med surg. final 2
A patient who has begun to awaken after 30 minutes in the postanesthesia care unit is restless and shouting at the nurse. The patient's oxygen saturation is 96%, and recent laboratory results are all normal. Which action by the nurse is most appropriate?
Assess for bladder distention
A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse include in the plan of care in collaboration with the speech therapist?
Assess the ability to swallow before using the fenestrated tube
A client with chronic heart failure is taking a diuretic and an angiotensin-converting enzyme inhibitor and who is on a low-sodium diet tells the home health nurse about a 5 pound weight gain in the last three days. The nurse's priority action will be to
Assess the client for clinical manifestations of acute heart failure
A client hospitalized for 1 week with subacute infective endocarditis is afebrile and has no signs of heart damage. Discharge with outpatient antibiotic therapy is planned. During discharge planning with the client what is most important for the nurse to do?
Assess the client's home environment in terms of family assistance and hospital access
A newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action?
Assign the patient to a room near the nurse's station
The nurse is caring for a 65 year old client with an exacerbation of COPD who is in respiratory distress. Which intervention should the nurse implement first?
Assist the client into a sitting position at 90 degrees
The nasogastric NG tube is removed on the second postoperative day, and the patient is placed on a clear liquid diet. Four hours later, the patient complains of sharp, cramping gas pains. What action by the nurse is the most appropriate?
Assist the patient to ambulate
Following a laryngectomy a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first?
Attempt to reinsert the tracheostomy tube with the obturator in place
The surgical unit nurse has just received a patient with a history of smoking from the postanesthesia care unit. Which action is most important at this time?
Auscultate for adventitious breath sounds
Two days after an acute myocardial infarction, a client complains for stabbing chest pain that increases with a deep breath. What action will the nurse take first?
Auscultate heart sounds
While caring for a 23-year-old client with mitral valve prolapse without valvular regurgitation the nurse determines that discharge teaching has been effective when the client states that it will be necessary to
Avoid the use of over the counter medications that contain stimulant drugs
The family members of a client who has just been admitted to the intensive care unit with multiple traumatic injuries have just arrived in the ICU waiting area. Which action should the nurse take?
Describes the client's injuries and the care being provided
A client is admitted to the ED. What signs and symptoms would make the nurse suspect the client is experiencing a myocardial infarction? Select all that apply
Diaphoresis and cool, clammy skin Crushing chest pain
The nurse is providing education on risk factors of primary hypertension. Which of the following should the nurse include as modifiable risk factors? Select all that apply
Diet Obesity
The nurse is conducting a seminar on actions to decrease the risk of future hearing loss to a group of college students. Which actions should the nurse include in the teaching?
Discuss the importance of limiting exposure to amplified music
An older patient is being discharged from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, " I do not know if I can take care of myself with this patch over my eye." Which action by the nurse is most appropriate?
Discuss the specific concerns regarding self-care.
The client diagnosed with chronic otitis media is scheduled for a mastoidectomy. Which discharge teaching should the nurse discuss to the client?
Do not allow water in the ear to keep the suture line dry
The nurse is administering eyedrops to a client. Which guidelines should the nurse adhere to when instilling the drops into the eye? Select all that apply
Do not touch the tip of the medication container to the eye. Hold the lower lid down and instill drops into the conjunctiva. Gently pat the skin to absorb excess eye drops on the cheek
The nurse is completing an admission assessment on a 20 year old client diagnosed with an acute asthma exacerbation. Which signs and symptoms would the nurse expect to find?
Dyspnea and wheezing
A nurse is caring for a client who has questions concerning the various treatment options for his new diagnosis of basal cell carcinoma. Which of the following treatments should the nurse include in the discussion? Select all that apply.
Electrosurgery Topical corticosteroids Radiation therapy Monographic surgery
A nurse is developing a plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse include in the plan?
Elevate the affected leg on two pillows
The nurse is caring for a client who complains of dyspnea, chest pain, and hemoptysis. The nurse suspects a pulmonary embolism. Which of the following is priority action for the nurse? Select all that apply.
Elevate the head of the bed to a semi-fowler's position Maintain the client's IV line Provide oxygen therapy Notify the healthcare provider
A nurse obtains a health history from a patient who has 35 pack-year smoking history. The patient complains of hoarseness and tightness in the throat and difficulty swallowing. Which question is most important for the nurse to ask?
How much alcohol do you drink in an average week?
