RN Comprehensive Online Practice 2019 B with NGN

A nurse is teaching a client who has a new prescription for total parenteral nutrition through a central line. Which of the following information should the nurse include in the teaching? "I will change your IV tubing once every 48 hours." "Abdominal distention is an expected effect of this therapy." "I will need to check your gastric residual before administering feedings." "I will need to measure your weight daily."

"I will need to measure your weight daily." The nurse should instruct the client that daily weight measurement is a necessary part of administering nutrition through a central line to avoid fluid overload and monitor for adequate weight gain.

A nurse is teaching a client who is at 20 weeks of gestation about common discomforts associated with pregnancy. Which of the following statements by the client indicates an understanding of the teaching? "I will decrease my intake of high-fiber foods." "I will apply hydrocortisone cream if I develop a rash on my face." "I will sleep flat on my back if I develop back pain." "I will wear a supportive bra overnight."

"I will wear a supportive bra overnight." The nurse should teach the client that wearing a supportive bra even while sleeping can promote comfort by providing support to enlarged breasts during pregnancy.

A home health nurse is evaluating a school-age child who has cystic fibrosis. The nurse should initiate a request for a high-frequency chest compression vest in response to which of the following parent statements? "My child doesn't like to sit still for nebulizer treatments." "I think that my child has been running a fever over the last couple of days." "My child has only a small amount of mucus after percussion therapy." "I am concerned about my child's future participation in team sports."

"My child has only a small amount of mucus after percussion therapy." The nurse should recommend a high-frequency chest compression vest for a child who has inadequate results from other airway clearance therapy techniques. Older children often require other techniques in addition to percussion and postural drainage to achieve adequate mucus expectoration.

A nurse is providing client teaching about the basal body temperature method of birth control. Which of the following information should the nurse include in the teaching? "Your body temperature will drop approximately 1 degree 1 week after ovulation." "You should take your body temperature each evening prior to going to sleep." "Your body temperature might decrease slightly just prior to ovulation." "Your body temperature is at its highest during menstruation."

"Your body temperature might decrease slightly just prior to ovulation." The nurse should teach the client that a decrease in body temperature of approximately 0.5° C (1° F) commonly occurs immediately prior to ovulation.

A nurse in a provider's office is assessing an adolescent who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Which of the following questions should the nurse ask to assess for an adverse effect of this medication? "Have you experienced muscle stiffness?" "Have you had any stomach pain or bloody stools?" "Have you experienced a dry cough?" "Have you noticed an increase in urine output?"

"Have you had any stomach pain or bloody stools?" The nurse should ask the client about the presence of stomach pain or bloody stools, which is an indication of gastrointestinal bleeding, an adverse effect of ibuprofen.

A nurse is admitting a client to the psychiatric unit after attempting suicide. The client states, "My family does not care whether I live or die." Which of the following responses should the nurse make? "I'm sure your family does not want you to die." "Why would you believe such things?" "How does this make you feel?" "You should talk to your family about your feelings."

"How does this make you feel?" This response encourages the client to evaluate their feelings.

A nurse is providing teaching about advance directives to a middle adult client. Which of the following client responses indicates an understanding of the teaching? "I can designate my partner as my health care surrogate." "I am only 40 years old, so I don't need to worry about this yet." "I will need a lawyer's help to draw up the documents." "I understand that my family can alter my advance directives if I become incapacitated."

"I can designate my partner as my health care surrogate." This statement indicates that the client recognizes that designating a health care surrogate is part of advance directives.

A nurse is conducting group therapy with clients who have breast cancer. The nurse should recognize which of the following statements by a client as an example of altruism? "I have experienced physical discomfort when intimate with my partner since my diagnosis." "I wish other women would stop socializing with my partner." "I told my doctor that I would like to start a support group for other women who are sick in my community." "I used to mistrust my doctor, but now I know that she is the best one to care for me during my illness."

"I told my doctor that I would like to start a support group for other women who are sick in my community." This statement indicates that the client is demonstrating altruism by reaching out and helping others.

A nurse is providing information to a client immediately before his scheduled Romberg test. Which of the following statements should the nurse make? "You will be standing with your feet 1 foot apart." "You will place and hold your hands on your hips." "I will be standing across the room from you to evaluate your sense of balance." "I will be checking you once with your eyes open and once with them closed."

"I will be checking you once with your eyes open and once with them closed." The nurse should inform the client that the Romberg test will be performed once with eyes open and once with eyes closed. A Romberg test is performed to assess balance and motor function.

A nurse is providing discharge instructions about newborn care to a client who is postpartum. Which of the following statements indicates to the nurse that the client understands the teaching? (Select all that apply.) "I will breastfeed my baby on a schedule of every 4 hours." "I will bathe my baby daily." "I will place my baby on her stomach for sleeping." "I will cover my baby's body when I wash her hair." "I will use the bulb syringe first in her mouth and then in her nose."

"I will cover my baby's body when I wash her hair" is correct. Newborns are highly susceptible to heat loss. The client should wrap the newborn in a towel when washing the hair to minimize heat loss "I will use the bulb syringe first in her mouth and then in her nose" is correct. The client should suction the newborn's mouth first to remove secretions that the newborn could aspirate when suctioning the nares.

A nurse is providing education to the parent of a school-age child who has asthma. Which of the following statements by the parent indicates an understanding of the teaching? "I will administer aspirin to my child to treat pain or fever." "I will record an average of three readings from my child's peak expiratory flow meter." "I will place carpet in my child's bedroom to control allergens." "I will make sure my child receives a yearly influenza immunization."

"I will make sure my child receives a yearly influenza immunization." Children who have asthma should be immunized and protected from infections. Therefore, the nurse should educate the parent to ensure the child receives a yearly influenza immunization.

A nurse has received change-of-shift report on four assigned clients. For which of the following clients should the nurse intervene to prevent a potential food and medication interaction? A client who is receiving verapamil and has a continuous infusion of total parenteral nutrition (TPN) A client who is taking phenytoin and is requesting a milkshake A client who is receiving a diet high in potassium-rich foods and furosemide by mouth A client who is receiving an MAOI and is requesting a cheeseburger for dinner

A client who is receiving an MAOI and is requesting a cheeseburger for dinner This client's food selection contains tyramine. Clients prescribed an MAOI must restrict intake of foods that contain tyramine due to adverse effects, such as hypertension.

A charge nurse is providing an educational session about infection control for a group of staff nurses. Which of the following statements by one of the staff nurses indicates an understanding of isolation precautions? "Droplet precautions should be initiated for a client who tests positive for measles." "A client who requires airborne precautions should be placed in a negative-pressure airflow room." "Airborne precautions should be initiated for a client who has Clostridium difficile." "A client who is immunocompromised should be placed in a negative-pressure airflow room."

A client who requires airborne precautions should be placed in a negative-pressure airflow room." Airborne precautions require a negative-pressure airflow room that has at least six to 12 air exchanges each hour using a HEPA filtration system.

A home health nurse is caring for a group of older adult clients. The nurse should initiate a referral to the Program of All-Inclusive Care for the Elderly (PACE) for which of the following clients? A client whose family requests hospital-based hospice care A client who requires transfer to a skilled care facility A client who qualifies for telehealth for pacemaker diagnostics A client whose caregiver requests adult day care services

A client whose caregiver requests adult day care services The nurse should initiate a referral for PACE for this client because PACE provides adult day care services along with in-home assessments and supportive services.

A nurse working in an emergency department is triaging four clients. Which of the following clients should the nurse recommend for treatment first? An older adult client who reports constipation of 4 days A preschooler who has a skin rash An adolescent who has a closed fracture A middle adult client who has unstable vital signs

A middle adult client who has unstable vital signs Using the stable vs. unstable approach to client care, the nurse should recommend priority treatment for the client who has unstable vital signs because this client requires immediate treatment to reduce the risk of further injury or possible death.

A nurse manager is preparing an educational session about advocacy to a group of nurses. The nurse manager should include which of the following information in the teaching? Advocacy is a leadership role that helps others to self-actualize. Subordinates are advocates for the nurse manager. Advocacy encourages clients to rely on health care staff for decision-making. Nurse managers should distrust people who expose inappropriate professional practices.

