Evolve Physiological Aspects of Care
The nurse providing post-procedure care to a client who had a cardiac catheterization through the femoral artery discovers a large amount of blood under the client's buttocks. After donning gloves, which action should the nurse take first?
Assess the catheterization site
What are the clinical indicators that a nurse expects when an intravenous (IV) line has infiltrated? (Select all that apply.)
Pallor Edema Decreased flow rate
A nurse assesses for hypocalcemia in a postoperative client. One of the initial signs that might be present is:
Paresthesias.
A nurse assesses drainage on a surgical dressing and documents the findings. Which documentation is most informative?
"A 10-mm-diameter area of drainage at 1900 hours."
A client is being treated for Influenza A (H1N1). The nurse has provided instructions to the client about how to decrease the risk of transmission to others. Which patient statement indicates a need for further instruction/clarification?
"I should obtain a pneumococcal vaccination each year."
At the conclusion of visiting hours, the parent of a 14-year-old adolescent scheduled for orthopedic surgery the next day hands the nurse a bottle of capsules and says, "These are for my child's allergy. Will you be sure my child takes one about 9 PM tonight?" What is the nurse's best response?
"I will get a prescription so that the medicine can be taken."
A nurse is providing preoperative teaching for a client regarding use of an incentive spirometer and should include what instructions?
"Inhale deeply through the spirometer, hold it as long as possible, and slowly exhale."
A client is scheduled for a transurethral resection of the prostate (TURP). Which statement made by the client most indicates the need for further preoperative teaching?
"My incision will probably be painful."
A client has a right above-the-knee amputation after trauma sustained in a work-related accident. Upon awakening from surgery, the client states, "What happened to me? I don't remember a thing." What is the nurse's best initial response?
"You were in a work-related accident this morning."
A client is scheduled to receive conscious sedation during a colonoscopy. The client asks the nurse, "How will they 'knock me out' for this procedure?" Which answer by the nurse correctly describes the route of administration for conscious sedation?
"You will receive medication through an intravenous catheter
A client with rheumatoid arthritis does not want the prescribed cortisone and informs the nurse. Later, the nurse attempts to administer cortisone. When the client asks what the medication is, the nurse gives an evasive answer. The client takes the medication and later discovers that it was cortisone. The client states an intent to sue. What factors in this situation must be considered in a legal action? (Select all that apply.)
1 Clients have a right to refuse treatment. 2 Nurses are required to answer clients truthfully. 3 The health care provider should have been notified
A client is in a state of uncompensated acidosis. What approximate arterial blood pH does the nurse expect the client to have?
7.20
When caring for a client with varicella and disseminated herpes zoster, the nurse should implement which types of precautions? (Select all that apply.)
Airborne Contact Standard
What response should a nurse be particularly alert for when assessing a client for side effects of long-term cortisone therapy?
Behavioral changes
A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client?
Blood lab results
A client admitted to the hospital with a diagnosis of malabsorption syndrome exhibits signs of tetany. The nurse concludes that the tetany was precipitated by the inadequate absorption of which electrolyte?
Calcium
A nurse addresses the needs of a client who is hyperventilating to prevent what complication?
Carbonic acid deficit
A nurse applies a cold pack to treat an acute musculoskeletal injury. Cold therapy decreases pain by:
Causing local vasoconstriction, preventing edema and muscle spasm
The nurse assesses an elderly client with a diagnosis of dehydration and recognizes which finding as an early sign of dehydration?
Change in mental status
A client is being discharged from the hospital with an indwelling urinary catheter. The client asks about the best way to prevent infection and keep the catheter clean. Which would be appropriate for the nurse to include in the client teaching?
Change the drainage bag at least once a week as needed
A client who experienced extensive burns is receiving IV fluids to replace fluid loss. The nurse should monitor for which initial sign of fluid overload?
Crackles in the lungs
The nurse understands that the action of an antidiuretic hormone (ADH) is to
Decrease water loss in urine
A nurse reviews a medical record of a client with ascites. What does the nurse identify that may be causing the ascites?
Decreased liver function
A nurse on the medical-surgical unit tells other staff members, "That client can just wait for the lorazepam (Ativan); I get so annoyed when people drink too much." What does this nurse's comment reflect?
Demonstration of a personal bias.
What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? (Select all that apply.)
Diarrhea Weakness Dysrhythmias
A nurse is caring for a client who is receiving an intravenous (IV) infusion. What should the nurse do first if the IV infusion infiltrates?
Discontinue the infusion.
A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the nurse give the client about this medication?
Drinking alcohol daily can cause drug-induced hepatitis
To prevent thrombophlebitis in the immediate postoperative period, which action is most important for a nurse to include in the client's plan of care?
Encourage early mobility.
The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia?
End-stage renal
A nurse is transcribing a practitioner's orders for a group of clients. Which order should the nurse clarify with the practitioner?
Erythropoietin (Procrit) 6000 units subcutaneously TIW
A client with limited mobility is being discharged. To prevent urinary stasis and formation of renal calculi, the nurse should instruct the client to:
Increase oral fluid intake to 2 to 3 L per day
The intake and output of a client over an eight-hour period is: 0800: Intravenous (IV) infusing; 900 mL left in bag; 0830: 150 mL voided; From 0900-1500 time period: 200 mL gastric tube formula + 50 mL water; Repeated x 2.; 1300: 220 mL voided; 1515: 235 mL voided; 1600: IV has 550 mL left in bag. What is the difference between the client's intake and output? Record the answer using a whole number. _________ mL
Intake includes 350 mL of IV fluid, 600 mL of nasogastric intubation (NGT) feeding, and 150 mL of water via NGT, for a total intake of 1100 mL; output includes voidings of 150, 220, and 235 mL, for a total output of 605 mL. Subtract 605 mL from 1100 mL for a difference of 495 mL. 495 ml
The nurse assesses an edematous client and recalls that edema occurs in what extracellular fluid compartment?