IV potassium chloride 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take?
Infuse the KCl at a rate of 10 mEq/hour
The nurse is caring for a client with moderate persistent asthma. Which daily use medications should the nurse discuss with the client? Select all that apply
Inhaled fluticasone/salmeterol Daily use of albuterol Montelukast Omalizumab
Which teaching instruction should the nurse discuss with an adult who frequently swims when discussing how to prevent external otitis media?
Insert a bulb syringe into each ear to remove excess water
A 66 year old client visited a community health fair that performed blood pressure checks. The client's blood pressure is 168/98. What is the most appropriate action for the nurse to take?
Instruct the client to see a healthcare provider as soon as possible
The clinic nurse is obtaining a history from a new client complaining of pain in both legs when walking but is relieved after a few minutes of rest. Which medical term would the nurse use to document the client's complaint?
Intermittent claudication
What information should the nurse include in the teaching plan for a young adult recently diagnosed with cystic fibrosis? Select all that apply
Perform chest physiotherapy twice daily Increase fluid intake to 1 liter daily to thin secretions Recognize and report signs and symptoms of infections Avoid anyone suspected of having upper respiratory infections
The nurse is caring for a client diagnosed with glaucoma. Which symptoms would the nurse expect the client to report?
Peripheral vision loss
Which action should the nurse take first when a patient develops a nosebleed?
Pinch the lower portion of the nose for 10 minutes
A nurse is caring for a client who has Meniere's disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make?
Please ring for assistance when you wish to get out of bed.
A client exhibiting sinus bradycardia is complaining of syncope and weakness and has a BP of 98/60. Which collaborative treatment should the nurse anticipate being implemented?
Prepare the client for insertion of a placemaker
A nurse is caring for a client who has herpes zoster. Which of the following actions should the nurse take?
Prepare to administer acyclovir
A client with an acute MI is having multifocal PVCs and couplets. The client is alert and has a BP reading of 118/78 mmHg with an irregular pulse of 86 bpm. What is the priority nursing action at this time?
Prepare to administer antidysrhythmic medication per protocol
A nurse is caring for a client who is prescribed warfarin therapy for an artificial heart valve.which of the following laboratory values should the nurse monitor for a therapeutic effect of warfarin?
Prothrombin time (PT)
Which action will the nurse take immediately after surgery for a patient who received ketamine as an anesthetic agent?
Provide a quiet environment in the postanesthesia care unit
A nurse is caring for a client who has pruritus following treatment for scabies. Which of the following actions should the nurse take?
Provide mittens for the client to wear at night
The nurse is caring for a client with COPD. What breathing technique to promote exhalation should the nurse teach?
Pursed lip breathing
The nurse is caring for a client who developed reflex tachycardia after being prescribed Isosorbide Mononitrate to treat chronic stable angina. Which of the following medications should the nurse anticipate the provider to prescribe?
Ranolazine
A 32-year-old male client who has profuse, purulent urethral discharge with painful urination is seen in the clinic. Which information will be most important for the nurse to obtain?
Recent sexual contacts
When obtaining a nursing history for a client with myocarditis what should the nurse specifically question the client about?
Recent symptoms of a viral illness, such as fever and malaise
The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective?
Reduced dyspnea with the head of bed at 30 degrees
Which action best describes the role of the certified registered nurse anesthetist on the surgical care team?
Releases or discharges patients from the postanesthesia care area.
A nurse is caring for a client who has contact dermatitis of the neck and upper chest. Which of the following is an expected finding?
Report of exposure to a skin irritant
A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 mEq/L?
Respiratory alkalosis
The nurse working on the heart failure unit knows that teaching an older female client with newly diagnosed heart failure is effective when the client states that
She will call the clinic if her weight goes from 124 to 128 pounds in a week
A client is admitted to the ED with diaphoresis, pale clammy skin, and BP of 90/70. Which intervention should the nurse implement first?
Start an IV with an 18 gauge catheter
A client's heart monitor shows sinus tachycardia and a rate of 132 bpm. The client is apneic and has no palpable pulses. What is the first action that the nurse should take?
Start cardiopulmonary resuscitation
The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take?
Teach about the need to get sputum specimens for 2 to 3 consecutive days
After teaching a client with newly diagnosed Raynaud's Phenomenon about how to manage the condition, which action by the client demonstrates that the teaching has been effective?
