Med Surg vATI

First-degree heart block

- Atrial impulses reach the ventricles through the AV node at a slower-than-normal rate. - P waves have a regular shape and appear consistently in front of the QRS complex.

diabetes macrovascular complications

- Coronary Artery Disease - Stroke - Hypertension

Right heart sided failure

- Dependent edma - Jugular distention - Weight gain

Dialysate interventions

- Do NOT use infusion pump - Report cloudy dialysate drainage - Warm solution using a heating pad or place in the warming section of cycling machine - Dwell time: 4-8 hours - Drainage: 10-20 minutes

Pin site interventions

- Do not apply any ointment to pin sites - Prophylactic broad spectrum IV antibiotic 24-48 hours after insertion - Sterile, absorbent, nonadherent dressing - Inspect pin sites every 8 hours - Cleanse with chlorhexidine solution

Fetal occult blood test

- Do not take NSAIDs for 7 days - Do not eat raw vegetables, red meat, or citritus fruits for 3 days before - Do not take Vitamin C supplements for 3 days before

A nurse is assessing a client who has suspected APPENDICITIS. Which of the following manifestations should the nurse expect?

- Elevated WBC count (20,000+) - Rebound tenderness (RLQ) - Anorexia

paracentesis

- Empty the bladder before the procedure - Weigh the client before and after procedure - Keep the client on bedrest after the procedure

Left Sided Heart Failure

- Frothy sputum - Dyspnea - Wheezing Treatment: Fluid restriction & diuretics to decrease preload & pulmonary congestion

Type 1 diabetes S/S

- Hyponatremia - Increased serum osmolality - Ketone in the urine - Hyperglycemia

status asthmaticus

- Labored breathing & wheezing - Distended neck veins - Use of accessory muscle - Bronchodilators - Epinephrine - Corticosteroids - Oxygen

Hyponatremia

- Low specific gravity - Elevated hemoglobin

A nurse is assessing a client who recently had a myocardial infarction. Which of the following findings indicates that the client might be developing PULMONARY EDEMA?

- Pink, frothy sputum - Tachypnea *A client who has pulmonary edema can develop pink, frothy sputum, wheezing, and tachypnea. *A client who has pulmonary edema can develop pink, frothy sputum, wheezing, and tachypnea.

Pulmonary embolism

- Pleural friction rub - Tachypnea - Tachycardia - Dyspnea - Sudden, sharp chest pain

Ventricular tachycardia

- Rapid, regular rhythm - HR: 140 + - P waves not visible

Complete heart block

- Regular rhythm - Low HR - Clear P waves that outnumber QRS complexes -

Radiation therapy interventions

- Remain 1m (3ft) away from infants, children, and pregnant women. - 1-hour of limited exposure to pregnant women - Use disposable utensils - Condom catheter & drainage bag - Facial tissues in underwear

Alzheimer's interventions

- Single date calender - Redirect the client by starting another activity - Use short, simple senteces when explaining an activity - Explanation should be done immediately before an activity

Phenytoin side effects

- Skin Rash - Bleeding gums - Increased facial hair - Constipation

lumbar laminectomy postoperative

- Slight elevation in temperature - No more than 125 mL of drainage in 4 hours - Decreased bowel sounds due to anesthesia - Monitor for paralytic ileus

Tension pneumothorax

- Trachial deviation - Dyspnea - Tachycardia - Tachypnea - Decreased or absent breath sounds over area

A nurse is providing teaching about health promotion activities for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

" I WILL CHECK MY BLOOD SUGAR LEVEL BEFORE EXCERCISING. " - Clients who have diabetes mellitus should not exercise if their blood glucose level is less than 80 mg/dL or greater than 250 mg/dL. A client who has type 1 diabetes mellitus and is hyperglycemic can experience even higher blood glucose levels. Hypoglycemia can also occur during exercise and up to 24 hr following exercise

A nurse is caring for a client who recently assumed the role of caregiver for their aging parents who have chronic illnesses. The nurse should identify that which of the following statements by the client indicates ACCEPTANCE of the role change?

