nursing 125
The nurse is caring for a postoperative client who complains of pain in the shoulder blades following laparoscopic cholecystectomy surgery. Which direction will the nurse give to the nursing assistant to help relieve the client's pain?
"Ambulate the client in the hallway."
Which question will best help the nurse to assess the activity level of a client with a history of heart failure?
"Do you become fatigue or develop heaviness in your arms or legs that you didn't have before?"
The nurse is caring for a client who has acute viral gastroenteritis. Which dietary instruction will the nurse provide to the client?
"Drink Gatorade if you do not like the taste of Pedialyte"
A client has been taking naproxen (Naprosyn) for several months. Which assessment question is important for the nurse to ask?
"Have you had any stomach pain or indigestion"
Which question will best assist the nurse in the assessment of a client with acute diarrhea?
"Have you traveled outside the country recently?"
Which client statement alerts the nurse to the occurrence of heart failure?
"I get short of breath when I climb stairs"
Which client statement alerts the nurse to possible heart failure?
"I have to stop halfway up the stairs to catch my breath"
Which statement by the client ordered sublingual nitroglycerin for chest pain indicates a need for further teaching regarding this therapy
"I keep my medicine in a clear plastic bag in my purse so that I can get to it easily if I have chest
Which statement made by the caregiver of a home care client indicates a need for clarification regarding pressure ulcer prevention and treatment?
"I massage his tail bone every morning when he gets up because it is red"
The nurse is providing discharge teaching for a client who has just undergone laparoscopic cholecystectomy surgery. Which statement by the client indicates understanding of the instructions?
"I will have a low-fat diet w/ small, frequent meals:
The nurse is providing discharge teaching for a client who will be going home w/ a T-tube following cholecystectomy surgery. Which statement by the client indicates the need for additional teaching?
"I will irrigate the T-tube w/ normal saline if the drainage appears too slow."
The nurse is preparing a client with diverticulitis for discharge from the hospital. Which statement by the client indicates that additional teaching is needed?
"I will take a senna laxative at bedtime to avoid becoming constipated"
Which statement indicates that the client needs additional teaching about her or his colonoscopy?
"I will take my Coumadin with a sip of water tomorrow morning
Which statement indicates that the nurse understands the spread of severe acute respiratory syndrome (SARS)?
"I will use airborne and contact precautions when I am in contact with the client"
The nurse is teaching the client about his fenestrated tracheostomy tube. Which statement by the client indicates an accurate understanding of the tube?
"I'm glad I will still be able to talk with this tube in place"
A client post-myocardial infarction is placed on a beta-blocker. Which statement best indicates that the client understands the action of this medication?
"It will decrease my blood pressure"
The nurse is caring for a teenage girl with a new ileostomy. She tells the nurse tearfully that she cannot go to the prom with an ostomy. Which is the nurse's best response
"Let's talk to the enterostomal therapist (ET) about options for ostomy supplies and dress styles so that you can look beautiful for the prom"
Which statement made by a client would alert the nurse to the possibility of right-sided heart failure?
"My shoes fit really tight"
Which statement made by a client would alert the nurse to the presence of edema?
"My shoes fit tighter by the end of the day"
Which statement by the nurse indicates an accurate understanding of tuberculosis (TB) as a disease process?
"The TB client can have a negative skin test if he is immunocompromised"
A client asks the nurse why it is important to be weighed every day if he or she has right-sided heart failure. How will the nurse respond?
"Weight is the best indication that you are gaining or losing fluid"
The client with tuberculosis asks his nurse when he will be considered noninfectious. Which is the nurse's best response?
"When you have three negative sputum cultures in a row"
A client with end-stage heart failure is awaiting a transplant. The client appears depressed and states, "I know a transplant is my last chance but I don't want to become a vegetable." What is the nurse's best response?
"Would you like information about advanced directives"
The nurse incorporates which information into the teaching plan for the client with severe esophageal varices who is scheduled for transjugular intrahepatic portal systemic shunt (TIPS) insertion?