The client exercises indoors during the winter months
A client diagnosed with essential hypertension is taking furosemide. Which assessment data would not require immediate intervention by the nurse?
The client has a 3 kg eight gain within 1 to 2 days
A nurse is providing discharge teaching to a client who has an implantable cardioverter/ defibrillator (ICD). Which of the following information should the nurse include?
The client should hold his cell phone on the side opposite the ICD
A nurse at an outpatient center is providing discharge teaching to a client and his spouse following surgical removal of a cataract. Which of the following should the nurse include in the teaching?
The client should wear dark glasses while outdoors
Which information given by a client admitted with chronic stable angina will help the nurse confirm this diagnosis
The client states that the pain "goes away" with one sublingual nitroglycerin tablet
The employer health nurse is preparing a class regarding sexually transmitted infection. Which high-risk behavior information should be included in the information.
The more sexual partners, the greater the chance of developing an STI
An experienced nurse orients a new nurse to the postanesthesia care unit. Which action by the new nurse, if observed by the experienced nurse, indicates that the orientation was successful?
The new nurse turns an unconscious patient to the side upon arrival in the PACU.
The nurse is calculating the nurse intake for a client diagnosed with hypertensive crisis. The client has received 880 ml of D5W, IVPB and 100 ml NS, 8 ounces of water, 4 ounces of milk, and 6 ounces of chicken broth. The client's urinary output is 1,480 ml. What is the total intake for the client?
1,520 ml
Doctor order: Clindamycin Oral Susp 600 mg po qid; Directions for mixing Add 100 mL of water and shake vigorously. Each 2.5 mL will contain 100 mg of Cleocin. How many tsp of Cleocin will you administer?
3 tsp
The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned with which assessment finding is observed?
400 mL of blood in collection camber
The nurse is teaching a client recently diagnosed with primary hypertension. Which instruction should the nurse provide when discussing heart healthy exercise?
Walking 30 min/day most days of the week
A client with hypertension who is taking chlorothiazide and Lisinopril has prazosin added to the medication regimen. What is most important for the nurse to teach the client to do?
Weigh every morning to monitor for fluid retention
A client diagnosed with primary hypertension ask the nurse, "I don't know why the doctor is worried about my blood pressure. I feel just great." Which statement by the nurse would be the most appropriate response?"
"Damage can be occurring to your eyes, heart, and kidneys even if you feel great."
Which statement made\ by a client with cystic fibrosis who has a lung infection demonstrates understanding of the prescribed medication regime?
"I should do my bronchodilator first, then my dornase alpha, followed by my tobi."
The nurse is teaching a client diagnosed with primary hypertension about the DASH diet. Which statement, if made by the client, demonstrated understanding of the teaching?
"I should eat at least four to five servings of vegetables daily."
After the nurse has finished teaching a client about the use of sublingual nitroglycerin, which client statement indicates the teaching has been effective?
"I will call an ambulance if I still have pain after taking 3 nitroglycerin 5 minutes apart."
A 38 year old male client is treated for hypertension with triamterene and hydrochlorothiazide, and metoprolol. Four months after his last clinic visit, his BP returns to pretreatment levels, and he admits to not taking his medication regularly. What is the nurse's best response to this client
"The drugs you are taking can cause sexual dysfunction in many clients. Are you experiencing any problems in this area?"
A client with asthma has been prescribed an inhaled corticosteroid. What information should the nurse teach regarding this medication?
"You should immediately rinse your mouth after taking this medication."
A nurse is assessing a client who has basal cell carcinoma on her nose. The nurse should expect which of the following findings?
A small translucent papule with rolled borders
The nurse is caring for a client diagnosed with septic shock. Which assessment finding warrants immediate intervention by the nurse?
A urinary output of 90 mL in the last four hours
The healthcare provider prescribes an angiotensin-converting enzyme inhibitor for a client diagnosed with a primary hypertension. Which statement is the most appropriate rationale for administering this medication?
ACE inhibitors prevent vasoconstriction and sodium and water retention
The nurse is admitting a client with complaints of severe chest pain, which is worse with inspiration and dyspnea. The nurse interprets the client's complaints as being most consistent with?
Acute pericarditis
The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which intervention should the nurse implement? Select all that apply
Administer 325 mg chewable aspirin tablet Apply oxygen via nasal cannula
A client with acute pericarditis has pain from pericardial inflammation. Which of the following are the best nursing interventions for the client? Select all that apply
Administer NSAIDS as ordered Position the client in fowler's position with a paddled table for the client to lean o
A patient seen in the asthma clinic has recorded daily peak flows that are 75% of the baseline. Which action will the nurse plan to take next?
