VATI Med surg proctored
A nurse is reinforcing teaching with a client who is in the early stages of COPD and wants to use nicotine chewing gum to stop smoking. Which of the following recommendations should the nurse make?
"Do not eat or drink anything for 15 minutes before or after chewing the gum. The client should not eat or drink anything 15 min before, during, or 15 min after chewing the gum. Food and beverages can interfere with the absorption of nicotine and diminish its therapeutic effects as nicotine replacement therapy.
A nurse is reinforcing teaching with a client who has chronic renal failure and is prescribed epoetin alfa. Which of the following information should the nurse include in the teaching?
"Eppetin alfa can reduce your need for a blood transfusion. Epoetin alfa is a hormone that stimulates the production of red blood cells. It is used in the treatment of specific types of anemia. Therapeutic effects are indicated by an increase in hematocrit resulting in a decreased requirement for blood transfusions.
A nurse is reinforcing teaching with a young adult client about testicular self-examination. Which of the following instructions should the nurse include?
"Examine your testicles after a warm shower." After exposure to warm water in a shower or bath, the scrotum relaxes and becomes easy to palpate. The testicle should feel smooth and round, and the client should report any lumps to his provider.
A nurse is collecting data from a client who reports dizziness and vertigo and is performing the Romberg test. Which of the following instructions should the nurse give the client about this test?
"Open your eyes." The nurse should instruct the client to stand with their feet together and eyes open. Then the client should close their eyes to determine if they lose balance. The test is negative if the client can remain upright and keep balance with minimal swaying and without moving their feet to another position. A positive test can indicate a dysfunction of the cerebellum or inner ear.
A nurse is reinforcing teaching with a client who is scheduled for an electroencephalogram (EEG). Which of the following information should the nurse include in the teaching?
"Shampoo your hair the night before the procedure The nurse should instruct the client to shampoo her hair to remove any olls or residue from styling products that might interfere with the adhesion of the scalp electrodes. Electrodes are attached to the client's scalp using electrode paste. An EEG is a diagnostic test that determines electrical activity in the brain and Identifies the presence of seizures or other conditions involving the cortex of the brain.
A nurse is reinforcing postoperative teaching with a client who is scheduled for cataract surgery on his right eye. Which of the following instructions should the nurse include?
"Wear a protective eye shield while sleeping The nurse should remind the client to wear an eye shield while sleeping. This protects the operative eye from injury due to rubbing or pressure from the pillow.
A nurse is reinforcing teaching about foods high in calcium with a client who has hypocalcemia. Which of the following foods should the nurse recommend as containing the most calcium?
3 oz canned salmon The nurse should determine that 3 oz canned salmon is the best food source to recommend because it contains 187.2 mg of calcium per serving. Other food sources high in calcium include sardines, tofu, milk, and milk products. The nurse should also instruct the client to spend time in the sunlight each day to absorb vitamin Dand engage in weight-bearing exercise to help metabolize calcium.
A nurse is assisting with the care of four clients. Which of the following clients is the priority for the nurse to see?
A client who has chest tubes and an oxygen saturation of 90% Using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority finding is the client's oxygen saturation level, which is below the expected reference range of 95% to 100%. Therefore, the nurse should attend to this client first.
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to see first?
A client who has diabetes mellitus and is diaphoretic When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority action is to attend to a client who has diabetes mellitus and is diaphoretic. Diaphoresis is a manifestation of hypoglycemia and can lead to decreased cerebral function. The nurse should check the client's blood glucose and administer a fast-acting glucose as prescribed.
A nurse is collecting data from a client who has tuberculosis and started combination antibiotic therapy 2 months ago. Which of the following diagnostic results indicates that the client is adhering to the medication regimen?
A negative sputum culture Tuberculosis is an infectious disease spread through airborne droplets. Sputum cultures are obtained to both diagnose tuberculosis and to determine whether the medication treatment has been effective. After the client begins antiblotic treatment for tuberculosis, a sputum culture is obtained monthly. A negative culture is an indication that the client is no longer infectious and the medication therapy has been effective.
A nurse is preparing to assist with a client who is scheduled for a bronchoscopy. Which of the following actions should the nurse take?
