CASAL II
place the client in supine position and assess VS
A client who had a myocardial infarction receives 15 mg of morphine sulfate for chest pain. Fifteen minutes after receiving the medication, the client complains of feeling dizzy. Which action will the nurse take?
Intravenous insertion site
A health care provider prescribes tissue plasminogen activator (t-PA) to be administered intravenously over 1 hour for a client experiencing a myocardial infarction. Which assessment component can identify problems caused by this medication's effect?
fatigue sleep hormonal flunctuations
Which factors can trigger a client's migraine attacks
check liver enzymes
A client who takes rifampin tells the nurse, "My urine looks orange." Which action would the nurse take?
apply wound dressing
A client with a puncture wound of the chest wall is transported to the emergency department. Which action would the nurse take?
with food and full glass of water
A client with arthritis states that the prescribed aspirin causes stomach irritation. How would the nurse instruct the client to take the aspirin?
The tilt table provides therapeutic weight bearing to limit loss of calcium from the bones.
A client with quadriplegia attends tilt table therapy daily and asks why the angle of the table gradually increases each day. Which response would the nurse use?
encourage deep coughing
Which nursing action will help a client obtain maximum benefits after postural drainage?
Avoid activities that risk traumatic injuries and exposure to infection.
A client is admitted to the hospital with pancytopenia as a result of chemotherapy. Which information will the nurse provide to minimize the risk for complications?
monitor VS q15mins
A client has a tonic-clonic seizure caused by an overdose of aspirin. Which action would the nurse take next?
hyporeflexia
A client is taking furosemide. At each clinic visit, the nurse will assess for which adverse effect?
Exhibits a positive Babinski sign
The nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral side of a client's foot is stroked. Which finding would the nurse document?
blurred vision
The postanesthesia care unit nurse providing care for a client who had a craniotomy for a meningioma would monitor for which specific clinical manifestation in this client?
Infrequent voiding of large residual volumes
Which clinical manifestations could confirm damage to the sensory limb of the bladder spinal reflex arc?
frontal lobe
Which lobe of the cerebrum includes the Broca speech center?
Peripheral vasoconstriction
Which physiological response occurs first when a client experiences sudden hypovolemia caused by hemorrhage?
hypovolemic shock
Which type of shock is associated with a ruptured abdominal aneurysm?
Acetaminophen extra strength
For a client with difficulty swallowing, the nurse will crush which medication?
prolonged bleeding time
The nurse is caring for a client who is receiving aspirin therapy. Which clinical indicator would be related to this therapy?
"Drink eight to ten glasses of water daily."
Trimethoprim-sulfamethoxazole is prescribed for a client with cystitis. Which instruction would the nurse include when providing medication teaching?
Report any occurrence of multiple bruises.
A client who had a femoropopliteal bypass graft is receiving clopidogrel postoperatively. Which instruction will the nurse teach the client related to the medication?
administer anti emetic
After cataract surgery, a client reports feeling nauseated. How can the nurse prevent vomiting?
optic nerve inflammation
A client asks the nurse what causes the sudden loss of vision common in persons with multiple sclerosis. Which factor would the nurse include in the explanation?
Deflate the balloon as soon as the PAWP is measured.
Which action will the nurse take when measuring a client's pulmonary artery wedge pressure (PAWP)?
nervous and weak
The nurse provides education about signs and symptoms of hypoglycemia to a client with newly diagnosed type 1 diabetes. The nurse concludes that the teaching was effective when the client acknowledges the need to drink orange juice when experiencing which symptoms?
broca's area
Which region of the brain regulates verbal expression?
Failure to capture
When a client has a newly implanted demand pacemaker and the nurse observes spikes on the cardiac monitor at a regular rate but no QRS following the spikes, how will the finding be documented?
Placing the child in the side-lying position Rationale The side-lying position promotes a patent airway; the tongue can move away from the back of the pharynx, and saliva can flow out of the mouth by gravity. Although monitoring vital signs is important, a patent airway is the priority. The crib sides should have been padded as a part of seizure precautions before the seizure. If the seizure was unexpected and seizure precautions were not previously instituted, they should be instituted after the immediate respiratory and safety needs of the toddler have been met. Suctioning may be unnecessary; the child should not be left alone while equipment is obtained.