Advocacy is a leadership role that helps others to self-actualize. The nurse manager should teach that advocacy is a leadership role that can help others to grow personally and professionally through self-actualization.

A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take? Perform ADLs for the client to promote rest. Allow for frequent rest periods throughout the day. Use heat to reduce joint inflammation. Develop a daily schedule for acetaminophen up to 6 g/day that covers peak periods of pain.

Allow for frequent rest periods throughout the day. The nurse should encourage clients who have rheumatoid arthritis to balance rest with exercise to maintain muscle strength, joint function, and range of motion.

A nurse is caring for a client who is in the fourth stage of labor and is receiving oxytocin via continuous IV infusion. Which of the following assessments is the nurse's priority? Amount of vaginal bleeding Amount of urinary output Pain level Fundal height

Amount of vaginal bleeding The first action the nurse should take using the nursing process is to assess the amount of vaginal bleeding. A client who is in the fourth stage of labor is at risk for hemorrhage, so assessing the amount of vaginal bleeding is the nurse's priority.

A nurse is caring for a group of clients. Which of the following clients should the nurse attend to first? An older adult client who is anxious and attempting to pull out an IV line A middle adult client who is reporting nausea after receiving pain medication An older adult client who has kidney failure and returned from dialysis 4 hr ago A middle adult client who has a terminal illness and is requesting a visit from the chaplain

An older adult client who is anxious and attempting to pull out an IV line A client who is anxious and attempting to pull out an IV line is at greatest risk for injury. Therefore, the nurse should attend to this client first.

For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client. Prescription for discharge Apply heat for abdominal pain as needed Ondansetron 4 mg PO for nausea Encourage deep breathing exercises every hour Change dressing when soiled A nurse is caring for a client following a laparoscopic cholecystectomy. Nurses' Notes 1030: 33-year-old client is 1 hr postoperative following a laparoscopic cholecystectomy. Alert and oriented to x 3. Skin warm and dry. Lungs clear auscultated throughout all lung fields. Normal sinus rhythm. Denies nausea and vomiting, bowel sounds hypoactive in all four quadrants. Peripheral pulses +2 bilaterally. Incision dressing clean and dry, incision upon inspection intact, no redness, swelling, or drainage noted. Client Education 1230: Discharge instructions given to client. Instructions on incision/wound care and proper hand washing. Client to report swelling, redness, drainage, bleeding, or warmth at operative site to surgeon. Client expected to experience carbon dioxide retention in the abdomen. Instructed the client to rest for 24 hr following surgery. Client can bathe or shower the day after surgery. Instructed the client to avoid lifting 2.3 kg (5 lb) or more for 1 week. Diet as tolerated. Provider Prescriptions 1030: Acetaminophen 500 mg PO every 4 hr as needed for pain Cefaclor 250 mg PO every 8 hr Vital Signs 1030: Temperature 36.0° C (96.8° F) Heart rate 82/min Respiratory rate 16/min Blood pressure 122/64 mm Hg Oxygen saturation 96% on room air

Anticipated Change dressing when soiled Apply heat for abdominal pain as needed Encourage deep breathing exercises every hour Contraindicated Ondansetron 4 mg PO for nausea When taking actions for a client who is postoperative following a laparoscopic cholecystectomy, the nurse should anticipate prescriptions for the client to apply heat for abdominal pain as needed, to encourage deep breathing, and to change the dressing when soiled. The client can use heat for abdominal pain related to carbon dioxide retention. During the procedure, carbon dioxide is inflated into the abdominal cavity for visualization for the provider. The client's dressing should be changed when soiled as needed. The dressing should be clean, dry, and intact to prevent infection. The nurse should identify that medication for nausea should be provided as needed and is contraindicated for scheduled administration.

A nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following interventions should the nurse include in the plan? Avoid including raw fruits in the client's diet. Restrict visits from young children to 2 hr per day. Measure the client's temperature once per shift. Use disposable gloves from a box outside the client's room.

Avoid including raw fruits in the client's diet. The nurse should exclude raw fruits and vegetables from the client's diet to reduce the risk of bacterial infections.

A nurse is assessing a client who has major depressive disorder and is taking amitriptyline. Which of the following findings should the nurse identify as an adverse effect of the medication? Diarrhea Frequent urination Excessive salivation Blurred vision

Blurred vision The nurse should identify blurred vision as an adverse effect of amitriptyline and notify the provider.

A nurse in a mental health clinic is assessing a client who has a history of seeking counseling for relationship problems. The client shows the nurse multiple superficial self-inflicted lacerations on their forearms. The nurse should identify these behaviors as characteristics of which of the following personality disorders? Borderline Antisocial Histrionic Paranoid

Borderline The nurse should identify that clients who have borderline personality disorder tend to be emotionally unstable, have troubled interpersonal relationships, and often engage in harmful behaviors such as cutting, substance use, and suicidal ideation.

A nurse is providing dietary teaching to a client who has a new prescription for phenelzine. Which of the following food recommendations should the nurse make? (Select all that apply.) Broccoli Yogurt Pepperoni pizza Cream cheese Bologna sandwich

Broccoli is correct. Clients who take phenelzine, an MAOI, should not eat foods that contain tyramine. Broccoli does not contain tyramine. Yogurt is correct. Clients who take phenelzine, an MAOI, should not eat foods that contain tyramine. Yogurt contains little or no tyramine. Cream cheese is correct. Clients who take phenelzine, an MAOI, should not eat foods that contain tyramine. Cream cheese contains little or no tyramine.

A nurse in an emergency department is assessing a school-age child who was brought in by their parents and has scald burns to both hands and wrists. The nurse suspects physical abuse. Which of the following actions should the nurse take? Discuss the suspicion of physical abuse with the provider. Confront the parents with the suspicion of physical abuse. Ask the hospital security to detain and question the parents. Contact Child Protective Services.

Contact Child Protective Services. The nurse has a legal responsibility to report suspected physical abuse to Child Protective Services.

A nurse is teaching about adverse effects with a client who is starting to take captopril. Which of the following findings should the nurse identify as an adverse effect of the medication to report to the provider? Tinnitus Cough Polyuria Blurred vision

Cough The client can develop a cough due to a buildup of bradykinin in the lungs. The client should report this finding to the provider.

A nurse is caring for a client who has a prescription for chlorpromazine. Which of the following findings should the nurse identify as an indication that the medication is effective? Decreased blood pressure Decreased hallucinations Decreased cholesterol Decreased esophageal reflux

Decreased hallucinations The nurse should recognize that chlorpromazine is an antipsychotic medication administered to decrease hallucinations and other manifestations of schizophrenia.

A nurse is updating the plan of care for a client who is 48 hr postoperative following a laryngectomy and is unable to speak. Which of the following actions should the nurse plan to take first? Determine the client's reading skills. Instruct the client on the technique for esophageal speech. Provide the client with an alphabet board. Show the client how to use an artificial larynx.

Determine the client's reading skills. The first action the nurse should take when using the nursing process is to assess the client. By determining the client's level of reading skills and cognition, the nurse can best provide the client with a variety of customized techniques to practice and use after verbal skills are lost.

A nurse on a medical-surgical unit is assessing a client who has had a stroke. For which of the following findings should the nurse initiate a referral for occupational therapy? Difficulty performing ADLs Inability to swallow clear liquids Elevated blood glucose levels Unsteady gait when ambulating

Difficulty performing ADLs The nurse should initiate a referral for occupational therapy to teach the client the skills necessary to become independent in performing ADLs such as bathing, dressing, and eating.

A nurse is admitting a client who has pneumonia. The nurse should initiate which of the following isolation precautions for the client? Droplet Airborne Contact Protective environment

Droplet The nurse should initiate droplet precautions for this client by placing the client in a private room and wearing a surgical mask when caring for the client. Pneumonia is transmitted by droplet particles.

A nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following activities is the nurse's priority? Instruct the client about the importance of regular medical appointments. Encourage the client to participate in daily exercise. Explain proper foot care techniques to the client. Ensure that the client understands the medication regimen.

Ensure that the client understands the medication regimen. The priority action the nurse should take when using the safety vs. risk reduction approach to client care is to ensure the client understands the medication regimen. The greatest risk to the client is the potential to develop hypoglycemia or hyperglycemia, which can be life-threatening if treated incorrectly.

