ATI - Adult Medical Surgical NGN B

A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation. Which of the following values should the nurse identify as a desired outcome for this therapy?

INR 2.5

A nurse is teaching a group of newly licensed nurses about pain management for older adult clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?

Ibuprofen can cause gastrointestinal bleeding in older adult clients.

A nurse is planning care for a client who has a sealed radiation implant for cervical cancer. Which of the following interventions should the nurse include in the plan of care?

Keep a lead-lined container in the client's room

A nurse is providing discharge instructions to a client who has active tuberculosis (TB). Which of the following information should the nurse include in the instructions?

Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures.

A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the nurse's priority?

Temperature 38.9° C (102° F)

A nurse is preparing to administer phenytoin 600 mg PO daily to a client. The amount available is oral solution 125 mg/5 mL. How many mL should the nurse administer?

24 mL

A nurse is evaluating the plan of care for four clients after 2 days of hospitalization. The nurse should identify the need to revise the plan for which of the following clients?

A client who is postoperative following abdominal surgery and reports feeling that something "popped" when they coughed

The nurse is caring for the client who is preoperative for an exploratory laparotomy. Select the 4 actions that the nurse should take.

Administer phenytoin with a sip of water prior to the surgery is correct. Medications for cardiac disease, respiratory disease, and seizure disorders should be administered before surgery. Administer gentamicin 100 mg IV is correct. The nufse should administer a broad-spectrum antibiotic for clients who have peritonitis Administer dextrose 5% in lactated Ringer's is correct. Hypertonic IV fluid should be administered to clients who have peritonitis to restore fluid volume balance. Dextrose 5% in lactated Ringer's (DsLR) is a hypertonic IV solution. Contact the wound, ostomy, and continence nurse is correct. The nurse should collaborate with the certified wound, ostomy, and continence nurse to discuss wound management, if necessary. Provide the client with high-flow supplemental oxygen is incorrect. The nurse should identify that the client's oxygen saturation is in the expected reference range; therefore, they do not need supplemental oxygen at this time.

A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following nonpharmacological interventions should the nurse suggest to the client to reduce pain?

Alternate application of heat and cold to the affected joints.

A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After ensuring a patent airway, which of the following nursing interventions is the priority?

Applying oxygen via face mask

A nurse is reviewing the laboratory results of a client who has AIDS and is taking amphotericin B for a fungal infection. The nurse should identify that which of the following values is an indication of an adverse effect of the medication?

BUN 34 mg/dL

A nurse is caring for a client who has a positive culture for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take?

Bathe the client using chlorhexidine solution.

The nurse is performing an assessment on the client. For each assessment finding, click to specify if the finding is consistent with appendicitis, diverticular disease, or Cohn's disease.

Blood in stool is consistent with diverticular disease and Crohn's disease. Clients who have diverticular disease can have a decreased hemoglobin and hematocrit level from chronic or severe bleeding. Stools should be checked for occult or frank bleeding. Anemia is common with Crohn's disease due to slow bleeding. Stools might contain bright red blood. Pain in right lower quadrant is consistent with appendicitis and Crohn's disease. Pain in the right lower quadrant is a manifestation of appendicitis. Clients who have inflammation from Cohn's disease usually have constant pain located in the right lower quadrant. Clients who have diverticular disease might experience pain in the left lower quadrant. Diarrhea is consistent with Crohn's disease. Clients who have Crohn's disease usually have severe diarrhea and malabsorption of nutrients. Clients who have diverticular disease might experience constipation. Nausea is consistent with appendicitis, diverticular disease, and Cohn's disease. Clients who have appendicitis, diverticular disease, or Crohn's disease might experience nausea.

A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following findings is an indication of lung re-expansion?

Bubbling in the water-seal chamber has ceased.

A nurse is providing teaching to a client who is perimenopausal and has a prescription for hormone replacement therapy. For which of the following adverse effects should the nurse instruct the client to notify the provider?