A 2-year-old child is admitted to the pediatric unit with a diagnosis of bacterial meningitis. Which is the most important safety measure for the nurse to institute immediately after the child has a seizure?
Quality of respirations and presence of pulses
A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. What are the priority nursing assessments?
Establish Patent Airway (dr wilson)
A client experienced a tonic-clonic seizure. Which nursing intervention is the priority during the tonic-clonic stage of the seizure?
Stool Softeners
A client has had a recent brain attack (cerebrovascular accident/stroke). Which preventative would the nurse anticipate will be prescribed daily to avoid straining due to constipation?
vitamin B12 injection for life
A client has had a total gastrectomy. Which topic will the nurse include in the discharge teaching?
Position the client to prevent contractures.
A client has left hemiplegia because of a cerebrovascular accident (CVA, "brain attack"). What can the nurse do to contribute to the client's rehabilitation?
hypotension
A client is admitted to the hospital for an adrenalectomy. Before the client's replacement steroid therapy is regulated fully, the nurse will monitor the client for which complication?
auscultate BS
A client is admitted to the hospital with a diagnosis of heart failure and acute pulmonary edema. The health care provider prescribes furosemide 40 mg intravenous (IV) stat to be repeated in 1 hour. Which nursing action will best evaluate the effectiveness of the furosemide in managing the client's condition?
cardiotoxicity
A client is receiving doxorubicin as part of a chemotherapy protocol. The nurse will assess the client for which system toxicity?
"I may have a sore throat."
A client is scheduled to receive general anesthesia during an upcoming surgery. The nurse provides education about common side effects of general anesthesia. The nurse concludes that the teaching has been effective when the client has which response?
Administer the medication at least an hour before ingestion of milk products.
A client is started on tetracycline antibiotic therapy. Which action would the nurse take when administering this medication?
Instruct the client to scan surroundings.
A client manifests right-sided hemianopsia as a result of a cerebrovascular accident (CVA, also known as a "brain attack"). Which goal would the nurse include in the client's plan of care?
twitching
A client taking levodopa is taught about the signs of levodopa toxicity. The nurse instructs the client to contact the primary health care provider if the client develops which symptom?
Decreased cardiac preload reduces cardiac workload.
A client who had a myocardial infarction receives a prescription for a nitroglycerin patch. Which statement would the nurse identify as the purpose of the nitroglycerin patch?
Salicylate toxicity
A client who takes four 325-mg tablets of buffered aspirin four times a day for severe arthritis complains of dizziness and ringing in the ears. Which complication would the nurse conclude that the client probably is experiencing?
digoxin
A client who takes multiple medications complains of severe nausea, and the client's heartbeat is irregular and slow. The nurse determines that these signs and symptoms are toxic effects of which medication?
Teach client to do purse-lip breathing
A client with an acute emphysema episode is dyspneic and anxious. To decrease the dyspnea, which action would the nurse take?
Weight daily Rationale The increased osmotic effect of therapy increases the intravascular volume and urinary output; weight loss reflects fluid loss. The vital signs will not change drastically; frequently is a nonspecific timeframe. The urinary output is measured hourly; half-hour outputs are insignificant in this instance. A serum, not urine, albumin level is significant; albumin in the urine indicates kidney dysfunction, not liver dysfunction.
A client with biliary cirrhosis receives serum albumin therapy. Which action will the nurse take to evaluate the client's response to therapy?
"Each dose should be taken with a full glass of water or juice."
A client with irritable bowel syndrome has instructions to take psyllium for constipation. Which statement is important for the nurse to include in the teaching plan?
On an empty stomach
A client with myasthenia gravis is prescribed pyridostigmine. The nurse will teach the client that it is important to take this medication based on which schedule?
Assess the client's pain before increasing the dose of morphine.
A terminally ill client is receiving a morphine drip that exceeds the typical recommended dosage. The client's spouse tells the nurse that the client is again uncomfortable and needs the morphine increased. The prescription states to titrate the morphine to comfort level. Which action will the nurse take?
check glucose level
After surgery, total parenteral nutrition (TPN) is instituted via a central venous infusion. During the fourth hour of the infusion the client complains of nausea, fatigue, and a headache. The hourly urine output is twice the amount of the previous hour. After contacting the primary health care provider, which action would the nurse take?
antiinflammatory
Aspirin is prescribed on a regular schedule for a client with rheumatoid arthritis. The nurse understands that the medication is being used primarily for which property?
