#1

A female client with multiple sclerosis reports having less fatigue and improved memory since she began using the herbe supplement, ginkgo biloba. Which information is most important for the nurse to include in the teaching plan for this client?

Ginkgo biloba use should be limited and not taken during pregnancy.

A client with psychosis who is receiving an antipsychotic medication is continually rubbing the back of the neck. Which nursing intervention is best for the nurse to implement?

Give a PRN prescription for benztropine

A client who was recently diagnosed with Raynaud's disease is concerned about pain management. Which nursing instruction she the nurse provide?

Wearing gloves when handling cold items guards against painful spasms.

While caring for a client with a full-thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values.

White Blood Cell Count

A young adult client with osteoarthritis of both knees tells the nurse the desire to continue daily walks in the park with friends. How should the nurse respond?

Encourage continued maintenance of the walking routine.

The nurse is providing teaching to a client with Type 2 diabetes mellitus and peripheral neuropathy. Which information should the nurse provide?

Family members can help with regular foot exams.

An obese client with emphysema who smokes at least a pack of cigarettes daily is admitted after experiencing a sudden increase dyspnea and activity intolerance. Oxygen therapy is initiated and it is determined that the client will be discharged with oxygen. W information is most important for the nurse to emphasize in the discharge teaching plan?

Guidelines for oxygen use.

An older client is admitted with an acute onset of diverticulitis and intravenous antibiotic therapy is initiated. Which intervention should the nurse implement next?

Initiate bowel prep protocol for surgery

A client receives a prescription for 1 liter of lactated Ringer's intravenously (IV) to be infused over 8 hours. The IV administration s delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

Lumbar puncture

A client arrives to the emergency department reporting an intermittent fever and night sweats for the past 3 weeks and has develo a productive cough containing small amounts of blood. Which intervention should the nurse prioritize?

Move into airborne isolation.

A client with a seizure disorder is seen at the clinic for a follow-up visit and a prescription renewal for phenytoin. Which a finding warrants immediate intervention by the nurse?

Puffy, bleeding gums

When administering medications to a group of clients, which client should the nurse closely monitor for development of acute kidney injury (AKI)?

Vancomycin

An overweight, young adult client who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. The cli reports feeling very weak and jittery. Which action(s) should the nurse implement? (Setect all that apply.)

Check his fingerstick glucose level Assess his skin temperature and moisture Measure his pulse and blood pressure

A client with gouty arthritis reports tenderness and swelling of the right ankle and great toe. The nurse observes the area of inflammation extends above the ankle area. The client receives prescriptions for colchicine and indomethacin. Which instruction should the nurse include in the discharge teaching?

Drink at least 8 cups (1920 mL) of water per day.

The nurse is providing discharge teaching to an older adult client hospitalized for treatment of venous leg ulcers. Which instructior should the nurse include in the teaching plan? (Select all that apply.)

Eat a diet that is high in protein and vitamins A and C.

The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage pain, which assessment data is most important for the nurse to obtain?

Eating patterns and dietary intake

The nurse is obtaining a health history from a new client who has a history of kidney stones. Which statement by the client indicates an increased risk for renal calculi?

Eats a vegetarian diet with cheese 2 to 3 times a day.

The nurse is evaluating a client's understanding of diet teaching about the DASH (Dietary Approaches to Stop Hypertension) eatir plan. Which behavior indicates that the cllent is adhering to the eating plan?

Enjoys fat free yogurt as an occasional snack food

A client who has a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding warrants t most immediate action by the nurse?

Further decline in level of consciousness

A client who is taking albendazole reports experiencing fatigue, nausea, and dark urine. The nurse observes a yellowing skin and sclera. Which laboratory result should the nurse review?

Hold both medications until contacting the healthcare provider.

The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis?

Hypoalbuminemia that results in decreased colloidal oncotic pressure.

After receiving five doses of filgrastim, the nurse notes that the client's white blood cell count has increased from 2,500/n 109L) to 5,000/mm? (5 x 10° /L). Which action should the nurse implement?

Implement neutropenic precautions.

Prior to administering oral doses of calcitriol and calcium carbonate to a client with hypoparathyroidism, the nurse notes client's total calcium level is 14 mg/dL (3.5 mol/L). Which action should the nurse implement?

Implement neutropenic precautions.

The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about huff coughing to clear secretions. During client's retum demonstration, the client uses pursed lips during exhalation. Which action should the nurse do next?

Instruct the client after inhaling deeply to quickly and forcefully exhale 2 to 3 times.

While caring for a client with Guillain-Barre syndrome, the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?

Lower leg weakness.

An older client who is agitated, dyspneic, orthopneic, and using accessory muscles to breathe is admitted for further treatment. Ini assessment includes a heart rate 128 beats/minute and irregular, respirations 38 breaths/minute, blood pressure 168/100 mm Hg wheezes and crackles in all lung fields. An hour after the administration of furosemide 60 mg intravenous (IV), which assessment should the nurse obtain to determine the client's response to treatment? (Select all that apply.)

Lung Sounds

A client who has small cell carcinoma of the lung is admitted with symptoms of syndrome of inappropriate antidiuretic hormone (SIADH). As the client responds to treatment, the client's serum sodium level increases from 120 mEq/L (120 mol/L) to 125 mE (125 mol/L). Based on this finding, which intervention should the nurse implement?