A nurse is preparing to transfer a client who has had a stroke to a rehabilitation facility. The client's family tells the nurse they are concerned about the level of care the client will receive. Which of the following actions should the nurse take? Facilitate an interdisciplinary conference at the new facility for the family. Refer the client and family to a social worker for assistance and a follow-up meeting. Reassure the client's family that the same provider will provide care at the new facility. Tell the family that the rehabilitation facility has an excellent client care record.

Facilitate an interdisciplinary conference at the new facility for the family. Initiating an interdisciplinary conference will address the family's concerns about providing optimal care for the client.

A nurse is performing an admission assessment on a client who had a recent positive pregnancy test. The first day of her last menstrual period (LMP) was May 8. According to Nägele's rule, which of the following dates should the nurse document as the client's estimated date of birth (EDB)? February 1 February 8 February 15 February 22

February 15 Using Nägele's rule, the nurse should add 7 days to the first day of the client's LMP (8 + 7 = 15) and then subtract 3 months. Therefore, the nurse should document the client's EDB as February 15th.

A nurse is preparing to teach about dietary management to a client who has Crohn's disease and an enteroenteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in their diet? Calories Protein Potassium Fiber

Fiber The nurse should instruct the client who has Crohn's disease and an enteroenteric fistula to consume a low-fiber diet to reduce diarrhea and inflammation.

A nurse is assessing a client who has bipolar disorder. Which of the following alterations in speech is the client using? (Click on the audio button to listen to the clip.) Tangentiality Flight of ideas Word salad Perseveration

Flight of ideas Flight of ideas is an alteration in speech in which the speaker talks continuously with sudden, frequent topic changes.

A nurse is caring for a client who has active tuberculosis (TB). Which of the following actions should the nurse plan to take to prevent the transmission of the disease? Initiate contact precautions for the client upon admission. Restrict visitors from entering the client's room during hospitalization. Wear a surgical mask while providing care for the client. Have the client wear a surgical mask while being transported outside the room.

Have the client wear a surgical mask while being transported outside the room. A client who has active TB should wear a surgical mask while being transported to prevent transmission of the disease.

A nurse is assessing a client who received 2 units of packed RBCs 48 hr ago. Which of the following findings should indicate to the nurse that the therapy has been effective? Hemoglobin 14.9 g/dL WBC count 12,000/mm3 Potassium 4.8 mEq/L BUN 18 mg/dL

Hemoglobin 14.9 g/dL The nurse should identify that packed RBCs are administered to clients who have a decreased level of hemoglobin or hematocrit. This hemoglobin level is within the expected reference range of 14 to 18 g/dL for males and 12 to 16 g/dL for females, indicating the therapy has been effective.

A nurse is preparing to administer insulin to a client via a pen device. Which of the following actions should the nurse take? Hold the insulin pen device perpendicular to the client's skin to inject the medication. Shake the insulin pen device prior to injecting the medication. Withdraw the insulin from the pen device into an insulin syringe. Hold the pen device in place for 3 seconds after injecting the insulin.

Hold the insulin pen device perpendicular to the client's skin to inject the medication. The nurse should hold the insulin pen perpendicular to the client's skin to inject the medication, which ensures the insulin enters the subcutaneous tissue.

A nurse on an inpatient unit is caring for a client who has schizophrenia and recently started taking risperidone. Which of the following actions should the nurse take? Implement fall precautions for the client. Monitor the client's thyroid function. Place the client on a fluid restriction. Discontinue the medication if hallucinations occur.

Implement fall precautions for the client. Risperidone can cause orthostatic hypotension and dizziness, which can lead to falls. Therefore, the nurse should initiate fall precautions for the client.

A nurse is conducting a physical examination for an adolescent and is assessing the range of motion of the legs. Which of the following images indicates the adolescent is abducting the hip joint?

In this image, the adolescent is abducting the hip joint by moving the leg away from the midline of the body.

A nurse is caring for a client who has a magnesium level of 2.7 mEq/L. Which of the following interventions should the nurse plan to take? Initiate continuous cardiac monitoring. Administer 40 mEq/L potassium chloride PO with orange juice. Provide a diet rich in legumes, nuts, and green vegetables. Monitor the client for tetany.

Initiate continuous cardiac monitoring. The nurse should initiate continuous cardiac monitoring because a client who has hypermagnesemia is at risk for cardiac dysrhythmias and cardiac arrest.

A nurse in an emergency department is caring for a child who has a fever and fluid-filled vesicles on the trunk and extremities. Which of the following interventions should the nurse identify as the priority? Encourage oral fluids. Apply topical calamine lotion. Administer acetaminophen as an antipyretic. Initiate transmission-based precautions.

Initiate transmission-based precautions. When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority action is to initiate transmission-based precautions for the child. The child most likely has varicella. Therefore, the nurse should isolate the child to prevent the spread of the infection.

A nurse is caring for a client who has a fecal impaction. Which of the following actions should the nurse take when digitally evacuating the stool? Place the client in the lithotomy position. Elicit a vagal response by performing gentle rectal stimulation. Administer oral bisacodyl 30 min prior to the procedure. Insert a lubricated gloved finger and advance along the rectal wall.

Insert a lubricated gloved finger and advance along the rectal wall. The nurse should insert a lubricated gloved finger and advance it along the rectal wall when digitally evacuating stool.

A nurse is preparing a client for a paracentesis. Which of the following actions should the nurse take? Instruct the client to void. Position the client on their left side. Insert an IV catheter. Prepare the client for moderate (conscious) sedation.

Instruct the client to void. The nurse should instruct the client to void prior to the procedure, because an empty bladder decreases the risk of a bladder puncture and minimizes the client's discomfort during the procedure.

A nurse is caring for a client who is taking valproic acid for seizure control. For which of the following adverse effects should the nurse monitor and report? Weight loss Jaundice Bradycardia Polyuria

Jaundice The nurse should monitor the client for jaundice and report any indication to the provider. Clients who take valproic acid are at risk for liver damage, which can lead to jaundice.

A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical aseptic technique? Hold hands folded below the waist after donning sterile gloves. Pick up and pour solutions with the palm of the hand covering bottle labels. Keep sterile items within a 1.3 cm (0.5 in) border of the sterile drape. Maintain sterile objects within the line of vision.

Maintain sterile objects within the line of vision. Objects out of the line of vision are not considered sterile. Therefore, the nurse should keep sterile objects in direct sight to maintain surgical asepsis.

A nurse manager is preparing to teach a group of newly licensed nurses about effective time management. Which of the following steps of the time management process should the nurse manager include as the priority? Organizing the work environment Delegating assigned tasks appropriately Making a list of activities to complete Rewarding yourself for accomplishing goals

Making a list of activities to complete According to evidence-based practice, planning is the most important step in managing time effectively. Therefore, the nurse manager should include making a list of activities to complete as the priority. Other planning activities include setting goals, establishing priorities, and scheduling activities.

A nurse is caring for a client who has fluid volume overload. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? Palpate the degree of edema. Regulate IV pump fluid rate. Measure the client's daily weight. Assess the client's vital signs.

Measure the client's daily weight. It is within the AP's range of function to measure a client's daily weight, so the nurse should delegate this task to the AP.

A nurse is caring for a client who had a stroke 6 hr ago. Which of the following interventions should the nurse implement to reduce the risk of increased intracranial pressure (ICP)? Flex the client's neck forward. Group several nursing activities to be completed at one time. Limit suctioning the client's airway to 30 seconds at a time. Place the client in a quiet environment.

Place the client in a quiet environment. The nurse should keep the client's environment quiet to minimize the risk of increasing ICP.

A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the client's family to obtain consent. Which of the following actions should the nurse take? Contact the facility's ethics committee. Obtain consent from the client's employer. Limit care to comfort measures. Proceed with provision of medical care.

Proceed with provision of medical care. When a client is unable to give informed consent in an emergency, health care personnel can proceed with necessary life-saving care because the law considers this implied consent.