60mins because the nurse will have to stop the primary infusion for an hr.
At 10:00 AM the nurse hangs a 1000-mL bag of 5% dextrose in water (D 5W) with 20 mEq of potassium chloride to be administered at 80 mL/h. At noon the health care provider prescribes a stat infusion of an intravenous (IV) antibiotic of 100 mL to be administered via piggyback over 1 hour. How much longer than expected will it take the primary bag to empty if the nurse interrupts the primary infusion for infusion of the antibiotic?
Deficient carbohydrate intake
Clients who receive intravenous (IV) fluids rather than total parenteral nutrition for gastrointestinal problems lose weight for which reason?
Keep the trachea free of secretions
During a client's immediate postoperative period after a laryngectomy, which is a nursing priority?
"Insulin is destroyed by gastric juices, rendering it ineffective."
During a teaching session about insulin injections, a client asks the nurse, "Why can't I take the insulin in pills instead of taking shots?" How will the nurse respond?
apex of the heart
During auscultation of the heart, where would the nurse expect the first heart sound (S 1) to be the loudest?
I am glad that I only have to take the medication once a day."
Immediately after a bilateral adrenalectomy, a client is receiving corticosteroids that are to be continued after discharge from the hospital. Which statement by the client indicates to the nurse that additional education is needed?
Liver failure
In addition to clients who are receiving insulin for type 1 diabetes, the nurse will assess for signs and symptoms of hypoglycemia in clients who have which diagnosis?
Monitor the client for an exacerbation of symptoms.
Long-term corticosteroid therapy has been initiated for a client with myasthenia gravis who experiences inadequate symptomatic control with pyridostigmine bromide. Which action is important for the nurse to take?
Take a blood sample for laboratory tests.
Once a client admitted with shock secondary to severe gastrointestinal (GI) bleeding is stabilized, which intervention would the nurse do next?
Although the medication decreases intestinal inflammation, it will not cure the colitis.
Prednisone is prescribed for a client with an exacerbation of colitis. Which explanation would the nurse provide for administering prednisone?
Helping the client set a date to stop smoking
The community health nurse is educating a client who is interested in discontinuing cigarette smoking. Which would the teaching plan include?
Once treatment with insulin for diabetic ketoacidosis is begun, potassium ions reenter the cell, causing hypokalemia; therefore, potassium, along with the replacement fluids, is needed to prevent hypokalemia
The nurse adds 20 mEq of potassium chloride to the intravenous solution of a client with diabetic ketoacidosis. Which purpose would this medication serve?
cardiac arrest
The nurse administers a parenteral preparation of potassium slowly to avoid which complication?
Irritability Heart palpitations
The nurse concludes that a client has a hypoglycemic reaction to insulin. Which clinical findings support this conclusion
with meals
The nurse evaluates that teaching for the oral pancreatic enzymes pancrelipase is understood when the client identifies which time for medication scheduling?
A decrease in serum potassium level
The nurse gave a client the prescribed sodium polystyrene sulfonate. Which assessment finding indicates that the medication has been effective?
abdominal girth
The nurse is administering serum albumin intravenously to a client with ascites. In response to this therapy, which client problem would the nurse expect to decrease?
administer oxygen
The nurse is caring for a client who just been brought into the emergency department after a myocardial infarction. Which action is the priority for this client?
midbrain
The nurse is conducting an assessment on a client brought to the emergency room after a motor vehicle accident. The client pulls his arms upward and inward in response to pain. The nurse recognizes that this response represents an injury to which area?
decrease in pallor
The nurse is evaluating the results of treatment with erythropoietin. Which assessment finding indicates an improvement in the underlying condition being treated?
Orthopneic
The nurse repositions a client who is diagnosed with emphysema to facilitate breathing. Which position facilitates maximum air exchange?
anomia
The nurse shows the client a picture of a baseball and asks the client to identify it and its characteristics. The client describes its color, size, and purpose but cannot identify it as a ball. How will the nurse document this finding?
