Physiological Adaptation

Review the client's health information in the electronic health record (EHR) and then answer the question. Which statements should the nurse teach the client? Select all that apply. "You should not have any abdominal pain when you go home."​ "You won't need to take any of your Crohn's medication anymore." "If you develop a fever when you go home, you need to contact your surgeon." "You are okay to take a bath when you get home."​ "You need to make sure you are taking deep breaths to prevent

"If you develop a fever when you go home, you need to contact your surgeon." "You need to make sure you are taking deep breaths to prevent pneumonia." "You had to receive blood to replenish blood that was lost during and after your surgery."

The nurse follows up with a client who recently started home peritoneal dialysis. Which statements by the client require immediate follow-up by the nurse? Select all that apply.​ "My partner helps me get the process started but, since we live together, my partner does not wear a mask." "The first few times that I did this there was some blood in the solution that came out at the end of the procedure. Now it is straw-colored or clear."​ "I end up doing about four to five exchanges a day doing

"My partner helps me get the process started but, since we live together, my partner does not wear a mask." "Sometimes all of the solution does not come back out, so I have to push the catheter in further and move around to get it moving."

The clinic nurse plans to enter the room of a client with impaired ventilation from a diagnosis of chronic obstructive pulmonary disease (COPD). The client has a history of anxiety as well. The nurse plans to complete the assessment to begin the client's visit. What order should the nurse use to collect assessment data? Rank order the responses from first action to last action.

1. Review the medical record for history and prescriptions. 2. Complete a general survey of the client. 3. Ask meaningful questions to elicit information from the client. 4. Assess vital signs and compliance with prescriptions. 5. Conduct a focused respiratory assessment to compare with history.

A nurse reviews the lab reports for a series of clients on the medical surgical floor with varying diagnoses. For each serum lab test listed, click to specify if the resulting value will be altered by the disease process of acute kidney injury, cirrhosis, or pancreatitis. Each lab test may be marked as altered in more than one disease process. (More than one option may be correct in each row.)​ Blood urea nitrogen (BUN) Creatinine Amylase Lipase Alanine transaminase (ALT) Alkaline phosphatase

AKI: BUN Creatinine Albumin Cirrhosis: BUN ALT ALP Albumin Bilirubin Pancreatitis: Amylase Lipase ALP Bilirubin

The critical care nurse cares for a client in the intensive care unit who has an arterial line. For each of the listed nursing actions, click to identify which actions are appropriate or inappropriate when caring for this client. The nurse uses a port on the arterial line to obtain an arterial blood sample for analysis. The nurse evaluates a client's response to fluid therapy by monitoring the blood pressure readings from the arterial line. The nurse zeros the line once every 24 hours to calibra

Appropriate Appropriate Inappropriate Appropriate Inappropriate Appropriate

The nurse assesses a client who is recovering from a surgical implantation of a pacemaker. Assessment findings include pallor, diaphoresis, and client reports of dizziness and lightheadedness. What are the top three priority actions by the nurse? Select 3 options. Check if any low battery life messages are being sent. Determine the client's core body temperature. Auscultate the client's lung sounds bilaterally. Ensure the client is in a supine or low-Fowler's position. Assess the client's heart

Auscultate the client's lung sounds bilaterally. Ensure the client is in a supine or low-Fowler's position. Assess the client's heart rate, blood pressure, and electrocardiogram (ECG) rhythm.

The nurse cares for a client who has been on positive pressure-controlled mechanical ventilation for 24 hours. During the respiratory assessment, the nurse finds an increase in adventitious lung sounds. Additionally, the nurse notes a temperature of 100 °F (37.8 °C). The client's skin is pale and dry. The nurse notes a decrease in tidal volume on the ventilator. Which actions should the nurse take next? Select all that apply.​ Swab the client's mouth with 0.12% chlorhexidine oral rinse. Coll

Collaborate with RT for chest physiotherapy Suction the client to remove excess secretions Verify the HOB is elevated at least 30-45 degrees Turn the client to one side while maintaining head elevation

The nurse cares for a client who has just completed a hemodialysis session. For each assessment finding listed, click to indicate whether the assessment finding is expected or concerning at this time. Serum potassium 5.5 mEq/L (reference range 3.5-5.0 mEq/L) Temperature 98.6 °F (37 °C) Blood pressure 108/78 mmHg Reported fatigue Serum phosphate 6 mg/dL (reference range 3-4.5 mg/dL) Clear lung sounds Serum sodium 136 mEq/L (reference range 136-145 mEq/L)

Concerning Expected Expected Expected Concerning Expected Expected

A hospitalized client with pneumonia and hyperthyroidism has tachy-dysrhythmias and requires telemetry. The nurse receives an alert from the telemetry team that the client's alarm is sounding. Upon entering the client's room, the nurse notices the client is coughing. What actions should the nurse take? Select all that apply. Ensure the electrodes are firmly adhered to the client's skin. Auscultate the client's apical pulse for rate and rhythm. Silence the alarm and plan to investigate when the c

Ensure the electrodes are firmly adhered to the client's skin. Auscultate the client's apical pulse for rate and rhythm. Ask the client if any pain or discomfort is being experienced.