Administer a bronchodilator and recheck the peak flow
A nurse in an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following actions should the nurse take first?
Administer epinephrine
A nurse assists a patient on the first postoperative day to ambulate, cough, deep breathe, and turn. Which action by the nurse is most helpful?
Administer ordered anal gastic medications before these activities
A young adult client who denies any history of smoking is seen in the clinic with a new diagnosis of chronic obstructive pulmonary disease (COPD). It is most appropriate for the nurse to teach the client about.
Ae-1 antitrypsin testing
A nurse is teaching a client who is postoperative following the insertion of a permanent pacemaker. Which of the following instructions should the nurse include? Select all that apply
Count your pulse for 1 min each morning Do not wear tight clothing over the insertion are
While in the holding area, a patient reveals to the nurse that his father had a high fever after surgery. What action by the nurse is a priority?
Alert the anesthesia care provider of the family member's reaction to surgery.
A patient who has never had any prior surgeries tells the nurse doing the preoperative assessment about an allergy to bananas and avocados. Which action is most important for the nurse to take?
Alert the surgery center about a possible latex allergy
A 20-year-old has a mandatory electrocardiogram before participating on a college soccer team. The client has sinus bradycardia, rate 52 bpm. Blood pressure is 114/54 and the student denies any health problems. What action by the nurse is most appropriate?
Allow the student to participate on the soccer team
A nurse on a coronary care unit is caring for a client who has had CPR following a cardiac arrest. The client is receiving Amiodarone 540mg/30mL hr. When the client asks the nurse why he is receiving the medication the nurse should explain that it has which of the following actions?
Amiodarone is an antidysrhythmic that slows the sinus rate and increases the PR and QT intervals and decreases peripheral vascular resistance
A client who experienced an acute myocardial infarction has sinus tachycardia of 126 bpm. The nurse recognizes that if this dysrhythmia is not treated, what is the worst thing the client could experience?
An increase in infarct size
A client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure. Which signs and symptoms would the nurse expect to find when assessing the client?
Apical pulse of 110 and 4+ pitting edema of feet
An alcoholic and homeless patient is diagnosed with active tuberculosis. Which interventions by the nurse will be most effective in ensuring adherence with the treatment regimen?
Arrange for a daily noon meal at the community center where the drug will be administered
A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action?
Ask the health care provider to order a basic metabolic panel
Which diagnostic test will be most useful to the nurse in determining whether a client admitted with acute shortness of breath has heart failure?
B-type natriuretic peptide
The nurse is caring for a client following a cardiac catheterization that was inserted through the femoral artery. While turning the client, the nurse discovers blood underneath the client on his bed. Which of the following should the nurse suspect?
Bleeding from the incisional site
A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?
Blood pressure 115/68 mmHg
A charge is teaching a group of nurses about clients who report using garlic,ginger, and ginkgo biloba. The charge nurse should identify which of the following as an adverse effect of these supplements?
Increased effects of oral anticoagulants
A patient with newly diagnosed lung cancer tells the nurse, I don't think I'm going to live to see my next birthday. Which response by the nurse is best?
Can you tell me what it is that makes you think you will die so soon?
A nurse is caring for a client who has poison ivy and is prescribed diphenhydramine. Which of the following instructions should the nurse give regarding the adverse effect of dry mouth associated with diphenhydramine?
Chew on sugarless gum or suck on hard, sour candy
After receiving change of shift report on a heart failure unit which client should the nurse assess first
Client who is taking digoxin and has a potassium level of 3.1 mEq/L
A client's rhythm strip indicates a normal HR and rhythm with normal P waves and QRS complexes, but the PR interval is 0.26 seconds. What is the most important action by the nurse?
Continue to assess the client
On admission of a patient to the postanesthesia care unit, the blood pressure is 122/72. Thirty minutes after admission, the BP falls to 144/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate?
Continue to take vital signs every 15 mins
A nurse is caring for a client who has full-thickness burns over 75% of his body. The nurse should use which of the following methods to monitor the cardiovascular system?
Monitor the pulmonary artery pressure
In the postanesthesia care unit, a patient's vital signs are blood pressure 116/72, pulse 74, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take first?