"Do you take antidepressants?" Clients prescribed adrenergic agonists should be asked whether they are taking any antidepressants, such as phenezeline, because these medications increase blood pressure as do the adrenergic agonists; hence, this may lead to a hypertensive crisis. Clients prescribed beta-adrenergic blockers should be asked about any respiratory disorders, such as asthma, because the drug causes constriction of pulmonary smooth muscle which may lead to narrowing of the airway. Carbonic anhydrase inhibitors are similar to sulfonamides. Therefore, they should not be prescribed to clients who are allergic to sulfonamides. While asking about contact lensesis appropriate, this is not the priority for adrenergic agonist; discoloration of lens is not a critical as hypertensive crisis.
The primary health care provider prescribes an adrenergic agonist to a client with increased intraocular pressure. Which question would the nurse ask the client before administering the medication?
Prothrombin
The surgeon prescribes vitamin K before surgery. The nurse recognizes that this is prescribed because vitamin K contributes to the formation of which substance?
cantaloupe
When a client who is taking a diuretic has been instructed to eat foods high in potassium, which fruit would the nurse suggest?
Importance of cleanliness around the site of the stoma
When a client with laryngeal cancer has a laryngectomy scheduled, which action will the nurse include in the postoperative teaching plan?
Put the stockings on before getting out of bed.
When a client with varicose veins has knee-length elastic support stockings prescribed, which information would the nurse include in client teaching?
vesicular BS
When auscultating a client's chest, the nurse hears swishing sounds of normal breathing. How would the nurse document this finding?
increased fremitus
When palpating the chest during a respiratory assessment, which finding would the nurse expect in a client with pneumonia?
Nail beds Conjunctivae Palms of hands
When performing a focused assessment on a client with a possible diagnosis of iron deficiency anemia, which locations would the nurse examine
Assess the client's feet for sensation. (dr wilson)
Which action is essential for the nurse to take after a client returns from spinal surgery?
Ensure airway-breathing-circulation (ABC). The client with any life-threatening complication such as dysrhythmias should be assessed for ABCs immediately because the client may suffer with airway obstruction. Oxygen saturation should be monitored during ongoing assessments and after providing the client with initial treatment. Intravenous access should be established after performing initial assessments such as vital signs. After assessing ABCs in a client with dysrhythmias, the client should be provided with oxygen via nasal cannula or nonrebreather mask to maintain oxygen levels.
Which action would the nurse perform immediately for a client with dysrhythmias according to priority?
Change slowly from sitting to standing.
Which advice would the nurse include in a teaching plan to reduce the side effects of diltiazem?
Corneal sensation
Which assessment would the nurse use to assess the client's trigeminal nerve function?
i may experience headache
Which client statement indicates understanding of the side effects of nitroglycerin ointment?
yellow
Which color of cerebrospinal fluid (CSF) may indicate subarachnoid hemorrhage in the client?
Body temperature of 81.2°F RATIONALE: Severe hypothermia such as body temperature of 81.2° F must be immediately corrected by infusing warm fluids and blood. This helps to prevent hypothermia-related complications. A Glasgow Coma score of 10 needs medium priority since it does indicate immediate danger to the client. Oxygen saturation of 90 percent indicates a manageable status. Presence of carotid pulse with blood pressure of 80 mm Hg is acceptable.
Which condition of a client with hemorrhagic stroke resulting from a motor bike accident requires immediate attention?
Loss of peripheral vision
Which finding would the nurse anticipate in the health history of a client who has open-angle (chronic) glaucoma?
Receives long-term steroid therapy
Which information from the client's history would the nurse identify as a risk factor for developing osteoporosis?
Is contraindicated in people with coronary artery disease.
Which information would the nurse include in the teaching plan for the client who is prescribed sumatriptan for migraine headache?
GI bleeding
Which life-threatening complication may occur in clients taking high-dose or long-term ibuprofen?
increases excretion of sodium
Which mechanism of action explains how hydrochlorothiazide increases urine output?
Monitor intake to prevent dehydration or starvation.
Which nursing action is specific to the plan of care for a client with trigeminal neuralgia?
Turn and reposition the client every 2 hours.
Which nursing action is the priority when the nurse discovers in an admission assessment that a client has a stage 1 pressure ulcer
to reduce ammonia
Why would lactulose be prescribed for a client with a history of cirrhosis of the liver?
Assess airway, breathing, and circulation
priority intervention for a client in ED with chest pain
Aspirin 325 mg, two tablets every 4 hours
A client develops tinnitus. Which of the client's medications would the nurse suspect is the cause of this new development?
Antacids commonly interfere with the absorption of other medications.
