nursing action has highest priority?
Initiate a continuous infusion of IV fluids per prescription.
The charge nurse observes a new nurse demonstrate the administration of two different liquid medications through a gastrostomy tube used for continuous feedings, as seen in the video. Which action(s) should the charge nurse take? (Select all that apply)
Instruct the nurse to administer each medication separately. Confirm that the nurse determined the amount of gastric residual. Add the liquid volumes when documenting fluid intake.
In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?
Watery diarrhea.
A client with schizophrenia reports auditory hallucinations when admitted to the hospital. What question is most important for the nurse to include in the assessment of this client?
What are the voices saying?"
an unlicensed assistive personal is assigned to provide personal care for a client whose prescribed activity is bedrest with bedside commode use. The UAP reports to the nurse that the client is so obvious that the USB fails, unable to safely assist the client in transferring from the bed to bed side commode. How should the nurse respond?
Determine the client's level of mobility and need for assistance
The nurse is providing teaching to a client with type two diabetes mellitus about important points for disease and symptom management. Which statement by the client indicates understanding?
Get an eye examination with an ophthalmologist annually.
The client Is a 42-year-old female who had a right above-the-knee amputation for osteomyelitis. The client has a drain in place and a surgical dressing that will need to be changed by the surgeon on post-op day. What should the nurse do Immedlately? Select all that apply.
Give naloxone 2 mg Intravenously Provide rescue breaths with a manual ventilation bag Call for rapid response
What actions should the nurse take to Azure safety during Morphine administration? Select all that apply
Have a manual risks nation bag at the bedside, take an initial respiratory rate ask the client about other medications she takes Opioids such as morphine can cause respiratory depression. The nurse should have a manual resuscitation bag at the bedside and should take an initial respiratory rate to monitor for a decrease in rate. The nurse should also ask about other medications that may increase the effects of Morphine or otherwise interact with the drug.
Student Nurse Statement "You can give naloxone intravenously Intramuscularly, or subcutaneously." "If the first dose does not yoses yo 'need ed to reverse respiratory depression." "Naloxone will not affect theclient's level of pain.' "When given IV, naloxone starts working Immediately and can last several hours "Naloxone works best on pure agonist opioids
Naloxone is a pure opiold antagonist and works best with pure opioid agonists such as Morphine. It can be given intravenously, subcutaneously, or intramuscularly, but it works almost immediately when given intravenously. Naloxone reverses respiratory depression but also can reverse the analgesic and sedative effects, so the didn't may experience severe pain after the dose is given. Naloxone can be given in small doses up to 10 mg, but once the 10 mg maximum dose is reached, the medical team should look for other causes of respiratory depression.
The lower limit for normal plasma glucose levels during the first 72 hours after birth is 40 to 45 mg/dL (2.2 to 2.5 mmol/L). Hypoglycemia is most common in the macrocosmic or LGA infant, but the nurse should monitor blood glucose levels in all infants of mothers with known or suspected diabetes. Hypoglycemia most frequently occurs within the first 1 to 6 hours after birth. Signs of hypoglycemia include jitteriness, apnea, tachypnea, hypotonia, decreased activity, and cyanosis. A Ballard score maturity assessment of 37 corresponds to 37 weeks gestation, which is a early term. Early term (37 0/7 through 38 6/7 weeks). Compared with full-term infants, early-term infants are at increased risk for morbidity and mortality.
Normal findings include acrocyanosis, soft fontanelles, Mongolian spots, and Apgar scores of 7 to 10.
The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing action(s) should the nurse assign to the PN? (Select all that apply.)
Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty. Administer a dose of Insulin per siding scale for a client with type 2 diabetes mellitus (DM). Perform dally surgical dressing change for a client who had an abdominal hysterectomy.
Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a colostomy bag?
Observe insertion site
an older client recently transferred to a rehabilitation facility after aortic valve replacement surgery is experiencing anxiety and difficulty adjusting to the transition. The healthcare provider describes an antidepressant and A mild sedative for sleep. Which intervention is most important for the nurse to include in Client's plan of care?
Obtain a blood pressure reading before client gets out of bed.
Three hours after birth, a new born becomes jittery and tachypneic. What should the nurse do first?
Obtain a capillary glucose level.
Client with a history of them India has become increasingly confused at night and is speaking at an abdominal surgical dressing and the death securing the intravenous line. The abdominal racing is no longer occlusive, And the IV insertion site is pink. Which intervention should the nurse implement?
Redress the abdominal incision An abdominal incision should be redressed using aseptic technique when it is no longer occlusive after a client has been picking at it. The IV site should be assessed to ensure that it has not been dislodged due to the client picking at the tape and a dressing reapplied, if needed.
A client recovering from pneumonia who has a history of severe chronic obstructive pulmonary disease (COPD) and peripheral vascular disease (PVD) is being discharged from a skilled nursing facility. Which action is most important for the nurse to implement?
Reinforce need for adequate hydration.
the nurse observes An unlicensed assistive Personnel applying and alcohol-based hand rub while leaving a client's room after taking vital signs. Which action should the nurse take ?
Remind the UAP to continue rubbing the hands together until they are dry
The nurse leading a care team in any medical surgical unit is assigning client care to a practical nurse and an unlicensed assistive personnel. Which task should the nurse assign to the PN?
Titrate oxygen to prescribe parameters.
The nurse is educating a client about essential hypertension prevention. Which information should the nurse provide? (Select all that apply.)
Uncontrolled hypertension can lead to renal damage. Weight management is promoted by taking dally walks for thirty minutes. Salt substitutes can help with maintaining a healthy diet. Sodium intake can be regulated by limiting canned foods in the diet.
when preparing to administer a prescribed medication to a homeless male of a community psychiatric clinic, the client tells the nurse that he usually takes different doses. Which action should a nurse take?
With hold the medication until the doses can be confirmed