" I changed the floor plan of our homes to accommodate my father's wheelchair. "

A nurse is providing discharge teaching about infection control at home for a client who has TUBERCULOSIS. Which of the following statements by the client indicates an understanding of the teaching?

" I will place my used tissues in a plastic bag. " - The sputum of a client who has tuberculosis is considered infectious until there are three consecutive sputum samples that test negative for Mycobacterium tuberculosis. Tissues that are soiled with the client's sputum should be placed in a plastic bag and sealed to avoid spreading the infection

A nurse is providing teaching to a client about strategies to manage MENOPAUSAL SYMPTOMS. Which of the following instructions should the nurse include in the teaching?

" Use water-based lubricant during intercourse to reduce discomfort. " - The nurse should instruct the client to use water-based lubricants to help relieve vaginal dryness and irritation during sexual intercourse. Atrophic vaginitis is a common manifestation of menopause.

A nurse is providing discharge teaching to a client following a loop electrosurgical excision procedure (LEEP) for the treatment of cervical cancer. Which of the following statements by the client indicates an understanding of the teaching?

"I may have mild cramping for several hours." - The client should expect very little discomfort from the LEEP procedure, which is performed in ambulatory care using a painless electrical current.

Dumping syndrome

- Anorexia - Iron deficiency anemia - Hypocalcemia - Tachycardia - Rapid gastric emptying - Nausea & abdomnial cramping

A nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions should the nurse implement to decrease the client's risk for ventilator-associated pneumonia (VAP)?

-Monitor for oral secretion every 2 hours -Provide oral care every 2 hours -Assess the client daily for readiness of extubation. *The nurse should monitor for oral secretions at least every 2 hr to decrease the likelihood of micro-organisms moving from the mouth into the respiratory tract. *The nurse should provide oral care every 2 hr using chlorhexidine rinse or sodium chloride solution with swabbing or tooth brushing. *The nurse should position the client with the head of the bed elevated at least 30° to prevent aspiration of bacteria into the airway. *To lower the risk of the client acquiring VAP, the nurse should assess the client daily for neurological readiness for discontinuing mechanical ventilation.

A nurse is caring for a client who has chronic venous insufficiency. Which of following areas should the nurse assess for the presence of a venous ulcer?

. The nurse should assess the ANKLE of a client who has chronic venous insufficiency for the presence of a venous ulcer. The ankle is the most common area for a venous ulcer.

A nurse is assessing a client for fluid volume deficit following lumbar spinal surgery. The nurse should identify which of the following findings as an indication the client is at risk for fluid volume deficit?

SURGICAL DRAIN OUTPUT 300 ML DURING AN 8 HOUR SHIFT. - A client who had lumbar spinal surgery should not have more than 250 mL from a drain in the first 24 hr. Therefore, 300 mL in 8 hr can indicate that the client is at risk for fluid volume deficit.

A nurse is caring for a client who had abdominal surgery. The client tells the nurse that "something gave way." The nurse removes the dressing and sees the wound has eviscerated. Identify the correct sequence of steps the nurse should follow.

1. Notify the surgeon about the finding. 2. Cover the client's wound with a sterile saline-soaked dressing. 3. Place the cleint in a low Fowler's position with their knee bent 4. Prepare the client to be transferred to surgery.

Potassium normal range

3.5-5.0

RBC count normal range

4.7-6.1 million

WBC normal range

5,000-10,000

A nurse is assessing a group of clients. For which of the following clients should the nurse make a referral to palliative care?

A CLIENT WHOSE MEDICATIONS TO MANAGE PARKINSON'S DISEASE ARE NO LONGER EFFECTIVE. - Palliative care is designed to maintain the client's current quality of life through symptom management, assist with decision making regarding care needs, and work with families to identify care outcomes

A nurse is providing preoperative teaching to a client who is scheduled for a RADICAL PROSTATECTOMY. Which of the following information should the nurse include in the teaching?

A PCA PUMP WILL BE USED FOR POSTOPERATIVE PAIN CONTROL. - A PCA pump is a common method of pain management in the first 24 hr following an open radical prostatectomy. The nurse should teach the client how to manage pain during the preoperative period rather than waiting until after surgery when the client is feeling the sedative effects of the anesthesia and pain medication.

