NURS 3234 Exam 3 Review Questions

The client has just returned from surgery. The client asks you for an extra dose of pain medication. What would be some signs that the client is in severe pain? Select all that apply.

elevated respiratory rate decreased blood pressure

Magnesium Normal Range

1.3-2.3 mEq/L

Sodium Normal Range

135-145 mEq/L

A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/ml What is the flow rate?

50 gtt/min

The nurse is conducting an assessment on a 42-year-old female client. The client admits to having unprotected sex with multiple individuals over the years. Based on the data collected during the assessment, which disorder should the nurse suspect this client has?

Syphilis this also had a picture with it ik i showed a fever

The nurse is assessing an older adult client that reports feeling fatigued and tired throughout the day. What intervention by the nurse will assist with the client's report of fatigue?

have the client further evaluated for depression

Referred pain with a MI

to neck, shoulder, chest or arms

The nurse is caring for a client who is being discharged with total parenteral nutrition (TPN) to be delivered via peripherally inserted central catheter (PICC). When teaching the client about care and management of the PICC line at home, what point(s) will the nurse include? Select all that apply.

"Contact your health care provider if you see yellow or greenish drainage at the PICC site." "If you have a cold or flulike symptoms, wear a mask when you are preparing to give yourself TPN." "Ensure that you have washed your hands thoroughly before handling the PICC line."

The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response?

"Let me refer you to the blood bank so they can provide you with information."

The health care provider is concerned that the client has hypokalemia. During the physical examination, which question should the nurse ask the client?

have you been experiencing muscle weakness or leg cramps?

The nurse is conducting an assessment on a newly admitted 18-year-old client. When questioned about sexual preference, the client appears slightly confused and confesses to not being sure. Which is an appropriate response(s) from the nurse? Select all that apply.

"What has happened to cause you to question yourself?" "Have you discussed this with your family?" "What have you done to help you try to determine this?"

A nurse is teaching a client regarding a newly implanted venous access system. Which statement by the nurse is incorrect?

"You won't have to endure any more needlesticks."

Edema

+1 Pitting = 2mm +2 = 4mm +3 = 6mm +4 = 8mm

A nurse is assessing an adult client with back pain. The client is unable to speak English. Which pain scale is most appropriate for the nurse to use in assessing the client's pain?

0-10 numeric pain rating scale

A nurse is preparing an IV solution for a patient who has hypernatremia. Which solutions are the best choices for this condition? Select all that apply. 5% dextrose in 0.9% NaCl 0.9% NaCl (normal saline) Lactated Ringer's solution 0.33% NaCl (⅓-strength normal saline) 0.45% NaCl (½-strength normal saline) 5% dextrose in Lactated Ringer's solution

0.33% NaCl 0.45% NaCl

Phlebitis Scale

0: no symptoms; 1: erythema w/or w/o pain; 2: pain at access site w/erythema and/or edma; 3: pain at access site with erythema and/or edema; streak formation, palpable cord; 4: pain at access site w/erythema and/or edema, streak formation, palpable cord more than 1 inch long, purulent drainage

A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells?

1 unit over 2 to 3 hours, no longer than 4 hours

The nurse is assessing a newly admitted client and finds that he has edema of his right ankle that is 2 mm and just perceptible. The nurse documents this at which grade?

1+

Which individual with diarrhea for three days is most likely to suffer from fluid and electrolyte imbalance?

infant

The nurse is administering 1,000 mL 0.9 normal saline over 10 hours (set delivers 60 gtt/1 mL). Using the formula below, the flow rate would be: gtt/min = milliliters per hour x drop factor (gtt/mL) ÷ 60 min/hr

100 gtt/min

The nurse is monitoring intake and output (I&O) for a client who has diarrhea. What will the nurse document as input on the I&O record? Select all that apply.

100 mL from melted ice chips serving of jello infusion of intravenous solution cup of ice cream

How long to infants typically sleep in a day?

16-17 hours in 4 hour chunks throughout the day

The client has vancomycin 250 mL intravenously prescribed daily. The vancomycin is to be administered over 90 minutes through an IV administration pump. How many mL/hr would the nurse set the IV administration pump to administer the vancomycin? Record your answer using a whole number.

167

When monitoring an IV site and infusion, a nurse notes pain at the access site with erythema and edema. What grade of phlebitis would the nurse document? 1 2 3 4

2

A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the nurse documents: "Pitting edema; 6-mm pit; pit remains several seconds after pressing with obvious skin swelling." What grade of edema has this nurse documented? 1+ pitting edema 2+ pitting edema 3+ pitting edema 4+ pitting edema

3+

Phosphate (PO42-) Normal Range

2.5-4.5 mg/dL

Bicarbonate (HCO3-) Normal Range

25-29 mEq/L

A nurse is measuring the intake and output of a client who is dehydrated. What is the average adult daily fluid intake in milliliters that the nurse would use as a comparison?

2600 ml

Potassium Normal Range

3.5-5.0 mEq/L

A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL?

3000

The nurse is calculating the infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 8 hours, with gravity infusion. Your tubing delivers 20 gtt [drops]/1mL. What is the infusion rate?

42 gtt/min

Which fluid should be administered slowly to prevent circulatory overload?

5% NaCl

A nurse is administering 500 mL of saline solution to a patient over 10 hours. The administration set delivers 60 gtts/min. Determine the infusion rate to administer via gravity infusion.

50 you do (500*60)/600

Which example best supports the diagnosis of Sexual Dysfunction: Dyspareunia?

50 year old woman in the process of menopause has pain and burning during intercourse

Calcium Normal Range

8.5-10.5 mg/dL

The nurse is calculating an infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 12 hours using an electronic infusion device. What is the infusion rate?

83 ml/hr

A client with type AB blood has experienced a precipitous drop in hemoglobin levels due to a gastrointestinal bleed and now requires a blood transfusion. Which blood types may this client safely receive? Select all that apply.

