Exam 8

telemetry with newly dx atrial fibrillation; warfarin; instruct client to do when taking med

avoid injury to prevent bruising be careful using a razor or fingernail clippers report any change in color of urine or stool

primigravid; early labor; exposed to rubella at 14 weeks; after birth, assess for what complication

cardiac disorders

healthy adolescent new onset diabetic ketoacidosis and receiving IV and oral fluids; monitor intake because quick replacement may result in

cerebral edema

childs iron deficiency anemia is related to frequent infections

children with iron deficiency anemia are more susceptible to infection than are other children

nursing goal immediately following surgery; cataract removed

client describes methods to prevent an increase in intraocular pressure

internal medicine; 4 phone calls; chronic pancreatitis; contact first

client reporting increased thirst and hunger

9 yr old; ED; extensive burns in restaurant fire; important intervention

conduct wound assessment

assigning a room for client with hep A; dx would be appropriate roommate

congestive heart failure

long term peritoneal dialysis at home; reduced outflow from cath; to determine if cath is obstructed, what should the nurse ask the client

constipation

administering colchicine to client who is experiencing exacerbation of gouty arthritis; monitor for what adverse reaction

diarrhea

nurse manager appropriately behaves as autocrat in which situation

directing staff activities if client experiences a cardiac arrest

PCA to manage postop pain; do when assisting with PCA

document the clients response to pain meds

4th postpartum day; primiparous; breast engorgment; to relieve; intervention before nursing her baby

express sm. amount of breast milk

multigravid at 32 wks experienced hemolytic disease of newborn in previous pregnancy; prepare client for frequent antibody titer evaluations from where

maternal blood

health teaching about physiologic changes expected during postpartum period; bottle feeding; effective

my menstrual flow should resume in approx. 6-10 weeks

accompanying client to mall to shop; neighbor of nurse approaches and tries to engage in conversation; most appropriate response by nurse to neighbor

now is not a good time to talk, I will telephone you later

client fell and fractured neck of femur; documenting site; where

under ball looking bone

ED complaining of visual changes and severe headache; BP 210/120; denies having HTN; emergency intervention; most common cause of malignant hypertension

untreated hypertension

prescription to admin IM injection to neonate;what site should nurse select

vastus lateralis

overdosed on phencyclidine (PCP); cautious about which behavior

violent behavior

osteoporosis about alendronate sodium; take the medication

with a full glass of water and remain upright for 30 min

ED with elevated blood alcohol level; driving wrong side of road; vitals are stable and he has a headache; do first

work through personal feelings related to substance use/abuse

dx with peripheral artery disease is being d/c; statement indicates need for further education

I should wipe any injury with iodine on a cotton ball

new mother; care of neonate after circumcision with a gomco clamp; statement indicates need additional instructions

I will remove any yellowish crusting gently with water

released from restraints; I'll never get that angry and lose it again, those restraints were the worst things that ever happened to me"

I'd like to talk with you about your experience

dexamethasone for 2 weeks; deficient knowledge when comment is made

If I forget a dose, it's no big deal, i'll just take it when I remember it

UAP psychiatry; balance in therapeutic milieu; further teaching

controlling clients helps them feel more comfortable

L&D at 30 weeks; hx of cesarean birth and reports severe abdominal pain that started less than 1 hr ago; better after vomit; loses consciousness; fetal HR is 100; priority intervention

prepare the client for immediate surgery

oncology unit; RN, LPN, UAP; client for RN

52 yr old with lung cancer admitted for acute dyspnea

outpatient addiction; now he drinks at home from the time he comes home from work until bed; priority first to last make comments

I hear how confused and frustrated you are it can happen that as one person sobers up, the spouse deteriorates what have you tried to do about your husbands behaviors what do you think you could do to have your husband come in for evaluation

wearing a back brace after spinal fusion; effective teaching

I should wear a thin cotton undershirt under the brace

statement about heart sounds is correct

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

special therapy using needles inserted in specific areas along channels in skin

acupuncture

dx ovarian cancer; spread to outside of pelvis; wants palliative care instead of aggressive therapy; priority nursing dx

acute pain

hemodialysis treatments; BP 200/100, HR 110, RR 36, o2 sat 89%; intervention

administer oxygen

long leg cast how to use crutches properly while descending a staircase; transfer body weight to the unaffected leg and then

advance both crutches

nurse manager; include what items as part of personnel budget

anticipated overtime payments for staff

male; impotence; which medication is a contributing factor

antihypertensives

initial assessment of post op client; IV infusion is different from solution ordered by physician; first action