"You will receive sedation, but the procedure may still be painful."
A client taking hydrochlorothiazide (Microzide) for control of hypertension. Which instruction will be given to this client before beginning therapy?
"Your diet should include foods high in potassium." The health care provider has prescribed the client sodium warfarin (Coumadin) while he or she is still receiving IV heparin. Nurses best action is to administer the meds as prescribed
The nurse is caring for a client who had ileostomy surgery 10 days ago. The client verbalized concerns that the effluent has not become formed and is still liquid green. Which is the nurse's best response?
"Your stools will become firmer over the next weeks as your body gets used to the ileostomy"
Which is the most accurate method of diagnosing gastroesophageal reflux disease
24 hour ambulatory pH monitoring
The client has a consistent and regular heart rate of 128 bests/min. Which physiologic alterations would be consistent with this finding?
A decrease in cardiac output and blood pressure
A client with systolic dysfunction has an ejection fraction of 38%. The nurse expects to observe which physiologic change?
A decrease in tissue perfusion
Which assessment finding does the nurse expect in the client with mitral insufficiency?
A high-pitched holosystolic murmur
The nurse correlates which rationale for a protein- restricted diet in the client with portal systemic encephalopathy?
A low protein diet will help reduce the amount of ammonia in the blood
The nurse correlates which rationale for a protein-restricted diet in the client with portal-systemic encephalopathy (PSE)?
A low-protein diet will help reduce the amount of ammonia in the blood
A client with heart failure develops an increased in preload. Which mechanism contributes to this increase?
Activation of the renin-angiotension-aldosterone system
A client has been admitted to the intensive care unit with worsening pulmonary manifestations of heart failure. Which primary collaborative intervention should the nurse perform?
Administer loop diuretics
The nurse is caring for an adult client w/ possible cholecystitis. Which laboratory findings lead the nurse to believe that this diagnosis is correct?
Alanine aminotransferase (ALT), 66 IU/L--- Alkaline phosphatase (ALP), 106 U/L
The nurse correlates decreased hepatic synthesis of which substance in the client who develops ascites?
Albumin
The nurse correlates which data in the client's history as a predisposing factor for Laennec's cirrhosis?
Alcohol abuse
Which dressing choice will the nurse make to protect a heavily draining deep pressure ulcer/ wound?
Alginate packing dry gauze cover
The nurse is caring for a postoperative client who complains of pain in the shoulder blades following laparoscopic cholecystectomy surgery? Which direction will the nurse give to the nursing assistant to help relieve the client's pain?
Ambulate the client in the hallway
What is the nurse's interpretation of a client's ECG that reveals ST-segment depression and T-wave inversion in leads II, III, and aVf
An episode of angina
A client is admitted with early-stage heart failure. Which assessment finding does the nurse expect?
An increase in heart rate and respiratory rate
A client with esophageal reflux who experiences regurgitation while lying flat is at risk for which
Aspiration
Client has bluish tinge to his palms, soles, and conjunctivae. What is nurse's next action?
Assess pulse oximetry
A client receiving continuous oxygen therapy by nasal cannula for an acute respiratory problem is becoming increasingly confused. What will the nurse do first?
Assess the client's pulse oximetry
The nurse is caring for a client who has started on TPN 2 days previously the client complains of blurred vision, dry mouth and frequent urination. Which is nurse's priority action?
Assessing client's blood sugar level
Which is a priority intervention for the client experiencing atrial fibrillation?
Assessing for shortness of breath
A client has been admitted to the acute care unit for an exacerbation of heart failure. Which is the nurse's priority intervention?
Assessing respiratory status
The nurse is caring for a client who was started on total parenteral nutrition (TPN) 2 days previously. The client complains of blurred vision, dry mouth, and frequent urination. Which is the nurse's priority action of the nurse?
Assessing the client's blood sugar level
A client with a stenotic mitral valve has presented to the clinic for further evaluation. Which intervention is the highest priority?