A client diagnosed with gastroesophageal reflux disease (GERD) is being treated with antacid therapy. When teaching the client about the antacids, which information would the nurse reinforce?
Refer to the date and time markings on the outside of the collection chamber.
A client has a closed chest drainage system in place. How would the nurse determine the amount of chest tube drainage?
Tachycardia and petechiae over the chest Tachycardia occurs because of an impaired gas exchange; petechiae are caused by occlusion of small vessels within the skin. Chest pain is not a common complaint with a fat embolism; fever may occur later. A positive Homans sign occurs with thrombophlebitis; it is not an indication of a fat embolism. Loss of sensation suggests neurologic dysfunction; it is not an indication of a fat embolism.
A client has an open reduction and internal fixation (ORIF) of a fractured hip. The nurse monitors this client for signs and symptoms of a fat embolism. Which client assessment finding reflects this complication?
Check the client's serum creatinine.
A client has been taking furosemide (Lasix) and valsartan (Diovan) for the past year. The hospital laboratory notifies the nurse that the client's serum potassium level is 6.2 mEq/L. What is the nurse's best action at this time?
stop the infusion
A client receiving intravenous vancomycin reports ringing in both ears. Which initial action would the nurse take?
WBCs
A client who is immunosuppressed is receiving filgrastim. When monitoring effectiveness, the nurse will check for an increase in which blood component?
Blood between the dura mater and the arachnoid layer
A client with a head injury has a computed tomography (CT) scan that shows a subdural hematoma. How would the nurse interpret this finding?
disturbances in hearing
A client with arthritis takes large doses of aspirin. Which symptom would the nurse include when teaching the client about the clinical manifestations of aspirin toxicity?
vitamin K
A client with chronic liver disease reports, "My gums have been bleeding spontaneously." The nurse identifies small hemorrhagic lesions on the client's face. The nurse concludes that the client needs which additional supplement?
Heart rate of 90 bpm
A client with supraventricular tachycardia (SVT) has a heart rate of 170 beats/minute. After treatment with diltiazem, which assessment indicates to the nurse that the diltiazem is effective?
Those brown spots result from small blood vessel damage; the blood contains iron, which leaves a brown spot."
A client with type 1 diabetes asks what causes several brown spots on the skin. What would be the best response by the nurse?
calcuim
After a surgical thyroidectomy a client exhibits carpopedal spasm and tremors. The client reports tingling in the fingers and around the mouth. The nurse suspects a deficiency in which mineral?
Babinski reflex
An adult client experiences a traumatic brain injury. Which finding identified by the nurse indicates possible damage to the upper motor neurons?
Unna boot that has been moistened with zinc oxide.
An ambulatory client has developed an ulcer as a result from chronic venous insufficiency that is non-healing and causing edema in the lower leg. The nurse should anticipate the healthcare provider's plan of care to include?
To increase oxygen concentration to heart cells
A client with a coronary occlusion is experiencing chest pain and distress. Which is the primary reason that the nurse administers oxygen?
Rest in an air conditioned room Fatigue is a common symptom in clients with multiple sclerosis[1][2]. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided.
The nurse teaches a client with multiple sclerosis methods to reduce fatigue. Which statement indicates an understanding of the education?
"It is not advisable because bleeding will increase."
The spouse of a client with an intracranial hemorrhage asks the nurse, "Why aren't they administering an anticoagulant?" How will the nurse respond?
reduce cerebral edema
Dexamethasone has been prescribed for a client after a craniotomy for a brain tumor. Which physiological response is responsible for this medication's therapeutic effect?
To provide prophylaxis against postoperative thrombus formation
Enoxaparin 40 mg subcutaneously daily is prescribed for a client who had abdominal surgery. The nurse explains that the medication is given for which purpose?
epistaxis (nosebleed)
For the client taking clopidogrel, the nurse will monitor for which adverse effect?
Metabolic acidosis; Decreased oxygen promotes the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis
The nurse assesses a client who is experiencing profound (late) hypovolemic shock. When monitoring the client's arterial blood gas results, which response would the nurse expect?
Crackles are located in the smaller air passages.