A, B, AB, O

A nurse is caring for an older adult with type 2 diabetes who is living in a long-term care facility. The nurse determines that the patient's fluid intake and output is approximately 1,200 mL daily. What patient teaching would the nurse provide for this patient? Select all that apply. A) "Try to drink at least six to eight glasses of water each day." B) "Try to limit your fluid intake to 1 quart of water daily." C) "Limit sugar, salt, and alcohol in your diet." D) "Report side effects of medications you are taking, especially diarrhea." E) "Temporarily increase foods containing caffeine for their diuretic effect." F) "Weigh yourself daily and report any changes in your weight."

A, C, D, F

The nurse is caring for a client who has a long history of using opioid pain medication. Which action will the nurse take to further assess the client's pain and provide pain relief?

Acknowledge the pain as the client reports it and administer pain medication as prescribed.

A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient? Encourage foods and fluids with high sodium content. Administer oral K supplements as ordered. Caution the patient about eating foods high in potassium content. Discuss calcium-losing aspects of nicotine and alcohol use.

Administer oral K supplements as ordered

Which nursing interventions would be anticipated with hospice care? Select all that apply.

Administer prescribed morphine for pain control. Ease respiratory function by providing oxygen via nasal cannula. Administer prescribed antiemetics to control nausea. Insert a Foley catheter to prevent incontinence.

The community health nurse is preparing for a family planning clinic. The nurse identifies which factors that influence contraceptive choices? Select All That Apply

Age Marital status Desire for future pregnancy Religious beliefs Level of education

A nurse is changing a client's peripheral IV dressing. Which step is recommended in this procedure?

Apply chlorhexidine to the site in order to disinfect.

The nurse is caring for a client with severe edema. Which intervention will the nurse choose to restore fluid balance? Select all that apply.

Ask provider to order a low-salt diet. Administer furosemide as ordered. Reduce infusing fluid volume as ordered. Treat the underlying condition that contributes to increased fluid volume.

Which nursing interventions would be appropriate for a client diagnosed with deficient fluid volume? Select all that apply.

Intravenous therapy Electrolyte management Nutrition management

A 28-year-old male comes to the clinic for an evaluation. The client complains of a penile discharge. After completing an assessment, the nurse suspects that the client has a chlamydia infection based on which finding? Select all that apply.

Burning on urination Swollen testes Testicular pain

A nurse measures a client's 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse also do with the information?

Compare the total intake and output of fluids for the 24 hours.

A nurse is monitoring a patient who is receiving an IV infusion of normal saline. The patient is apprehensive and presents with a pounding headache, rapid pulse rate, chills, and dyspnea. What would be the nurse's priority intervention related to these symptoms? Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. Slow the rate of infusion, notify the primary care provider immediately and monitor vital signs. Pinch off the catheter or secure the system to prevent entry of air, place the patient in the Trendelenburg position, and call for assistance. Discontinue the infusion immediately, apply warm compresses to the site, and restart the IV at another site.

Discontinue infusion immediately, monitor vitals signs, and report findings to primary care provider immediately

Within 15 minutes after the start of a blood transfusion, the client complains of chills and headache. During frequent vital signs, the nurse begins to see an elevation in the temperature. What condition is the client experiencing?

febrile reaction

The nurse is caring for a client with "hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy." What is an appropriate expected outcome?

ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet.

Which of the following statements is an appropriate nursing diagnosis for a client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion?

Extracellular Volume Excess related to heart failure, as evidenced by edema and orthopnea

A 13-year-old female client comes in for a sports physical for school. During the exam, the client mentions she has a great boyfriend. Which question should the nurse prioritize with this client?

Have you received HPV vaccination?

Which statement by the client indicates acceptance of dying?

I have finalized all my financial arrangements for my family

A nurse is collecting a sexual health history from an older adult woman who is postmenopausal. Which client statement requires further education by the nurse?

I have noticed I have less lubrication with sexual intercourse

A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause?

I've been taking antacids almost every 2 hours over the past several days

A patient has been encouraged to increase fluid intake. Which measure would be most effective for the nurse to implement? Explaining the mechanisms involved in transporting fluids to and from intracellular compartments. Keeping fluids readily available for the patient. Emphasizing the long-term outcome of increasing fluids when the patient returns home. Planning to offer most daily fluids in the evening.

Keeping fluids readily available for the patient

A client is experiencing withdrawal from alcohol and admitted to the behavioral health unit. The client begins to have muscle weakness, tremors, hyperactive deep tendon reflexes, and a change in mental status. What should the nurse prepare to replace in this client?

Magnesium

A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable indicator of a patient's fluid balance status? Recording intake and output. Testing skin turgor. Reviewing the complete blood count. Measuring weight daily.

Measuring daily weight

The clinic nurse sees the client today and asks about his chief concern. The client describes to the nurse his inability to attain an erection. Which would be a priority for the nurse to assess? Select all that apply.

Medications that the client is taking Specifics about the erectile problem If there is a history of diabetes

Which acid-base imbalance would the nurse suspect after assessing the following arterial blood gas values: pH, 7.30; PaCO2, 36 mm Hg; HCO3−, 14 mEq/L? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis

Metabolic acidosis

A nurse is providing care to a client who has been vomiting for the past 2 days. The nurse would assess this client for which imbalance? Select all that apply.

Metabolic alkalosis Hypokalemia

A nurse is performing physical assessments for patients with fluid imbalance. Which finding indicates a fluid volume excess? A pinched and drawn facial expression Deep, rapid respirations. Moist crackles heard upon auscultation Tachycardia

Moist crackles heard upon auscultation

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response?

fluid in the tissue space between and around cells

The nurse is caring for a client whose blood type is A negative. Which donor blood type does the nurse confirm as compatible for this client?

O negative

The nurse is caring for a client whose blood type is B negative. Which donor blood type does the nurse confirm as compatible for this client?

O negative

The client is to receive two units of packed red blood cells (PRBC) for anemia following surgery. The nurse is preparing to administer the first unit. What interventions would the nurse take to administer the PRBC safely? Select all that apply.