Calf pain Numbness in the arms Intense headache

A home health nurse is providing teaching to a client who has a stage 1 pressure injury on the greater trochanter of his left hip. Which of the following instructions should the nurse include in the teaching?

Change position every hour

A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the following actions should the nurse take first?

Check for the type and number of units of blood to administer.

A nurse in an emergency department is assessing an older adult client who has a fractured wrist following a fall. During the assessment, the client states, "Last week I crashed my car because my vision suddenly became blurry." Which of the following actions is the nurse's priority?

Check the client's neurologic status.

A nurse is assessing a client's hydration status. Which of the following findings indicates fluid volume overload?

Distended neck veins

The nurse is caring for the client 1 hr following chest tube insertion. Click to highlight the findings in the nurses* note that indicate the client's condition is improving.

Client reports pain as 3 on a scale of 0 to 10 is correct. The nurse should identify that the client's pain has decreased, indicating their condition is improving. Client reports shortness of breath has decreased is correct. The nurse should identify that the client's shortness of breath has decreased, indicating their condition is improving. Client reports nausea, awaiting prescription for nausea is incorrect. The nurse should identify that nausea is an indication that the client's condition is not improving. Transfused 1 unit of packed RBs, awaiting second unit is incorrect. The transfusion of 1 unit of packed RBCs is not an indication that the client's condition is improving. Wound dressing is dry and intact is correct. The nurse should identify that a dry and intact wound dressing indicates the client's wound is no longer bleeding. Respiratory rate 24/min, blood pressure 108/74 mm Hg, and oxygen saturation 95% on 2 L/min via nasal cannula are correct. The nurse should identify that the client's vital signs have improved, indicating improved hemodynamic function.

A nurse is planning care for a client who is postoperative following a laparotomy and has a closed-suction drain. Which of the following actions should the nurse take to manage the drain?

Compress the drain reservoir after emptying.

A nurse is caring for a client who is receiving total parenteral nutrition (TP) and is PO. When reviewing the chart, the nurse notes the following prescription: capillary blood glucose AC and HS. Which of the following actions should the nurse take?

Contact the provider to clarify the prescription.

A nurse is checking the ECG rhythm strip for a client who has a temporary pacemaker. The nurse notes a pacemaker artifact followed by a QRS complex. Which of the following actions should the nurse take?

Document that depolarization has occurred.

A nurse is providing teaching to a client who has a new prescription for psyllium. Which of the following information should the nurse include in the teaching?

Drink 240 milliliters of water after Administration

A nurse is assessing a client who has advanced lung cancer and is receiving palliative care. The client has just undergone thoracentesis. The nurse should expect a reduction in which of the following common manifestations of advanced cancer?

Dyspnea

A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following interventions should the nurse include in the plan?

Encourage the client to take deep breaths after the procedure.

A nurse is caring for a client who is 4 hr postoperative following an open reduction internal fixation of the right ankle. Which of the following assessment findings should the nurse report to the provider?

Extremity cool upon palpation

A nurse is providing education to a client who has tuberculosis (TB) and their family. Which of the following information should the nurse include in the teaching?

Family members in the household should undergo TB testing

A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the following instructions should the nurse include?

Flex the foot every hour when awake.

A nurse is preparing to present a program about prevention of atherosclerosis at a health fair. Which of the following recommendations should the nurse plan to include?

Follow a smoking cessation program. Maintain an appropriate weight. Eat a low-fat diet.

A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement. Which of the following statements should the nurse make?

Ginkgo biloba can cause an increased risk for bleeding.

A nurse is caring for a client who has DKA. Which of the following findings should indicate to the nurse that the client's condition is improving?

Glucose 272 mg/dL

A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect?

Hair loss on the lower legs

A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The client's initial vital signs were heart rate 80/min, blood pressure 130/70 mm Hg, respiratory rate 16/min, and temperature 36° C (96.80 F). Which of the following vital sign changes should alert the nurse that the client might be hemorrhaging?