Select the 6 actions the nurse should take. Provide emotional support. Administer oxygen. Administer terbutaline. Firmly massage the uterine fundus. Weigh the perineal pads. Insert indwelling urinary catheter. Administer methylergonovine. A nurse is caring for a client who is 1 hr postpartum. Nurses' Notes 1200: Large amount of lochia rubra noted on perineal pad. Fundus boggy at two fingerbreadths above the umbilicus. Oxytocin 20 units being administered via continuous IV infusion. 1215: Large amount of lochia rubra with several large clots noted. Client reports feeling anxious. Skin cool and clammy. Provider notified. Vital Signs 1200: Temperature 37.5° C (99.5° F) Heart rate 92/min Respiratory rate 22/min Blood pressure 100/60 mm Hg SaO2​ 97% on room air 1215: Temperature 37.1° C (98.8° F) Heart rate 112/min Respiratory rate 26/min Blood pressure 90/52 mm Hg SaO2 92% on room air

Provide emotional support. Administer oxygen. Firmly massage the uterine fundus. Weigh the perineal pads. Insert indwelling urinary catheter. Administer methylergonovine. When taking action for the client, the nurse should firmly massage the uterine fundus, administer methylergonovine, weigh the perineal pads, provide emotional support, inserting an indwelling urinary catheter, and administer oxygen. The nurse should identify that the client is experiencing a postpartum hemorrhage, which requires immediate intervention to prevent hemorrhagic shock.

A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client? Radial vein of the inner arm Great saphenous vein of the leg Dorsal plexus vein of the foot Basilic vein of the hand

Radial vein of the inner arm The nurse should select the radial vein of the inner arm when initiating IV access for an older adult client because this site will have adequate subcutaneous tissue.

A nurse is caring for a client who is pregnant. The nurse is providing discharge teaching to the client. For each discharge instruction, click to specify if each action is recommended or contraindicated for the client. Nursing action Drink warm ginger ale when nauseated. Eat every 2 to 3 hr. Alternate eating solid foods and liquids. Increase intake of high-fat foods.

Recommended Drink warm ginger ale when nauseated. Eat every 2 to 3 hr. Alternate eating solid foods and liquids. Contraindicated Increase intake of high-fat foods. When taking action and providing discharge teaching for a client who has hyperemesis gravidarum, the nurse should recommend the client should eat every 2 to 3 hr to avoid having an empty stomach, which can increase nausea. The client should separate liquids from solids every 2 to 3 hr to help minimize nausea. The client should eat foods high in protein that are low in fat. Warm ginger ale or ginger tea can also decrease nausea.

A nurse is assessing a client after administering epinephrine for an anaphylactic reaction. Which of the following findings should the nurse identify as an adverse effect of this medication? Hypotension Report of tinnitus Report of chest pain Ecchymosis

Report of chest pain The nurse should identify that a report of chest pain by the client can indicate an adverse effect of the medication. Epinephrine increases cardiac workload and oxygen demand, which can result in angina.

A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, PaCO2 of 60 mm Hg, and HCO3- of 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances? Respiratory alkalosis Metabolic alkalosis Respiratory acidosis Metabolic acidosis

Respiratory acidosis A client who has respiratory acidosis will have a decreased pH below the expected reference range of 7.35 to 7.45, an increased PaCO2 above the expected reference range of 35 to 45 mm Hg, and an HCO3- within the expected reference range of 22 to 26 mEq/L.

A nurse is developing a client education program about osteoporosis for older adult clients. The nurse should include which of the following variables as a risk factor for osteoporosis? Obesity Acromegaly Estrogen replacement therapy Sedentary lifestyle

Sedentary lifestyle A sedentary lifestyle is a risk factor for osteoporosis. The nurse should encourage older adult clients to engage in weight-bearing exercises because they will promote bone health by increasing calcium and phosphorus levels.

A nurse in an outpatient mental health clinic is caring for a client. Select the 3 findings that require immediate follow-up. Speech Neuro status Weight Restlessness Auditory hallucinations

Speech Restlessness Auditory hallucinations When recognizing cues, the nurse should identify that the findings of restlessness, auditory hallucinations, and pressured speech require immediate follow-up. These findings are indications of psychosis. The nurse should notify the provider for additional evaluation and treatment.

A nurse preceptor is evaluating the performance of a newly licensed nurse. Which of the following actions by the newly licensed nurse requires intervention by the preceptor? Documents client tasks upon completion Starts a task then determines what supplies are needed Completes a client assessment while infusing an IV antibiotic over 30 min Returns to the nurses' station after completing several tasks in the same location

Starts a task then determines what supplies are needed The preceptor should intervene and instruct the newly licensed nurse to gather supplies before performing client tasks to practice effective time management.

A nurse in an outpatient mental health facility is assessing a child who has autism spectrum disorder. Which of the following manifestations should the nurse expect? Strict adherence to routines Difficulty paying attention to tasks Disobedience to authority figures Excessive anxiety when separated from parents

Strict adherence to routines The nurse should identify that a child who has autism spectrum disorder can exhibit strict adherence to routines or rituals, a fixation to specific objects, and resistance to change.

A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan? Massage bony prominences on the client's left side. Support the client's left arm on a pillow while sitting. Position the bedside table on the client's left side. Place the client's cane on their left side while ambulating.

Support the client's left arm on a pillow while sitting. The nurse should the support the client's affected arm to prevent the extremity from hanging freely because this can cause shoulder subluxation.

A school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. Upon arrival at the playground, which of the following actions should the nurse take first? Instruct a staff member to maintain a log of emergency care provided. Apply cervical spine collars to children who have suspected neck trauma. Notify guardians of the emergency and injuries to their children. Survey the scene for potential hazards to staff and children.

Survey the scene for potential hazards to staff and children. The first action the nurse should take when using the nursing process is to assess the situation. By surveying the scene, the nurse can identify potential hazards to staff and children. These findings allow the nurse and staff to enter the scene and safely provide care to injured children and help decrease the risk for further injury.

A nurse is caring for a client who is receiving positive end-expiratory pressure (PEEP) via mechanical ventilation. The nurse should monitor the client for which of the following adverse effects of PEEP? Hypoxemia Tension pneumothorax Malignant hypertension Atelectasis

Tension pneumothorax The nurse should identify that tension pneumothorax is a possible adverse effect of PEEP. The nurse should monitor the client's lung sounds hourly for indications of a tension pneumothorax, such as tracheal deviation, absent breath sounds, and distended neck veins.

An RN is observing a licensed practical nurse (LPN) and an assistive personnel (AP) move a client up in bed. For which of the following situations should the nurse intervene? The LPN and AP lower the side rails before lifting the client up in bed. Prior to lifting the client, the LPN and AP raise the bed to waist level. The LPN and the AP grasp the client under his arms to lift him up in bed. The LPN and the AP ask the client to flex his knees and push his heels into the bed as they lift.

The LPN and the AP grasp the client under his arms to lift him up in bed. The LPN and AP should not grasp the client under the arms when lifting, as this can result in shoulder dislocation or other injury to the client. Therefore, the RN should intervene and instruct the nurses to use a draw sheet or friction-reducing device to lift the client.