Obtain baseline vital signs prior to beginning the transfusion. Verify client identification and blood product information with a second nurse. Wear clean gloves when spiking the blood container with the administration set. Check that informed consent has been obtained from the client.

The client has a sodium level of 131 mEq/L and has been placed on fluid restrictions of 1,000 mL per day. What interventions would the nurse include in the plan of care to assist the client in adhering to the fluid restriction? Select all that apply.

Offer the client fluids in small containers. Provide a moisturizer for the lips and mouth. Remove the water pitcher from the client's bedside.

ACID BASE BALANCE

PH 7.35-7.45 (high means basic) PaCO2 35-45 (high means acidic) HC03 22-27 (high means basic)

A client with chronic anemia is admitted for the administration of blood. What would the nurse expect the physician to order?

Packed cells

The nurse is caring for a client suspected of being infected with human papillomavirus (HPV). Which clinical manifestation observed by the nurse would correlate with this suspicion?

Pale, soft, papillary lesions on the genitalia and perianal area

The nurse is working in the emergency department when a male client states, "I have been exposed to gonorrhea from a sexual partner and I think I have it." What symptoms should the nurse assess in this client that correlate with the client's suspicions of infection? Select all that apply.

Purulent penile discharge difficulty urinating increased frequency of urination

A nurse is flushing a patient's peripheral venous access device. The nurse finds that the access site is leaking fluid during flushing. What would be the nurse's priority intervention in this situation? Remove the IV from the site and start at another location. Immediately notify the primary care provider. Use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes. Aspirate the catheter and attempt to flush again.

Remove the IV from the site and start at another location

A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse's priority actions related to these symptoms? Slow or stop the infusion; monitor vital signs, notify the health care provider, place the patient in upright position with feet dependent. Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider stat, administer antihistamine parenterally as needed. Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider, and treat symptoms. Stop the infusion immediately, obtain a culture of the patient's blood, monitor vital signs, notify the health care provider, administer antibiotics stat.

Slow or stop the infusion; monitor vital signs, notify the health care provider, place the patient in upright position with feet dependent.

The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. Which action should the nurse take?

Stop the transfusion and notify the health care provider.

A nurse is inspecting the IV access site of a client receiving intravenous therapy. The nurse suspects that the IV has infiltrated based on which finding at the site? Select all that apply.

Swelling Pallor Coolness

What signs of complications and their probable causes may occur when administering an IV solution to a client? Select all that apply.

Swelling, pain, coolness, or pallor at the insertion site may indicate infiltration of the IV. Redness, swelling, heat, and pain at the site may indicate phlebitis. Local or systemic manifestations may indicate an infection is present at the site.

The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is:

fluid volume excess

Infiltration

The escape of fluid into the surrounding tissue when the IV catheter is not in the vein; dislodged needle, penetrated vessel - swelling, pallor, coldness, pain around site, significant decrease in flow rate

A nurse uses an infusion pump to administer the IV solution to a client. The nurse is aware that an infusion pump adjusts the pressure according to the resistance it meets and there is a possibility that the needle may get displaced. How would a change in the needle's position affect the infusion pump?

The pump will continue to infuse the fluid even when the needle is displaced

Isotonic Solutions

Total osmolality close to that of the ECF; replace ECF → no fluid shift b/c solutions are equally concentrated • 0.9% NaCl (normal saline solution). • Lactated Ringer's solution.

A male client comes to the clinic because he thinks that he has syphilis. Which test would the nurse expect the client to have done?

VDRL

The nurse is preparing to administer fluid replacement to a client. Which action should the nurse take first?

Verify the prescription for type of solution and amount of infusion.

A dialysis unit nurse caring for a client with renal failure will expect the client to exhibit which fluid and electrolyte imbalances?

fluid volume excess and acidosis

A client with protracted nausea and vomiting has been receiving intravenous solution at 125 ml/h for the past several hours. The administration of this solution has resulted in an increase in blood pressure because the water in the solution has passed through the semipermeable membrane of blood cells, causing them to swell. What type of solution has the client been receiving?

a hypotonic solution

The oncoming nurse is assigned to the following clients. Which client should the nurse assess first?

a newly admitted 88 year old with a 2 day history of vomiting and loose stool

During a well-check visit of a toddler, the parent mentions that the child is exhibiting sexual behaviors. Which information on growth and development of a toddler will the nurse discuss with the parent?

acknowledge that masturbation is normal

The nursing instructor is talking with the junior nursing class about male reproductive issues. The instructor tells the students that the causes of erectile dysfunction include which of the following? Select all that apply.

alcoholism spinal cord trauma diabetes

A client with dehydration will have an increase in:

aldosterone

A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs?

an implanted central venous access device (CVAD)

A woman reports pain with intercourse. Which client medications should the nurse check for that contribute to dyspareunia?

antihistamines

A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client?

avoid salty or excessively sweet fluids

A client has been admitted with fluid volume deficit. Which assessment data would the nurse anticipate? Select all that apply.

blood pressure 100/48 mmHg poor skin turgor heart rate 128/bpm

A 16-year-old girl tells the nurse that her friend has genital warts and asks the nurse how to make sure that she does not get them. Which of the following should the nurse recommend?

get the HPV vaccine

A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that he had a banana, yogurt, and bran cereal for breakfast and a turkey sandwich with a glass of milk for lunch. The intake of which food would be a cause for concern?

banana

The nurse is providing care for a client with a peripheral intravenous catheter in situ. What intervention should the nurse implement in the care of this IV?

change the site every three to four days

A client has a history of poorly controlled diabetes. Which health concern will the nurse discuss with the client?

erectile dysfunciton

The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland?

calcium and phosphorus

HPV

can lead to cervical cancer vaccine exists genital warts can be asymptomatic and can resolve spontaneously

The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L (3,2 mmol/L). For what complications should the nurse be aware, related to the potassium level?

cardiac dysrhythmias

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?

cardiac irregularities

Which diagnostic test is used to diagnose a chlamydial infection?

cervical culture

A client has been admitted with fluid volume excess related to right-sided heart failure. Which assessment data would the nurse expect related to the fluid volume excess? Select all that apply.