Encourage the patient to take deep breaths
Which action should the perioperative nurse take to best protect the patient from burn injury during surgery?
Ensure correct placement of the grounding pad
A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first?
Epinephrine
A patient who is taking rifampin for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which is the best response by the nurse?
Explain that orange discolored urine and tears are normal while taking this medication
A client in the intensive care unit with decompensated heart failure (ADHF) complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All of the following medications have been ordered for the client. The nurse's priority action will be to
Give IV morphine sulfate 4 mg
A client with cystic fibrosis (CF) reports increased sweating and weakness during the summer months. Which action by the nurse would be the most appropriate?
Have the client add dietary salt to meals
A client diagnosed with rule out myocardial infarction experiences chest pain while walking to the bathroom. What action should the nurse implement first?
Have the client sit down immediately
The nurse is admitting a client with possible rheumatic fever. Which question on the admission history will be most pertinent to ask?
Have you had a recent sore throat?
The nurse obtains a health history from a 65-year-old client with a prosthetic mitral valve who has symptoms of infective endocarditis. Which question by the nurse is most appropriate?
Have you had dental work done recently?
Which nursing intervention will be most effective when assisting the client with coronary artery disease (CAD) to make appropriate dietary changes?
Help the client modify favorite high-fat recipes by using monounsaturated oils when possible
Which data identified during the preoperative assessment alert the nurse that special protection techniques should be implemented during surgery?
History of spinal and hip arthritis
A nurse is reviewing discharge instructions with a client who has Raynaud's disease. Which of the following client statements indicates an understanding of the teaching?
I am going to take stress management class
The nurse is providing instructions to a client with recurrent staphylococcal and seborrheic blepharitis on treatment and cleansing. Which statement if made by the client demonstrates the teaching was effective?
I can gently wash the lids margins with baby shampoo
The nurse discusses management of upper respiratory infections with a patient who has acute sinusitis. Which statement by the patient indicates that additional teaching is needed?
I can use my nasal decongestant spray until the congestion is all gone
The nurse completes discharge instruction for a patient with a total laryngectomy. Which statement by the patient indicates that additional instructions is needed?
I must keep the stoma covered with an occlusive dressing at all times
A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the provider?
I need something for the pain in my eye. I can't stand it
A 65-year-old client is diagnosed with macular degeneration. Which statement by the client indicates the client needs more teaching?
I need to use low watt light bulbs in my house
A nurse preparing education for a client is diagnosed with Meniere's disease. Which statement indicates the client understands the medical understanding for this disease?
I should sleep with the head of my bed elevated
A client diagnosed with external otitis is being discharged from the emergency department with an ear wick in place. Which statement by the client indicates a need for further teaching.
I will clean the ear canal daily with a cotton tipped applicator
Which statement by the patient indicates that the teaching has been effective for a patient scheduled for radiation therapy of the larynx?
I will need to buy a water bottle to carry with me
The nurse is providing teaching to a client on treatment for whooping cough. Which statement , if made by the client, indicates the need for additional teaching?
I will need to take a cough suppressant for my symptoms
The nurse teaches a patient about discharge instructions after a rhinoplasty. Which statement, if made by the patient, indicates that the teaching was successful?
I will safely remove and reapply nasal packing daily
A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following statements should indicate to the nurse the need for additional teaching?
I will take my medication at the first sign of an attack
A nurse is providing teaching to a client who has a prescription for heat therapy for treatment of cellulitis of the right lower leg. Which of the following client statements indicates an understanding of the teaching?
I'll wrap a warm, wet towel around my right calf every 4 hours.
The nurse is caring for a client whose telemetry shows Atrial Fibrillation. Which action should the nurse implement first?
Immediate initiation of CPR
The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake?
Increase fluids if your mouth feels dry
A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which of the findings indicates to the nurse that the client may be developing hypovolemic shock?
Increase in the heart rate from 88 to 110/min
A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?
Large incisions will be made in the eschar to improve circulation
A patient received inhalation anesthesia during surgery. Postoperatively the nurse should monitor the patient for which complication?
Laryngospasm
A patient undergoing an emergency appendectomy has been using St. John's wort to prevent depression. Which complication would the nurse expect in the postanesthesia care unit?
Longer time to recover from anesthesia
A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism. The nurse should instruct the client to avoid the following unsafe action?
