Ch 29 PrepU

The client reports severe pain when breathing in deeply. The description suggests to the nurse that the client is experiencing which respiratory condition?

inflammation of the parietal pleura

Which of the following would put the client at risk for falls? Select all that apply.

Dizziness Hypotension Confusion

A hospitalized client continues to exhibit residual effects of a stroke. Which symptom is the priority concern?

Dysphagia

The nurse is walking by a client's room and notices the client's pulse oximeter reads 89% on the monitor. What is the nurse's best action?

Enter the room and auscultate the client's lung sounds.

The client has decreased sensation in his legs. What additional assessment should the nurse include?

Fall

During assessment, the nurse notes the client has limited movement of his lower extremities and sways when standing with feet together. The nurse identifies that the client is at risk for what?

Falls

The nurse is providing care for a client admitted with new onset chest pain. What is a priorityquestion the nurse should ask this client?

How would you rate your pain on a scale of 1 to 10, with 10 being the worst?"

The nurse notes the client has weak pulses bilaterally. The nurse understands that this could indicate the client is experiencing what?

Hypovolemia

The client has a Glasgow Coma Score of 7. The nurse understands this client is considered to be what?

In coma

What nursing diagnosis would be most appropriate for a client admitted with heart failure?

Ineffective tissue perfusion

The nursing assistant obtains vital signs and reports a blood pressure of 180/95 to the nurse. What is the nurse's best action?

Instruct the nursing assistant to obtain a manual blood pressure.

When entering a client's room, the nurse washes the hands and asks the client for his name. What is the nurse's next best action?

Introduce self and explain what will be done.

An older client is admitted with a change in mental status, but no other motor deficits are observed. The caregiver tells the nurse that the client seemed okay yesterday but confused today. How should the nurse respond?

It is common for older clients to have mental status changes when they have an infection.

A client is admitted for observation after complaining of chest pain. A 12-lead electrocardiogram (ECG) reveals a normal sinus rhythm. The staff nurse questions the charge about whether the client can be observed or should be sent home because the ECG is normal. What is the charge nurse's best response?

It's acceptable for a client to be admitted for observation."

A hospitalized client who suffered a recent stroke hasn't started a diet yet and has referrals in to speech therapy, occupational therapy, and physical therapy. What is the nurse's best action at mealtime?

Keep the client NPO until speech therapy has seen client.

The nurse is assessing risk for falls. What data should be included in the fall risk assessment? Select all that apply.

Medical diagnosis History of falls IV/heparin lock

A client with an elevated blood pressure asks the nurse why he is not taking his blood pressure medication from home while he is hospitalized. The nurse reviews the orders and discovers that indeed the client is not taking his usual blood pressure medication. Which preventive measure was most likely omitted on admission?

Medication reconciliation

When listening to heart sounds, the nurse notes a swishing sound. The nurse recognizes that this as what?

Murmur

Which of the following would the nurse consider to be an urgent situation?

New onset chest pain

When considering high-yield screening questions, which question would likely gather the mostrelevant information concerning a client's mental status?

Over the last 2 weeks, have your become less interested in your hobbies?"

The client presents with pain, swelling, redness and warmth in his left leg. Based upon the assessment, the nurse suspects the client has what?

Venous thromboembolism

Upon assessment, the nurse finds the left calf to be red and warm. The client states it only "aches". The nurse would suspect what?

Venous thromboembolism

The nurse administers pain medication to a client at 1600. At what time should the nurse return to reassess the client's pain level?

1630

Which Glasgow Coma Score indicates the client is in a deep coma?

3

The nurse suspects a client weighing 161 pounds may be exhibiting signs of sepsis. Which urinary output value indicates acute oliguria?

50 mL in past 2 hours

Which of the following changes in a hospitalized client's status should prompt you to perform an urgent assessment?

A new onset of confusion

When planning an assessment of an older adult in a hospital setting, you shouldprioritize which of the following variables?

Age-related physiologic changes

A hospitalized client experiences respiratory distress. The nurse should include which most appropriate client outcome in the plan of care?

Airway patent, breathing quiet, denies dyspnea

What would be included in a shift assessment? Select all that apply.

Auscultation of lungs on a client with pneumonia Inspection of skin on a client that is not mobile Palpating pulses on a client with PVD

The nurse enters a client's hospital room and the client asks the nurse to raise him up in the bed. What is the nurse's best action?

Call for help and use the draw sheet to move the client.

A hospitalized client is prescribed a short course of corticosteroids. The client is placed on sliding scale regular insulin. The nurse should routinely assess which laboratory value while the client is hospitalized?

Capillary blood glucose

A client with a right subclavian central line develops fever of 101.0 degrees Fahrenheit. What is the nurse's best action?

Check the insertion site for redness.

Which assessment notation describes a client's level of consciousness?

Client was alert and cooperative during the assessment."

Which assessment is most likely performed when a client is admitted to the hospital?

Comprehensive

A hospitalized client reports nausea, vomiting, right lower quadrant abdominal pain with cramping, and frequent watery stools with significant weight loss. The nurse should further assess the client for other signs and symptoms of which disorder?

Crohn disease

What finding upon assessment would indicate the client is experiencing shock?

Systolic blood pressure 50

The client has been diagnosis with severe sepsis. Which finding would indicate the client is experiencing low cardiac output?

Tachycardia; hypotension

The nurse is caring for a client hospitalized for surgical repair of a foot fracture. How should the nurse assess the muscle strength in the client's feet?

Tell client to push feet against resistance.

What symptom(s) found during assessment would cause the nurse to suspect the client may be experiencing sepsis? Select all that apply.

Temperature greater than 102 °F (38.9 °C) Respiratory rate 36 breaths per minute Altered mental state Documented or suspected infection

An older female client who is hospitalized requires frequent linen changes due to incontinence when they cough or sneeze. How should the nurse document the client's incontinence?

The client requires frequent linen changes due to stress incontinence."

Which statement regarding the location of landmarks is associated with the assessment of the respiratory system?

The inferior tip of the scapula usually lies at the level of the 7th rib.

When deciding whether to delegate a task to another care provider, you should prioritize what factor?

The other person's level of skill and education

Which observation confirms to the nurse that the client is experiencing a normal inspiration?

The thoracic cavity enlarges.

The nurse is admitting a client to the surgical unit. The nurse should begin the general survey at which point in the admission process?

Upon meeting the client and family members

A new order for intravenous (IV) antibiotics has been prescribed for a female client who is hospitalized. The nurse reviews the client's chart, which indicates no known drug allergies and an admission diagnosis of a urinary tract infection (UTI). What is the first action of the nurse?

Verify whether the client has allergies.

The diagnosis of superficial phlebitis increases the client's risk for which vascular disorder?

deep vein thrombosis