crackles in the lungs distended neck veins

A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status?

daily weights

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?

decreased potassium levels

Cross-matching of blood is ordered for a client before major surgery. What does this process do?

determines compatibility between blood specimens

Erectile Dysfunction Risk Factors

diabetes antihypertensive meds age alcohol prostate cancer (hormone deprivation therapy)

The nurse reviews the laboratory test results of a client and notes that the client's potassium level is elevated. What would the nurse expect to find when assessing the client's gastrointestinal system?

diarrhea

A nurse inspecting the IV site of a client notices signs of phlebitis (inflammation). What would be the appropriate nursing intervention for this situation?

discontinue the IV and relocate it to another spot

A nurse is caring for a client with phlebitis. The nurse notices that the client's forearm, which has the tubing, has become red and slightly warm. Which actions should the nurse perform to avoid further complications and provide relief to the client?

discontinue the IV promptly

A male client presents to the clinic with reports of erectile dysfunction. Which statement by the nurse will assist in identifying the potential cause of the erectile dysfunction?

do you take any meds like antihypertensives, antidepressants, or illicit drugs?

What term is used to describe painful intercourse?

dyspareunia

A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of:

electrolytes

The nurse's morning assessment of a client who has a history of heart failure reveals the presence of 2+ pitting edema in the client's ankles and feet bilaterally. Which action should the nurse take to help alleviate the edema?

elevate the legs

A student is learning how to administer intravenous fluids, including accessing a vein. What is the most potentially harmful risk posed for the client when accessing the vein?

infection

While conducting a sexual history, the nurse asks a client about protection from sexually transmitted infections (STIs). Which question would be most appropriate for the nurse to ask?

have you had any sexually transmitted infections and if so, which ones?

A nurse is explaining premenstrual syndrome to a female client. The client demonstrates understands when stating what may occur in the premenstrual phase?

headache

During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect?

hemolytic transfusion reaction; incompatibility of blood product

The nurse prepares to assess a client who is presenting to the infertility clinic for her first appointment. What should the nurse include when obtaining data from the client?

history n an untreated sexually transmitted infection

A nurse reads a client's chart and sees that she may have dyspareunia. Which of the following would be priority assessments? Select all that apply.

history of hormonal imbalance client's ability to use vaginal lubricants during sexual act physical assessment of internal and external genitalia

A man 68 years of age comes to the clinic complaining that he is having difficulty obtaining an erection. When reviewing the client's history, what might the nurse note that contributes to impotence?

history of hypertension

While obtaining a health history from a client, which question is most appropriate for the nurse to ask the client to assess fluid balance?

how much do you typically urinate during the day?

A nurse is providing care to a client with hypocalcemia. The nurse would monitor the client's laboratory test results for which imbalance?

hyperphosphatemia

A client needs an intravenous fluid that will pull fluids into the vascular space. What type of fluid does the nurse prepare to administer as prescribed?

hypertonic

The nurse is caring for a client who was in a motor vehicle accident and has severe cerebral edema. Which fluid does the nurse anticipate infusing?

hypertonic

The nurse is caring for a client, who was admitted after falling from a ladder. The client has a brain injury which is causing the pressure inside the skull to increase that may result in a lack of circulation and possible death to brain cells. Considering this information, which intravenous solution would be most appropriate?

hypertonic

A client who is admitted to the health care facility has been diagnosed with cerebral edema. Which intravenous solution needs to be administered to this client?

hypertonic solution

Hypertonic Solutions

hypertonic to plasma → lower solute concentration; fluid shifts from hypotonic solution into the more concentrated solution to create a balance (cells swell) - 5% dextrose in LR - 5% dextrose in 0.9% NaCl

A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of:

hypokalemia

A nurse is reviewing the client's serum electrolyte levels which are as follows:Sodium: 138 mEq/L (138 mmol/L)Potassium: 3.2 mEq/L (3.2 mmol/L)Calcium: 10.0 mg/dL (2.5 mmol/L)Magnesium: 2.0 mEq/L (1.0 mmol/L)Chloride: 100 mEq/L (100 mmol/L)Phosphate: 4.5 mg/dL (2.6 mEq/L)Based on these levels, the nurse would identify which imbalance?

hypokalemia

Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. This electrolyte imbalance is known as:

hyponatremia

Hypotonic Solutions

hypotonic to plasma; replace ICF → higher solute concentration; fluid is drawn into the hypertonic solution to create a balance (cells shrink) - 0.33% and 0.45% NaCl solutions

An older adult client with hypokalemia is being discharged to the home of a caregiver. Which information should the nurse include in the family teaching?

include more bananas in the diet

Arterial blood gases reveal that a client's pH is 7.20. What physiologic process will contribute to a restoration of correct acid-base balance?

increased respiratory rate

A nurse assessing the IV site of a client observes swelling and pallor around the site, and notes a significant decrease in the flow rate. The client reports coldness around the infusion site. What IV complication does this describe?

infiltration

A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate?

infiltration occurs when IV fluid escapes into the tissue while phlebitis inflammation of the vein

Speed Shock

infusion is too fast - pounding headache, fainting, rapid pulse, apprehension, chills, back pain, dyspnea

A client is hypotensive secondary to hypovolemia resulting from dehydration. Based on the nurse's knowledge about intravenous solutions, the nurse would expect the physician to prescribe which type of solution?

isotonic

Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume?

isotonic

When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L (140 mmol/L); potassium, 4.1 mEq/L (4.1 mmol/L); calcium 7.9 mg/dL (1.975 mmol/L), and magnesium 1.9 mg/dL (0.781 mmol/L); the nurse should notify the physician of the client's:

low calcium

A nurse carefully assesses the acid-base balance of a patient whose carbonic acid (H2CO3) level is decreased. This is most likely a patient with damage to the: Kidneys Lungs Adrenal glands Blood vessels

lungs

A client has the following arterial blood gas results:pH: 7.33PaCO2: 42 mm HgHCO3: 19 mEq/L (19 mmol/L)PaO2: 95 mm HgWhich imbalance would the nurse suspect?