The nurse auscultates fine crackles in a client who has arrived in the emergency department with respiratory distress. When the nurse is providing information to the client about crackles, which is appropriate to include?
extension
The nurse is assessing a client who has a head injury. Which movement of the client's arm after the nurse applies nailbed pressure would cause the most concern?
urinary output Q1h
The nurse is assessing the adequacy of a client's intravenous fluid replacement therapy during the first 2 to 3 days after sustaining full-thickness burns to the trunk and right thigh. Which assessment will provide the nurse with the most significant data?
sooty
The nurse is caring for a client 2 days after the client was admitted with burn injury. When performing the respiratory assessment, the nurse observes for which type of sputum?
"TPN provides total nutrition when gastrointestinal function is questionable."
The nurse is caring for a client who is receiving total parenteral nutrition (TPN) after extensive colon surgery. The nurse concludes that the client understands teaching about the purpose of TPN when the client makes which statement?`
Inhales deeply through the mouthpiece, relaxes, and then exhales
The nurse teaches a postoperative client how to use an incentive spirometer. Which client behavior indicates to the nurse that the spirometer is being used correctly?
The client requires an intervention immediately.
When the nurse requests a client to rate his or her pain intensity on a scale of 0 to 10, the client states the pain is "99." Which interpretation would the nurse apply to the client's response?
temporal lobe
Which area of the cerebral lobe is linked to Wernicke's area of speech?
COPD
Which condition unrelated to cardiac disease is the major cause of right ventricular failure?
Extraocular muscle function
Which factor is the nurse assessing when checking the cardinal positions from the image?
It assesses myocardial ischemia and perfusion.
Which information would the nurse include when explaining the purpose of a thallium scan to the client who has a history of chest pain?
"Check pulses in the legs regularly."
Which instruction will the home health nurse give when teaching a client with arterial insufficiency of both lower extremities?
remove a previous patch (recheck question)
Which instruction would the nurse include in a teaching plan for nitroglycerin patches?
Ensure that the medication is stored in its original dark container.
Which instructions will the nurse give a client for whom nitroglycerin tablets are prescribed?
Take the temperature.
Which intervention would the nurse perform first for a clinic client reporting a productive cough with copious yellow sputum, fever, and chills for the past 2 days?
Teaching how to transfer from a bed to chair in the least painful manner
Which nursing intervention is the highest priority for an older client with diabetes mellitus who presents with a large leg ulcer?
Pseudoephedrine
Which over-the-counter medication would the nurse teach a client taking antihypertensive medication to avoid?
Tissue necrosis and inflammation
Which physiological process causes temperature elevation after a client has had a myocardial infarction?
Low Fowler's Position
Which position would the nurse place a client in during the immediate period after injury to the frontal lobe of the brain?
decrease fecal bulk
While awaiting surgery, a client with a history of Crohn disease is receiving total parenteral nutrition (TPN) on an outpatient basis. The nurse teaches the client that TPN helps prepare for surgery by which process?
Stay with client during first 15 minutes of infusion.
The provider prescribes one unit of packed red blood cells to be administered to a client. To ensure the client's safety, which action will the nurse take during administration of blood products?
aura phase
A client reports a severe unilateral throbbing headache, nausea, intolerance to light and sound, and double vision. Which phase of this headache involves double vision?
analgesic
A client has been given a prescription for acetylsalicylic acidm(Aspirin). The nurse recalls that this medication has which property?
Keep collection device below the level of the client's chest
A client with a chest tube is to be transported via a stretcher. When transporting the client, what would the nurse do?
Monitor the client's blood pressure during therapy.
A health care provider prescribes enalapril for a client. Which nursing action is important?
Have the prescription, dosage calculations, and pump settings checked by a second nurse.
A health care provider prescribes milrinone for a client with congestive heart failure. Which action would the nurse perform first?
check intact gag reflex (check with Dr wilson)
After observing new-onset restlessness in a client with a swallowing disorder, which action would the nurse take first?
assess respiratory status
During the administration of an antibiotic, the client becomes restless and flushed, and begins to wheeze. Which action will the nurse take after stopping the antibiotic infusion?
Tracheostomy set and oxygen
Which type of emergency equipment would the nurse ensure is readily available at the bedside after a client has surgery for a malignant lesion on a vocal cord?
Tinnitus Weakness Leg cramps
Intravenous furosemide has been prescribed for a client with severe edema and hypertension. Which subjective clinical manifestations lead the nurse to suspect that the furosemide is infusing too rapidly
Obtain blood pressure readings from both the client's arms.
The clinic nurse is assessing the blood pressure of a client diagnosed hypertension. How should the nurse assess this client's blood pressure?
