Med surg Hesi
A client who had C5 spinal cord injury two years ago is admitted to the emergency department with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment findings should the nurse expect this client to exhibit?
Pain and burning sensation upon urination and hematuria
An older client with long-term type two diabetes mellitus is seen in the clinic for a routine health assessment. Which assessments would the nurse complete to determine if a patient with type two diabetes Mellitus is experiencing long term complications?
Sensation in feet and legs Skin condition of lower extremities Visual acuity
An adult client is diagnosed with restless leg syndrome and is referred to the sleep clinic. The healthcare provider prescribes ferrous sulfate 325mg PO daily Which laboratory values should the nurse monitor?
Serum iron and ferritin
A nurse caring for a client with diabetes insipidus (DI). Which data warrants the most immediate intervention by the nurse?
Serum sodium of 185mEq/L (185 mmol/L)
While caring for a client with full thickness burn covering 40% of the body the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider the nurse should review which of the clients laboratory values?
White blood cell count
The healthcare provider prescribes penicillin 200,000 units IM for a client with pneumonia. Available vial is labeled penicillin 500,000 units. How many ML should the nurse administer to this client?
0.4
A client receives a prescription for 1 L of lactated ringers IV to be infused over six hours. How many ML/hr Should the nurse program the infusion pump to deliver
167
Which client has the highest risk for developing skin cancer?
A 65 year old fair skin client who is a construction worker
The family suspects that acquired immune deficiency syndrome dementia is occurring in their son who is HIV positive. Which symptom confirms there suspicions?
A change has recently occurred in his hand writing
A client receives Prescriptions for a multi drug regimen for the treatment of tuberculosis. Which information should the nurse prioritize?
Adherence to the regimen is imperative
A client with the history of peptic ulcer disease is admitted after vomiting bright red blood several times over the course of two hours. In reviewing the laboratory results the nurse finds the clients hemoglobin is 12g/dl And the hematocrit is 35%. Which action should the nurse prepare to take?
Administer 1000 ML's normal saline
an adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action?
Administer IV antibiotics as prescribed
A client with lung cancer who wears a subcutaneous morphine sulfate patch for pain is short of breath and is difficult to arouse. When performing a head to toe assessment the nurse discovers for analgesic patches on the clients body. Which intervention should the nurse implement first
Administer a narcotic antagonist
Four days following an abdominal aortic aneurysm repair the client is exhibiting edema of both lower extremities and pedal pulses are not palpable. Which action should the nurse implement first?
Assess pulses with a vascular Doppler
An older Adult client with a long history of chronic obstructive pulmonary disease is omitted with progressive shortness of breath and persistent cough. The client is anxious and is complaining of dry mouth. Which intervention should the nurse implement?
Assist client to an upright position
A client with cholelithiasis is admitted with jaundice due to obstruction of the common bile duct. Which finding is most important for the nurse to report to the healthcare provider?
Distended hard and rigid abdomen
While completing a health assessment For a client with migraine headaches the nurse assesses bilateral weakness in the clients hand grips. The client reports joint pain and trouble twisting a door knob due to weakness. Which action should the nurse take in response to these findings?
Consult with the occupational therapist for a functional assessment
The home health nurse provides teaching about insulin self injection to a client who was recently diagnosed with diabetes mellitus. When the client begins to perform a return demonstration of an insulin injection into the abdomen as seen in the video which instruction should the nurse provide?
Continue with the insulin injection
A client with gouty arthritis reports tenderness and swelling of the right ankle and great toe. The nurse observes the area of inflammation extends above the ankle area. The client receives prescriptions for colchicine and indomethacin. Which instruction should the nurse include in the discharge teaching?
Drink at least 8 cups of water per day
When conducting discharge teaching for a client diagnosed with diverticulosis which diet instruction should the nurse include?
Eat high fiber diet and increase fluid intake
The nurse is collecting information from a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client maintain the pain Which assessment data is most important for the nurse to obtain?
Eating patterns and dietary intake
The nurse is obtaining a health history from a new client who has a history of kidney stones. Which statement by the client indicates an increased risk for renal calculi?
Eats a vegetarian diet with cheese 2 to 3 times a day
The nurse is planning care for an older adult client who experienced a cerebrovascular Accident several weeks ago. The client has expressive aphasia and often becomes frustrated with the nursing staff. Which intervention should the nurse implement?
Encourage clients use of pitcher chart
The nurse is providing teaching to a client with type two diabetes mellitus and peripheral neuropathy. Which information should the nurse provide?
Family members can help with regular foot exams
Which food is most important for the nurse to encourage a client with Osteomalacia to include in a daily diet?
Fortified milk and cereal
An obese client with emphysema who smokes at least a pack of cigarettes daily is admitted after experiencing a sudden increase in dyspnea and activity intolerance. Oxygen therapy is initiated and it is determined that the client will be discharge with oxygen. Which information is most important for the nurse to emphasize in the discharge teaching plan?
Guidelines for oxygen use
A client with a history of type one diabetes and asthma is readmitted to the unit for the third time in two months with a current fasting blood sugar of 325. The client describes to the nurse of not understanding why the blood glucose level continues to be out of control. Which interventions should the nurse implement? SATA
Have the client describe a typical day at work home and social activities Have a client demonstrate technique used to monitor blood glucose level
The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis?