metabolic acidosis

A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)?

metabolic alkalosis

A young man has developed gastric esophageal reflux disease. He is treating it with antacids. Which acid-base imbalance is he at risk for developing?

metabolic alkalosis

The nurse is reviewing the client's arterial blood gas results. The test reveals a pH of 7.52, a PaO2level of 49 mm Hg (6.52 kPa) and an HCO3 level of 28 mEq/L (28 mmol/L), the nurse suspects the client is most likely experiencing which condition?

metabolic alkalosis

Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL (2.05 mmol/L). For what assessment findings will the nurse be looking?

muscle cramping and tetany

Mr. Jones is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L (3.2 mmol/L). For what manifestations should the nurse be alert?

muscle weakness, fatigue, and dysrhythmias

The clinic nurse is explaining the action of sildenafil (Viagra) to a client. The nurse should assess his medication regimen to determine if he is taking medications that are contraindicated with Viagra. Which of the following medications is contraindicated with Viagra?

nitrates

A nurse monitoring a client's IV infusion auscultates the client's lung sounds and detects crackles in the bases in lungs that were previously clear. What would be the most appropriate intervention in this situation?

notify the PCP immediately for possible fluid overload

A nurse is providing care to a client who is on fluid restriction. Which action by the nurse would be most appropriate?

offer the client sugar-free candy to help combat thirst

A client has a prescription to restrict fluids. What is one comfort measure nurses can implement for this client to alleviate a common problem?

oral hygiene

The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths/min. Which arterial blood gas data does the nurse anticipate finding?

pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l)

A client with dehydration is being administered IV fluids. During rounds, the nurse noticed that the skin immediately surrounding the IV site was reddish in color and showing signs of inflammation. The nurse recognizes that what phenomenon is likely responsible?

phlebitis

A client with renal disease requires IV fluids. It is important for the nurse to:

place the fluids on an electronic device

A client sustained severe trauma in a motor vehicle accident and has had 26 units of packed red blood cells infused since admission 2 days previously. What does the nurse predict will be prescribed to replace the clotting factors lost with the infusion of large amounts of packed red blood cells?

plasma

A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client?

platelets

Fluid volume deficit

poor skin turgor tachycardia decreased BP thirst dark urine and decreased urine output loss of K+

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte?

potassium

Causes of Menstrual Irregularities

pregnant or breast feeding eating disorders PCOS PID Uterine fibroids

A nurse is initiating a peripheral venous access IV infusion for a patient. Following the procedure, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would be the nurse's next action related to these findings? Reposition the extremity and raise the height of the IV pole. Apply pressure to the dressing on the IV. Pull the catheter out slightly and reinsert it. Put on gloves; remove the catheter

put on gloves; remove catheter

A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action?

remove the IV

The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client?

renal failure

A client has a physician's order for NPO (nothing by mouth) following abdominal surgery to repair a bowel obstruction. The client has a nasogastric tube inserted to low intermittent suction. The client requires intravenous therapy for what purpose?

replace fluids and electrolytes

A woman aged 58 years is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires:

replacement of fluids for those lost from vomiting and diarrhea

A client with uncontrolled diabetes develops hypophosphatemia. Which finding would the nurse most likely assess? Select all that apply.

respiratory muscle weakness confusion ventricular dysrhythmia

A nurse is assessing for the presence of edema in a client who is confined to bed and who often lies supine. The nurse would pay particular attention to which area?

sacral area

A specially trained nurse has inserted a PICC line. What would be done next?

send the client to the radiology department

Which of the following statements best describes the relationship between biologic sex and gender identity?

sex is chromosomal determined, while gender is a psychosocial construct

The nurse is preparing to provide education to a group of high school students on sexually transmitted infection (STI) prevention. The nurse knows that this age group often uses oral-genital stimulation as a way to prevent pregnancy. Which concept should the nurse make sure to convey to the group?

skin to skin contact can spread herpes and genital warts

A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?

start an IV of normal saline as prescribed

The nurse is performing an assessment for an older adult client admitted with dehydration. When assessing the skin turgor of this client, which area of the body will be best for the nurse to assess?

sternum

During a blood transfusion of a client, the nurse observes the appearance of rash and flushing in the client, although the vital signs are stable. Which intervention should the nurse perform for this client first?

stop the transfusion immediately

Infant Sleep Safety

supine position and little stuff in bed (reduce risk of SIDS)

The nurse is performing an assessment for a client related to pain. In order to determine the need for pain medication, what should the nurse base the decision on?

temporal pattern

The nurse is assessing a client who was hospitalized due to a fall with brief loss of consciousness. Which sign(s) alerts the nurse that the client is severely dehydrated? Select all that apply.

the client has dark, colored urine with a noticeable odor the client has been working outside in warm temperatures. The client reports dizziness when standing up from a chair

A patient calls the clinic and tells the nurse they have a foamy, greenish, and itchy vaginal discharge. The patient asks the nurse what the significance of this discharge is. What is the best response by the nurse?

the patient may have trichomoniasis

A student has joined the marching band at high school. The band begins practicing outside during hot summer weather. Which health promotion information will the school nurse teach the students?

the student should drink large amounts of water on practice days

A client that is post-menopausal reports painful intercourse for the last two months. When performing an assessment of the client, what data should the nurse obtain?

the use of antihistamines, tranquilizers or alcohol

A couple have presented to the healthcare provider for a follow up visit following the husband's uncomplicated myocardial infarction (MI) one week ago. The nurse determines that education on resuming intimate sexual contact should be discussed. What timeline regarding sexual intercourse should the nurse be sure is included in the discussion?

three months if no symptoms of chest pain

A client visits a community clinic reporting a foul-smelling vaginal discharge that is thin, foamy, and green in color; itching of vulva and vagina; and burning on urination. Which STI would the nurse suspect?

trichomonas vaginalis

Which sexually transmitted infection has the following characteristics: thin, foamy, greenish vaginal discharge that causes itching of the vulva and vagina?