A nurse is inspecting the skin of a client who has basal cell carcinoma. The nurse should identify which of the following lesion characteristics on the client's skin?

A pearly, waxy nodule. - Basal cell carcinoma has a nodular lesion with well defined borders & pearly or waxy apperance from ocerexposure to the sun.

A nurse is caring for a client who is intubated and receiving mechanical ventilation for heroin toxicity. Which of the following assessments is the nurse's priority?

ABGS. - When using the airway, breathing, and circulation (ABC) approach to client care, the nurse's priority assessment is to monitor the client's ABGs, including respiratory status.

A home health nurse is inspecting a client's residence for electrical hazards as part of the agency's quality improvement plan. Which of the following findings should the nurse identify as a safety hazard?

AN IV PUMP IS PLUGGED INTO AN OUTLET NEAR THE SINK. - The nurse should plug all electrical appliances into outlets away from wet areas. Water conducts electricity and places the client at risk for electrocution.

A nurse is planning preventative strategies for a client who is at risk for PRESSURE INJURIES. Which of the following actions should the nurse include in the plan?

APPLY MOISTURIZER TO DAMP SKIN AFTER BATHING. - Applying a moisturizer to damp skin after bathing helps prevent dry skin. The drier the skin is, the greater the risk is for skin breakdown.

A nurse is providing teaching to a client who has a new prescription for WARFARIN. Which of the following medications should the nurse instruct the client to avoid?

ASPIRIN & NAPROXEN. - Aspirin is an antiplatelet medication. It can increase the risk of bleeding when taken with warfarin. - . Naproxen is an NSAID that relieves mild to moderate pain. It can increase the risk of bleeding if taken with warfarin.

A nurse is planning care for a client who is receiving intermittent IV fluids via a peripherally inserted central catheter (PICC). Which of the following information should the nurse include in the client's plan of care?

ASSESS THE PICC INFUSION SYSTEM SYSTEMATICALLY. The nurse should assess the infusion system in a systematic fashion beginning with the insertion site, observing for signs of infection, and working upward and following the tubing to ensure that all connections are secure.

A nurse is caring for a client who had a surgical repair of an ABDOMINAL AORTIC ANEURYSM 3 days ago. The client's vital signs are: temperature 38.3° C (100.9° F), heart rate 80/min, respirations 16/min, and blood pressure 128/76 mm Hg. Which of the following actions is the nurse's priority?

ASSESS THE SURGICAL INCISION FOR SIGNS OF INFECTION. - A surgical wound infection typically appears 3 to 6 days following the surgery. Fever from the third postoperative day onward indicates that this client's greatest risk is either a wound infection or a pulmonary infection; therefore, this is the priority action the nurse should take.

A nurse is assessing a client's ECG strip and notes an irregular heart rate of 98/min with NO CLEAR P WAVES. Which of the following cardiac dysrhythmias should the nurse document?

ATRIAL FIBRILLATION. - With atrial fibrillation, multiple rapid impulses from many different foci cause depolarization of the atria in a rapid, disorganized manner. This causes a chaotic rhythm on the ECG strip that has no clear P waves, no atrial contractions, and an irregular rhythm.

A nurse is teaching a client how to obtain a specimen at home for a FECAL OCCULT BLOOD TEST. Which of the following actions should the nurse instruct the client to take for 3 days prior to collecting the specimen?

AVOID EATING RED MEAT. - A client should not eat red meat for 3 days before collecting the specimen because red meat contains hemoglobin, myoglobin, and some enzymes that can cause a false-positive result in a fecal occult blood test.

A nurse is caring for a client who has acute kidney injury and a POTASSIUM level of 6.5 mEq/L. Which of the following ECG changes should the nurse expect?

PEAKED T WAVES. - Elevated potassium levels result in tall, peaked T waves, flat or absent P waves, prolonged PR intervals, wide QRS complexes, and ectopic beats. Hyperkalemia can progress to complete heart block, ventricular fibrillation, and asystole.