Heart rate 110/min

A nurse is caring for a client.

History and Physical Client admitted to the medical-surgical unit with severe, acute abdominal pain, abdominal distention, diarrhea, mucus and small amount of blood in the stool, and a 12% weight loss over the past 2 months. Client's weight 2 months ago was 100.3 kg (221.1 lb). Client has a history of Crohn's disease and a seizure disorder that is managed with diet and medication. Respirations are equal and unlabored. S,S, heart tones auscultated. Abdominal assessment performed with muscle guarding and tenderness in the right lower quadrant noted on palpation. Abdomen is firm and rigid upon examination. Abdominal pain rated as an 8 on a scale of 0 to 10. Client states that pain is constant and localized in the lower right abdominal quadrant. Reports anorexia. Hypoactive bowel sounds noted upon auscultation. Graphic Record Day 1 0700: Temperature 38.3° C (101 ° F) Heart rate 102/min Respiratory rate 18/min Blood pressure 142/88 mm Hg Oxygen saturation 97% on room air 1300: Temperature 38.9° C (102° F) Heart rate 112/min Respiratory rate 22/min Blood pressure 104/68 mm Hg Oxygen saturation 96% on room air Diagnostic Results Day 1: Hgb 12 g/dL (12 to 18 g/dL) Hct 34% (37% to 52%) 0800: WBC count 19,000/mm (5,000 to 10,000/mm3) Neutrophils 75% (55% to 70%) Erythrocyte sedimentation rate (ESR) 18 mm/hr (less than 15 mm/hr) PREVIOUS Medication Administration Record Day 1: Phenytoin 200 mg PO daily Day 4: Hydrocodone/acetaminophen 10 mg/325 mg PO every 4 hr PRN pain Provider Prescriptions Day 1 1300: Prepare client for exploratory laparotomy.

A nurse is providing teaching to a client who has asthma about the use of a metered-dose inhaler. The nurse should identify that which of the following client actions indicates an understanding of the teaching?

Holding breath for 10 seconds after inhaling

A nurse is planning care for a client who is having a modified radical mastectomy of the right breast. Which of the following interventions should the nurse include in the plan of care?

Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24-hr period.

A nurse is caring for an older adult client who has dementia and requires acute care for a respiratory infection. The client is agitated and is attempting to remove their IV catheter. Which of the following actions should nurse take to avoid restraining the client?

Keep the client occupied with a manual activity.

A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction?

Low back pain and apprehension

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?

Low urine specific gravity

A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Which of the following statements made by the client reflects an understanding of the teaching?

My joints ache because I have Lyme disease.

A nurse is caring for a client who is 4 hr postoperative following a total vaginal hysterectomy.

Nurses' Notes 2000: Client reports pain as 3 on a scale of 0 to 10. Breath sounds clear and present throughout. Three abdominal bandages to abdomen, dry and intact with no drainage noted. Client voided 90 mL of clear-yellow urine into bedpan. Perineal pad with small amount of blood, no clots; perineal pad changed at this time. 2400: Client sleeping, arouses to verbal stimuli. Reports pain as 2 on a scale of 0 to 10 with repositioning. Client voided 125 mL of blood-tinged urine into bedpan. Perineal pad saturated with blood, large clots present. Vital Signs 2000: Blood pressure 128/78 mm Hg Respiratory rate 16/min Temperature 37° C (98.6° F) Heart rate 88/min Oxygen saturation 97% on room air 2400: Blood pressure 106/56 mm Hg Respiratory rate 14/min Temperature 37° C (98.6° F) Heart rate 102/min Oxygen saturation 95% on room air

A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the following results should the nurse expect?

PaCO2 56

A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of the following findings should the nurse identify as a manifestation of this condition?