Assessment of blood pressure
A client presents with pressure ulcer on the ankle. Which is the first intervention that the nurse will implement?
Assessment of pulses, skin color, and temperature
The client is experiencing sinus bradycardia with hypotension and dizziness. Which will the nurse administer?
Atropine (Atropine)
Which is the priority assessment of a client experiencing regurgitation
Auscultating lungs for crackles
A client's heart rate and rhythm is regular. What does the nurse assume from this finding?
Automaticity of the cells in the conduction system is normal
Which precaution will the nurse teach the client with urticarial who is prescribed to take diphenhydramine (Benadryl)?
Avoid alcoholic beverages
The nurse monitors for which complication in the client with end-stage cirrhosis who develops severe vomiting.
Bleeding esophageal varices
The nurse recognizes which lab test as most specific in diagnosing an acute myocardial infarction
CK-MB isoenzyme
The nurse is caring for a client who is having approximately 20 foul-smelling stools/day. Laboratory Gram stain testing indicates the presence of white blood cells (WBCs) and red blood cells (RBCs) in the stool. Which organism does the nurse expect to see in the culture report?
Campylobacter jejuni
The nurse correlates which clinical manifestations with a diagnosis of variant (prinzmetal's) angina
Chest pain occurring with minimal exertion that limits the client's activity
Which finding puts a client at greatest risk for wound infection?
Client who is immunocompromised
Which client's wound will the nurse recommend for surgical management?
Client with Stage IV pressure ulcer with necrotic tissue
For which client would the nurse 1st prioritize care?
Client with cellulitis
The client at greatest risk for developing intimal injury leading to atherosclerosis
Client with diabetes who also smokes one pack of cigarettes a day
A nurse obtains a pulmonary artery pressure reading of 25/12 mm Hg in a client recovering from a myocardial infarction. Which is the nurse's first intervention based on these findings?
Compared the results with previous readings
A client with third-degree heart block is admitted to the telemetry unit. The nurse observes wide QRS complexes, with a heart rate of 35 beats/min on the monitor. What physical assessment parameter would be important to incorporate for this client?
Confusion or syncope
The nurse assesses a client receiving 60% oxygen via a tracheostomy collar. Which assessment finding requires immediate action by the nurse?
Constant, nonproductive coughing
The nurse correlates which action to the administration of vasopressin for the client with bleeding esophageal varices?
Constriction of preportal splanchnic arterioles
The nurse correlates which action to the administration of vasopressin for the client with bleeding esophageal varies?
Constriction of preportal splanchnic arterioles
Which clinical manifestation would support the nurse's assessment of venous congestion in the client admitted with cirrhosis and an enlarged liver?
Crackles on auscultation
The nurse is assessing a client after a thoracentesis. Which answer represents an accurate intervention by the nurse?
Crepitus felt at site, physician notified
A client with third-degree AV block presents to the emergency room with a heart rate of 40 beats/min. Which nursing diagnosis would most likely be a priority for this client?
Decreased Cardiac Output
A client has had a recent myocardial infarction involving the left ventricle. Which assessment finding is expected?
Decreased cardiac output
A client with a history of having several myocardial infarctions has excessive filling of the ventricles as a result. Which physiologic response will the nurse expect to see in this client?
Decreased cardiac output
Which is an explanation of conditions that foster esophageal reflux
Decreased lower esophageal sphincter tone
Assessing skin turgor on young adult, nurse's notices skin does not return to original state when pinched/ released. Nurse will assess for further signs of
Dehydration
Which is the nurse's priority intervention for a confused client who is to start oxygen therapy?
Determine which method of oxygen delivery the client will best tolerate.
For which clinical manifestation of myocardial infarction should the nurse monitor in the older adult
Disorientation or confusion
The client asks the nurse how to avoid becoming ill with salmonella infection again. Which are appropriate responses from the nurse?