Hypoalbuminemia that results in the decreased colloidal oncotic pressure
A hospitalized client with peripheral arterial Disease is instructed regarding leg and foot care. Which statement by the client indicates to the nurse that learning has occurred?
I can use a mirror to check the bottoms of my feet for signs of breakdown
A client with the history of asthma and bronchitis arrives at the clinic with shortness of breath productive cough with thickened tenacious mucous and the inability to walk up a flight of stairs without experiencing breathlessness which action is most important for the nurse to instruct the client about self care
Increase the daily intake of oral fluids to liquefy secretions
The nurse observes an increase number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (turp) What is the best initial nursing action?
Increase the flow of the bladder irrigation
During spring break a young adult presents to the urgent care clinic and reports a stiff neck a fever for the past six hours And a headache. Which intervention is most important for the nurse to implement first?
Initiate isolation precautions
A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse?
Irregular apical pulse
An adult Who was recently diagnosed with glaucoma tells the nurse " it feels like I am driving through a tunnel" The client expresses great concern about going blind. Which nursing Instruction is most important for the nurse to provide this client?
Maintain prescribed eyedrop regimen
The nurse is caring for a client in the post anesthesia care unit who underwent a thoracotomy two hours ago. The nurse observes the following vital signs: HR 140bmp RR 26 BP 140/90 Which intervention is most important for the nurse to implement?
Medicate for pain and monitor vital signs according to protocol
A client arrives to the medical surgical unit four hours after a transurethral resection of the prostate. A triple lumen catheter for continuous bladder irrigation with normal saline is infusing and the nurse observes dark pink tinged outflow with blood clots in the tubing and collection bag. Which action should the nurse take?
Monitoring catheter drainage
The nurse is preparing a client for surgery who was admitted to the emergency center following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the postoperative assessment The nurse determines that the client currently receives heparin sodium 5000 units SQ daily. What is the priority nursing action?
Notify the healthcare provider of the clients medication history
The nurse assesses a client who is newly diagnosed with hyperthyroidism and observes that the clients eyeballs are protuberant, causing a wide-eyed appearance and eye discomfort. Based on this finding, which action should the nurse include in this clients plan of care?
Obtain a prescription for artificial drops
A client tells the clinic nurse about experiencing burning on urination and assessment reveals that the client had sexual intercourse four days ago with a person who was casually met. Which action should the nurse implement?
Obtain a specimen of urethral drainage for culture
A client with herpes zoster on the thorax tells the nurse of having difficulty sleeping. Which is the probable etiology Of this problem?
Pain
To reduce the risk for pulmonary complication for a client with amyotrophic lateral sclerosis (ALS). Which interventions should the nurse implement? SATA
Perform chest physiotherapy Teach the client breathing exercises Encourage use of incentive spirometer
A client is hospitalized with heart failure (HF). Which intervention should the nurse implement to improve ventilation and reduce venous return?
Place the client in high Fowler position
The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs Which laboratory results of the nurse review?
Platelet count
The nurse is caring for a client who is postoperative for a femoral head fracture repair. Which intervention should the nurse plan to administer for deep vein thrombosis prophylaxis? SATA
Pneumatic compression devices Calf pump exercises Prescribed anticoagulant therapy
The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. which instructions regarding skin care of the portal site should the nurse provide?
Protect the skin of the radiation portal site from sunlight exposure
The nurse is providing discharge instructions to a client who is receiving prednisone 5 mg by mouth daily for a rash due to contact with poison ivy. Which symptom should the nurse tell the client to report to the healthcare provider?
Rapid weight gain
A client in the operating room received succinylcholine. The client is experiencing muscle rigidity and has an extremely high temperature. Which action should the nurse implement?
Repair ice packs for placement in the clients auxiliary area
After three days of persistent epigastric pain a female client Presents to the clinic. She has been taking oral anti-acids without relief. Her vital signs are 122 bpm respirations 16 breaths per minute oxygen saturation 96% and blood pressure 116/70 the nurse obtains a 12 lead ECG. Which assessment finding is most critical?
ST elevation in 3 leads
A client with acute renal injury weighs 50kg And has potassium level of 6.7 is admitted to the hospital. Which prescribe medication should the nurse administer first?
Sodium polystyrene sulfonate 15grams by mouth
The healthcare provider prescribes diagnostic test for a client whose chest x-ray indicates pneumonia. Which diagnostic test should the nurse review for implementation in the most therapeutic treatment of pneumonia?
Sputum culture and sensitivity
A client with chronic kidney disease is started on hemodialysis. During the first dialysis treatment the clients blood pressure drops from 150/90 to 80/30. Which action should the nurse take first?
Stop the dialysis treatment
The nurse is developing a plan of care for a client who reports blurred vision and Who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?
The clients daily blood pressure will be less than 140/80 this month
A client with orthopnea expresses concern about the ability to get enough air during a scheduled thoracentesis. On which information should the nurse response be based?
The procedure is performed with the client in an upright position
The nurse is obtaining the admission history for a client with suspected peptic ulcer (PUD). Which subjective data reported by the client supports this medical diagnosis?
Upper mid-abdominal pain described as gnawing and burning
A client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that the client's distal pulses are diminished in the left foot. Which interventions should the nurse implement? SATA
Verify pedal pulses using a Doppler pulse device Evaluate the application of the splint to the left leg Monitor left leg for pain, pallor, paresthesia, paralysis pressure