Red man sydrome

Results from infusing vancomycin too rapidly. The nurse should infuse the medication over at least 60 min. - Hypotension - Tachycardia - Ototoxcity - Renal failure - Flushing

A nurse is caring for a male client who has a new prescription for CYCLOSPORINE following a kidney transplant. Which of the following findings should the nurse identify as an adverse effect of this therapy?

BUN 24 mg/dL. - A BUN of 24 mg/dL is above the expected reference range of 10 to 20 mg/dL, indicating renal impairment. An adverse effect of cyclosporine is nephrotoxicity

A nurse is caring for a client immediately following intubation with an endotracheal (ET) tube. Which of the following methods should the nurse identify as the most reliable for verifying placement of the ET tube?

CHECK FOR END-TIDAL CARBON DIOXIDE LEVELS. - According to evidence-based practice, the most reliable method for verifying ET tube placement is checking for end-tidal carbon dioxide levels by using capnometry. A chest x-ray is another reliable method for verifying placement.

A nurse is monitoring a client following a LUMBAR LAMINECTOMY. The client has a drain and indwelling urinary catheter. The nurse should identify which of the following findings as an indication of a COMPLICATION of the surgery?

CLEAR DRAINAGE OF DRESSINGS - This is an indication of a cerebral spinal leak *The nurse should identify clear drainage on or around the dressing as an indication of a cerebral spinal leak and should report this finding to the provider immediately.

A nurse is assessing a client who has a central venous catheter (CVC) with intravenous (IV) fluids infusing. The client suddenly develops shortness of breath, and the nurse notes that the IV tubing and needleless connector device are disconnected. Which of the following actions should the nurse take first?

CLOSE THE PINCH CLAMP ON THE CVC. - The greatest risk to this client is air embolism resulting from accidental disconnection of the CVC tubing. Therefore, the priority action is to clamp the catheter immediately by closing the pinch clamp to prevent any further air from entering the system. When an air embolism occurs, air enters through the central vein into the right ventricle and lodges by the pulmonary valve, decreasing the amount of blood that is able to enter into the ventricle and the pulmonary arteries.

Squamous cell carcinoma

Firm, nodular, and crusty lesion with an ulcerated center from sun exposure, chronic irritation, burns, or irradiation to the skin.

A nurse is assessing a client who is undergoing radiation therapy for breast cancer. Which of the following findings is an indication to the nurse that the client is experiencing an adverse effect of the therapy?

SKIN CHANGES. A client who is receiving radiation therapy to the breast will have localized adverse effects of the treatment, such as skin changes, esophagitis, and lymphedema.

A nurse is reviewing the health histories of a group of clients. Which of the following findings should the nurse identify as an indication that a client is at an increased risk for urinary tract infections (UTIs)?

DIABETES MELLITUS. - Diabetes mellitus is a predisposing factor for UTIs. Clients who have underlying diseases that compromise their immune response have an increased risk for UTIs.

A nurse is preparing to discharge a client who is postoperative following a TOTAL HIP ARTHROPLASTY. Which of the following equipment should the nurse ensure that the client has available at home prior to discharge?

ELEVATED TOILET SEAT. - A client who is postoperative following a total hip arthroplasty is at risk for dislocation of the hip prosthesis. Limitations on hip flexion and adduction decrease the risk. The client should avoid flexing the hip greater than 90° and should avoid using toilet seats that are low to the ground. An elevated toilet seat should be in place in the client's home prior to the client's discharge.

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse identify as a manifestation of left-sided heart failure?

Frothy sputum Pink-tinged frothy sputum can be an early indication of pulmonary edema and can be life-threatening. Therefore, the nurse should notify the provider immediately. *The nurse should identify that frothy sputum, dyspnea, and wheezing are manifestations of left-sided heart failure. Treatment includes fluid restriction and diuretics to decrease preload and reduce pulmonary congestion. Pink-tinged frothy sputum can be an early indication of pulmonary edema and can be life-threatening. Therefore, the nurse should notify the provider immediately.

Lung cancer

Hemoptysis Bloody expectorant when coughing

weeping vescile

Herpes Zoster - Weeping, blister type lesions.