Review the client's health information in the electronic health record (EHR) and then answer the question. Identify the priority condition, findings, and management strategies. Select the correct options from the dropdown options in the table.

Findings: Abdominal pain Organ protrusion Condition: Evisceration Management: Apply sterile soaked gauze Notify surgical team

Review the client's health information in the electronic health record (EHR) and then answer the question. Click to specify if the findings indicate improvement or worsening condition. ​ Abdominal assessment Bowel sounds Heart rate White blood cell count Temperature Skin temperature

Improving Improving Improving Worsening Worsening Improving

The nurse provides education to a client on the correct use of the incentive spirometer (IS). Click to specify whether the client's actions during the return demonstration indicate the teaching was effective or ineffective. The client gently blows into the incentive spirometer in a steady motion. The client performs 10 breaths in succession once per hour during waking hours. The client inhales through their nose while using the incentive spirometer. The client assumes the semi-Fowler's position

Ineffective Effective Ineffective Effective Effective Effective

Review the client's health information in the electronic health record (EHR) and then answer the question. Identify the priority assessment data that the nurse should collect for this client. Click to select and drag the correct responses to the boxes provided.

LOC Pain assessment Surgical incision assessment Respiratory depth 15-min BP checks Bowel sounds

The nurse plans the care for a client diagnosed with acute osteomyelitis as a complication from a recent open ulnar fracture. Click to specify whether the listed activities are expected or not expected as part of the initial plan of care for this client. 10-day course of potent antibiotics Elevation of arm on a small pillow Splinting of the limb Surgical debridement Range of motion in joints above and below injured area Lifting restrictions in extremity Administration of pain medication Review o

Not expected Expected Expected Not expected Expected Expected Expected Expected

The nurse cares for a client being discharged home after surgical placement of a non-continent ileostomy. ​ Complete the sentences by choosing from the list of options.​ The nurse needs to include all of these in the discharge teaching, but should prioritize ______ as the most important point. The nurse should emphasize the need to call the healthcare provider if the _________. Additionally, the nurse should remind the client _______.

Signs of dehydration client gets a headache or feels dizzy to empty the pouch every time the client's bladder is emptied

Review the client's health information in the electronic health record (EHR) and then answer the question. Complete the sentences using the drop-down choices. ​ The client's ______ indicates a concern for hemodynamic instability associated with _________. The client's _______ is ______ and indicates potential dehydration.

blood pressure internal bleeding BUN elevated

Review the nurse's note in the electronic health record (EHR) and then answer the question. Click to highlight the sections of the nurse's note that are most related to the suspected complication the client is experiencing. Highlight all sections that apply.

chest pain pericardial friction rub

Review the client's health information in the electronic health record (EHR) and then answer the question. Complete the sentences by choosing from the list of options.​ The nurse knows that _______ is the priority concern for the client. The nurse's first action is to ______. Next, the nurse should anticipate a prescription for _________. The nurse should question the prescription to administer ________.

heat stroke apply ice and cooling blankets administration of cooled IV fluids acetaminophen

Review the client's health information in the electronic health record (EHR) and then answer the question. Identify the three factors that concern the nurse most for a risk of fluid and electrolyte imbalance. Select to highlight.​ S: Preston Waters is a 39-year-old male who had an ileocecal resection. We have recovered him in PACU and he's ready for transfer. ​ B: Client has a history of Crohn's Disease for 15 years and required resection. They started with a laparoscopic approach, but the s

ileocecal resection history of Crohn's disease Moderate blood loss of 450 mL

A hospitalized client lost consciousness during cardiac catheterization. This image shows the current telemetry reading. Complete the sentences by choosing from the list of options. Based on the assessment information, the client is most likely experiencing __________ due to the procedure. The most common medication for the treatment of this client's situation is ________. The nurse should ________ before administering the medication.

ventricular tachycardia amiodarone check the client's allergies