Interstitial
A client receiving steroid therapy states, "I have difficulty controlling my temper, which is so unlike me, and I don't know why this is happening." What is the nurse's best response?
Interview the client to determine whether other mood swings are being experienced
The nurse is caring for a client who is on a low carbohydrate diet. With this diet, there is decreased glucose available for energy, and fat is metabolized for energy resulting in an increased production of which substance in the urine?
Ketones
Based on the client's reported pain level, the nurse administers 8 mg of the prescribed morphine. The medication is available in a 10 mg syringe. Wasting of the remaining 2 mg of morphine should be done by the nurse and a witness. It is most appropriate for the nurse to ask which member of the health care team to be the witness?
Licensed practical nurse (LPN)
A client reports vomiting and diarrhea for three days. What clinical finding most accurately will indicate that the client has a fluid deficit?
Loss of body weight
A health care provider prescribes transdermal fentanyl (Duragesic) 25 mcg/hr every 72 hours. During the first 24 hours after starting the fentanyl, what is the most important nursing intervention?
Manage pain with oral pain medication
A pain scale of 1 to 10 is used by a nurse to assess a client's degree of pain. The client rates the pain as an 8 before receiving an analgesic and a 7 after being medicated. What conclusion should the nurse make regarding the client's response to pain medication?
Medication is not adequately effective
After gastric surgery a client has a nasogastric tube in place. What should the nurse do when caring for this client?
Monitor for signs of electrolyte imbalance
A health care provider prescribes digoxin (Lanoxin) for a client. The nurse teaches the client to be alert for which common early indication of digoxin toxicity?
Nausea
The count of hydrocodone (Vicodin) is incorrect. After several minutes of searching the medication cart and Physiological Aspects of Care records, no explanation is found. Who should the primary nurse notify about the discrepancy?
Nursing unit manager
A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment? (Select all that apply.)
Pain history including location, intensity and quality of pain Pain pattern including precipitating and alleviating factors
A client being treated for Influenza A (H1N1) is scheduled for a computed tomography (CT) scan. To ensure client and visitor safety during transport, the nurse should take which precaution?
Place a surgical mask on the client
A nurse assesses a client's serum electrolyte levels in the laboratory report. What electrolyte in intracellular fluid should the nurse consider most important?
Potassium
What does a nurse consider the most significant influence on many clients' perception of pain when interpreting findings from a pain assessment?
Previous experience and cultural values
A client undergoes a bowel resection. When assessing the client 4 hours postoperatively, the nurse identifies which finding as an early sign of shock?
Restlessness
A client with arthritis increases the dose of ibuprofen (Motrin, Advil) to abate joint discomfort. After several weeks the client becomes increasingly weak. The client is admitted to the hospital and is diagnosed with severe anemia. What clinical indicators does the nurse expect to identify when performing an admission assessment? (Select all that apply.)
Tachycardia Melena
A client with Addison's disease is receiving cortisone therapy. The nurse expects what clinical indicators if the client abruptly stops the medication? (Select all that apply.)
Tachypnea Hypotension
A client has received instructions to take 650 mg aspirin (ASA) every 6 hours as needed for arthritic pain. What should the nurse include in the client's medication teaching? (Select all that apply.)
Take the aspirin with meals or a snack Do not chew enteric-coated tablets Report persistent abdominal pain
A client's serum potassium level has increased to 5.8 mEq/L. What action should the nurse implement first?
Take vital signs and notify the charge nurse or health care provider
A nursing supervisor sends unlicensed assistive personnel (UAP) to help relieve the burden of care on a short-staffed medical-surgical unit. Which tasks can be delegated to UAP? (Select all that apply.)
Taking routine vital signs. Answering clients' call lights. Changing linens on an occupied bed.
A child is being treated with oral ampicillin (Omnipen) for otitis media. What should be included in the discharge instructions that the nurse provides to the parents of the client?
Complete the entire course of antibiotic therapy
Filgrastim (Neupogen) 5 mcg/kg/day by injection is prescribed for a client who weighs 132 lb. The vial label reads filgrastim 300 mcg/mL. How many milliliters should the nurse administer? Record the answer using a whole number. ______ mL
1ml
The nurse is caring for a client who is receiving therapy for vitamin B12 deficiency. Which finding indicates that the therapy is having the desired effect?
Correct4 Improved hemoglobin and hematocrit levels
A nurse provides teaching for a client who is scheduled for a cholecystectomy. In the initial postoperative period, the nurse explains that the most important part of the treatment plan is:
Coughing and deep breathing
What is a nurse's responsibility when administering prescribed opioid analgesics? (Select all that apply.)
Count the client's respirations. Document the intensity of the client's pain. Verify the number of doses in the locked cabinet before administering the prescribed dose.
A client with an abdominal wound infected with methicillin-resistant Staphylococcus aureus (MRSA) is scheduled for a computed tomography (CT) scan of the abdomen. To ensure client and visitor safety during transport, the nurse should implement which precaution?
Cover the infected site with a dressing.
A client with a diagnosis of uncontrolled diabetes began receiving Lasix (Furosemide) two days ago. The nurse reviews the morning lab results and discovers that the client's potassium level is 2.8 mEq/L. What is the most appropriate action for the nurse to take?
Notify the primary healthcare provider of the result, which is critically low
A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the nurse question?
Parenteral albumin (Albuminar)