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

I WILL KEEP THE MEDICATION REFRIGERATED - The nurse should instruct the client to refrigerate the oral cephalosporin suspension to maintain its full strength until the completion of the medication regimen

A nurse is providing teaching to a client who has a new prescription for LEVOTHYROXINE to treat hypothyroidism. Which of the following statements by the client indicates an understanding of the teaching?

IF MY HEART STARTS RACING, MY PROVIDER MIGHT NEED TO ADJUST MY DOSAGE. - Levothyroxine increases metabolism, which can increase oxygen consumption and heart rate. If the client's heart is racing, the dosage might be too high, causing thyrotoxicosis with manifestations of tachycardia, insomnia, tremors and nervousness, hyperthermia, heat intolerance, and sweating. The provider should retest the client's thyroid hormone levels and adjust the dosage accordingly.

A nurse is preparing a teaching plan for a client who is starting to receive hemodialysis for chronic kidney disease. Which of the following instructions should the nurse include in the teaching?

INCREASE YOUR INTAKE OF PROTEIN TO 1-1.5 G/KG PER DAY. - A client who receives hemodialysis for chronic kidney disease needs protein to prevent a negative nitrogen balance and muscle wasting. A client who is receiving hemodialysis is allowed 1 g to 1.5 g of protein/kg/day (same question diff answer options) Avoid food products that contain trans-fats. *A client who receives hemodialysis for chronic kidney disease should avoid foods that contain saturated and trans fats. Healthier fat sources should be substituted to reduce cardiovascular and dyslipidemia risks.

A nurse is assessing a client who has RIGHT-SIDED HEART FAILURE. Which of the following findings should the nurse identify as a manifestation of RIGHT- SIDED HEART FAILURE?

INCREASED ABDOMINAL GIRTH

A nurse notes that a client's eyes are protruding slightly from their orbits. Which of the following laboratory findings should the nurse expect?

INCREASED T4 LEVELS. - Exophthalmos, an abnormal protrusion of the eyeballs, is a classic sign of hyperthyroidism. Elevated thyroid hormone levels (T3 and T4) and a decreased thyroid stimulating hormone level reflect primary hyperthyroidism.

A nurse is assessing a client who has a new diagnosis of diabetes mellitus. The nurse should identify that which of the following findings is a manifestation of hyperglycemia?

INCREASED THIRST. - The nurse should teach the client that increased thirst, or polydipsia, is a manifestation of hyperglycemia, which can lead to dehydration. Other manifestations of hyperglycemia include an increase in appetite, or polyphagia, an increase in urine production, or polyuria, and fatigue.

A nurse is caring for a client who has multiple leg fractures and is 24 hr postoperative following placement of skeletal traction. Which of the following actions should the nurse take?

INSPECT THE PIN SITES AT LEAST EVERY 8 HOURS. - The nurse should inspect the pin sites at least every 8 hr, noting any inflammation or evidence of infection. Expected findings after the insertion of pins include redness, warmth, and serosanguineous drainage, which should subside after 72 hr.

A nurse is caring for a client who has DUMPING SYNDROME following a gastric resection. The nurse should monitor the client for which of the following complications of DUMPING SYNDROME?

IRON DEFICIENCY ANEMIA. - The nurse should monitor the client for manifestations of anemia, such as pallor, tachycardia, and fatigue. Rapid emptying of the stomach contents into the intestine can lead to reduced absorption of iron in the duodenum, causing iron-deficiency anemia.

A nurse is caring for a client who has deep-vein thrombosis and is receiving heparin via continuous IV infusion. The client's weight is 80 kg (176.4 lb). Using the client information provided, which of the following actions should the nurse take?

STOP THE HEPARIN INFUSION FOR 1 HOUR. - According to the titration table, when the aPTT is greater than 95, the nurse should stop the infusion for 1 hr, then restart the infusion with a decrease of 3 units/kg/hr, which is a decrease of 240 units/hr for a client who weighs 80 kg (176.4 lb).

Melanoma

Irregular border and varigated colored lesions of red, white, blue. - Most often on the upper back or lower legs

A nurse is providing teaching for a client who has constipation-predominant irritable bowel syndrome (IBS-C). Which of the following statements should the nurse include in the teaching?