Complete the following sentence by using the lists of options. The client is at greatest risk for developing Select... as evidenced by Select.... A nurse is caring for a client who is postoperative following coronary artery bypass surgery (CABG). Laboratory Results 0630: Sodium 145 mEq/L (136 to 145 mEq/L) Potassium 3.2 mEq/L (3.5 to 5.0 mEq/L) Chloride 116 mEq/L (98 to 106 mEq/L ) BUN 24 mg/dL (10 to 20 mg/dl ) Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L Total calcium 9.0 mg/dL (9.0 to 10.5 mg/dL) Phosphate 4.6 mg/dL (3.0 to 4.5 mg/dL) Glucose 95 mg/dL (74 to 106 mg/dL) WBC count 9,500/mm3 (5,000 to 10,000/mm3​) I&O 0700: 4 hr input 400 mL4 hr output 350 mL 1100: 4 hr input 475 mL4 hr output 360 mL 1500: 4 hr input 350 mL4 hr output 375 mL Vital Signs 0700: Temperature 37.6° C (99.6° F) Heart rate 86/min Respiratory rate 20/min Blood pressure 115/70 mm Hg Oxygen saturation 100% on 2 L via nasal cannula 1100: Temperature 37.2° C (99.0° F) Heart rate 88/min Respiratory rate 18/min Blood pressure 110/72 mm Hg Oxygen saturation 100% on 2 L via nasal cannula 1500: Temperature 37.7° C (99.8° F) Heart rate 80/min Respiratory rate 20/min Blood pressure 108/70 mm Hg Oxygen saturation 100% on 2 L via nasal cannula Nurses' Notes 0700: Client alert and oriented x 3. Reports pain as 6 on a scale of 0 to 10. Administered morphine 5 mg IV. Incisional dressing intact. No redness or excessive drainage noted. Urinary catheter patent, draining clear yellow urine. Chest tube patent. No redness or edema noted at chest tube site. 1100: Client alert and oriented to person, place, and time. Reports pain as 1 on a scale of 0 to 10. Incisional dressing intact. No redness or excessive drainage noted. Urinary catheter patent, draining clear yellow urine. Chest tube patent. No redness or edema noted at chest tube site. Client states their leg muscles are cramping. Assisted the client with range-of-motion exercises to lower extremities. Client tolerated activity. 1500: Client alert and oriented to person, place, and time. Reports pain as 2 on a scale of 0 to 10. Incisional dressing intact. No redness or excessive drainage noted. Urinary catheter patent, draining clear yellow urine. Chest tube patent. No redness or edema noted at chest tube site. Client continues to report leg muscle cramps. Medication Administration Record 0700: 0.9% sodium chloride at 150 mL/hr via continuous infusionEnoxaparin 40 mg subcutaneously dailyMorphine 5 mg IV every 4 hr PRN incisional pain

The client is at greatest risk for developing dysrhythmias as evidenced by electrolyte imbalance. The nurse should analyze cues to determine the client is at greatest risk for developing dysrhythmias related to hypokalemia, as evidenced by the laboratory report and the client's report of muscle cramping. Potassium and magnesium depletion are common manifestations in clients who are postoperative following CABG. Due to medication or hemodilution, it is important for the nurse to closely monitor electrolytes.

Complete the following sentence by using the lists of options. The client is at highest risk for developing Select... as evidenced by the Select.... A nurse is caring for a client who is 1 day postoperative following a total thyroidectomy. Laboratory Results 0700: Sodium 143 mEq/L (136 to 145 mEq/L) Potassium 3.5 mEq/L (3.5 to 5.0 mEq/L) Chloride 104 mEq/L (98 to 106 mEq/L ) BUN 15 mg/dl (10 to 20 mg/dl) Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L ) Total calcium 8.0 mg/dL (9.0 to 10.5 mg/dL) Phosphate 4.6 mg/dL (3.0 to 4.5 mg/dL) Glucose 95 mg/dL (74 to 106 mg/dL) WBC 9,500/mm3 (5,000 to 10,000/mm3) Nurses' Notes 0700: Client alert and oriented x 3. Respirations even and unlabored with no adventitious sounds. Bowel sounds active in all 4 quadrants. Surgical dressing dry, slight edema at incision site noted. Client rates dull pain in neck of 2 on a 0 to 10 scale. Declines pain medication.1100: Client alert and oriented to person, place, and time. Respirations even and unlabored with no adventitious sounds. Bowel sounds active in all 4 quadrants. Surgical dressing dry, slight edema at incision site noted. Client reports muscle cramps in legs as a pain level of 5 on a 0 to 10 scale. Morphine 5 mg IV administered. Encouraged client to ambulate with assistance.1200: Client alert and oriented to person, place, and time. Respirations even and unlabored with no adventitious sounds. Bowel sounds active in all 4 quadrants. Surgical dressing dry, slight edema at incision site noted. Client ambulated down the hall with assistance. Client reports numbness around lips. Vital Signs 0700: Temperature 37.6° C (99.6° F)Heart rate 65/minRespiratory rate 16/minBlood pressure 115/70 mm HgOxygen saturation 98% on room air0900: Temperature 37.2° C (99.0° F)Heart rate 72/minRespiratory rate 18/minBlood pressure 110/72 mm HgOxygen saturation 100% on room air1100: Temperature 37.7° C (99.86° F)Heart rate 76/minRespiratory rate 16/minBlood pressure 108/70 mm HgOxygen saturation 100% on room air Medication Administration Record 1100: 0.9% Sodium chloride at 150 mL/hr Morphine sulfate 5 mg IV

The client is at highest risk for developing hypocalcemia as evidenced by the report of numbness around lips. The nurse should recognize cues and determine that the client is at highest risk for developing hypocalcemia as evidenced by the client's report of muscle spasms, numbness around lips, and decreased calcium level. Hypocalcemia is more likely to occur in clients who have experienced a thyroidectomy, due to accidental damage to the parathyroid. Numbness around the lips is a clinical manifestation specific to hypocalcemia. Hypocalcemia presents as muscle spasms and can lead to cardiac dysrhythmias. Hypocalcemia is the highest priority, as it requires immediate treatment with calcium gluconate to avoid dysrhythmias and other complications.

A nurse is caring for a client who is 24 hr postoperative following a cesarean birth. Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing Box 1 as evidenced by Box 2. Box 1 postpartum hemorrhage infection hyperglycemia seizures hypoxemia Box 2 Oxygen saturation platelet count WBC blood pressure capillary blood glucose

The client is at risk for developing seizures as evidenced by blood pressure . When analyzing cues, the nurse should recognize the client is at risk for developing seizures as evidenced by the client's blood pressure. The client is reporting a new onset of headache, blurred vision, and nausea. Assessment of the client demonstrates significantly elevated blood pressure, hyperreflexia, and clonus. These findings indicate central nervous system irritability, which increases the risk for seizures, also known as eclampsia.

A nurse is caring for a client who is 3 days postoperative following a T4 spinal cord injury. Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing Box 1 due to Box 2. Box 1 infection spinal shock hemorrhagic stroke respiratory depression injection site reaction Box 2 urinary catheter placement tardive dyskinesia hypervolemia autonomic dysreflexia dexamethasone intake

The client is at risk for developing spinal shock due to autonomic dysreflexia .

A nurse is caring for a client who has a prescription for a continuous passive motion (CPM) machine following a total knee arthroplasty. Which of the following actions should the nurse take? Turn off the CPM machine during mealtime. Maintain the client's affected hip in an externally rotated position. Instruct the client how to adjust the CPM settings for comfort. Store the CPM machine under the client's bed when not in use.

Turn off the CPM machine during mealtime. The nurse should turn off the CPM machine during meals to promote client comfort and dietary intake.

A nurse is caring for a client who is postoperative following administration of general anesthesia.

Upon recognizing and analyzing the client cues of tachycardia, tachypnea, hypotension, and irregular heart rhythm, the nurse's priority hypothesis should be that this client is most likely experiencing malignant hyperthermia and that it is important to generate solutions and take actions that will correct dysrhythmias, provide oxygen to tissues, correct electrolyte imbalances, and reverse metabolic and respiratory acidosis. Therefore, the nurse should prepare to administer dantrolene and administer oxygen. The nurse should monitor the PCO2 level on the client's ABGs for hypercapnia and observe the client for muscle rigidity of the jaw and chest muscles.

A nurse is providing teaching for a client who has a fracture of the right fibula with a short-leg cast in place and a new prescription for crutches. The client is non-weight-bearing for 6 weeks. Which of the following instructions should the nurse include in the teaching? Adjust the crutches for comfort as needed. Use a three-point gait. Wear leather-soled shoes. Advance the affected leg first when walking upstairs.

Use a three-point gait. A three-point crutch gait allows the client to be mobile without bearing weight on the affected extremity.

A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse plan to take? Select a 1-inch needle. Use a 45º angle when inserting the needle. Use the ventrogluteal site. Pinch the skin up during injection.

Use the ventrogluteal site. The nurse should use the ventrogluteal site because it has a thick area of muscle and contains no large nerves or blood vessels.

A nurse is providing discharge teaching for the parents of a preschool-age child who has a new prescription for amoxicillin/clavulanate suspension. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) "You will give the medication every 4 hours." "Shake the medication bottle well before each dose is given." "Store the medication in the refrigerator." "Report diarrhea to the provider immediately." "Discard the unused portion of medication after 21 days."

"Shake the medication bottle well before each dose is given" is correct. A suspension medication should be mixed before administration. "Store the medication in the refrigerator" is correct. This medication should be kept cool, not at room temperature. "Report diarrhea to the provider immediately" is correct. Diarrhea can be a manifestation of a Clostridium difficile infection and should be reported to the provider.