Do not eat uncooked cookie dough or cake batter-----Wash your hands before and after using the bathroom----Use separate cutting boards for raw meats & vegetables-----Avoid eating eggs that are sunny side up or undercooked-----Make sure that all juices and milk are pasteurized before drinking
A client has wound on left trochanter that is 4in in diameter with black tissue at the perimeter and bone is exposed. What is nurse best action?
Document as Stage IV pressure ulcer and prepare client for possible surgical intervention
When changing the dressing on a partial thickness wound nurse observes small pale pink bumps within the wound bed. What's best action?
Documenting and continuing current treatment
The nurse is caring for a client who has just undergone traditional cholecystectomy surgery and has a Jackson- Pratt drain in place. The nurse notes that there is serosanguineous drainage present in the drain. What is the nurse's priority action?
Documenting the finding in the client's chart
The nurse is caring for a client who has just undergone traditional cholecystectomy surgery and has a Jackson-Pratt (JP) drain in place. The nurse notes that there is serosanguineous drainage present in the drain. Which is the nurse's priority?
Documenting the finding in the client's chart
Which finding alerts the nurse to the presence of hepatomegaly?
Dullness percussed over the liver
Which assessment finding supports a diagnosis of impaired tissue perfusion in the client with heart failure?
Dyspnea on exertion
Which teaching is a priority for the client with gastroesophageal reflux?
Eat 4-6 meals each day
What will the nurse teach the client with diverticula about dietary needs?
Eat soft foods and smaller meals
Which instruction will the nurse give the client to prevent nighttime reflux?
Elevate the head of the bed 6-8 inches for sleep
The nurse is caring for a client w/ Crohn's disease who has developed a fistula. Which nursing intervention is the highest priority?
Encouraging the client to consume a diet high in protein and calories
Which laboratory finding does the nurse anticipate to note for a female client with an exacerbation of ulcerative colitis?
Erythrocyte sedimentation rate (ESR), 55mm/hr
The nurse is caring for a client who has undergone traditional cholecystectomy surgery earlier in the day. The nurse notes that there is approximately 150 mL of serosanguineous drainage present in the T-tube drain. Which is the nurse's priority action?
Gently milk the T-tube drain tubing to maintain patency
The nurse is caring for a client who has undergone traditional cholecystectomy surgery earlier in the day. The nurse notes that there is approximately 150 mL of serosanguineous drainage present in the T-tube drain. Which is the nurse's priority action?
Gently milking the T-tube drain tubing to maintain patency
The nurse finds a positive Blumberg's sign in a client with abdominal pain. Which action will the nurse plan?
Have the client NPO in preparation for surgery
The nurse is caring for a client with ulcerative colitis and severe diarrhea. Which nursing assessment is the highest priority?
Heart rate and rhythm
Which laboratory results does the nurse expect in the client with heart failure?
Hemoglobin, 14.2 g/dL; hematocrit (Hct), 32.8%/Serum sodium, 130 mEq per L/Proteinuria/Microalbuminuria
A nurse is caring for a client with chronic atrial fibrillation who is at risk for systemic emboli. Which drug should the nurse expect to administer to prevent this complication?
Heparin (Heparin)
Which dietary choice is best for a client who has been identified as being at risk for imbalanced nutrition and formation of pressure ulcers?
High protein diet with vitamins and mineral supplements
Which laboratory result alerts the nurse that a female client is at high risk for cardiovascular disease?
Homocysteine = 25mmol/dL
Which conditions are caused by left-sided heart failure?
Hypertensive disease/Crackles heard/Confusion/S3S4 gallop/Cough worsens at night
A client is taking triamterene-hydrochlorothiazide (Dyazide) and furosemide (Lasix). Which assessment finding alerts the nurse to a serious side effect?
Hypokalemia
The nurse is providing discharge teaching for a client who has just undergone laparoscopic cholecystectomy surgey? Which statement by the client indicates understanding of the instructions?
