Critical Thinking Final

There is a shooting in a shopping mall. Three victims with gunshot wounds are brought to the emergency department. What should the nurse do to preserve forensic evidence? Select all that apply.

-Place each item of clothing in a separate paper bag. - Hang wet clothing to dry.

While changing the client's colostomy bag and dressing, the nurse determines that the client is ready to participate in self-care when the client:

asks about the supplies used during the dressing change.

A client is to take one daily dose of ranitidine at home to treat a peptic ulcer. The client understands proper drug administration of ranitidine when the client will take the drug:

at bedtime.

The nurse is instructing the unlicensed assistive personnel (UAP) about the correct technique for obtaining a clean-catch urine culture from a female client. Which statement indicates

"I will ask the client to clean her labia, void into the toilet, and then into the specimen cup."

Which nursing diagnosis takes highest priority for a child in the early stages of burn recovery?

Risk for infection

A client whose condition remains stable after a myocardial infarction gradually increases activity. To determine whether the activity is appropriate for the client the nurse should assess the client for:

dyspnea.

A recently extubated client has shortness of breath. The nurse reports the client's discomfort and the results of the recently prescribed arterial blood gas analysis to the health care provider (HCP). After reviewing the report of the complete blood count (see report), the nurse should also report which results to the HCP?

hemoglobin and hematocrit

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects:

respiratory alkalosis.

A client's chest tube is connected to a drainage system with a water seal. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. The fluctuation means that:

the chest tube system is functioning properly.

When examining a client who has abdominal pain, a nurse should assess:

the symptomatic quadrant last.

A client had a repair of a thoracoabdominal aneurysm 2 days ago. Which finding should the nurse consider unexpected and report to the health care provider (HCP) immediately?

weakness and numbness in the lower extremities

The nurse is developing a teaching plan for a client who will be starting a prescription for simvastatin 40 mg/day. What instructions should the nurse give the client? Select all that apply.

-"If you miss a dose, take it when you remember it." -"Report muscle pain or tenderness to your health care provider." -"Continue to follow a diet that is low in saturated fats."

A client with a history of cardiac disease has just returned to the cardiac unit post-cardiac catheterization at the femoral site. The nurse is aware that interventions for this client would include which of the following? Select all that apply.

-Check the pulse distal to the catheter insertion site. -Ensure that the client is kept flat in bed immediately after the procedure. -Monitor heart rate and rhythm.

A client is being discharged to home 3 days after transurethral resection of the prostate (TURP). What should the nurse instruct the client to do? Select all that apply.

-Drink at least 3,000 mL of water per day. -Report bright red bleeding to the health care provider (HCP). -Report a temperature over 99° F (37.2° C).

The nurse is caring for a client with diabetes insipidus. Which of the following laboratory findings are indicative of this disorder? Select all that apply.

-Elevated serum hematocrit -Elevated serum creatinine

Which of the following clients is the most appropriate candidate for whom the nurse would assist in coordinating hospice services?

A client with lung cancer and a 3- to 4-month life expectancy.

Which factors are major components of a client's general background history?

Allergies and socioeconomic status

A client returned to the recovery room after a dilatation and curettage has the postoperative medication prescriptions shown in the medical record. What should the nurse do next?

Ask the client to rate the intensity of her pain on a scale of 1 to 10, and administer the analgesia according to the intensity of the pain.

The nurse is reviewing the following worksheet when prioritizing afternoon nursing care. Which order for administering client care at 1:00 pm (1300 hours) is best?

Client 4, Client 1, Client 3, Client 2

Which statement regarding heart sounds is correct?

S1 is loudest at the apex, and S2 is loudest at the base.

The nurse is reviewing the physician orders for a client who has returned to the unit following a surgical procedure. Which of the following orders should the nurse question? Select all that apply.

-Resume all pre-op orders when the patient returns to the unit. -Offer the client a laxative of choice if there is no bowel movement tomorrow. -Administer medications as taken at home. -Leave medications at bedside for the client to take as needed.

The nurse is designing a benchmarking study to gather information about nursing care practices for wound care. Which sources of information are used for benchmarking? Select all that apply.

-government reports -literature reviews -standard-setting organizations -databases

After teaching the parent of a child newly diagnosed with Type I diabetes about signs of hyperglycemia, which sign, if stated by the parent, indicates teaching has been successful? Select all that apply.

-nausea -thirst

A middle-aged woman who is receiving radiation therapy tells the nurse that she feels inadequate as a wife and mother because she can no longer carry out her usual duties with the same energy as before. What recommendations should the nurse make to help the client cope with this situation?

Suggest that she prioritize her activities and ask for help from friends and family.

A client involved in a motor vehicle accident is admitted to the intensive care unit. The emergency department admission record indicates that the client hit her head on the steering wheel. The client complains of a headache, and a nursing assessment reveals that she has difficulty comprehending language and diminished hearing. Based on these findings, the nurse suspects injury to which lobe of the brain?

Temporal

A nurse is reviewing laboratory values for a client diagnosed with hyperlipidemia 6 months ago. Which results indicate that the client has been following his therapeutic regimen?

High density lipoproteins (HDL) increase from 25 mg/dl (0.65 mmol/L) to 40 mg/dl (1.03 mmol/L).

A client tells the nurse he is experiencing dyspnea. Which action by the nurse is most appropriate?

Placing the client in high Fowler's position

When assessing a client with cellulitis of the right leg, which finding should the nurse expect to observe?

Red, swollen skin with inflammation spreading to surrounding tissues

A graduate nurse is asked to present a case study, during interdisciplinary rounds, on a client who has compartment syndrome from a leg injury. What would be the best approach by the graduate nurse to ensure a good comfort level with the topic? Select all that apply.

Research the condition and present what was learned. Review the client's chart to obtain assessment findings and treatment.

A nurse is administering atropine sulfate to a client about to undergo electroconvulsive therapy (ECT). Which assessment indicates that the medication is effective?

The client states that his mouth is dry.

A nurse on the medical-surgical unit just received report on her client care assignment. Which client should she assess first?

The client with unilateral leg swelling who's complaining of anxiety and shortness of breath

A client who is 89 years of age is in traction for a broken hip. At 1100 on 3/26 the client is experiencing pain. Prescriptions include morphine sulfate 2 to 4 mg intravenous push every 2 to 4 hours for pain. The client rates the pain as an 8 on the visual analog scale (0-10). Prior to intervening to manage the pain, the nurse reviews the progress notes (see exhibit). At 1100 on 3/26 the nurse should:

administer 2 mg morphine sulfate IVP now and reassess in 10 to 15 minutes.

The nurse is preparing to teach a client with a peptic ulcer about the diet that should be followed after discharge. The nurse should explain that the diet should include:

any foods that are tolerated.

When monitoring a client who is receiving tissue plasminogen activator (t-PA), the nurse should have resuscitation equipment available because reperfusion of the cardiac tissue can result in:

cardiac arrhythmias.

The nurse is reviewing the postoperative prescriptions (see chart) just written by a health care provider (HCP) for a client with type 1 diabetes who has returned to the surgery floor from the recovery room following surgery for a left hip replacement. The client has pain of 5 on a scale of 1 to 10. The hand-off report from the nurse in the recovery room indicated that the vital signs have been stable for the last 30 minutes. After obtaining the client's glucose level, the nurse should first:

contact the health care provider (HCP) to rewrite the insulin prescription.