Administer supplemental oxygen. Prior to the procedure, the nurse should administer oxygen and then continue to monitor the client's oxygen saturation level throughout and following the bronchoscopy. A bronchoscopy is performed as either a diagnostic ora therapeutic procedure and involves visualizing the larynx and tracheobronchial tree.
A nurse is reinforcing teaching with a client who has varicose veins of the right lower extremity. Which of the following instructions should the nurse include in the teaching?
Apply elastic support hose before getting out of bed in the morning The nurse should instruct the client to apply elastic support hose before placing legs in a dependent position because blood vessels contain less congested blood after sleeping during the night. Varicose veins are the result of increased pressure within the vessel wall and valve, which are incompetent at promoting venous return. It manifests as aching pain and fatigue to the extremity, and it can cause visible dilation of the veins.
A nurse examining a client's rhythm strip notices no visible P waves but many small, erratic spikes throughout the strip, as well as a variable ventricular rate. The nurse should identify and report this pattern as which of the following dysrhythmias?
Atrial fibrillation The nurse should identify that during atrial fibrillation, the atrioventricular node cannot respond to so many atrial impulses. Therefore, it sends impulses to the ventricles in an erratic way, which accounts for these characteristics on the client's rhythm strip.
A nurse is reinforcing teaching with a client who is experiencing neutropenia as a result of chemotherapy. Which of the following information should the nurse include? (Select all that apply.)
Bathe with antimicrobial soap daily. Take temperature daily. Avoid gardening
A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse expect?
Cardiac dysrhythmias The nurse should monitor the client who has hypokalemia, an electrolyte imbalance, for life-threatening cardlac dysrhythmilas, abdominal pain, and distention.
A nurse is assisting with the care of a client who has cellulitis and is receiving IV ceftriaxone. During data collection, the nurse notes the client is flushed and the client reports urticaria. After stopping the IV infusion, which of the following actions should the nurse take first?
Check the client's respirations. After stopping the IV infusion, the first action the nurse should take when using the airway, breathing, circulation approach to client care is to count the client's respirations and monitor for dyspnea because a client experiencing an allergic reaction can progress to anaphylactic shock and death.
A nurse is reviewing the medical record for a client who has a new prescription for combined oral contraception. Which of the following findings is a risk factor for the development of thromboembolism?
Cigarette smoking The concurrent use of combined oral contraceptive and tobacco increases the risk of thromboembolism or pulmonary embolus. The nurse should inform the client about this risk and shoulf reinforce teaching about methods of smoking cessation with the client
A nurse is reinforcing teaching with a newly licensed nurse about enoxaparin. The nurse should include in the teaching that which of the following medications can interact with enoxaparin? (Select all that apply.)
Clopidogrel Aspirin Ginkgo biloba
A nurse is contributing to the plan of care for a client who has dysphagia following a stroke. Which of the following actions should the nurse include in the plan of care to prevent aspiration?
Keep the client upright for 30 min after a meal. The nurse should keep the client upright for 30 to 60 min after a meal to reduce the risk for aspiration.
A nurse is reinforcing teaching about reducing sodium intake with a client who has hypertension. The nurse should instruct the client that which of the following foods has the highest amount of sodium?
Deli sliced turkey A 100 g portion of deli sliced turkey has 898 mg of sodium. The nurse should instruct the client that deli sliced turkey has the highest amount of sodium.
A nurse is collecting data from a client who has diabetes mellitus and a blood glucose level of 61 mg/dL. Which of the following findings should the nurse expect?
Difficulty concentrating The nurse should identify a blood glucose of 61 mg/dL is below the expected reference range of 74 to 110 mg/dL. The nurse should expect a client who is experiencing hypoglycemia to exhibit difficulty concentrating, slurred speech, and a change in emotional behavior. Other manifestations of hypoglycemia can include pale, cool skin, headache, hunger, and sweating. The nurse should administer 15 to 20 g of a fast-acting sugar to a client who is experiencing hypoglycemia.
A nurse is contacting the provider of a client who has heart failure and a potassium level of 3.4 mEq/L. Which of the following client medications should the nurse expect the provider to withhold?