TAKE PSYLLIUM IN THE EVENING. - A client who has IBS-C should take a bulk-forming laxative, such as psyllium, to increase the bulk of the stool, reduce constipation, and promote regular bowel movements.

A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of TYPE 1 DIABETES?

KETONES IN THE URINE - Clients who have type 1 diabetes mellitus can have ketones in the urine, which are a byproduct of the breakdown of fats for energy. Ketones in the urine are an indicator of inadequate amounts of insulin and high blood glucose levels

A nurse is assessing a client who has an exacerbation of diverticular disease. In which of the following quadrants should the nurse anticipate the client to be experiencing abdominal pain?

LEFT LOWER QUADRANT. - Diverticula commonly develop in the sigmoid colon because of the high pressure it takes to move stool into the rectum. Therefore, the pain with this disorder is often in the left lower quadrant.

A nurse in an emergency department is assessing a client who is overusing prescribed diuretics and has a sodium level of 127 mEq/L. Which of the following laboratory findings should the nurse expect?

LOW URINE SPECFIC GRAVITY. *A client who has hyponatremia as a result of diuretic overuse has a low urine specific gravity. The increased excretion of water alters the ratio of particulate matter, which affects the specific gravity.

A nurse is teaching a client about preventing the transmission of HIV. Which of the following information should the nurse include?

MEDICATION IS AVALIABLE THAT WILL REDUCE THE RISK OF HIV TRANSMISSION. - Tenofovir/emtricitabine is an oral medication that can be used prophylactically by a client who does not have an HIV infection to reduce the risk for HIV transmission. Pre-exposure prophylaxis is recommended for men who have sexual relationships with men, clients who are heterosexual and sexually active, noninfected partners who have a sexual relationship with a partner who has HIV, and clients who use intravenous drugs.

A nurse is caring for a client who is receiving a transfusion of packed RBCs. The nurse notes that the client's blood type is AB positive and the blood infusing is labeled type B negative. Which of the following actions should the nurse take?

MONITOR THE CLIENT FOR ANY ADVERSE REACTIONS. - Although the client is a universal recipient and can receive any ABO blood type, the nurse should continue to monitor for any adverse reactions, which is standard procedure for any blood transfusion.

A nurse is planning care for a client who has a lump in their right breast. Which of the following findings increases the client's risk of developing breast cancer?

ORAL CONTRACEPTIVES WERE TAKEN FOR THE LAST 6 YEARS. - Clients who take hormones, such as estrogen therapy, fertility drugs, and oral contraceptives, have an increased risk of developing breast cancer. (Answer from same question with diff answer options) Menopausal Obesity *During menopause, increased fat tissue can lead to higher stores of estrogen. Higher levels of estrogen in the body increase the risk for postmenopausal breast cancer.

A nurse is assessing a client who has Cushing's syndrome. Which of the following findings should the nurse expect?

Osteoporosis Bone become thinner as a result of mineral loss & nitrogen depletion.

A nurse is assessing a client who has a new diagnosis of PERICARDITIS. Which of the following findings should the nurse identify as a manifestation of cardiac tamponade?

PARADOXICAL PULSE. - Cardiac tamponade results from an excess of fluid in the pericardial cavity and causes a sudden drop in cardiac output. Paradoxical pulse is a systolic blood pressure of 10 mm Hg or more on expiration and is a manifestation of cardiac tamponade. The nurse should report manifestations of cardiac tamponade to the provider immediately.

A nurse is teaching a client about self-management of their halo fixator device. Which of the following information should the nurse include in the teaching?

PLACE A SMALL PILLOW UNDER THE HEAD WHILE LYING SUPINE. - The halo fixator device is worn for a period of 8 to 12 weeks and immobilizes the cervical spine, preventing flexion and hyperextension of the neck. The use of a small pillow under the head provides support to the head and neck, preventing additional discomfort and pressure from the device.

A nurse is planning care for a client who is scheduled for surgery and has a LATEX ALLERGY. Which of the following actions should the nurse plan to take?

PLACE MONITORING CORDS & TUBES IN A STOCKINETTE. -The nurse should place monitoring devices in a stockinette to prevent direct contact with the client's skin. *The nurse should ensure that epinephrine is readily available in the surgical suite in case of an anaphylactic reaction.