Pain that increases with passive movement

The client is experiencing manifestations or pancreatitis as evidenced by they amylase and lipase

Pancreatitis is correct. The client's laboratory results and physical assessment indicate the client is experiencing manifestations of pancreatitis. Clients who have pancreatitis experience an increase in pancreatic enzymes, amylase, and lipase. Amylase and lipase is correct. The client's laboratory results and physical assessment indicate the client is experiencing manifestations of pancreatitis. Clients who have pancreatitis experience an increase in pancreatic enzymes, amylase, and lipase.

Click to highlight the findings the nurse should report to the provider immediately.

Perineal pad saturated with blood, large clots present, blood pressure trend, and heart rate of 102/min are correct. The client has manifestations of vaginal hemorrhage, including vaginal bleeding, blood clots, reduced blood pressure, and tachycardia. The nurse should report these findings to the provider. Client sleeping, arouses to verbal stimuli, respiratory rate 14/min, oxygen saturation 95% on room air, breath sounds clear, and reports pain as 2 on scale of 0 to 10 are incorrect. These are expected findings. Therefore, the nurse does not need to report these findings to the provider.

A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take?

Place a pressure bag around the flush solution.

A nurse is planning care for a client who is postoperative following a parathyroidectomy. Which of the following actions should the nurse identify as the priority?

Place a tracheostomy tray at the bedside.

A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care?

Place personal items, such as pictures, at the client's bedside.

A nurse is teaching a client about osteoporosis prevention. The nurse should instruct the client that which of the following medications can increase their risk for developing osteoporosis?

Prednisone

A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the following findings should the nurse identify as the priority?

Report of sore throat

A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The client is unable to void on the bedpan. Which of the following actions should the nurse take first?

Scan the bladder with a portable ultrasound.

A nurse is caring for a client who has homonymous hemianopsia as a result of a stroke. To reduce the risk of falls when ambulating, the nurse should provide which of the following instructions to the client?

Scan the environment by turning your head from side to side.

A nurse is reviewing the medical record of a client who has osteomyelitis and a prescription for gentamicin. Which of the following findings from the client's medical record should indicate to the nurse the need to withhold the medication and notify the provider?

Serum creatinine

A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions should the nurse anticipate taking?

Slow the infusion rate

For each assessment finding, click to specify if the finding is consistent with emphysema, asthma, or pneumonia. Each finding may support more than 1 disease process.

Temperature is consistent with pneumonia. Fever is a manifestation of pneumonia and is related to inflammation or infection Breath sounds are consistent with emphysema, asthma, and pneumonia The client's wheezing is a manifestation of emphysema, asthma, and pneumonia. It is the result of narrowed airways and alveoli. ABG results are consistent with emphysema and pneumonia. The client's ABG results indicate respiratory acidosis, which is a manifestation of emphysema and pneumonia. Respiratory rate is consistent with emphysema, asthma, and pneumonia. The client's respiratory rate is a manifestation of emphysema, asthma, and pneumonia. Heart rate is consistent with emphysema and pneumonia. The client is experiencing tachycardia, which is a manifestation of emphysema and pneumonia. Cough is consistent with emphysema, asthma, and pneumonia. The client's cough is a manifestation of emphysema, asthma, and pneumonia.

Complete the following sentence by using the lists of options.

The client is most likely experiencing a hemothorax as evidenced by the client's respiratory findings

A nurse is assessing a client while suctioning the client's tracheostomy tube. Which of the following findings should indicate to the nurse the client is experiencing hypoxia?

The client's heart rate increases.

For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Transfuse packed RBs is anticipated. The client's increased heart rate and decreased blood pressure indicate decreased circulating blood volume due to trauma. Therefore, the nurse should anticipate transfusing packed RBCs. Place the client in Trendelenburg position is contraindicated. Due to clinical manifestations of hypovolemia, the nurse should position the client flat or place their head of bed no more than 30° to promote venous return to the heart. Prepare the client for chest tube insertion is anticipated. The client has manifestations of a hemothorax. Therefore, a chest tube is indicated. Cover the client with a cooling blanket is contraindicated. The client's temperature is below the expected reference range, which is a manifestation of hypothermia. Therefore, covering the client with a cooling blanket is contraindicated. Initiate NO status is anticipated. The client might require a surgical procedure. Therefore, the nurse should anticipate initiating NPO status.