Digoxin The nurse should expect the provider to withhold digoxin when the client's potassium level is low to decrease the client's risk of dysrhythrmias due to digoxin toxicity. Potassium assists in displacing digoxin, because digoxin binds to potassiurm, and reduces the risk for digoxin toxicity.
A nurse is caring for a client who is receiving peripheral IV therapy. The nurse notes that the IV site is red, warm, and painful to the touch. Which of the following actions should the nurse take?
Discontinue the IV and apply a warm, moist compress to the site. these complications include pain at the IV site, along with redness and warmth. The nurse should stop the infusion, remove the IV, inspect the catheter to ensure Complications of intravenous therapy involve inflammation of the vein, phlebitis, and can include the presence of clots or thrombophlebitis. Manifestations of it is intact, and apply a warm, moist compress to the area.
A nurse is caring for a client who has a new diagnosis of moderate Alzheimer's disease. Which of the following provider prescriptions should the nurse expect?
Donepezil 5 mg PO dally Donepezil is a cholinesterase inhibitor used to treat mild, moderate, and severe Alzheimer's disease.
A nurse is collecting data from a client who has left homonymous hemianopsia following a stroke. Which of the following client findings indicates effective management of homonymous hemianopsia?
Eats items from both sides of the lunch tray Left homonymous hemianopsia is blindness in the left visual field of both eyes. A client who eats from both sides of their lunch tray is turning their head from side to side, displaying effective management of left homonymous hemianopsia.
A nurse is caring for a client who has burns to the face, neck, and upper chest. The client has expressed concerns regarding the change to their physical appearance. Which of the following actions should the nurse take?
Encourage the client to ask questions about their treatment The nurse should assist the client through the grief process by encouraging them to ask questions and verbalize concerns. Including the client in the treatment plan provides the client with a sense of control.
A nurse is collecting data from a client and auscultates intermittent high-pitched sounds during inspiration over the lower base of the lungs. The nurse should identify this finding as which of the following lung sounds?
Fine crackles Fine crackles are auscultated in the base of the lungs as air moves through airway secretions. Fine crackles are intermittent, high-pitched sounds heard more often during inspiration.
A nurse is caring for a client who is receiving bolus enteral feedings and is prescribed digoxin and furosemide. Which of the following actions should the nurse take?
Flush the tube with water before and after each medication The nurse should flush the tube with at least 15 mL of water before and after each medication to ensure the client receives the total dose of the medication and to reduce the risk of clogging the tube.
A nurse is collecting data from a client who has diabetic ketoacidosis (DKA). Which of the following findings should the nurse expect?
Fruity breath odor The nurse should expect a client who has DKA to exhibit an acetone or fruity breath odor. This occurs as the lungs attempt to rid the body of excess ketones.
A nurse is collecting data from a client who has a new diagnosis of pheochromocytoma. Which of the following findings should the nurse expect?
Hypertension The nurse should expect a client who has a pheochromocytoma to exhibit severe hypertension. The client's systolic blood pressure can be as high as 300 mm Hg. with a diastolic blood pressure exceeding 150 mm Hg. Other manifestations include nausea, diaphoresis, weakness, and severe headache. Pheochromocytoma is a rare tumor of the adrenal gland that secretes excessive amounts of epinephrine and norepinephrine.
A nurse is reinforcing teaching about mammograms with an adult client who is postmenopausal. Which of the following statements indicates to the nurse that the client understands the teaching?
I should have a mammogram every 1 to 2 years." The nurse should remind the client that the American Cancer Society recommends clients continue to have a mammogram every 1 to 2 years as they age and are in good health.
A nurse is reinforcing teaching with the caregiver of a client who has a visual impairment due to macular degeneration. Which of the following comments by the client's caregiver indicates an understanding of the teaching?
I will close the blinds to manage glare. Glare from direct sunlight or light that is intensified through glass, such as windows, can further impair the client's vision and place them at risk for injury. The client's caregiver can use blinds or shades to minimize glare, and the client can wear yellow- or amber-tinted glasses to minimize glare.