trichomoniasis

A client tells the nurse that she is experiencing stabbing pain in her mouth, gums, teeth, and chin following brushing her teeth. These are symptoms of:

trigeminal neuralgia

A 5-year-old client reports abdominal pain. Which action(s) will the nurse take to assess the pain? Select all that apply.

use the wong baker FACES pain rating scale observe the client ask the client to describe the pain

An 82-year-old client is newly admitted to an assisted living facility. Which intervention promotes safety at night for the client?

using a night light in the bathroom

A nurse needs to get an accurate fluid output assessment of a client with severe diarrhea. Which action should the nurse perform?

weight the clients wet linen or dressing

The nurse assessing an adolescent's need for further information regarding sexual health should ask which question?

what questions or concerns do you have about your sexual health

A new mother is discussing her 6-month-old infant's sleep habits and expresses concern about the infant obtaining too much sleep. The mother reports the infant's circadian cycle as listed above. The best statement by the nurse is:

your infant is obtaining the average hours of sleep per day for an infant

The nurse is assessing the pain of a preschooler. Which pain scales would be appropriate for the nurse to utilize? (Select all that apply.)

FLACC scale wong-baker faces scale comfort scale

The nurse is developing a discharge teaching plan for clients taking opioid pain medication. Which of the following should the nurse include? Select all that apply.

do not drive while taking pain meds don't smoke without someone else present avoid alcohol

A client with peripheral neuropathy states, "Sometimes I get the worst pain from just a bedsheet brushing over my foot." What is the nurse's most appropriate action?

document the clients allodynia

The nurse is providing care for a confused client who no longer is able to make health care decisions. Which document will the nurse review on the client's medical record to determine the designated person to make decisions on the client's behalf?

durable power of attorney form

A perimenopausal woman reports insomnia. Which intervention(s) will the nurse suggest to the client? Select all that apply.

eliminate caffeine and alcohol in the evening because both are associated with disturbances in the normal sleep cycle eat a small snack of protein and carb before bedtime discuss the use of a sleep aid with the healthcare provider

A client is experiencing acute pain following the amputation of a limb. What nursing interventions would be most appropriate when treating this client?

encourage the use of nonpharmacologic complementary therapies as adjuncts to the medical regimen

The nurse identifies that a client is in stage 3 sleep. What assessment finding by the nurse is indicative of this stage?

enuresis

The nurse is admitting a dying client with osteosarcoma. Which nursing action is priority?

examine the effectiveness of the current pain regimen

A middle-age adult man has just started an exercise program. What would the nurse teach him about timing of exercise and sleep?

exercising within 2 hours of bedtime can hinder ability to sleep

Which medication would the nurse most likely see on the medication administration record (MAR) of a client with diabetic neuropathy?

gabapentin

A nurse implements a back massage as an intervention to relieve pain. What theory is the motivation for this intervention?

gate control theory

what independent nursing action can be used to facilitate sleep in hospitalized clients who are on bed rest?

giving a back massage

A client reports periodic difficulty falling asleep. Which teaching will the nurse provide? Select all that apply.

go on a daily walk adhere to a regular schedule for waking and going to sleep decrease caffeine intake

The emergency room nurse is caring for a client who will need a lumbar puncture. The health care provider prescribes lidocaine 2.5% and prilocaine 2.5% cream (EMLA) to decrease the pain associated with the procedure. When should the nurse administer the cream?

one hour prior to the procedure

A nurse is developing a plan of care for a dying client. Which physiologic basic human need should be addressed?

personal hygiene

What is the rationale for using CPAP to treat sleep apnea?

positive air pressure holds the airway open

The client has been in the intensive care unit for several days. The client appears to be sleeping throughout the night. The nurse records the data listed above. The nurse evaluates that rapid eye movement (REM) sleep is occurring at:

0100 there was a picture that went with this question I am not sure what it had on it so look up what REM sleep vitals are

The nurse is caring for four clients. Which client does the nurse identify as the most likely to have undertreated pain? Select all that apply.

29-year-old who has a speech impediment 34-year-old with schizophrenia 41-year-old who is from a different country 60-year-old with early onset dementia

A client is prescribed escitalopram, diuretics, and pseudoephedrine. The client states, "I'm tired all the time." What does the nurse understand may be happening to this client?

Decrease in R.E.M. sleep due to prescribed medications

The client is actively dying and has a prescription for Do Not Resuscitate. The nonresponsive client is mouth breathing and has noisy respirations. The client is incontinent of urine and feces. The family is at the bedside. What interventions would be appropriate for the nurse to perform to meet the needs of the client and the family? Select all that apply.

Elevate the head of the bed to a semi-Fowler's position. Encourage the family to reminisce about positive, enjoyable events that the client and family shared together. Cleanse the client's mouth every shift and PRN

Which statement made by a client with terminal illness indicates acceptance of the diagnosis?

I do not feel like watching football game tonight. I just want to be alone

The nurse is assessing a client with a history of sleep apnea who is noncompliant regarding wearing the continuous positive airway pressure (CPAP) apparatus. Which statement made by the client indicates understanding of risks related to noncompliance?

I know if I do not wear the CPAP the oxygen in my blood may drop and damage my heart

The hospice nurse is educating a client's family on the physical signs of approaching death. The nurse identifies that the education has been effective when the family says they will know that death is imminent when they see which related symptoms? Select all that apply.

Irregular respiratory rate restlessness bowel incontinence cyanosis of dependent areas

A terminally ill client asks the nurse what assisted suicide is. Which response is best for the nurse to provide?

It is when a lethal combination of drugs is made available to the client wishing to die

A factory worker has a work schedule involving rotating work hours between days, evenings, and nights. The client tells the nurse about being a "morning person" and not sleeping well when working the night shift. Which information will the nurse teach the client about sleep hygiene?

Modify the sleep environment to simulate quiet and darkness.

The nurse is admitting a client that has obesity and is diagnosed with obstructive sleep apnea (OSA). The client states, "I just wake up a lot and don't feel rested but it's not a big deal." What education should the nurse provide about the complications related to OSA?