I will have a low fat diet with small frequent meals
The nurse is providing discharge teaching for a client who will be going home wit a T-tube following cholecystectomy surgery. Which statement by the client indicates the need for additional teaching?
I will irrigate the T- tube with normal saline if the drainage appears too slow
Which statement indicates that the client understands the management of his or her hiatal hernia?
I will remain upright for several hours after each meal
The nurse is preparing a client with diverticulitis for discharge from the hospital. Which statement by the client indicates that additional teaching is needed?
I will take senna laxative at bedtime to avoid becoming constipated
Which nursing diagnosis would be considered a priority for the client with heart failure?
Impaired Gas Exchange
Assessing client's lower extremities, nurse notices one leg pale/cooler to touch. These symptoms are most characteristic of
Impaired Tissue perfusion
Which client is at greatest risk for pressure ulcer development?
Incontinent client with limited mobility
Which manifestations in a client receiving oxygen therapy at 60% for more than 24 hours would alert the nurse to the possibility of oxygen toxicity?
Increased dyspnea
A client brought to the emergency room following a myocardial infarction is found to be hypotensive. Which compensatory change is expected as a result of baroreceptor stimulation?
Increased heart rate
A client's heart disease has resulted in a reduction of stroke volume. Which compensatory mechanism is expected?
Increased heart rate
The nurse correlates which rationale with the administration of aspirin plus nitroglycerin to the client experiencing angina-like chest pain
Inhibition of platelet aggregation and clot formation
Nurse observes yellow tinged sclera on a client with dark skin. Nurse best action
Inspect client's oral mucosa and hard palate
Which should be the priority intervention of a teaching plan to instruct a client about the proper use of an incentive spirometer?
Instruct the client to exhale, put the mouthpiece in place, and take a breath for 5 to 10 seconds
A client with myocardial ischemia is having frequent PVCs. Which medication will the nurse administer?
Lidocaine (Xylocaine)
The client is experiencing occasional premature atrial contractions (PACs) accompanied by palpitations. These episodes resolve spontaneously without treatment. What instructions will be included in a teaching plan for this client?
Limit or abstain from caffeine
The nurse correlates which pathophysiologic processes with the development of coronary artery disease (CAD)
Macrophages and T cells form a connective tissue matrix in the vessel intima where lipids accumulate
The client with ischemic heart disease has an ECG tracing that shows first-degree heart block. What is the nurse's best action?
Measure blood pressure
Which client is most at risk of developing left-sided heart failure?
Middle-aged woman with aortic stenosis.
Which finding in the client receiving an infusion of vasopressin to treat bleeding esophageal varices indicates to the nrse a serious adverse effect of the drug?
Midsternal chest pain
Which finding in the client receiving an infusion of vasopressin to treat bleeding esophageal varices indicates to the nurse a serious adverse effect of the drug?
Midsternal chest pain
Which assessment finding does the nurse expect in the client with mitral valve prolapse?
Midsystolic click and late systolic murmur
Which is priority-nursing intervention for client during the first 24hrs after a skin graft procedure?
Monitoring graft site to assess 'take' of the newly grafted skin
Which assessment finding does the nurse expect in a client diagnosed with aortic stenosis?
Narrowed pulse pressure
Which characteristic puts a client at risk for gastroesophageal reflux disease?
Nasogastric tube
After receiving a total of three nitroglycerin sublingual tablets, a client admitted to the hospital with complaints of chest pain states there is no change in the level of discomfort. What will the nurse do next?
Notify the health care provider
The nurse assesses the client with a new tracheotomy, and the tracheostomy tube is pulsating in synchrony with the client's heartbeat. Which is the nurse's priority action.
Notify the physician immediately
The nurse notes frank red blood in the drainage container from the NG tube of a client who is 2 days postesophagogastrostomy. Which is the nurse's priority action
Notifying the physician that the suture line is bleeding
Atherosclerosis factors that are responsible for the condition
Nurse's best response, "a combination of platelet and fats accumulate, narrowing the artery and reducing blood flow."