A nurse is contributing to the plan of care for a client who is in skeletal traction. Which of the following interventions should the nurse include?
Keep the client's body centered in the bed. The nurse should keep the client's body centered on the bed to maintain alignment of the body with the direction of the pull of traction. This will ensure continued alignment of the bone.
A nurse is reviewing principles of body mechanics with a client following a lumbar laminectomy. Which of the following statements by the client indicates an understanding of the teaching?
I will flex at the knees and use my leg muscle to lift an object off the floor. The nurse should review bending and lifting restrictions with the client who has had a laminectomy. Bending at the waist is not permitted. The client should be instructed to flex at the knees and use their leg muscles to decrease the risk of back injury when lifting an object off the floor. Weight limits should also be reinforced; following a laminectomy, a weight restriction of 4,5 kg (10 Ib) is prescribed.
A nurse is reinforcing teaching about preventing UTIS with a female client. Which of the following statements by the client indicates an understanding of the information?
I will increase my intake of water." The nurse should instruct the client to drink eight full glasses (about 2,000 mL) per day to reduce the risk of UTIS.
A nurse is reinforcing teaching with a client who has a history of calcium oxalate kidney stones. Which of the following statements by the client indicates an understanding of the instructions?
I'll be sure to eliminate peanuts from my diet. Peanuts are a source of oxalate, therefore, the client should avoid them to reduce the formation of calcium oxalate stones. Certain fruits, nuts, grains, and legumes contain oxalate, and the client should minimize or eliminate intake of these foods.
A nurse is reinforcing teaching with a client about advance directives. The nurse should identify that which of the following client responses indicates an understanding of the teaching?
If i have advance directives with a do-not-resuscitate order, Ican change it later. The nurse should instruct the client that she can change the advance directives at any time after the document is signed,
A nurse is collecting data from a client who had a stroke that affected the right side of the brain. Which of the following findings should the nurse expect?
Impulsive behavior The behavior of a client who had a stroke that affected the right side of the brain can become quick and impulsive. The client can also have a short attention span and neglect the left side of the body.
A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. The client has reduced urinary output, red urine, and reports bladder pain. Which of the following actions should the nurse take first?
Increase the flow rate of the irrigation When providing client care, the nurse should use the least restrictive intervention first; therefore, the nurse should first increase the flow rate of continuous bladder irrigation to keep the urinary output light pink or yellow.
A nurse is reinforcing teaching about the prevention of sexually transmitted infections (STIS) with a client who is sexually active. Which of the following information should the nurse include in the teaching?
Inserting a polyurethane female condom is effective for prevention of STIS. The nurse should reinforce that polyurethane female condoms are effective in preventing STIS, including HIV.
A registered nurse (RN) in an acute care facility is caring for a group of clients with the assistance of a licensed practical nurse (LPN). Which of the following tasks should the RN delegate to the LPN? (Select all that apply.)
Inserting an NG tube Monitoring an IV infusion Administering IM medications
A nurse is assisting a client who is on bed rest to perform isometric exercises. which of the following actions should the nurse take?
Instruct the client to tighten and then relax muscles repeatedly. The nurse should instruct the client to perform isometric exercises by holding muscles tight for 5 seconds and then relaxing them. This form of exercise inivolves static contraction of a muscle without any movement of the Joint, Immobility can cause systemic physiologic effects such as increased heart rate, increased bone demineralization, decreased muscle strength, joint contractures, and activity intolerance. Isometric exercises increase muscle mass, tone, and strength while promoting circulation.
A nurse is reviewing the medical record of a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?
Joint pain The nurse should expect a client who has SLE to exhibit manifestations such as joint pain, photosensitivity. hair loss, and malaise. SLE is an autoimmune disease that causes the body to produce antibodies that attack body cells instead of pathogens, such as bacteria and fungl.
A nurse is contributing to the plan of care for a client who had a stroke and is experiencing dysphagia. Which of the following interventions should the nurse include in the plan?
Keep the client's glasses of liquid at least two-thirds full. The nurse should keep the client's glasses of liquid at least two-thirds full so the client can drink the liquids without tilting their head back, which can increase the risk for aspiration.