A nurse is assisting with the care of a client who is scheduled for a THORACENTESIS. Which of the following interventions should the nurse plan to take?

PLACE THE CLIENT LEANING FORWARD OVER THE BEDSIDE TABLE FOR THE PROCEDURE. - This allows the provider complete access to the client's chest and back. This position also expands the spaces between the ribs where the pleural fluid accumulates.

A nurse in a long-term care facility is caring for a client who has dementia. Which of the following actions should the nurse take?

PROVIDE FINGER FOOD AT MEALTIME. - The nurse should provide the client who has dementia with fingers foods. Clients who have dementia can have difficulty sitting still and tend to wander, which makes weight loss and malnutrition a concern. Therefore, foods that the client can hold while ambulating are ideal.

A nurse is caring for a client who has developed acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse identify as a manifestation of this syndrome?

REFRACTORY HYPOXEMIA - A client who has ARDS has refractory hypoxemia, which is hypoxemia that does not improve with oxygen therapy. Extensive pulmonary edema evident on a chest x-ray is a manifestation of ARDS.

A nurse is caring for a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?

REPORT CLOUDY DIALYSATE DRAINAGE TO THE PROVIDER. - The most serious complication of peritoneal dialysis is peritonitis, an inflammation of the peritoneum. Assessment findings include cloudy dialysate drainage, rebound abdominal tenderness, and diffuse abdominal pain. The nurse should report these findings immediately to the provider, who can then prescribe a fluid culture, quick exchanges to wash out mediators of infection, and antibiotics.

A nurse is assessing a client who has a history of type 2 diabetes mellitus. The nurse should identify which of the following findings as an indication of a microvascular complication?

RETINOPATHY. - Diabetic retinopathy is a microvascular complication of diabetes mellitus resulting from pathologic changes in small blood vessels, which eventually cause tissue damage, cell death in the retina, and blindness.

A nurse is teaching a client who has a new prescription for PHENYTOIN to treat a seizure disorder. Which of the following adverse effects should the nurse instruct the client to report IMMEDIATELY to the provider?

SKIN RASH. - the nurse should determine that the priority finding is a rash, which can have a measles-like appearance and progress to exfoliative dermatitis or Stevens-Johnson syndrome. The client should report this finding to the provider immediately. *When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a rash, which can have a measles-like appearance and progress to exfoliative dermatitis or Stevens-Johnson syndrome. The client should report this finding to the provider immediately.

A home health nurse is assisting a client with planning care for a family member who has Alzheimer's disease. Which of the following instructions should the nurse include?

Remove clutter from rooms and hallways - This allows the client is able to walk without the risk of falling or tripping over objects. Later in the disease, the client can experience seizures, so cluttered areas could be a risk to the client

A nurse is caring for a client who is experiencing anxiety as well as numbness and tingling of the lips and fingers. The client's ABGs are: pH 7.48, PCO2 30 mm Hg, HCO3- 24 mEq/L, PaO2 85 mm Hg. Which of the following acid-base imbalances should the nurse identify that the client is experiencing?

Respiratory alkalosis - The pH is alkaline - PCO2 is low representing alveolar hyperventilation & respiratory alkalosis

A nurse is completing an admission assessment for a client who has bacterial meningitis. Which of the following personal protective equipment should the nurse use while caring for the client?

SURGICAL MASK. - The nurse should adhere to droplet precautions in addition to standard precautions for clients who have bacterial meningitis, provided the causative pathogen spreads via droplets. - The nurse should place these clients in a private room and wear a mask when within 0.9 m (3 feet) of the client to prevent acquiring the infection. - Clients should wear a mask whenever they are outside their room

A nurse is performing a risk assessment for a client. Which of the following factors should the nurse identify as increasing the client's risk for falls?

THE CLIENT HAD A CATARACT SURGERY 1 DAY AGO. - A client who had recent eye surgery is at increased risk for falls. The nurse should ensure the client is wearing prescription glasses when ambulating and that environmental hazards, such as loose rugs, are removed because the client's vision might be blurred.