A hospice nurse is consulting with a client and her family about receiving home services. Which of the following statements should the nurse identify as an indication that the family understands home hospice care? "We can expect the hospice nurse to provide support for us after our mother's death." "A hospice nurse will come to the house each time our mother needs pain medication." "Now that my mother is receiving hospice services, we will not be able to get respite care." "Hospice care focuses on arranging treatment that will prolong our mother's life."

"We can expect the hospice nurse to provide support for us after our mother's death." Hospice care includes bereavement services after a family member's death.

A nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster. Which of the following clients should the nurse recommend for discharge? A client who has cellulitis and is receiving oral antibiotics every 8 hr A client who is postoperative following an upper endoscopy procedure and is alert but does not have a gag reflex A mother and their newborn 12 hr postdelivery A client who has lower extremity weakness and is newly admitted for observation

A client who has cellulitis and is receiving oral antibiotics every 8 hr A client who has cellulitis and is receiving oral antibiotics can safely continue this treatment at home. Therefore, the nurse should recommend this client for discharge.

A nurse has just received change-of-shift report on four clients. Which of the following clients should the nurse assess first? A client who is postoperative with abdominal distention and no bowel sounds A client who has diabetes mellitus and a blood glucose level of 105 mg/dL A client who has heart failure and 2+ pitting edema A client who is receiving maintenance IV fluids and needs a new IV catheter

A client who is postoperative with abdominal distention and no bowel sounds Using the acute vs. chronic approach to client care, the nurse should first assess the client who is postoperative with abdominal distention and no bowel sounds because these manifestations are indications of a paralytic ileus.

A nurse is preparing to administer lactated Ringer's 1,500 mL IV to infuse at 50 mL/hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

12.5

A nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 min as a test dose to a client who has severe oliguria. The client weighs 198 lb. What is the amount in grams the nurse should administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

18g

A nurse on a pediatric unit has received change-of-shift report for four children. Which of the following children should the nurse assess first? A 6-month-old infant who has croup and an O2 saturation of 92% on room air A 15-year-old adolescent who is 2 hr postoperative following an open reduction and internal fixation of the left ankle and is requesting pain medication A 3-year-old toddler who has gastroenteritis, moderate dehydration, and had two loose bowel movements over the past 24 hr A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain

A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain Using the urgent vs. nonurgent approach to client care, the nurse should determine that the client to assess first is the child awaiting an appendectomy who suddenly experiences pain relief as this can be an indication of peritonitis from a ruptured appendix. The nurse should notify the provider immediately.

For each assessment finding, click to specify if the finding is consistent with attention deficit hyperactivity disorder (ADHD) or intellectual disability (ID). Each finding may support more than 1 disease process. Assessment Findings Intellectual impairment Interrupting others Impaired language skills Hyperreactivity to sensory input Losing necessary things A nurse is caring for a school-age child. Nurses' Notes First visit: A child is brought to the clinic accompanied by guardians. The guardians have received feedback from the child's teacher that the child has become disinterested in schoolwork and has difficulty paying attention during class. The child often loses their school supplies. The guardians report that the child demonstrates these behaviors at home as well. The child refuses to participate in household chores, keeps their room untidy, does not clean up when told to, and is generally careless and disinterested. On assessing, the child is found to be talkative, restless, and easily distracted. 2 weeks later: The child's guardians report that the child seems to be doing better at school. The child is improving at paying attention during class and completing assignments on time. Vital Signs First visit: Blood pressure 94/56 mm Hg Heart rate 90/min Respiratory rate 24/min Temperature 37.2° C (99° F) SaO2 99% on room air 2 weeks later: Blood pressure 98/60 mm Hg Heart rate 88/min Respiratory rate 22/min Temperature 37° C (98.6° F) SaO2 99% on room air Provider Prescriptions Atomoxetine 10 mg PO daily with breakfast for 5 days, then increase dose to 18 mg PO daily with breakfast

ADHD Hyperreactivity to sensory input Losing necessary things Interrupting others Intellectual impairment ID Intellectual impairment Hyperreactivity to sensory input When analyzing cues, the nurse should identify that manifestations of ADHD include losing necessary things, interrupting others, intellectual impairment, and hyper reactivity to sensory input. In ADHD, the client often loses necessary things in daily life, such as pencils, erasers, and books. The client often interrupts others and has difficulty waiting for their turn in conversation. The client might have an intellectual impairment, which can lead to poor academic performance and difficulties with socialization. The client might exhibit hyperreactivity or hyporeactivity to stimuli.

A nurse in a community center is providing an educational session to a group of clients about ovarian cancer. Which of the following manifestations of ovarian cancer should the nurse include in the teaching? Diarrhea Urinary retention Purulent discharge Abdominal bloating

Abdominal bloating The nurse should include the presence of abdominal bloating as an early manifestation of ovarian cancer. Other manifestations include an increase in abdominal girth, pelvic or abdominal pain, early satiety, and urinary frequency or urgency.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Action to Take Hold all antipsychotic medications. Request a prescription for benztropine. Administer lorazepam as prescribed. Provide a cooling blanket. Initiate reverse isolation procedures. Condition Most Likely Experiencing Akathisia Neuroleptic malignant syndrome Pseudoparkinsonism Severe neutropenia Parameter to Monitor Hydration status Temperature Manifestations of infection Motor restlessness Dysphagia Medical History 1030: Diagnosed with schizophrenia 2 years ago Migraine headaches Unresponsive to second-generation medications (clozapine and risperidone), changed to first-generation medication 6 months ago Current medications: Haloperidol 5 mg PO TID Sumatriptan 50 mg PO every 2 hr PRN headache Vital Signs 1030: Heart rate 122/min Respiratory rate 28/min Blood pressure 182/85 mm Hg Temperature 39.7° C (103.5° F) Oxygen saturation 90% on room air Nurses' Notes 1030: Client arrived at ED via ambulance. Emergency medical technicians (EMTs) report being called to client's home by the client's partner. According to EMTs, partner stated they found the client with decreased responsiveness, muscle rigidity, posturing, and diaphoresis. 1045: Client unresponsive to questions, does not follow simple commands. Sinus tachycardia; S1S2 on auscultation; peripheral pulses +4. Respirations rapid and labored at 28/min, chest clear on auscultation. Bowel sounds active x 4 quadrants; incontinent of urine. Febrile, diaphoretic. Muscle rigidity with extensor posturing of arms. 1100: Assessment reported to ED provider, prescription for transfer to intensive care unit received.

Action to Take Hold all antipsychotic medications Provide a cooling blanket. Condition Most Likely Experiencing Neuroleptic malignant syndrome Parameter to Monitor Hydration status Temperature Upon recognizing and analyzing the client cues of decreased responsiveness, muscle rigidity, posturing, diaphoresis, and vital signs that are outside the expected reference ranges, the nurse's priority hypotheses should be that this client is most likely experiencing neuroleptic malignant syndrome, which is related to the client's haloperidol therapy. It is important to generate solutions and take actions that will decrease the client's temperature, blood pressure, heart rate, and respiratory status, which will improve the client's neurological status. The nurse should hold the client's antipsychotic medications and apply a cooling blanket to reduce the client's temperature. Neuroleptic malignant syndrome is a life-threatening condition. Therefore, the nurse should monitor the client's laboratory and arterial blood gas values as multiorgan failure can occur. To evaluate interventions and track the client's condition, the nurse should monitor the client's temperature, hydration status, and provide for early detection of complications.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor for that condition. Actions to Take Assist client with menu selection of fresh fruits and vegetables. Encourage oral fluid intake. Prepare to administer IV fluids. Assist client to semi-Fowler's position. Prepare to insert a feeding tube. Potential Condition Intestinal obstruction Renal calculi Inguinal hernia Joint contracture Parameters to Monitor Hematuria Palpable bulge in abdomen Urine output Range of motion Bowel sounds Nurses' Notes 1300: Client reports intermittent abdominal pain as 5 on a scale of 0 to 10 on left side of abdomen. Last bowel movement 5 days ago. Client reports usual pattern is one bowel movement daily. Oral fluid intake 1,950 mL/24 hr. Urine output 1,820 mL/24 hr. 1900: Client reports nausea and constant abdominal pain as 5 on a scale of 0 to 10 throughout abdomen. Pain began after eating dinner. Physical Examination 1300: Abdomen distended, dull to percussion, firm and nontender on palpation. Hypoactive bowel sounds in lower quadrants. Skin warm and dry to touch in trunk and all extremities. Pedal pulses strong and equal bilaterally. Capillary refill less than 3 seconds in toes bilaterally.1900: Abdomen distended, dull to percussion, firm and nontender on palpation. Hypoactive bowel sounds in all quadrants. Vital Signs 1400: Temperature 37° C (98.6° F) Heart rate 88/min and regular Respiratory rate 18/min Blood pressure 130/84 mm Hg Oxygen saturation 97% on room air Medical History History of osteoarthritis, hypertension, GERD, and iron-deficiency anemia. Medication Administration Record 0800: Ferrous sulfate 325 mg PO once daily 0900: Lisinopril 10 mg PO once daily Atorvastatin 40 mg PO once daily Docusate sodium 200 mg PO twice daily 1100: Hydrocodone 5 mg/acetaminophen 325 mg PO every 4 hr as needed for postoperative pain Diagnostic Results 0700: Hct 42% (42% to 52%) Hgb 14 g/dL (14 to 18 g/dL) Potassium 3.7 mEq/L (3.5 to 5 mEq/L) Sodium 140 mEq/L (136 to 145 mEq/L)