A nurse is reinforcing teaching about the use of an oxygen concentrator in the home for a client who has end-stage emphysema. Which of the following instructions should the nurse include to promote client safety?
Maintain an electrical backup system. medical services and the electric company of the The nurse should remind the client to maintain an electrical backup system to ensure continuity of oxygen therapy. This includes notifying local emergency use of home oxygen equipment. In the event of power loss, the client should notify 911, the provider, and the home health care agency.
A nurse is caring for a client who has deep vein thrombosis. Which of the following actions should the nurse take to promote venous return?
Maintain the use of compression stockings except when bathing the client. The antiembolic stockings should be removed for short periods (30 to 60 min) when bathing
A nurse is caring for a client who has a foot fracture and requires crutches. Which of the following actions should the nurse take to ensure client safety?
Measure the crutches with two finger widths below the axilla. The axillary bar on crutches should be measured with two finger widths under the axilla, Measuring two finger widths below the axilla can reduce the risk for nerve damage.
A nurse is monitoring a client who has a new prescription for furosemide for peripheral edema. For which of the following adverse effects should the nurse monitor?
Muscle weakness Furosemide is a loop diuretic, which is used to treat hypertension and edema. Furosemide can cause excess excretion of potassium. The nurse should monitor the client for manifestations of hypokalemia such as nausea, muscle weakness, and spasms.
A nurse is reinforcing teaching with a client who has a new prescription for simvastatin. Which of the following adverse effects should the nurse include in the teaching?
Myalgia Simvastatin is a lipid-lowering agent used to treat hypercholesteremia. Adverse effects of the medication include myalgia, which is muscle pain, and rhabdomyolysis, a life-threatening destruction of muscle tissue. The nurse should instruct the client to report the onset of muscle pain, tenderness, and weakness to the provider immediately.
A nurse is collecting data from a client who was admitted with a Glasgow coma scale (GCS) of 3. Which of the following findings should the nurse expect?
Nonresponsive to commands A client who has a GCS of less than 8 has evidence of severe head injury and is in a comatose state. The GCS is a standardized tool that allows for the evaluation of a client's level of consciousness. The test is divided into three sections that evaluate eye opening, motor response, and verbal response. The GCS ranges from a high score of 15 (fully alert) to a low score of 3 (fully comatose).
A nurse is assisting in the planning of a health education class for a group of older adult clients. Which of the following recommendations should the nurse include?
Obtain a pneumococcal immunization The pneumococcal immunization should be obtained to prevent pneumonia and is generally given at or near the age of 65, One dose provides lifelong immunity
A nurse is caring for a client who is experiencing difficulty using utensils to eat following a stroke. Which of the following referrals should the nurse recommend?
Occupational therapist The nurse should initiate a referral to an occupational therapist to assist the client who has impaired function to gain the skills for ADLS, including using eating utensils.
A nurse is collecting data from a client who has acute cholecystitis. Which of the following manifestations should the nurse expect?
Pain radiating to the right shoulder Pain radiating to the right shoulder is a common manifestation of acute cholecystitis due to the contraction of the bile ducts of the gallbladder.
A nurse is reinforcing dietary teaching with a client who has a new diagnosis of gastroesophageal reflux disease (GERD) about foods to avoid because they worsen the manifestations of GERD. Which of the following foods should the nurse instruct the client to avoid?
Peppermint The nurse should remind the client that foods that relax the esophageal sphincter and thus worsen the manifestations of GERD include peppermint and spearmint. GERD is a condition in which gastric acids and gastric contents reflux into the esophagus due to delayed stomach emptying or relaxation of the lower esophageal sphincter.
A nurse is monitoring a client who has a pneumothorax and a chest tube in place with a closed-chest drainage system connected to low suction. For which of the following findings should the nurse notify the charge nurse?
Persistent bubbling in the water-seal chamber Excessive and persistent bubbling in the water-seal chamber indicates an air leak in the drainage system. The nurse should notify the charge nurse of this finding.
A nurse is collecting data from a client who has a fracture of the femur. The nurse notes respiratory distress, fever, and petechiae. Which of the following actions should the nurse take after notifying the provider?