A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago. The nurse should identify which of the following findings as an indication of a myocardial infarction (MI)?

Troponin I 8 ng/mL

A nurse is planning discharge teaching for a client who has an external fixation device for a fracture of the lower extremity. Which of the following instructions should the nurse include in the plan of care?

Use crutches with rubber tips.

A nurse is providing discharge teaching to a client who is to self-administer heparin subcutaneously. Which of the following statements by the client indicates an understanding of the teaching?

I will use an electric razor to shave

A nurse in the emergency department is caring for a client.

Nurses Notes 0900: Client presents with apdominal pain in the upper left quadrant for the past 2 days. States pain became worse this morning and is radiating to the back. Rates pain as 8 on a scale of 0 to 10. Hypoactive bowel sounds; reports nausea, no vomiting; client is passing flatus. Febrile, oriented to person, place, and time. Tachypnea with diminished breath sounds. Sinus tachycardia. Client voids 300 mL of clear, amber urine. 0930: Client vomited 100 mL brown liguid. Vital Signs 0900: Admission: Temperature 38.9° C (102° F) Heart rate 115/min Respiratory rate 26/min Blood pressure 122/58 mm Hg Oxygen saturation 96% on room air Diagnostic Results 0930: Complete Blood Count (CBC): WBC count 16,500/mm (5,000 to 10,000/mm3) Hemoglobin 16 g/dL (12 to 16 g/dL) Hematocrit 48% (37% to 47%) Platelet count 190,000/mm (150,000 to 400,000/mm3) Amylase 480 units/L (30 to 220 units/L) Lipase 290 units/L (0 to 160 units/L) Glucose 200 mg/dL (74 to 106 mg/dL)

A nurse is caring for a client who is scheduled for a right knee arthroplasty.

Nurses' Notes 0600: Client is admitted for surgery this a.m. Vital signs recorded. Consents reviewed. Client reports understanding of surgery and has no further questions for provider. 0700: Client performed surgical preparation with glorhexidine at home this a.m. Client states they have had no oral intake since midnight except sips to take antihypertensive medication. Client states they have not taken NSAIDs for 10 days. IV catheter inserted to right arm with lactated Ringer's infusing at 10 mL/hr. 0800: Preoperative teaching provided. Discussed the following topics with the client: • The importance of turning, coughing, and deep breathing following anesthesia; explained use of incentive spirometer • The need to get out of bed and ambulate as soon as possible following the surgery; ambulation will be managed by a physical therapist with the use of a walker or crutches • Control of pain following surgery • Postoperative leg exercises • The use of compression stockings or pneumatic compression devices to prevent deep vein thrombosis • The use of anticoagulant medication to prevent deep vein thrombosis Client acknowledges understanding of all teaching. 0900: Preoperative antibiotic initiated on call from surgical team. 0915: Client transported to surgery.

A nurse is caring for a client.

Nurses' Notes 1200: Client was admitted to the unit with shortness of breath, a nonproductive cough, chest discomfort, and myalgia. Prefers orthopneic position. Client reports that manifestations began about 2 days ago. 1215: Oxygen applied at 2 L/min via nasal cannula. Wheezes noted bilaterally. Use of accessory muscles noted. Client speaks in short phrases, with report of increased shortness of breath when speaking. Oral mucosa is pink; capillary refill is 4 seconds. Vital Signs 1200: Temperature 38.7° C (101.6° F) Blood pressure 104/64 mm Hg Heart rate 100/min * Respiratory rate 24/min Oxygen saturation 90% on room air 1215: Temperature 38.7° C (101.6° F) Blood pressure 106/64 mm Hg Heart rate 104/min Respiratory rate 24/min Oxygen saturation 93% on oxygen 2 L/min via nasal cannula Diagnostic Results ABGs: pH 7.30 (7.35 to 7.45) Pa0, 70 mm Hg (80 to 100 mm Hg) PaCO, 47 mm Hg (35 to 45 mm Hg) HCO; 24 mEq/L (21 to 28 mE/L) Sa0, 90% on room air (95% to 100%) Sputum culture collected: Results pending Medical History. Client reports having a sinus infection for about 2 weeks. Reports smoking approximately two packs of cigarettes a week. Client states that sleep during the night is interrupted by coughing and shortness of breath most nights of the week. Client reports not having received the influenza vaccination.