Actions to Take Assist client to semi-Fowler's position Prepare to administer IV fluids. Potential Condition intestinal obstruction Parameters to Monitor Bowel sounds Urine output Upon recognizing and analyzing the client cues of hypoactive bowel sounds in all quadrants, abdominal distention, change in pain from intermittent to constant, and last bowel movement 5 days ago, the nurse's primary hypothesis should be that the client is most likely experiencing intestinal obstruction. It is important to generate solutions and actions that relieve the pressure from abdominal distention to promote lung expansion and to reduce the risk of developing fluid and electrolyte imbalances because the client is NPO. Therefore, the nurse should assist the client to semi-Fowler's position and prepare to administer IV fluids as prescribed. The nurse should assess bowel sounds at least twice daily for the return of peristalsis and monitor urine output because the client is receiving IV fluids. A manifestation of intestinal obstruction is dehydration.

Which of the following interventions should the nurse implement? Select all that apply. Raise the knee position on the client's bed. Use an automated blood pressure cuff on the client's arm. Administer IV fluids. Prepare for platelet transfusion. Assess the client's mouth every 8 hr. Assess peripheral circulation hourly. Use humidification with oxygen therapy. A nurse is caring for a client during a follow up visit at a gastrointestinal clinic Nurses' Notes 0600: Client admitted to the ED with fatigue, shortness of breath, and weakness for the last 2 days. Client states that they have a history of sickle cell disease (SCD). Client is alert and orientated to person, place, and time. Restless. Client rates generalized pain as a 9 on a scale of 0 to 10. Vital signs taken and blood drawn for laboratory tests. Oxygen 2 L via nasal cannula applied. Awaiting prescription for pain management. 0615: Client still rates pain as a 9 on a scale of 0 to 10. Hydromorphone 4 mg IV administered. Vital Signs 0600: Temperature 37.8° C (100° F) Heart rate 104/minR espiratory rate 26/min Blood pressure 88/56 mm Hg Oxygen saturation 90% on 2 L via nasal cannula Diagnostic Results 0645: Hematocrit 25% (37% to 52%) Hemoglobin 8.3 g/dL (12 to 16 g/dL) WBC count 18,000/mm3 (5,000 to 10,000/mm3) Reticulocytes 8% (0.5% to 2%) Total bilirubin 1.9 mg/dL (0.3 to 1.0 mg/dL)

Administer IV fluids is correct. Hydration is a priority when caring for a client in sickle cell crisis because it decreases the rate of cell sickling and can reduce pain. Hypotonic fluids are typically infused at 250 mL/hr for 4 hr. Use humidification with oxygen therapy in correct. Oxygen administered without humidification can cause drying of the mucous membranes, especially in clients who are already fluid-depleted. Placing humidification on the oxygen therapy promotes comfort and reduces the risk of sores and lesions of the mucous membranes. Assess peripheral circulation hourly is correct. The nurse should assess the client's peripheral circulation because of the risk of venous occlusion caused by the sickling and clumping of the red blood cells. Assess the client's mouth every 8 hr is correct. The nurse should assess the client's mouth at least every 8 hr for the presence of sores or lesions and any other signs of infection.

For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client. Potential Order Keep the client supine. Oxygen therapy to keep oxygen saturation above 95%. Maintain the client's hips in flexion. Keep the lights in the client's room dim. Cluster nursing care. Monitor blood glucose every 4 hr. Nurses' Notes Day 1, 1000: Client presents to the emergency department (ED) with right-sided hemiparesis, lethargy, and aphasia. The client's symptoms started 1 hr prior to arrival at the ED. Client received fibrinolytic therapy and was transferred to the ICU. Day 2, 0800: Client is awake and alert to person, place, and time. Client has weak right-side hand grasp. However, this is improved from admission. Client to be evaluated by speech therapy due to aphasia. Day 2, 1930: Called to the client's room by a family member. Client is lethargic and restless, oriented to person and place. Client reports headache. The client's family member also reports that the client just vomited in an emesis basin. Client's speech is slurred.

Anticipated Oxygen therapy to keep oxygen saturation above 95% Monitor blood glucose every 4 hr Keep the lights in the client's room dim. Contraindicated Cluster nursing care. Maintain the client's hips in flexion. Keep the client supine. Oxygen therapy to keep oxygen saturation above 95% is anticipated. The nurse should titrate oxygen therapy to maintain the oxygen saturation level above 95% to avoid hypoxia. The client is exhibiting manifestations of increased intracranial pressure (ICP). Therefore, oxygenation and perfusion are the priority for this client. Cluster nursing care is contraindicated. This client is exhibiting manifestations of increased ICP. The nurse should spread out nursing care out because clustering can contribute to increased ICP. Keep the client supine is contraindicated. The nurse should elevate the head of the bed to promote blood return to the heart of the client who has increased ICP. Monitor blood glucose every 4 hr in anticipated. The client is exhibiting manifestations of increased ICP. Therefore, the nurse should frequently monitor the client's vital signs and blood glucose to avoid secondary brain injury. Maintain the client's hips in flexion is contraindicated. The client has manifestations of increased ICP. Extreme hip flexion leads to increased intrathoracic pressure and subsequently a decrease in cerebral outflow. Keep the lights in the client's room dim is anticipated. The nurse should dim the lights in the client's room because many clients with have increased ICP experience photophobia.

A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling off a stepstool at home. Which of the following prescriptions should the nurse clarify with the provider? Obtain capillary blood glucose level every 2 hr. Check the neurovascular status of the client's lower extremities every hour. Apply a cold pack to the client's ankle for 30 min every hour. Maintain the affected ankle elevated and immobilized.

Apply a cold pack to the client's ankle for 30 min every hour. The nurse should clarify a prescription for a cold pack to the client's ankle because type 1 diabetes mellitus is a contraindication for receiving cold therapy. A client who has type 1 diabetes mellitus can have impaired circulation due to arteriosclerosis and a loss of sensory perception due to neuropathy. Ice can further impair circulation.

A nurse is caring for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? Evaluate dietary intake for a client who has anorexia. Measure the vital signs of a client who just returned from the PACU. Arrange the lunch tray for a client who has a hip fracture. Assess I&O for a client who is receiving dialysis.

Arrange the lunch tray for a client who has a hip fracture. Assisting a client with meals is within the range of function of the AP.

A nurse is caring for a client who has active pulmonary tuberculosis. Which of the following actions should the nurse take? Wear a surgical mask when providing client care. Have visitors maintain a distance of 1.8 m (6 feet) from the client. Restrict fresh flowers from the client's room. Assign the client to a private room with negative air pressure.

Assign the client to a private room with negative air pressure. To control the spread of active tuberculosis, the nurse should assign the client to a private room with negative air pressure.