Place the client in high-Fowler's position. The nurse should identify that the client is experiencing manifestations of a fat embolism, a life-threatening complication of long bone fractures. This occurs when fat globules lodge in small vessels, leading to vessel rupture and the release of fat globules into the circulation. The nurse should place the client in high-Fowler's position to facilitate lung expansion and oxygenation.
A nurse is collecting data from a client who is 4 hr postoperative following abdominal surgery. The nurse notes the wound is eviscerating. Which of the following actions should the nurse take?
Place the client supine with her knees bent The nurse should place the client in a supine position with the knees bent to decrease strain on the abdominal muscles. This position also decreases tension on the surgical site. Wound evisceration is a medical emergency that requires immediate surgical repair.
A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect? (Select all that apply.)
Poripheral edema Hepatomegaly Abdominal distention
A nurse is preparing to transfer a client from a bed to a chair following a total knee arthroplasty. The client has a prescription for partial weight bearing. Which of the following actions should the nurse take?
Position feet apart before pivoting the client. The nurse should spread their feet apart before pivoting the client to maintain a wide base of support.
A nurse is caring for a client who has phantom pain after healing from a below-the-knee amputation. Which of the following medications should the nurse expect the provider to prescribe to relieve the client's pain?
Pregabalin Pregabalin is an anticonvulsive medication that is an adjuvant medication for treating neuropathic pain such as phantom limb pain. Typically, with this type of pain, analgesics and opioids are ineffective.
A nurse is collecting data from a client who has a new ileostomy. Which of the following findings about the stoma should the nurse report to the provider?
Purple in appearance A stoma that appears purple in appearance can indicate inadequate blood flow to the stoma. The nurse should report the finding immediately to the provider.
A nurse is reinforcing teaching about home care with the caregiver of a client who is in the early stages of Alzheimer's disease. Which of the following information should the nurse include?
Put labels on the kitchen cabinets and drawers. The nurse should instruct the caregiver to put labels or symbols on common areas, such as the door of the bathroom, kitchen cabinets, and drawers. A client who is in the early stages of Alzheimer's disease can have difficulty finding common items or recalling their location. Labeling prevents the client from having to look in numerous places to locate an item.
A nurse is reinforcing teaching with an older adult client about age-related changes. Which of the following physiological changes should the nurse include in the teaching? (Select all that apply.)
Reduction in height Loss of skin elasticity Decreased near vision
A nurse is reinforcing teaching with a client who has hypertension and a prescription for lisinopril. Which of the following information should the nurse include in the teaching?
Report a persistent dry cough. Lisinopril is an ACE inhibitor that is used to treat hypertension or heart failure. A persistent, dry cough is an adverse effect of lisinopril, and the client should report the finding to the provider. After discontinuation of the medication, the cough should subside within 10 days,
A nurse is collecting data from a client who has bacterial meningitis. Which of the following findings should the nurse expect?
Severe headache The nurse should expect a client who has meningitis to have severe and persistent headaches that worsen with movement of the head.
A nurse is caring for a client who has type 1 diabetes mellitus and has undergone a below-the-knee amputation. Which of the following is the nighest priority finding?
Skin flap of the residual limb is cool to the touch When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is that the skin flap of the residual limb is cool to the touch. The nurse should immediately report this finding to the provider. The skin flap of the residual limb should be warm to the touch, indicating adequate tissue perfusion.
A nurse is administering a tap water enema to a client who has constipation. The client reports abdominal cramping during instillation of the enema. Which of the following actions should the nurse take?
Slow the rate of fluid flow The nurse should slow down the flow of the enema fluid to allow the intestinal spasm to pass if cramping occurs during administration of the enema. Lowering the helght of the enema bag will decrease the rate the fluid enters the bowel. Tap water enemas consist of 500 ml to 1Lof fluid that is instilled into the bowel to soften feces. The volume of fluid stimulates peristalsis.
A nurse is preparing to perform a closed irrigation of an indwelling urinary catheter for a client who had abdominal surgery. Which of the following actions should the nurse plan to take?