A nurse is caring for a client who is receiving VANCOMYCIN intermittent IV bolus therapy for METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS. Which of the following findings is an indication to the nurse that the client is experiencing an ADVERSE EFFECT of the medication?

THE CLIENT IS BECOMING FLUSHED. - Flushing is a manifestation of an infusion reaction to vancomycin that also causes a rash on the face and upper body, called red man syndrome.

A nurse is providing preoperative teaching about stool consistency to a client who will undergo a COLECTOMY with the placement of an ileostomy. Which of the following information about stool consistency should the nurse include in the teaching?

THE STOOL WILL HAVE A HIGH VOLUME OF LIQUID. - The nurse should include in the teaching that when peristalsis returns, the client can have an initial period of high-volume liquid stool output, more than 1,000 mL/day. Later, as the proximal small bowel adapts, stool volume should decrease.

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

TURN THE CLIENT BY LOG ROLLING WITH A TURNING SHEET. - The nurse should turn the client by log rolling with a turning sheet to keep the client's back straight and to prevent back spasms from occurring.

A nurse is assessing a client who takes SALMETEROL to treat moderate asthma. Which of the following findings should indicate to the nurse that the medication has been effective?

The client's daily peal expiratory flow (PEF) measures 85% above personal best. *A client who has asthma should use a peak flow meter twice daily to monitor asthma control. A PEF in the green zone, or 80% or above personal best, indicates the effectiveness of medication therapy. - Forced expiratory volume measures the amount of air the client exhales during 1 second and is part of pulmonary function testing. Effective use of a bronchodilator should increase the client's forced expiratory volume

A nurse is caring for a group of clients. In which of the following scenarios is the nurse acting as a client advocate?

The nurse refers a client who has chronic obstructive pulmonary disease for palliative care services. - Palliative care is an interdisciplinary approach to client care that works toward optimizing the quality of life for a client who has a chronic illness. Nurses advocate for their clients when they promote the health, safety, and rights of the client, such as providing a referral for needed services to relieve suffering and promote a client's quality of life.

A nurse is caring for a client who has atopic dermatitis and a prescription for triamcinolone ointment. The nurse should assess the client to monitor for which of the following adverse effects?

Thinning of the skin. Thinning of the skin and delayed healing are adverse effects of topical glucocorticoid preparations. The client should only apply the ointment to dry patches of the skin because topical steroids can cause atrophy of the dermis and epidermis, which can result in thinning of the skin.y.

Topical Glucocorticoids Side effects

Tiamcinolone - Hypopigmentation - Excessive hair growth (hypertrichosis) - Thinning of the skin

A nurse is teaching a client who is scheduled to receive RADIOACTIVE IODINE THERAPHY for treatment of hyperthyroidism. Which of the following instructions should the nurse include in the teaching?

USE DISPOSABLE UTENSILS FOR MEALS. - The client who receives radioactive iodine has radioactivity in the body fluids, including saliva, for several weeks following treatment. The nurse should instruct the client to use disposable utensils, plates, and cups during this time period to decrease the risk for radiation exposure to other members of the household

An emergency room nurse is assessing a client who has asthma and difficulty breathing. Which of the following findings should indicate to the nurse that the client is experiencing status asthmaticus?

USE OF ASSCESSORY MUSCLES. - A client who has status asthmaticus uses accessory muscles to help facilitate breathing, which is a manifestation of a severe airflow obstruction. The situation is life-threatening and the nurse should intervene immediately with strong systemic bronchodilators, epinephrine, corticosteroids, and oxygen.

A nurse is caring for a client who is hemorrhaging and hypotensive from esophageal variceal bleeding. Which of the following actions should the nurse take first?

VERIFY THAT THE CLIENT HAS ADEQUATE IV ACCESS. - When using the airway, breathing, and circulation approach to client care, the nurse should first verify that the client has at least a 20-gauge IV for the administration of blood.

A nurse is providing teaching to a group of clients about the prevention of CORONARY ARTERY DISEASE. Which of the following information should the nurse include in the teaching?

WALK 30 MIN DAILY AT A COMFORTABLE PACE. - The clients should walk 30 min daily at a comfortable pace to prevent weight gain and decrease the risk of coronary artery disease.