Select the 3 findings that require follow-up by the nurse.

Oxygen saturation is correct. The client has an oxygen saturation that is less than the expected reference level, indicating hypoxia. The nurse should plan to increase the client's supplemental oxygen. Pain level is correct. The nurse should follow up on the client's pain level. Wound drainage is correct. The nurse should apply a pressure dressing to control bleeding.

Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

The nurse is caring for the client who has manifestations of peritonitis therefore, the priority finding for the nurse to report is laboratory values Peritonitis is correct. The client has manifestations of peritonitis, including rigid abdomen and elevated WBC count and ESR. Peritonitis is an inflammation and infection of the abdominal cavit that can occur when bacteria enter the peritoneum through a perforation in the bowel as a complication of Crohn's disease. Laboratory values is correct. The nurse should identify that the client's laboratory values is the priority to report when using the urgent vs. nonurgent priority framework. An elevated WBC count and a high neutrophil count indicates an infection, which is a manifestation of peritonitis.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

The nurse should insert a large-gauge IV and initiate a fluid challenge because the client is most likely experiencing hypovolemia as evidenced by the client's restlessness, tachycardia, hypotension, decreased pulses, cool extremities, and decreased urine output. The nurse should monitor the client's urine output and blood pressure to evaluate the effectiveness of treatment.

A nurse is reviewing the laboratory results of a client who has aplastic anemia. Which of the following findings indicates a potential complication?

WBC 2,000/mm3

A nurse is providing education to a client who is at risk for osteoporosis. Which of the following instructions should the nurse include?

Walk for 30 min four times per week.

A nurse is obtaining a medication history from a client who is scheduled to undergo cataract surgery. The nurse should recognize that which of the following client medications is a contraindication for the surgery and notify the provider?

Warfarin

A nurse is planning a health promotional presentation for a group of African American clients at a community center. Which of the following disorders presents the greatest risk to this group of clients?

hypertension

A nurse is assessing a client following the completion of hemodialysis. Which of the following findings is the nurse's priority to report to the provider?

restlessness

A nurse is providing follow-up care for a client who sustained a compound fracture 3 weeks ago. The nurse should recognize that an unexpected finding for which of the following laboratory values is a manifestation of osteomyelitis and should be reported to the provider?

sedimentation rate

A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube. The nurse should recognize that which of the following complications is associated with long-term mechanical ventilation?

stress ulcers

A nurse is caring for a client following extubation of an endotracheal tube 10 min ago. Which of the following findings should the nurse report to the provider immediately?

stridor

A nurse is caring for a client who has terminal cancer. The client tells the nurse, "I wish I could stop these treatments. I am ready to die." Which of the following statements should the nurse make?

"Discontinuing with the treatments is your choice if it is your wish to do so."

The nurse is providing discharge teaching to the client. Which of the following statements made by the client indicates an understanding of the teaching?

"I can continue to drink coffee in the mornings" is incorrect. The client should be instructed to avoid gastrointestinal stimulants, such as caffeine. "I should schedule several rest periods throughout the day" is correct. The client should be reminded to take rest periods throughout the day to promote healing. "I should alternate taking acetaminophen with my prescribed pain medication" is incorrect. The nurse should instruct the client to avoid taking additional acetaminophen because the prescribed pain medication already contains acetaminophen. Additional doses of acetaminophen can result in hepatic toxicity. "I should notify my provider if my temperature is higher than 101° F" is correct. The nurse should instruct the client to report manifestations of an infection, such as pain, temperature greater than 38.3° C (101° F), swelling, redness, warmth, or bleeding at the incision site. *' can resume lifting objects after 2 weeks" is incorrect. The nurse should instruct the client that lifting objects following an exploratory laparotomy is contraindicated. The client should wait a minimum of 6 weeks, or as instructed by the provider, to allow the incision to heal.