Massaging her legs
A 39-year-old client with a history of IV drug use is seen at a community clinic. The client reports difficulty walking stating " I don't know where my feet are." Diagnostic screening reveals positive Venereal Disease Research Laboratory and fluorescent treponemal antibody absorption tests. Based on the client's history, what will the nurse assess? Select all that apply
Mental status for judgement and orientation Heart sounds Skin and mucous membranes for gummas
The nurse is caring for a female client with a BP of 145/90 mmHg, an HDL cholesterol of 40 mg/dL, fasting triglycerides 155 mg/dL, fasting blood glucose of 125 mg/dL, and waist measurement of 38 inches. The nurse understands the client most likely has which of the following conditions?
Metabolic syndrome
When teaching the client with newly diagnosed heart failure about a 2000 mg sodium diet, the nurse explains that foods to be restricted include
Milk, yogurt, and other milk products
Which action should the nurse include in the plan of care when caring for a client admitted with acute decompensated heart failure (ADHF) who is receiving nesiritide?
Monitor blood pressure frequently
A registered nurse is working with a licensed practical nurse in caring for a group of clients on a cardiac telemetry unit. Which nursing activity could be delegated to the licensed practical nurse?
Monitor vital signs and oxygen saturations before, during and after ambulation
The client is diagnosed with acute pericarditis. Which signs and symptoms warrants immediate attention by the nurse?
Muffled heart sounds
The nurse teaches a patient about the transmission of pulmonary tuberculosis. Which statement if made by the patient indicates that teaching was effective?
My husband will be sleeping in the guest bedroom
The nurse plans discharge teaching for a client with chronic heart failure who has prescriptions for digoxin and hydrochlorothiazide. Appropriate instruction for the client include
Notify the health care provider if nausea develops
A nurse in a clinic for a female client who was exposed to gonorrhea. Which of the following actions should the nurse take?
Obtain information about the client's recent sexual experiences
What should the nurse teach the client who has endocarditis about preventing recurrence of the infection?
Obtain prophylactic antibiotic therapy before certain invasive medical or dental procedures
Five minutes after receiving the ordered preoperative midazolam by IV injection, the patient asks to get up to go to the bathroom to urinate. Which action by the nurse is most appropriate?
Offer a urinal or bedpan and position the patient in the bed to promote voiding
A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication?
Oral digoxin 0.25 mg daily
The nurse is assessing the client diagnosed with COPD. Which assessment data requires immediate intervention by the nurse?
Oxygen flow rate set on ten (10) liters/min
A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which findings are observed during the initial assessment?
Paradoxic chest movement
A client who has chronic heart failure tells the nurse, "I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" the nurse will document this assessment finding as
Paroxysmal nocturnal dyspnea
Which assessment data collected by the nurse who is admitting a client with chest pain suggest that the pain is caused by an acute myocardial infarction?
The pain has lasted longer than 30 minutes
A 38-year-old female is admitted for an elective surgical procedure. Which information obtained by the nurse during the preoperative assessment is most important to report to the anesthesiologist before surgery?
The patient's statement that her last menstrual period was 8 weeks previously.
The nurse educator facilitates student clinical experiences in the surgical suite. Which action, if performed by the student, would require the nurse educator to intervene?
The student wears surgical scrubs in the semi restricted area.
A client with no history of heart disease has a rhythm strip that shows an occasional distorted P wave followed by a normal AV and ventricular conduction. About what should the nurse question the client?
The use of caffeine
A nurse in a community clinic is counseling a client who received a positive test result for chlamydia. Which of the following statements should the nurse provide?
This infection is treated with one dose of azithromycin
A client is admitted with a diagnosis of acute left-sided infective endocarditis. What is the best test to confirm this diagnosis?
Three blood cultures from three different sites
A 22-year-old client diagnosed with gonorrhea is treated with a single IM dose of ceftriaxone and is given a prescription for doxycycline twice daily for 7 days. The nurse explains to the client that this combination of antibiotics is prescribed to
Treat coexisting chlamydial infection
The nurse is caring for a client diagnosed with an acute myocardial infarction. Which cardiac enzyme would the nurse expect to be elevated first?
Troponin
When discussing risk factors modification with a 63-year-old client who has a 4-cm abdominal aortic aneurysm and a history of hypertension the nurse will focus discharge on which client risk factor?
Uncontrolled hypertension
A nurse in a clinic is caring for a female client who has a new diagnosis of acne vulgaris on her cheeks. Which of the following should the nurse include in the teaching plan for this client?