A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurse's priority? Assess fluid intake every 24 hr. Ambulate three times a day. Assist with deep breathing and coughing. Monitor the incision site for findings of infection.

Assist with deep breathing and coughing. The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to assist the client with deep breathing and coughing, which reduces the risk for postoperative pneumonia.

A nurse manager is reviewing clients' rights with the nurses on the unit. The nurse manager should tell the nurses that informed consent promotes which of the following ethical principles? Autonomy Nonmaleficence Justice Fidelity

Autonomy Autonomy refers to a client's ability to make their own decisions about treatment. Informed consent promotes autonomy by providing clients with complete information about treatment.

A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect? Pink, frothy sputum Bradycardia Flushed, dry skin Wheezing

Pink, frothy sputum A client who has manifestations of pulmonary edema can have pink, frothy sputum due to fluid leaking across the pulmonary capillaries and into the lung tissue.

Select the 4 client findings that lead the nurse to suspect that the client is experiencing thyroid storm. Wound drainage Mental status Temperature Pain Blood pressure Heart rate A nurse is caring for a client who is immediately postoperative following a subtotal thyroidectomy. Vital Signs 1100: Temperature 37.4° C (99.4° F)Heart rate 98/minRespiratory rate 18/minBlood pressure 128/68 mm HgPulse oximetry 97% on room air 1115: Temperature 37.8° C (100.1° F)Heart rate 110/minRespiratory rate 16/minBlood pressure 138/74 mm HgPulse oximetry 95% on room air1130: Temperature 38.6° C (101.5° F)Heart rate 136/minRespiratory rate 16/minBlood pressure 154/86 mm HgPulse oximetry 95% on 2 L/min via nasal cannula Medication Administration Record 1110: Morphine 4 mg IV bolus Nurses' Notes 1100: The client is asleep, easily aroused. Rates pain at incision site as 8 on a scale of 0 to 10. Portable wound bulb suction device in place with scant serosanguinous drainage present. Dressing to neck dry and intact.1115: Client asleep. Arousable with name called loudly multiple times. Client rates pain as 7 on a scale of 0 to 10. Reports having a hard time staying awake.1130: Client asleep. Arousable with name called loudly several times. Client rates pain as 5 on a scale of 0 to 10. Restless upon awakening, oriented to person.

Mental status Temperature Blood pressure Heart rate When analyzing cues, the nurse should identify that thyroid storm can be caused by trauma to the thyroid gland, such as surgery, and excessive release of thyroid hormone greatly increases the metabolic rate. Fever greater than 38.5° C (101.3° F), heart rate greater than 130/min, systolic hypertension, and mental status changes, such as confusion, restlessness, and sleepiness, are characteristic of thyroid storm.

A nurse is caring for a client who has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take? Assess the client's IV site every 8 hr. Check the client's WBC count every 48 hr. Monitor the client's mouth every 8 hr. Change the client's IV tubing every 48 hr.

Monitor the client's mouth every 8 hr. The nurse should monitor the client's mouth at least every 8 hr for manifestations of an infection, such as sores or lesions.

A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider? Heart rate 136/min Nasal flaring Transient strabismus Overlapping of sutures

Nasal flaring The nurse should report any indications of respiratory distress such as nasal flaring, retractions, and grunting.

A nurse is assigning task roles for a group of clients in a community mental health clinic. Which of the following tasks should the nurse assign to the member of the group functioning as the orienteer? Measuring the group's work against the assigned objectives Noting the progress of the group toward assigned goals Sharing experiences as an authority figure Offering new and fresh ideas on an issue

Noting the progress of the group toward assigned goals Noting the progress of the group toward assigned goals is the task of the orienteer.

Complete the following sentence by using the lists of options. The client is at risk for experiencing Select... due to the client's Select.... A nurse is providing phone advice for a client who is pregnant Nurses' Notes Week 6 of gestation: Spoke with client over the phone. Client reports nausea and vomiting with a weight loss of 0.9 kg (2 lb) from their pre-pregnancy weight. Client reports no noted change in voiding pattern and denies dry mucus membranes. Advised client to eat small frequent meals of nongreasy, dry, sweet or salty foods, such as dry toast, crackers, and pretzels. Encouraged client to call back if nausea and vomiting worsens.Week 10 of gestation: Spoke with client over the phone. Client reports a 6.8 kg (15 lb) weight loss over the past month. Client states nausea continues, making it difficult to eat. They describe a diet of water, toast, and pretzels because other foods are unappealing. They report tolerating a cup of black coffee each morning. Advised client to be seen by the provider today.

The client is at risk for experiencing metabolic acidosis due to the client's weight loss. When prioritizing hypotheses, the nurse should identify that the client is at risk for developing metabolic acidosis due to excessive weight loss. The intake and retention of food is not meeting the client's nutritional requirements. Undernutrition can lead to the breakdown of fatty tissue which increases the release of nonvolatile acids into the blood stream.

A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which of the following observations should the nurse identify as an indication for potential violence? The client is taking numerous deep, measured breaths. The client is calmly telling their partner that "the staff here is so controlling." The client is sitting with their head in their hands and appears to be crying. The client is pacing around the chair in which their partner is sitting.

The client is pacing around the chair in which their partner is sitting. Hyperactivity and pacing indicates that this client is at risk for violent behavior. The nurse should assess the situation further and attempt to de-escalate the situation by speaking to the client in a low, calm voice using short sentences.

A nurse is assessing a client who is at 11 weeks of gestation and reports drinking ginger tea. Which of the following findings indicates the client's use of ginger tea is effective? The client reports a decrease in episodes of nausea. The client reports a decrease in breast tenderness. The client reports a decrease in headaches. The client reports a decrease in urinary frequency.

The client reports a decrease in episodes of nausea. The nurse should realize that a decrease in the client's nausea indicates the ginger tea is effective. The client can also safely use ginger ale and ginger snaps to alleviate nausea associated with pregnancy.

A nurse is caring for a client who is in spinal cord injury (SCI) unit. Complete the following sentence by using the list of options. The nurse should first address the client's Select... blood pressure temperature oxygen saturation followed by the client's Select.... Select... bowel sounds urinary output deep tendon reflexes

The nurse should first address the client's oxygen saturation followed by the client's urinary output. The nurse should determine that the priority hypothesis is decreased oxygenation followed by decreased urine output. When using the airway, breathing, circulation framework, the priority finding the nurse should address is the oxygen saturation measurement of 92%. Impaired functioning of the intercostal muscles and nerves of the diaphragm increases the risk of atelectasis and pneumonia for the client who has a SCI as evidenced by oxygen saturation of 92%. The nurse should analyze the cues and determine that the next priority finding to address is the client's urine output. Urine output of 30 mL/hr or less for more than 2 hr requires assessment. When using the greatest risk framework, the nurse should identify that the urine output should be addressed next. The nurse should recognize the risk of autonomic dysreflexia from urinary retention and should observe the client's abdominal distention, assess for bladder distention, and check the urinary catheter tubing for obstruction.

A nurse is creating a plan of care for a newly admitted child. Which of the following actions should the nurse include in the plan? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) Initiate droplet isolation precautions. Keep the child on NPO status for 12 hr. Maintain the child on bed rest for 24 hr. Administer high-dose antibiotic therapy. History and Physical 8-year-old male admitted with cystic fibrosis Reports shortness of breath Wheezing throughout lung fields Productive cough with thick sputum Graphic Record Heart rate 108/min Respiratory rate 26/min Temperature 37.2°C (98.9°F) Blood pressure 100/62 mm Hg Oxygen saturation 92% Diagnostic Results Sputum culture: Burkholderia cepacia

The nurse should include administering high-dose antibiotic therapy in the child's plan of care. Children who have cystic fibrosis metabolize antibiotics more rapidly and require higher doses of antibiotics to help fight aggressive infections such as Burkholderia cepacia.

A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse include in the change-of-shift report? The last time the provider evaluated the client The client's most recent ventilator settings The time of the client's last dose of pain medication The frequency in which the client presses the call button

The time of the client's last dose of pain medication The nurse should recognize that an effective handoff report provides a baseline of the client's status for comparison and should include any recent changes or priority situations affecting the client's condition. Therefore, the time of the client's last dose of pain medication is important to include so the receiving nurse can anticipate what time to give the next dose.