Clients taking oral hypoglycemics may subconsciously relax dietary rules to gain a sense of control.
The health care provider prescribes an oral hypoglycemic medication for the client with type 2 diabetes. Which statement will the nurse need to consider when developing the teaching plan?
administer in abdomen only
The health care provider prescribes enoxaparin to be administered subcutaneously. To ensure client safety, which measure would the nurse take when administering this medication?
hypoglycemia
The health care provider prescribes metformin as monotherapy for the client with type 2 diabetes. The nurse will teach the client to monitor for which adverse effect?
to determine if the medication is adquate
The health care provider prescribes peak and trough levels after initiation of intravenous antibiotic therapy. The client asks why these blood tests are necessary. Which reason would the nurse provide?
Pallor Tachycardia Pallor occurs with hemorrhage as the peripheral blood vessels constrict in an effort to shunt blood to the vital organs in the center of the body. Heart rate accelerates in hemorrhage as the body attempts to increase blood flow and oxygen to body tissues. Urinary output decreases with hemorrhage because of a lowered glomerular filtration rate secondary to hypovolemia. Respirations increase and become shallow with hemorrhage as the body attempts to take in more oxygen. Hypotension occurs in response to hemorrhage as the person experiences hypovolemia.
When a client develops internal bleeding after abdominal surgery, which clinical manifestations would the nurse expect the client to exhibit
Listen to the client's breath sounds. Rationale Because weight gain may indicate fluid retention in this client, the nurse needs to further assess for fluid overload. Lung congestion associated with fluid overload would affect oxygenation, and the initial action of the nurse should be assessment of lung sounds. Checking for lower extremity edema will also help establish fluid overload, but peripheral edema does not increase risk for life-threatening complications such as hypoxemia. The health care provider would be notified after obtaining more assessment data. The pulse rate will be assessed, but is not directly associated with fluid overload.
When a client with a history of heart failure arrives for a scheduled clinic appointment and has gained 6 lb (2.7 kg), which nursing action has the highest priority?
Petechiae At the time of a fracture or orthopedic surgery, fat globules may move from the bone marrow into the bloodstream. Also, elevated catecholamines cause mobilization of fatty acids and the development of fat globules. In addition to obstructing vessels in the lung, brain, and kidneys with systemic embolization of small vessels from fat globules, petechiae are noted in the buccal membranes, conjunctival sacs, hard palate, chest, and anterior axillary folds
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 unique to a fat embolus?
failure to secure the catheter adequately
A client's intravenous (IV) infusion infiltrates. Which factor would the nurse recognize as the cause of the infiltration?
Paroxysmal nocturnal dyspnea
An older adult client who has type 1 diabetes and chronic bronchitis is prescribed atenolol for the management of angina pectoris. What clinical manifestation should alert the nurse to the fact that the client may be developing a life-threatening response to the drug?
red wine
A client diagnosed with tuberculosis is taking isoniazid. To prevent a food and medication interaction, the nurse will advise the client to avoid which food item?
Will meet the client's nutritional needs without causing the discomfort precipitated by eating
A client is admitted to the hospital with a diagnosis of acute pancreatitis. The health care provider's prescriptions include nothing by mouth and total parenteral nutrition (TPN). The nurse explains that the TPN therapy provides which benefit?
Mark the time and fluid level on the side of the drainage chamber
A client is admitted to the postanesthesia care unit after a segmental resection of the right lower lobe of the lung. A chest tube drainage system is in place. When caring for this tube, what would the nurse do?
continue taking meds even if i feel better
A client is diagnosed with pulmonary tuberculosis, and the health care provider prescribes a combination of rifampin and isoniazid. The nurse evaluates that the teaching regarding the medications is effective when the client reports which action as most important?
dizziness with strenuous activity
A client is receiving metoprolol. Which potential effect will the nurse teach the client to expect?
hypo-volemic shock
A client just had a total hip replacement and is experiencing restlessness and changes in mentation. Which complication would the nurse consider the client may be experiencing based on these responses?
Chronic venous insufficiency.
A client presents with swelling of bilateral lower extremities and darkening of the skin from the feet up into the lower legs. Which disease process should the nurse suspect?