Use a new cosmetic pad with each limited application of makeup
The nurse plans to teach a patient how to manage allergic rhinitis. Which information should the nurse include in the teaching plan?
Use of oral antihistamines for 2 weeks before the allergy season may prevent reactions
The nurse is caring for a client with exercise-induced asthma. What information should the nurse include when providing education to the client?
Use your bronchodilator medication immediately prior to beginning exercise
The nurse is caring for a client with cystic fibrosis. What should the nurse teach as the most effective treatment for cystic fibrosis?
Vigorous and consistent airway clearance techniques
The nurse is caring for a client with intermittent asthma. What should the nurse teach about identifying specific triggers of asthma?
Viral upper infections are a common precipitating factor in acute asthma attacks
The nurse is caring for a client with COPD. Which health information is most important for the nurse to obtain?
Willingness to modify lifestyle
A client is scheduled for pulmonary function testing. Which action should the nurse take to prepare the client for this procedure?
Withhold bronchodilators for 6 to 12 hours before the examination
A 48-year-old male client who has been diagnosed with gonococcal urethritis tells the nurse he had recent sexual contact with a woman but says she did not appear to have any disease. In responding to the client, the nurse explains that
Women may not be aware they have gonorrhea because they often do not have symptoms of infection
What instructions should the nurse include when providing discharge instructions to a client diagnosed with the peripheral arterial disease? Select all that apply
You should wear comfortable shoes with rounded toes You will need to modify your diet to a low sodium low fat diet You should contact a smoking cessation program You will need to inspect your feet and legs daily
A nurse is teaching a client who has a new diagnosis of atopic dermatitis. Which of the following statements should the nurse include in the teaching?
You will need to take the entire prescription of antibiotics even if your condition improves
A client with dilated cardiomyopathy has a new onset of A Fib. that has been unresponsive to drug therapy for several days. The priority teaching needed for this client would include information about
anticoagulant therapy
The nurse is caring for a client who recently had valve replacement. Which drugs would the nurse expect to be prescribed for the client with a mechanical valve replacement?
anticoagulants
The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?
bp 90/40 mmhg
A nurse is caring for a client who has valvular heart disease and is at risk for developing left sided heart failure. Which of the following manifestations should alert the nurse that the client is developing this condition?
breathlessness
The nurse obtains a rhythm strip on a client who has had a myocardial infarction and makes the following analysis; no visible P wave, P-R interval not measurable, ventricular rate 162, R-R interval regular, and QRS complex wide and distorted, QRS duration 0.18 seconds. The nurse interprets the client's cardiac rhythm as
v tach
A client diagnosed with primary hypertension asks the nurse, "Why do I have high blood pressure?" Which response by the nurse would be most appropriate?
d. "There is no specific cause for hypertension, but there are many risk factors."
A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be the most accurate way for the nurse to evaluate fluid balance?
daily weight
Dietary teaching that includes eating dietary sources of potassium is indicated for the hypertensive client taking which drug?
hydrochlorothiazide
A nurse is assessing a male client who has advanced peripheral artery disease. Which of the following findings should the nurse expect?
leg pain at rest
The nurse is caring for a client with peripheral artery disease who is taking Clopidogrel. Which of the following medication orders should the nurse question?
omeprazole
An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action, if recommended by the nurse , will be most helpful in reducing the incidence of lung disease?
require the use of protectie
The nurse is caring for a 50-year-old client who weighs 210lbs, a 70 pack year smoking history, hypertension, high sodium intake,and a sedentary lifestyle. Which is the most important factor for peripheral artery disease to address in the nursing plan for care?
smoking cessation
A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hr following a burn injury?
sodium chloride
A patient scheduled for an elective hysterectomy tells the nurse " I am afraid that I will die in surgery like my mother did!" Which response by the nurse is most appropriate?
tell me more about what happened to your mother
The nurse is caring for a client diagnosed with arterial occlusive disease. Which assessment finding would warrant immediate intervention by the nurse?
the client has numbness and tingling
A patient arrives at the ambulatory surgery center for a scheduled laparoscopy procedure in outpatient surgery. Which information is the most concern to the nurse?
the patient is planning to drive home after surgery
A client has a 6-cm thoracic aortic aneurysm that was discovered during a routine chest x-ray. When obtaining an admission history from the client it will be most important for the nurse to ask about
trouble swallowing