On auscultation of the carotid arteries of a client with atherosclerosis, the nurse hears a swishing sound over the right carotid.
Nurses best action is to notify the health care provider
The client with hyperlipidemia, who is being treated with dietary fat restrictions and an exercise program, asks the nurse why his serum lipid levels are still elevated
Nurses best response, " you may have a genetic predisposition to hyperlipidemia
A client with severe GERD is still having symptoms of reflux despite taking omeprazole (Prilosec) 20mg daily. What will the nurse do next?
Obtain an order for omeprazole twice daily
The nurse is caring for a client with suspected upper GI bleeding. The nurse inserts an NG tube for gastric lavage and checks placement of the tube in the stomach. When aspirating fluid from the tube, the pH is found to be 6. Which is the priority action of the nurse
Obtaining an order for a STAT chest x-ray
The nurse is preparing to administer tube feedings through a client's new Salem sump nasogastric tube. The nurse is unable to withdraw any fluid from the tube before starting the feeding. Which is the priority action of the nurse?
Obtaining an order for a chest x-ray to confirm tube placement before starting the tube feeding
The nurse is preparing to administer tube feeding through a clients new salem sump nasogastric tube. The nurse is unable to withdraw any fluid from the tube before starting the feeding which is the priority action of the nurse?
Obtaining an order for a chest x-ray to conform tube placement
Client with persistent hand rash. What information is most important regarding his history?
Occupation/hobbies
The nurse is caring for a client who has food poisoning that may be the result of Clostridium botulinum infection. Which is the priority nursing assessment for this client?
Oxygen saturation and respiratory rate
Which laboratory value warrants immediate intervention?
PaCO2 of 48mm Hg
The nurse is preparing to perform an abdominal assessment on a client with suspected cholecystitis. In what sequence will the nurse palpate the client's abdomen
Palpate the upper quadrants last
The nurse conducts a physical assessment for a client with anorexia and severe abdominal pain. The nurse notes that the abdomen is rigid and the client's temperature is 101.1° F (38.4° C). Which condition does the nurse suspect based on this information?
Perforated gastric ulcer with peritonitis
While suctioning the client who had a tracheostomy placed 4 days ago, the nurse notes particles of food in the tracheal secretions. What is the nurses' priority action?
Performs a more thorough assessment
The client is taking enalapril (Vasotec), an angiotensin- converting enzyme (ACE) inhibitor, for hypertension. Which assessment finding with this requires immediate intervention?
Persistent dry cough
The nurse is prioritizing care to prevent pressure sores for a client who is immobilized. Which interventions are appropriate?
Place a small pillow between bony surfaces/ Using a lift/draw sheet to assist with repositioning/ Keeping the heels off the bed surfaces
The client with heart failure is experiencing respiratory difficulty. Which is the nurse's priority action?
Place the client in a high Fowler's position
The client with end-stage cirrhosis presents with gastrointestinal (GI) bleeding, combativeness, and confusion. The nurse recognizes these as complications of which disorder?
Portal-systemic encephalopathy
What is the priority nursing diagnosis for a client admitted with acute myocardial infarction?
Potential for decreased cardiac output
The nurse is caring for a client with a gastric ulcer who suddenly develops sharp mid-epigastric pain. The nurse notes that the client's abdomen is hard and very tender to light palpation. Which is the priority action
Preparing the client for emergency surgery
The nurse is caring for a client who has been brought to the emergency room with upper GI bleeding. The client is unconscious and requires lavage to stop bleeding. Which is the nurse's priority action
Preparing to intubate the client with an endotracheal tube
The nurse is caring for a client who has had a total colectomy with an ileoanal reservoir. Which is the priority nursing intervention for this client?
Providing careful perineal care after each stool
The client is becoming frustrated because of his inability to communicate while he has a tracheostomy. Which intervention by the nurse will most effectively enhance his ability to communicate?