A nurse is caring for a client who has breast cancer and tells the nurse that they would like to have acupuncture because it provides greater relief than pain medication. Which of the following statements should the nurse make?

"I can speak with the provider about incorporating acupuncture into your treatment plan."

A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron supplement. Which of the following statements by the client indicates an understanding of the teaching?

"I will eat more high-fiber foods."

A nurse is providing discharge teaching about infection prevention to a client who has AIDS. Which of the following statements by the client indicates understanding of the teaching?

"I will no longer floss my teeth after brushing my teeth."

The nurse provided preoperative teaching to the client. Which of the following statements by the client indicates an understanding of the teaching?

"I will probably be going home with a walker." "I will be sure to ask for pain medication before my knee starts to hurt too bad." "I will need to do the breathing exercises every 1 to 2 hours after the surgery."

A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following information should the nurse include in the teaching?

"Increase fiber intake to avoid constipation."

A nurse is providing teaching to a client who has stage Il cervical cancer and is scheduled for brachytherapy. Which of the following instructions should the nurse include?

"You will need to stay still in the bed during each treatment session."

A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation (TENS) for the management of bone cancer pain. The nurse should explain that applying a TENS unit to the painful area has which of the following effects?

A tingling sensation replacing the pain

After reviewing the findings in the client's medical record, the nurse should first address the client's abdominal distention followed by the clients acute pain.

Abdominal distention is correct. When using the greatest risk framework, the nurse should identify that abdominal distention is a manifestation of an inflammatory intestinal disorder. The nurse should address this finding first to reduce the risk of life-threatening complications, such as obstruction or infection. Acute pain is correct. When using the greatest risk frankawork, the nurse should identify that acute abdominal pain is a manifestation of an inflammatory intestinal disorder. The nurse should address this finding next to reduce the risk of life-threatening complications, such as obstruction or infection.

A nurse is caring for a client who has increased intracranial pressure (ICP) and is receiving mannitol via continuous IV infusion. Which of the following findings should the nurse report to the provider as an adverse effect of this medication?

Crackles heard on auscultation

A nurse is teaching a family about the care of a parent who has a new diagnosis of Alzheimer's disease. Which of the following information should the nurse include in the teaching?

Create complete outfits and allow the client to select one each day

A nurse is providing preoperative teaching for a client who is scheduled for a mastectomy. Which of the following statements should the nurse make?

I will refer you to community resources that can provide support

A nurse has received report on a client who is being admitted to the emergency department.

Nurses' Notes 2330: Report received from ambulance crew: Client has a penetrating wound to the anterior upper right chest. Client is alert and oriented with a Glasgow Coma Scale (GCS) score of 15. Client's shirt covered with bright red blood. Client reports pain as 6 on a scale of 0 to 10. Shortness of breath noted. 2345: Client is alert and oriented with a GCS score of 15. Client has a penetrating wound to the anterior right upper chest measuring 2.5 cm (1 in). No other wounds or injuries found. Bilateral radial and pedal pulses are +1. Left lung sounds are clear, right upper lung sounds diminished. Client still reports pain as 6 on a scale of 0 to 10 over anterior chest. Bowel sounds are present in all 4 quadrants. Graphic Record 2330: Current vital signs from ambulance crew: Heart rate 125/min Respiratory rate 28/min Temperature 36° C (96.8° F) Blood pressure 145/90 mm Hg Sa0, 90% on oxygen 2 L/min via nasal cannula 2345: Temperature 35.9° C (96.6° F) A Heart rate 135/min Respiratory rate 34/min Blood pressure 96/45 mm Hg Sa0, 92% on 40% face mask Diagnostic Results Hematocrit 26% (Male 42% to 52%) Hemoglobin 8.7 g/dL (Male 14 to 18 g/dL) WBC count 9,000/mm? (5,000 to 10,000/mm3) Platelet count 148,000/mm (150,000 to 400,000/mm3) Lactate (arterial) 5 mg/dL (3 to 7 mg/dL) Provider Prescriptions Transfuse 2 units of packed RBCs. Prepare the client for chest tube insertion. Initiate NPO status.