OSA contributes to hypertension and heart disease

The nurse is caring for a client that is at the end of life. After the client is pronounced dead, what actions by the nurse are essential components of care? Select all that apply.

Removing all tubes according to agency policy, unless an autopsy is to be performed Placing identification tags on the client's dentures or other prostheses Arranging for family members to view the body before it is discharged to the mortician

The nurse is teaching a client with terminal cancer who is interested in hospice care. Which home hospice benefits will the nurse explain? Select all that apply.

The nurse and physician are on call 24 hours, every day of the week. Counseling services are available. Pain will be managed with medication, if needed. Homemaker services can be included.

Which clients would the nurse identify that are at risk for the development or presence of sexual dysfunction? Select all that apply.

a 52-year-old male with a history of hypertension a postmenopausal female client a 30-year-old female experiencing PMS

Which client likely faces a risk for the nursing diagnosis of Disturbed Sleep Pattern: Difficulty Remaining Asleep?

a client who receives IV antibiotics every 3 hours

A nurse is reviewing the medication administration record. Which order does the nurse question?

a diuretic administered twice daily at 9am and 9pm

The client experiences intractable chronic pain from cancer. The nurse is developing a care plan to provide the client adequate pain relief. What principle(s) will guide the treatment plan? Select all that apply.

administer pain meds around the clock give oral medications for pain relief assess the client's pain experience at every visit contact the health provider if the client reports unreleased pain

A hospital client's pain is being treated with epidural analgesia. Which nursing action would pose a threat to the client's safety?

administering an oral dose of morphine to treat the clients breakthrough pain

The nurse is caring for a client who reports throbbing pain at the site of a recent laceration from a pocketknife. How will the nurse document this type of pain? Select all that apply.

acute cutaneous

A postoperative client who reported a pain level of 8 was medicated with an IV opioid 20 minutes ago. The client now reports a pain level of 9. Which would be the nurse's best action?

administer a nonopioid medication

A nurse assesses a client who was administered an opioid analgesic and finds the client unresponsive to shaking and stimulation. Which is the nurse's immediate plan of action?

administer naloxone

The nurse caring for a client receiving opioid therapy notes that the client's respirations are 7. What is the first action by the nurse?

administer naloxone

The client is scheduled for a polysomnography to determine if the client has obstructive sleep apnea (OSA). The nurse instructs the client to:

anticipate sleeping overnight at a health care center

A client is dying and the nurse has developed a strong rapport with the client and spouse. The spouse states to the nurse, "I just don't know how I am going to deal with the process. It makes me nervous to think I can't deal with it." What is the priority concern with the spouse of the client?

anxiety related to unknown reaction to stages of death

An older adult client experiences the death of a spouse. Which behavior by the client exemplifies the grief stage of reorganization?

appears sad and reaches out to adult children for support

A nurse is caring for a client who is prescribed continuous positive airway pressure (CPAP) for sleep apnea. Which action will the nurse take?

apply a CPAP mask while sleeping

The nurse is caring for an older client with chronic pain due to osteoarthritis, hypertension, and mild dementia. The client reports blurred vision, and the spouse states, "I'm worried. Today I noticed that there was blood in the stool, and there is more confusion than usual." What is the priority nursing action?

ask the client and caregiver for a medication history

The nurse observes the sleep pattern of an obese client with cardiac disease and notes occasional periods of apnea. Which action should the nurse take?

assess the clients vital signs and pulse oximetry

A client has been in the hospital for the past 10 days following the development of an infection at her surgical incision site. Each morning, the client reports overwhelming fatigue and has told the nurse, "I just can't manage to get any sleep around here." How should the nurse first respond to this client's statement?

assess the faros that the client believes contribute to the problem

The nurse learns during the assessment of a client that the client has difficulty falling asleep, wakes up early, and does not feel refreshed in the morning. This client is most likely experiencing:

disturbed sleep pattern

What name is given to the rhythmic biologic clock that exists in humans?

circadian rhythm

A client who suffered multiple trauma in a motor vehicle accident is receiving care in an orthopedic trauma unit. The client has a documented history or opioid addiction and the hospital's advanced pain control team has become involved in his pain control plan. Which of the following are aspects of addiction? Select all that apply.

compulsive use of a particular drug the need to use opioids for purposes other than pain relief

A nurse is caring for a client with insomnia. Which teaching will the nurse provide to help the client improve sleep?

create a bedtime routine

A client reports throbbing pain caused by a laceration that occurred to the finger while cutting vegetables. Which terminology should the nurse use to document this pain? Select all that apply.

cutaneous acute

The nurse is performing an intake assessment of a 60-year-old client who admits to having a nightcap of 4 to 6 ounces of scotch whisky each night. What effect might this alcohol be having on the client's sleep?

decreased REM sleep

A nurse working the night shift assesses a client's vital signs at 4 a.m. (0400). What would be the expected findings, based on knowledge of NREM sleep?

decreased tpr and bp

During an orientation class for new RN graduates, the nurse educator identifies which conditions as potential risks for clients to experience sleep pattern disturbance? Select all that apply.

depression substance use constipation stroke

The nurse has entered the room of a newly admitted client and observed a continuous positive airway pressure (CPAP) on the client's bedside table. Which action(s) will the nurse take to assess the client's use of the CPAP machine? Select all that apply.

discuss the clients habit of using the CPAP examine the fit of the mask

The action of ibuprofen is to:

have an anti-prostaglandin effect on the CNS

A 62-year-old client informs the nurse that the parent has been anxious and disoriented in the morning. The client also informs the nurse that the parent gets up frequently to use the bathroom. Which nursing intervention can decrease the disruption of sleep?

have your parent take diuretic medicine in the morning

A critical care nurse is aware of the legislation that surrounds organ donation. When caring for a potential organ donor, the nurse is aware that:

hospitals are mandated to notify transplantation programs of potential donors

A 54-year-old man is recovering from an outbreak of Herpes zoster on his left chest. He tells the nurse that even his shirt touching him causes a horrible pain on the left side of the chest. What term would best describe the client's pain?