assess the client, call physician, then hang the ordered solution

schizophrenia is mute, cant perform ADLs and stares out window for hours; first priority

assist the client with feeding

nurse and NA caring for a group of adolescents; task delegate to NA

assisting adolescent dx with paraplegia with a meal

arm cast reports severe pain in affected extremity and decreased sensation and motion; swelling in fingers increased; priority

call HCP

primiparous; 20 hrs after giving birth; starting postpartum exercises; instructions most appropriate

flex the knees while supine then inhale deeply and exhale while contracting the abdominal muscles

liquid oral iron supplements; child; most important information to provide

give the medicine via a dropper or through a straw

receiving shift report on a group of clients; nurse see first

heart failure who has a PaO2 of 75 and O2 sat of 90% on a nonrebreather mask

heat and cold treatments; manage arthritis; knowledge deficit

heat producing liniments can be used with other heat devices

depression; hospitalized for 3 days; tranylcypromine sulfate; tyramine foods reaction

hypertensive crisis

diabetes for 10 years; nurse gives usual dose of insulin at 7 am, at 1030 the client has light headedness and sweating; report and recommend intervention for

hypoglycemia

correctional facility wearing handcuffs; 2 officers socializing with nursing staff; best action

insist that the officers stay in the room at all times

asthma; focused assessment to detect

inspiratory and expiratory wheezing

family stage intervention for alcoholic adolescent; successful when adolescent

is motivated to enter an alcohol rehab program

cell cycle nonspecific alkylating agent thiotepa 60 mg weekly for 4 weeks by bladder instillation; chemo; how does thiotepa exert its therapeutic effect

it interferes with DNA replication and RNA transcription

admin moderate sedation to client with COPD; next action based on principle that

it may be necessary to raise the head of this clients bed

teaching adolescent with seizure disorder; valporic acid; immediately report what s/s to HCP

jaundice

stage IV parkinsons is admitted to ED with heart failure; no CPR;LPN says the client shouldnt have come to the hospital because they have an advance directive; RN response

just because the client has an advance directive doesnt mean that we shouldnt treat reversible conditions such as heart failure

neonate is returned to mothers room from nursery; mother undress baby and check diaper; nurse respond

let me know if you need any assistance or supplies for you or the baby

fecal impaction should watch for

liquid or semiliquid stools

medication appropriate to admin if prescribed to client experiencing symptoms of early alcohol withdrawal

lorazepam

prenatal record; gravida 2 para 0111; pregnant twice, what else does this info reveal

one pregnancy resulted in an abortion and one resulted in a preterm neonate who is living

ovarian cancer to a group; topic priority

ovarian cancer s/s are often vague until late in development

activity restriction and sexual dysfunction; tests completed and dx L5-S1; assessment findings should be expected

pain radiating down the right leg

assessing pregnant client using leopolds maneuvers; actions appropriate for this

palpate the clients upper abdomen using both hands note the shape and consistency of the palpated part note the mobility of the palpated part

mother asks the nurse again what caused her childs phenylketonuria (PKU); why does she keep asking

parents of a chronically ill child commonly require a long time to work through the grieving process for their childs disease

teaching a client with emphysema how to do pursed lip breathing; expected outcome

prolonged exhalation

one on one teaching the client doesnt make eye contact; culturally sensitive strategy would be appropriate

provide detailed written information

12 yr old with CF treated for pneumonia; HCP calling in telephone order for ampicillin; take what actions

repeat the prescription to the HCP ask the HCP to confirm that the prescription is correct as understood by nurse

sexual contact with someone whom she suspects has genital herpes; information should nurse give

report any difficulty urinating

new nurse asked to start IV on antepartum client; isn't familiar with IV pumps used; should

review the units procedure manual

diazepam 10 mg IV for status epilepticus; statement about diazepam is true

should be administered no faster than 5 mg/min in adult

custody of clients daily kardex and care plan; to give change of shift report; steps to maintain confidentiality

shred the documents or place them in a container to protect confidentiality

lab value will require intervention in client receiving lithium

sodium 130

suspicious of staff members; help establish therapeutic relationship; plan

spend brief intervals with the client each day

bowel resection; 7 days postop for removal of staples; mid incision pain; incision is separating; priority

stop the staple removal, cover the incision, report the findings to the physician

following cesarean birth for abruptio placentae; multigravid; I feel like such a failure; nurse consider when responding

the clients feeling of grief is a normal reaction

L&D area; believes membranes have ruptured; when getting hx what should nurse ask first

the time of membrane rupture