Mod 2

A client who has been diagnosed with chronic venous insufficiency has received teaching regarding how to prevent venous stasis ulcerations. Which statements by the client indicate to the nurse that teaching has been effective?

1. "Stationary standing should be kept to a minimum." 3. "Protecting my legs from trauma is very important." 4. "I will wear compression stockings every day." 5. "I will elevate the foot of my bed 6 inches (15.24 cm) when I sleep."

During the admission examination of a client diagnosed with acute pyelonephritis, what signs or symptoms would the nurse expect to find?

1. Anorexia 3. Chills 4. Fever 5. Hematuria -Dysuria -Costovertebral angle tenderness -Urinary frequency

What dietary supplements or herbs should the nurse instruct a client to avoid when prescribed digoxin?

1. Black licorice 4. Ginseng 5. St. John's Wort

A nurse is caring for a client post heart catheterization with a left femoral stick. What signs and symptoms would indicate to the nurse that the primary healthcare provider should be notified?

1. Capillary refill of 6 seconds to left toes. 2. Epigastric discomfort 3. Paresthesia to left leg 4. Left pedal pulse 0/4; Right pedal pulse 2+/4

The nurse is teaching a male client how to perform intermittent self-catheterization. In what order should this procedure be taught?

1. Clean the meatus 2. Lubricate several inches of the catheter tip 3. Hold your penis on both sides just behind the head 4. Insert the catheter 6 inches (15.24 cm) into the urethra 5. Gently, but firmly push past the sphincter muscle 2-3 inches(5-7.6 cm) 6. Allow urine to drain completely

What information should a community health nurse include while planning an educational program on prevention of deep vein thrombus formation for a group of people who attend a senior citizens center?

1. Exercise legs hourly when traveling by plane 2. Stop smoking 3. Lose weight 5. Exercise daily

Which signs and symptoms experienced by the client correlate with chronic renal failure diagnosis?

1. Fatigue 2. Anorexia 4. Swollen extremities 5. Hyperkalemia

What should a nurse include when planning an educational program for a group of women on how to prevent a urinary tract infection (UTI)?

1. Increase daily intake to at least 9 cups (2160 mL) of water.

What teaching points should the nurse include when teaching a client how to prevent a venous stasis ulcer?

1. Maintain a healthy weight. 3. Exercise helps to improve circulation. 5. Elevate legs above the heart for 30 minutes three times a day. -leg exercises -wear graduated compression stockings -avoid crossing legs -minimize stationary standing

The client is being admitted for a myocardial infarction (MI). Which assessment finding is expected?

1. Reports of nausea and vomiting

The nurse is assessing a client admitted with a diagnosis of chronic renal failure. Which finding would the nurse expect to see in the client?

2. Anorexia 4. Dependent edema

The nurse is planning to teach a client about home peritoneal dialysis. What information should the nurse include?

2. Apply a prescription antibiotic cream to the skin around the catheter with a cotton-tip swab. 4. Pat the skin around the site dry after cleaning.

An elderly client with a history of coronary artery disease (CAD) has just been admitted to the telemetry unit following a syncopal episode at home. The admitting nurse places EKG leads on the client and notes the following rhythm on the monitor. When the client indicates the need to void, the nurse knows that what would be the safest action?

2. Assist client with the use of a bedpan.

What assessment finding would the nurse expect when evaluating whether treatment has been effective for a client hospitalized with systolic heart failure?

2. CVP of 6 mm Hg 3. One day weight loss of 2 pounds (0.91 kg) 6. Urine output at 50 mL/hr

A community health nurse is presenting a seminar to a group of senior citizens on ways to reduce the risks of peripheral artery disease (PAD). What topics should the nurse include?

2. DASH diet 3. Maintaining a BMI less than 25 kg/m2 4. Managing diabetes

A client is admitted with arterial disease of the lower extremities. Which client teachings would the nurse initiate?

2. Discourage use of caffeine. 3. Protect extremities from cold exposure. 4. Maintain a warm environment at home. 5. Encourage isometric exercise.

The nurse is caring for a client who is receiving enoxaparin after a diagnosis of deep vein thrombosis of the left leg. Which nursing interventions would be appropriate for this client?

2. Initiate bedrest 3. Elevate left leg 4. Monitor closely for bleeding 5. Monitor complete blood count

A client arrives to the emergency department with reports of palpitations, chest discomfort, and lightheadedness. The nurse connects the client to a cardiac monitor and notes a weak, thready pulse, and a BP of 90/50. What actions should the nurse take?