Maintain Fluid Restriction

An adult who was recently diagnosed with glaucoma tells the nurse, "it feels like am driving through a tunnel." The client express great concern about going blind. Which nursing instruction is most important for the nurse to provide this client?

Maintain prescribed eye drop regimen.

The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes the following vital signs: heart rate 140 beats/minute, respirations 26 breaths/minute, and blood pressure 140/90 mm H Which intervention is most important for the nurse to implement?

Medicate forpain and monitorvitalsignsaccordingto protocol

Which information should the nurse include in the teaching plan of a client diagnosed with gastrosophageal reflux disease (GERD)

Minimize symptoms by wearing loose, comfortable clothing.

A client with right hydronephrosis and a history of renal calculi is preparing for discharge following a retrograde pyelogram. Which instruction should the nurse include in the client's discharge instructions?

Monitor urinary stream for decreased output.

A client arrives to the medical-surgical unit 4 hours after a transurethral resection of the prostate. A triple-lumen catheter for continuous bladder irrigation with normal saline is infusing and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag. Which action should the nurse take?

Monitoring catheter drainage

A client presents to the emergency department reporting chest pair that is radiating to the left arm, shortness of breath, and diaphoresis. Which medication should the nurse anticipate being prescribed by the healthcare provider?

Morphine

The nurse is preparing a client for surgery who was admitted to the emergency center following a motor vehicle collision. The clie has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, nurse determines that the client currently receives heparin sodium 5,000 units subcutaneously daily. Which is the priority nursing action?

Notify the healthcare provider of the client's history

Which group of foods is best for the nurse to recommend for clients with a strong family history of colon and rectal cancers?

Oatmeal, raisins, and fruit with skin.

The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis. Which diagnostic proced should the nurse prepare the client for the healthcare provider?

Positive Kernig's sign and nuchal rigidity.

A client with a history of chronic obstructive pulmonary disease (COPD) receives a new prescription for an ipratropium inhaler. Which action indicates to the nurse that additional teaching is needed?

Primes the inhaler with 7 pumps

After falling down the basement steps, a client is brought to the emergency room. X-rays confirms that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?

Right foot pale with sluggish capillary refill

The healthcare provider prescribes diagnostic tests for a client whose chest ray indicates pneumonia. Which diagnostic test shot the nurse review for implementation in the most therapeutic treatment of the pneumonia?

Sputum culture and sensitivity

The nurse is caring for a client who reports a sudden, severe headache, and facial numbness. The nurse asks the client to smile: observes an uneven smile with a facial droop to the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headaches or trauma. Which intervention should the nurse should perform in the immediate management of the client?

Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.

The parent of an adolescent tells the clinic nurse, "My child has athlete's feet. I have been applying triple antibiotic ointment for tv days, but there has been no improvement." Which instruction should the nurse provide?

Stop using the ointment and encourage complete drying of feet and wearing clean socks.

An adult client who had a gastric bypass surgery 2 weeks ago, is admitted with possible anastomosis leakage. The client's abdom is tender to touch, and the vital signs are: temperature 101° F (38.39 C), heart rate 130 beats/minute, respiratory rate 26 breaths/minute, and blood pressure 100/50 mm Hg. Which intervention is most important for the nurse to include in the client's pl; care?

Strict IV fluids

The nurse is preparing a client for discharge who was recently diagnosed with Addison's disease. Which instruction is most impor for the nurse to include in this client's discharge teaching plan?

Take prescribed cortisone accurately.

A client receives a prescription for dalteparin 2500 units subcutaneously 2 hours before a scheduled procedure. The medication is available in a 5000 units/0.2 mL prefilled syringe. How many mL should the nurse administer? (Enter numeric value only.)

0.1

A client receives a prescription for 1 liter of lactated Ringer's intravenously (IV) to be infused over 8 hours. The IV administration s delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

125

A client receives a prescription for 1 liter of 0.9% sodium chloride, US intravenously (IV) to be infused over 4 hours. The IV administration set delivers 10 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

21

A client with stage I bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 or to 10 scale. Which intervention should the nurse implement?

Administer opioid and non-opioid medication simultaneously.

The nurse is caring for a client with human immunodeficiency virus (HIV) who has developed oral thrush and is experiencing bum and soreness in the mouth. Which intervention should the nurse implement first?

Adminiter a topical analgesic

While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences on the client's fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take?

Discuss approaches to the chronic pain control with the client

The nurse is providing teaching to a client admitted with a blood glucose level of 580 mg/dL about preventing complications relate diabetes mellitus. Which information stated by the client indicates understanding?

Apply lotion to entire foot to prevent gracks in the skin.

A nurse is assessing a client who has an arteriovenous (AV) graft in the right forearm for hemodialysis access. The nurse ausculte a bruit over the graft area. Which intervention should the nurse implement?

Document the findings

A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client's medical rec should the nurse recognize as a contraindication for peritoneal dialysis?

Crohn's disease with colectomy.

The nurse is caring for a client with a burn that is severely edematous with a wound bed that is brown and yellow in appearance. " client expresses feeling no pain. Which classification of burn depth should the nurse document?

Deep partial-thickness

A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?

low back pain and hypotension.