Stop the irrigatian if resistance is felt during fiuid instillation. The nurse should plan to discontinue the irrigation and contact the provider if resistance is felt. This can indicate the client has a total occlusion of the catheter or that the catheter is displaced.
A nurse is contributing to the plan of care for a client who has a neurogenic bladder following a spinal cord injury. Which of the following interventions should the nurse include in the plan to develop bladder control?
Stroke the inner thigh A client who has a spinal cord injury can experience a loss of urinary control. The injury to the spinal cord results in a neurogenic bladder, which means the client is unaware of the need to void. This can resultin bladder distention, renal calculi, or autonomic dysreflexia. The nurse should monitor urinary output and implement a bladder retraining program that includes teaching the client how to trigger voiding, such as stroking the inner thigh.
A nurse is reinforcing discharge teaching with a client who has a new cast. The client is prescribed hydrocodone for pain. The nurse should instruct the client to report immediately which of the following findings to the provider?
Swelling of the affected extremity When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding for the client to report to the provider is swelling of the affected extremity. This should be immediately reported to the provider because it is an indication of external pressure restricting blood flow and can result in the development of compartment syndrome and loss of function.
A nurse is collecting data from a client who reports amenorrhea and insomnia. Which of the following data should the nurse report to the provider? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)
T4 The client's T4 is above the expected reference range of 4 to 12 mcg/dL, which indicates hyperthyroidism. The nurse should report this value to the provider so that treatment for hyperthyroidism can begin.
A nurse is caring for a client who has heart failure and a new prescription for furosemide. The nurse should monitor the client for which of the following adverse effects of the medication?
Tinnitus The nurse should monitor clients who take furosemide for tinnitus and hearing loss. Audiometry is recommended for clients recelving prolonged IV furosemide.
A nurse is reinforcing teaching with a client who has a prescription for clopidogrel following a thrombotic stroke. Which of the following information should the nurse include in the teaching?
The medication prevents clot formation. Clopidogrel is an antiplatelet medication that prevents platelets from sticking together and, as a result, prolongs bleeding time, It is used to prevent blockage of coronary arteries and prevent clot formation.
A nurse is preparing to remove personal protective equipment (PPE) after irrigating a client's wound infection and applying a fresh sterile dressing. Identify the sequence for removing PPE. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
The nurse should remove the most contaminated piece of PPE. the gloves, first, Next, the nurse should remove the face shield and then the gown. The nurse should remove the least contaminated piece of PPE, the mask or respirator, last.
A nurse is preparing to administer eardrops to an adult client who has otitis media. Which of the following actions should the nurse plan to take?
Warm the bottle by holding it in the palm for 5 min before administration. The nurse should plan to warm the bottle of drops slightly by holding it in the palm of the hand or putting the bottle in a pocket for about 5 min. Administering cold ear drops can cause the client to experience discomfort or dizziness.
A nurse is reinforcing teaching with a client who is recovering from severe diarrhea and is ready to resume eating solid foods. Which of the following food items should the nurse recommend?
Yogurt The nurse should recommend adding yogurt to the diet to provide probiotics and add substance to the stool, making it more formed. A client who is recovering from diarrhea should consume a diet that is low in fiber. Taking probiotics can also help restore the natural gastrointestinal flora.
A nurse is reinforcing teaching with a client who has gastric bleeding and is to have a gastric lavage by closed system irrigation. Which of the following statements should the nurse include?
You should expect to be positioned in a semi-upright position for the procedure." The nurse should place the client in a semi-Fowler's or high-Fowler's position to enhance the flow of the irrigating solution during the gastric lavage. Gastric lavage removes large amounts of blood, including clots, and other gastric contents, and irrigates the lining of the stomach.
A nurse is reinforcing teaching with a client who is scheduled for a thoracentesis to remove pleural fluid. Which of the following information should the nurse include in the teaching?
You will lean forward on the overbed table for this procedure. A thoracentesis is a therapeutic or diagnostic procedure that involves insertion of a needle into the pleural space. It can be performed at the client's bedside with the client leaning forward on pillows and across an overbed table. This position widens the intercostal spaces and makes it easier to insert the needle into the posterior chest and remove the pleural fluid.