2. Initiate oxygen at 2 liters per nasal cannula. 3. Prepare for immediate synchronized cardioversion. -Apply oxygen saturation monitor to client

What signs/symptoms would the nurse expect to assess in a client diagnosed with acute pericarditis?

2. Muffled heart sounds 3. Pericardial friction rub 5. Chest pain on deep inspiration

The nurse is caring for a client with acute renal failure. The morning assessment findings indicate the client has become confused and irritable. Which finding is most likely responsible for the change in behavior?

3. Elevated blood urea nitrogen (BUN)

A home health nurse is educating a client about home care considerations for clean intermittent catheterization. Which statement made by the client would indicate to the nurse that teaching was successful?

4. "Catheterization should be done when I feel the need to void."

When an explosion occurs at a local shopping center, an off-duty nurse quickly begins to triage those injured. The nurse knows which client needs immediate attention?

4. An adolescent with a rigid, board-like lower abdomen.

A client returns to the unit after having extracorporeal lithotripsy. Which would be the best indicator that the treatment has been effective?

4. There is sediment in the urinary catheter drainage bag.

A construction worker comes into the occupational health nurse's clinic reporting chest heaviness. The nurse should assess for what additional signs and symptoms?

1. Anxiety 2. Dizziness 4. Shortness of breath 5. Upper back pain -Lightheadedness -Dyspnea -irregular pulse

A nurse is planning care for a newly admitted client diagnosed with acute nephrotic syndrome. What interventions would the nurse include in the plan of care?

1. Monitor triglyceride level 3. Auscultate lung sounds. 4. Monitor blood pressure. 5. Assess for venous thrombo-embolism (VTE).

A client had a coronary artery bypass surgery (CABG) x 3 performed 24 hours ago. What assessment findings would make the nurse suspect cardiac tamponade?

2. Increased central venous pressure 3. Distended bilateral neck veins 5. Decreasing blood pressure

A small community has experienced a mudslide that hit a restaurant causing mass casualties. What would the nurse do first?

3. Activate the community emergency response team.

The nurse is planning care for a client who has incomplete emptying of the bladder with reports of dribbling, hesitancy, and frequency. Which intervention would the nurse include in this plan?

1. After voiding, instruct client to void a second time. 4. Have client place hand in warm water. 5. Demonstrate intermittent catheterization for retention.

The nurse is planning to educate a client who has a diagnosis of right sided heart failure? What information should the nurse include?

2. It is common to see swelling of lower extremities. 4. Side effects of this disease include fatigue and depression. 5. Nausea and anorexia occurs -There is a backup of blood in the right upper chamber of the heart.

A client has sublingual (SL) nitroglycerin prn added to the medication regimen. Which statement made by the client indicates to the nurse that further teaching is needed?

2. "I will wait at least 1 hour after I take my erection agent before using Nitroglycerin." 3. "I can take up to 3 tablets every 10 minutes if my angina occurs." 5. "I will keep my medication handy, in a pocket." -"I will take this medication if I have an episode of chest pain." -"I know that I must put this tablet under my tongue for it to work."

In order to maintain asepsis, what would the nurse teach the client on home peritoneal dialysis?

2. Cap Tenckhoff catheter when not in use. 5. Wash around the catheter insertion site daily.

The nurse sees the following rhythm on the cardiac monitor for a client recovering from a myocardial infarction. What would be the nurse's first action upon entering the client's room?

3. Assess for carotid pulse

As a member of the emergency preparedness planning team at the hospital, which action should the nurse encourage the team to implement?

2. Provide education to employees on the response plan. 3. Practice the response plan on a regular basis. 4. Evaluate the hospital's level of preparedness. 5. Coordinate with neighboring hospitals regarding different emergency response plans.

What potential contributing factors for transient urinary incontinence should a nurse assess in an elderly female client?

1. Fecal impaction 2. Diuretic use 3. Diabetic 5. Vaginitis

A client was admitted two days ago in the oliguric phase of acute kidney injury (AKI). What evaluation by the nurse would indicate that further treatment is necessary?

1. Fixed urine specific gravity 4. Minimal crackles auscultated in bases of left lung

A nurse, planning an educational seminar on chronic kidney disease, would invite clients with which medical conditions?

2. Hyperlipidemia 3. Obesity 4. Polycystic kidney disease 5. Nephrotic syndrome -Diabetes -Hypertension -Glomerulonephritis