A nurse is caring for a client who is postoperative.

Nurses' Notes Client admitted to medical-surgical unit from PACU. Client reports incisional pain as 2 on a scale of 0 to 10. Client appears restless and frequently asks for water. Bilateral lower extremities cool with +1 pedal pulses. Urine output is 40 mL for the past 2 hr. Moderate amount of bright red drainage noted on surgical incision dressing. Vital Signs Temperature 37.6° C (99.7° F) Heart rate 114/min Respiratory rate 22/min Blood pressure 88/54 mm Hg Oxygen saturation 93% on room air Diagnostic Results Hgb 18 g/dL (12 to 16 g/dL) Hct 54% (37% to 47 %) Total WBC count 11,000/mm3 (5,000 to 10,000/mm3) Troponin T 0.04 ng/mL (less than 0.1 ng/mL) Medical History. History of hypertension. Acute myocardial infarction 1 year ago.

The nurse is planning care for the client who has peritonitis and Crohn's disease. For each potential provider's prescription, click to specify if each potential prescription is anticipated or contraindicated for the client.

Obtain blood cultures is indicated. Blood culture studies might be performed to determine the causative organism and the recommended antibiotic therapy that should be prescribed. Obtain vital signs every hour is indicated. Vital signs should be obtained hourly to monitor the client for changes. Administer a hypotonic IV solution is contraindicated. The nurse should anticipate a prescription for hypertonic IV fluids. Hypotonic fluids will further disrupt the client's fluid and electrolyte imbalance. Insert a nasogastric tube is indicated. A nasogastric tube might be inserted to decompress the stomach.

The nurse should first address the client's blood pressure followed by the client's oxygenation

Oxygenation and blood pressure are correct. Using the airway, breathing, circulation priority framework, the nurse should first address the client's oxygenation, followed by the client's blood pressure. The client's oxygenation is below the expected reference range and is the priority. The nurse should then address the client's circulation because the client's blood pressure is below the expected reference range.

The nurse is caring for the client following the placement of a chest tube for a hemothorax. Which of the following actions should the nurse take?

Place the client in high-Fowler's position is correct. The nurse should place the client in high-Fowler's position to promote drainage of the hemothorax. Ensure there is continuous bubbling in the water seal chamber is incorrect. The nurse should monitor the water seal chamber for continuous bubbling because this is an indication of a leak in the chest tube system. Monitor drainage every 30 min for the first hour is incorrect. The nurse should monitor the drainage from the chest tube every 15 min for the first 2 hr to identify excessive drainage. Strip the drainage tubing to ensure it is patent is incorrect. The nurse should not strip the chest tube because this can cause increased intrathoracic pressure. Place two rubber-tipped hemostats in the client's room is correct. The nurse should place two rubber-tipped hemostats in the client's room to use in case of an emergency, such as chest tube dislodgment. Palpate the chest tube insertion site for subcutaneous emphysema is correct. The nurse should palpate the chest tube insertion site for subcutaneous emphysema because this is a manifestation of an air leak. Ensure that all chest tube connections fire securely attached is correct. The nurse should ensure that all connections between the chest tube and drainage system are secure and intact to reduce the risk of a tension pneumothorax

A nurse is admitting a client who has active tuberculosis. Which of the following types of transmission precautions should the nurse initiate?

airborne

A nurse is performing a preoperative assessment for a client. The nurse should identify that an allergy to which of the following foods can indicate a latex allergy?

avocados