EAQ Nursing Process - Planning

The nurse plans interventions for a client with smoke inhalation based on a negative chest x-ray and arterial blood gases that show a PO2 of 85 mm Hg, a PCO2 of 45 mm Hg, and a pH of 7.35. Which interventions should the nurse anticipate will be ordered? Select all that apply.

*Coughing *Deep breathing *Humidified oxygen

A nurse is discussing an infant's diet with a mother who is breastfeeding. Why should the nurse recommend that the infant be offered solid foods by 5 or 6 months of age? Select all that apply.

*Fetal iron reserves are depleted. *Food can be taken from a spoon.

A nurse is planning education for a parent group related to procedures to be taken if accidental poisoning is suspected. What should the nurse include? Select all that apply.

*Identify the material ingested *Call the poison control center

Which responses should a nurse expect a client experiencing hypoglycemia to exhibit? Select all that apply.

*Palpitations *Tachycardia *Nervousness

A child who has been undergoing prolonged steroid therapy takes on a cushingoid appearance. What will the nursing evaluation probably reveal? Select all that apply.

*Truncal obesity *Thin extremities

Filgrastim (Neupogen) 5 mcg/kg/day by injection is prescribed for a client who weighs 132 lb. The vial label reads filgrastim 300 mcg/mL. How many milliliters should the nurse administer? Record the answer using a whole number. ______ mL

1

What is the major nursing concern when caring for a client with the diagnosis of hyperthyroidism?

Arranging for sufficient rest periods

During a childbirth preparation class, the nurse discusses the importance of the "spurt" of energy that occurs before labor. Why is it important to conserve this energy?

Fatigue may influence pain medication requirements.

A client at 40 weeks' gestation is admitted to the birthing unit in early active labor. She tells the nurse that her membranes ruptured 26 hours ago. Assessments of the fetal heart rate range between 168 and 174 beats/min. What is the priority nursing action?

Obtaining maternal vital signs

A client at 34 weeks gestation is receiving terbutaline subcutaneously. Her contractions increase to every 5 minutes, and her cervix dilates to 4 cm. The tocolytic is discontinued. What is the priority nursing care during this time?

Promoting maternal-fetal well-being during labor

A nurse performs cupping, percussion, and postural drainage every 4 hours for a 6-month-old infant with cystic fibrosis. When is the besttime to schedule chest physiotherapy?

Two hours after meals

A client with hepatic cirrhosis begins to develop slurred speech, confusion, drowsiness, and a flapping tremor. With this evidence of impending hepatic coma, which diet can the nurse expect will be prescribed for this client?

20 g of protein, 2000 calories

A client is receiving warfarin for a pulmonary embolism. Which drug is often contraindicated when taking warfarin?

Acetylsalicylic acid

A primary healthcare provider prescribes atenolol 20 mg by mouth four times a day for a client who has had double coronary artery bypass surgery. What information is most important for the nurse to include in the discharge teaching plan for this client?

Avoid abruptly discontinuing the medication.

A nurse is caring for a client who is scheduled to have an abdominal perineal resection for colorectal cancer. The client has type B negative blood. If a blood infusion is needed, which type is preferred for administration?

B negative

What should the nurse consider as the goal of therapy when administering allopurinol to a client with gout?

Decrease uric acid production

A client who is to have sclerotherapy asks the nurse, "How did I get varicose veins?" Which etiology should the nurse take into consideration when formulating a response?

Defective valves within the veins

A client with a history of endometriosis has abdominal surgery to remove adhesions. What should this client's postoperative plan of care include?

Encouraging the client to ambulate in the hallway

After a cocaine binge an individual is found unconscious and is admitted to the hospital with acute cocaine toxicity. What should the initial nursing action be directed toward?

Establishing a patent airway

A nurse has been caring for a suicidal client for 3 weeks on an inpatient unit. One morning the client greets the nurse cheerfully and states, "Everything is looking up. I'm not going to have problems for very long." What does the client's behavior and statement indicate?

Increased risk of suicide

Which action involving client needs may a nurse delegate to a nursing assistant?

Providing ice chips to a primigravida in early labor per order

An 18-year-old primigravida at 36 weeks' gestation is admitted with a diagnosis of mild preeclampsia. What is the nurse's most important goal for this client?

Reducing her blood pressure

A nurse is caring for a client who has abruptly stopped taking a barbiturate. What should the nurse anticipate that the client may experience?

Seizures

A recovering alcoholic joins Alcoholics Anonymous (AA) to help maintain sobriety. What type of group is AA?

Self-help group

A nurse checking the perineum of a client with a radium implant for cervical cancer observes the packing protruding from the vagina. The nurse notifies the primary healthcare provider to have the packing removed. What is the primary reason that the packing needs to be removed immediately?

The radioactive packing will injure healthy tissue.