Taking an antacid preparation will decrease pain due to gastric acid
A client who has a gastric ulcer asks what to do if epigastric pain occurs. The nurse evaluates that teaching is effective when the client makes which statement?
detach retina
A client who was involved in a motor vehicle crash reports seeing flashes of light. Which condition would the nurse be prepared to address?
1 Reduction in the circulating blood volume A decreased intravascular volume results in hypovolemia and hypotension, which is evidenced by a decreased blood pressure and a decreased pulse pressure. Vasomotor stimulation to the arterial walls is increased with shock. Vasodilation resulting from diminished vasoconstrictor tone is a description of neurogenic shock, which is unlikely in this situation. Although electrolyte imbalances can precipitate cardiac decompensation, cardiogenic shock is unlikely in this situation.
After a client sustains multiple internal injuries in a motor vehicle accident, the blood pressure suddenly drops from 134/90 to 80/60 mm Hg. What is the likely cause of this drop in blood pressure?
Paresthesias and paralysis
The nurse assesses a client admitted with suspected Guillain-Barré syndrome who reports numbness, which began in the hands and feet and now involves the arms, legs, and lower trunk. For which related clinical manifestations would the nurse assess in this client?
Determine the integrity of the intravenous delivery system.
The nurse assesses the client's use of a patient-controlled analgesia pump and identifies that the client attempted to self-administer the analgesic 10 times. Further assessment reveals that the client is still experiencing pain. Which action would the nurse take next?
"Screening for the human immunodeficiency virus [HIV] antibodies has minimized this risk."
The nurse is caring for a client who is to receive a blood transfusion. How will the nurse respond when the client expresses fear that acquired immunodeficiency syndrome (AIDS) may be acquired as a result of the blood transfusion?
Allergies
The nurse is reviewing a newly admitted client's medication administration record (MAR). Which element, if missing, makes the record incomplete?
Extended-release formulations are designed to be released slowly and crushing the tablet will prevent this from occurring.
The nurse prepares to administer extended-release metformin to an older adult who has asked that it be crushed because it is difficult to swallow. Which rationale will prompt the nurse to ask the provider for a different form of metformin?
To report any abdominal distress
The nurse provides medication teaching to a client with a prescription for potassium supplements. The nurse concludes that the teaching was effective when the client agrees to which commitment?
Hypokalemia Rationale:In case of hypokalemia, the nurse should assess the respiratory status of the client every 2 hours. In case of hyperkalemia, the nurse should notify the healthcare team if the heart rate falls below 60 beats per minute or T waves become spiked. In case of hyponatremia, the nurse should be aware of muscle weakness in the client and immediately check respiratory effectiveness. In case of hypernatremia, the nurse should assess the client hourly for excessive losses of fluid, sodium, or potassium.
The nurse would assess the respiratory status of the client at 2-hour intervals as a safety priority for which condition affecting the client?
Place client in a high-Fowler position; Placing the client in a high-Fowler position promotes lung expansion and gas exchange; it also decreases venous return and cardiac workload. Initiating oxygen therapy may be done, but positioning should be done first because it will have an immediate effect. Time is needed to set up the system for the delivery of oxygen
The nurse's physical assessment of a client with heart failure reveals tachypnea and bilateral crackles. Which is the priority nursing intervention?
signs of bleeding
Tissue plasminogen activator (t-PA) is to be administered to a client in the emergency department. Before beginning the infusion, which assessment is the nurse's priority?
Avoid massaging the injection site after the injection.
To prevent excessive bruising when administering subcutaneous heparin, which technique will the nurse employ?
reinforce the dressing because you are anticipating more drainage
Which action would the nurse take first after observing serosanguineous drainage on the abdominal dressing of a client in the postanesthesia care unit (PACU) who had an abdominal cholecystectomy?
monitoring breathing status
Which assessment is a nursing priority to prevent complications in clients with respiratory acidosis?
Urinary output of 200 mL during the previous 8 hours
Which assessment would be brought to the health care provider's attention before administration of intravenous potassium chloride?
Permanent tooth discoloration
Which effect has resulted in the avoidance of tetracycline use in children under 8 years old?
Eliminates surface bacteria that may contaminate the culture
Which effect of povidone-iodine would the nurse consider when using it on the client's skin before obtaining a specimen for a blood culture?
It is caused by an overactive hypothalamus.
Which statement indicates the nurse has a correct understanding about trigeminal autonomic cephalalgia (cluster headaches)?