hyperalgesia

A nurse is caring for a client who is sleeping for abnormally long periods of time. This condition may be caused by injury to which body structure?

hypothalamus

A nurse notes that a client admitted to a long-term care facility sleeps for an abnormally long time. After researching sleep disorders, the nurse learns that which area of this client's brain may have suffered damage?

hypothalamus

The nurse anticipates a dying client to exhibit which signs of impending death? Select all that apply.

incontinence restlessness loss of sensation Cheyne-Stokes respirations

After the death of a terminally ill spouse, a client reports frequent headaches and loss of appetite. The client states, "How am I going to live without him?" What type of grief is the client experiencing?

inhibited grief

A nurse at the health care facility is caring for an older adult client who complains of sleeplessness. Which condition is a manifestation of depression in an older client?

insomnia

A hospice nurse is assessing a client with end-stage chronic obstructive pulmonary disease (COPD). Which assessment findings would suggest that the client is dying? Select all that apply.

jaundiced skin cheyne stokes respirations decreased urine output

Based on the circadian cycle, the body prepares for sleep at night by decreasing the body temperature and releasing which chemical?

melatonin

Which natural chemical does the body produce at night to decrease wakefulness and promote sleep?

melatonin

A client in his 40s has asked the nurse how much sleep he should be getting in order to maximize his health and well-being. How should the nurse respond?

most adults need between 7 and 9 hours but everyone is different

A postoperative client who has been receiving morphine for pain management is exhibiting a depressed respiratory rate and is not responsive to stimuli. Which drug has the potential to reverse the respiratory-depressant effect of an opioid?

naloxone

the nurse is caring for a client who had a below-the-knee amputation of the left leg 8 months ago. The client is reporting left foot pain of 7 on a 1-to-10 scale. The pain began earlier today. How will the nurse document this type of pain? Select all that apply.

neuropathic acute

The nurse is caring for new parents. During her education session, the nurse instructs the parents on a newborn's sleep patterns. Which statement is accurate about a newborn's sleep patterns?

newborns sleep 16-17 hours per day

A client is alert but nonverbal after a motor vehicle accident. Which action(s) will the nurse include in the assessment of pain for this client? Select all that apply.

observing for grimacing and other signs of pain using the wong baker FACES pain rating scale checking for loss of function of the extremities communicating with the client in writing performing vital signs

A client reports awakening during the night and does not feel as though restful sleep is achieved. The nurse reviews the medications the client is prescribed and identifies one of the medication that the client may take that may have an effect on sleep patterns. Which medication will the nurse discuss with the client?

prednisone

The nurse is preparing a care plan for a client receiving opioid analgesics. Which factors associated with opioid analgesic use will the nurse include in the plan of care?

preventing contipation

A nurse is caring for a client who has been diagnosed with a disturbed sleep pattern. Which measures should the nurse implement to promote sleep? Select all that apply.

promoting daytime exercises providing a back massage assisting with progressive relaxation

A nurse educates a young couple on putting their newborn on his back to sleep. What is the rationale for this information?

prone position increase the risk for sudden infant death syndrome

The nurse is caring for a client receiving epidural opioids . What side effects of the medication should the nurse assess for? Select all that apply.

pruritus urinary retention nausea infection

Which statement accurately describes the process known as grief reaction?

reactions to grief may differ from client to family

A nurse is caring for a postsurgical client whose pain is being treated with the opioid hydromorphone. The nurse's most recent assessment reveals that the client is drowsy and drifting off during conversation with the nurse; however, the client can be aroused. What is the nurse's most appropriate action?

report this finding to the primary care provider and seek decrease in the clients opioid dosing

The parents of a boy 10 years of age are worried about his sleepwalking (somnambulism). What topic should the nurse discuss with the parents?

safety

A client has voiced concerns about her inability to fall asleep. When reviewing her history, what information would the nurse expect to find? Select all that apply.

smokes a pack of cigarettes daily drinks coffee with all meals history of hyperthyroidism

A client's partner expresses concern to the nurse about the client's snoring. Which assessment parameters will the nurse teach the couple to observe for the possibility of sleep apnea?

snoring with periods of irregular silence

A client with a sleep disorder experiences cataplexy. Which is a feature of this condition?

sudden loss of motor tone that may cause the person to fall asleep; usually experienced during a period of strong emotion

A maternity nurse is instructing new parents on the proper sleeping position for their newborn child. In what position does the nurse instruct the parents to place the infant?

supine position

A client taking a diuretic twice daily for treatment of hypertension reports being awakened often by a full bladder. What teaching regarding the diuretic will the nurse provide?

take it before 6pm

A nurse is caring for a client newly diagnosed with sleep apnea. Which should the nurse teach the client about the most important reason why the continuous positive air pressure (CPAP) device should be used during sleep?

the CPAP assures you get enough oxygen throughout the night

A nurse is working with an older adult client who has been diagnosed with onset insomnia and informs the nurse about waking at least once during the night. What actions by the nurse can help promote adequate sleep? Select all that apply.

the nurse encourages the client to remove the tv from the bedroom the nurse advises the client to exercise no closer than 6 hours to bedtime the nurse encourages the client to minimize caffeine intake several hours prior to bedtime the nurse helped the client come up with a bedtime routine that can be implemented each night

A client has been reluctant to ask for breakthrough doses of the opioid prescribed, despite showing signs of pain. The client states to the nurse, "I don't want to become addicted to the medication." How should the nurse respond to the client's statement?

there's only an extremely small chance that you will become addicted to this drug

A client is diagnosed with narcolepsy. What is a characteristic of this disorder?

uncontrollable desire to sleep

The nurse is providing instructions to a client who has been prescribed a patient controlled analgesia (PCA) pump postoperatively. The nurse will include which information in the client instructions? Select all that apply.

you should be the only person pressing the button the device is set up to deliver a predetermined dose each time you press the button you will be asked to rate your pain frequently to reassess your need for this device you will hear a bell sound when the infuser delivers the medication