Client needs

The nurse is to inject an intravenous medication via a locked peripheral intravenous port. The nurse flushes the port with saline, administers the intravenous medication, and again flushes the port with saline. During this process, when should the nurse clean the injection port with an antiseptic swab?

at each entry of the capped injection port Rationale: The nurse should clean the capped injection port prior to each time it is entered.

A client has been taking carbamazepine for 2 years. What should the nurse assess the client for? Select all that apply.

bruising sore throat light-colored stool Rationale: The nurse should assess the client for signs of bone marrow depression, manifested by bruising or unusual bleeding, and signs of infection such as a sore throat. The nurse should also assess the client for signs of hepatic dysfunction, such as light-colored stool or dark-colored urine.

The nurse assesses an infant with an undescended testis. The nurse should be alert for which symptom?

bulging in the inguinal area Rationale: A bulging in the inguinal area may suggest an inguinal hernia.

Following a transient ischemic attack (TIA), a client is prescribed 81 mg of acetylsalicylic acid (aspirin) by mouth daily. Which client statement indicates that teaching has been successful?

"I will take this medication with a full glass of water."

A client is admitted to the hospital for a recent suicide attempt. While on the unit, the client has been taking antidepressants as prescribed, attending group therapy, and engaging with other clients and staff. The client states, "I have lots of things to do when I get home, and I don't really need to be in the hospital anymore." Which response by the nurse would be most appropriate?

"Tell me how you feel about killing yourself." Rationale: Asking about suicidal ideation in an open-ended manner is correct because the client may have more energy and capacity to act on suicidal thoughts.

The nurse teaches a client with type 2 diabetes mellitus about diabetic retinopathy. Which statement if made by the client would indicate to the nurse that teaching was effective?

"Tight control of blood sugar and blood pressure can prevent damage to my eye." Rationale:

A nurse assessing the heart rate and rhythm of an 8-year-old child hears a murmur that's barely audible even in a quiet room. The child's heart rate is 80 beats/minute. The nurse should document her assessment findings as:

"heart rate regular, grade I murmur auscultated." Rationale: A grade I murmur is barely audible in a quiet room; a grade II murmur is faint but clearly audible.

A client loses control and throws two chairs toward another client. What should the nurse do next?

Call for assistance to restrain the client and administer a PRN intramuscular tranquilizer.

Using the Morse Fall Risk Scale (see exhibit), the nurse should initiate the highest fall risk precautions for which client?

Client with a history of Parkinson disease, admitted for pneumonia and receiving IV antibiotics, who has fallen at home but is able to ambulate with a cane and who during hospitalization has gotten out of bed without calling for assistance

The nurse and parents plan for the discharge of a child with leukemia who is receiving dactinomycin and vincristine. Which intervention should the nurse include in the teaching plan?

Encourage increased fluid intake. Rationale: Dactinomycin and vincristine both cause nausea and vomiting. Oral fluids are encouraged, and antiemetics are given to prevent dehydration.

A client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. What is the best action by the nurse?

Evaluate client protein levels. Rationale: Clients on bed rest suffer from lack of movement and a negative nitrogen balance. Therefore, inadequate protein intake impairs wound healing.

The nurse is assisting the health care provider in irrigating a client wound. If the nurse is holding the gauze pads to collect the drainage during the irrigation procedure, which protective barriers are required? Select all that apply.

Gloves, gown, face mask, eye shield

The nurse prepares to teach an adolescent scheduled for an appendectomy about what to expect. The adolescent says, "I would rather look this up on the internet." What should the nurse do?

Help the client find information on the internet. Rationale: Part of providing client-centered care is to honor the client's preferred method of learning.

The nurse should complete which of the following assessments on a client who has received tissue plasminogen activator or alteplase recombinant therapy?

Neurologic signs frequently throughout the course of therapy. Rationale: The nurse needs to assess neurologic status throughout the therapy. Altered sensorium or neurologic changes may indicate intracranial bleeding for the client who has received tissue plasminogen activator or alteplase.

A single parent has only one child. The parent shares dreading the fall when the child leaves for college. Which type(s) of loss is this client likely to experience? Select all that apply.

Perceived loss Psychological loss Maturational loss Anticipatory loss

Which documentation tool will the nurse use to record the client's vital signs every 4 hours?

a graphic sheet Rationale: A graphic sheet is a form used to record specific client variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other client characteristics.

A client who is 16 weeks pregnant has an elevated alpha-fetoprotein (AFP) level. The nurse understands that the physician is likely to refer this client to

a perinatologist.

A client with severe shortness of breath comes to the emergency department. The client tells the emergency department staff that they recently traveled to China for business. Based on the client's travel history and presentation, the staff suspects severe acute respiratory syndrome (SARS). Which isolation precautions should the staff institute?

airborne and contact precautions Rationale: SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. The client should be placed on airborne and contact precautions to prevent the spread of infection.

A client in an inpatient psychiatric unit tells the nurse, "I'm going to divorce my no-good spouse. I hope they rot in hell. But I miss them so bad. I am in love. When are they going to come get me out of here?" The nurse interprets the client's statements as indicative of which condition?

ambivalence Rationale: Ambivalence refers to strong conflicting attitudes or feelings toward an object, person, goal, or situation, evidenced in this instance by the client stating they are going to divorce their spouse and then stating that they miss and love them.

A client uses timolol maleate eye drops. What is the expected outcome of this drug?

reducing aqueous humor formation Rationale: Timolol maleate is commonly administered to control glaucoma. The drug's action is not completely understood, but it is believed to reduce aqueous humor formation, thereby reducing intraocular pressure.