Providing the client with a communication board and keep the call bell within reach
The nurse is caring for a client with a new tracheostomy. Which assessment finding requires the nurse's immediate action?
Recannulation of the airway after the client accidentally coughs out the tube
The client with heart failure has been ordered to receive a daily nitroglycerin transdermal patch. Which is the priority nursing intervention?
Removing the patch overnight
Indicate which assessment findings are considered abnormal for an adult client.
Respiratory rate of 34 breaths/min----Diaphragmatic excursion of 1 cm----Suprasternal retractions present during inhalation----Bronchial breath sounds heard over lateral area of left lung
Which illness in the client's history would alert the nurse to the possibility of an abnormality of the heart valves?
Rheumatic fever
Which is the priority nursing diagnosis for the client going home with a surgical wound on the coccyx that is to heal by second intention?
Risk for infection
Nursing diagnosis has the highest priority when planning care for an older client who has very thin skin on backs of hands/arms
Risk for injury
What changes in the ECG tracing would the nurse monitor for in the client with a myocardial infarction
ST segment elevation, T wave inversion, abnormal Q wave
The client presents with a heart rate of 40 beats/min. The nurse expects that an electrophysiological study may determine an alteration in which structure?
Sinoatrial (SA) node
Breakfast food recommendations most appropriate for a low cholesterol diet
Skim milk, cereal, banana, decaf coffee/No eggs
The nurse assesses for which modifiable risk factor in the client with coronary artery disease
Smoking
The nurses assesses for modifiable risk factors in the client with coronary artery disease. Which intervention is the priority to assist the client in decreasing the risk for CAD?
Smoking
Which alteration, when manifested in a client with atrial fibrillation, should alert the nurse to the possibility of an embolic stroke?
Speech alterations
The nurse is taking the history of a client with suspected CAD who has had episodes of chest discomfort while mowing the lawn. Because the chest discomfort subsides when the client rests, the nurse correlates this with which condition
Stable angina
The nurse is preparing to begin teaching the client about how to care for his new ileostomy. Which consideration is the highest priority for the nurse when planning teaching for this client?
Starting the teaching when the client is ready to look at the stoma
The nurse is preparing to begin teaching the client how to care for his new ileostomy. Which consideration is the highest priority for the nurse when planning teaching for this client?
Starting the teaching when the client is ready to look at the stoma
A client is admitted with early-stage heart failure. Which immediate compensatory response would the nurse expect to see in this client?
Stimulation of adrenergic receptors, causing an increase in heart rate
Which nursing intervention is the priority in the client being treated for bleeding esophageal varices with an esophagogastric tube?
Suctioning the oral cavity of secretions
A client with heart failure is going through rehabilitation to increase his or her activity tolerance. The nurse will stop the client's activity if which symptom is assessed?
Systolic blood pressure change from 136 to 96 mm Hg
An older adult client with heart failure has developed atrial fibrillation
T4 (thyroxine) and TSH (thyroid-stimulating hormone)
In reviewing client charts, which finding by the nurse correlates with an increased risk for developing hepatorenal syndrome secondary to cirrhosis?
Taking acetaminophen (Tylenol) for pain
The nurse is caring for a client who had a T-tube placed 3 days ago. Which assessment finding indicates to the nurse that the procedure was successful?
The client had a soft, brown, formed stool this morning
The nurse is caring for a client with cholecystitis. Which assessment finding indicates to the nurse that the condition is chronic rather than acute?
The client has clay-colored stools & dark amber urine
The nurse is caring for a client with cholecystitis. Which assessment finding indicates to the nurse that the condition is chronic rather than acute?
The client has clay-colored stools and dark amber urine
What clinical manifestation alerts the nurse to the possibility that the client's mitral stenosis has progressed?
The client has dyspnea on exertion
What is the nurse's interpretation of a large wide Q wave on the ECG of the client undergoing preadmission testing for surgery?
The client has had a myocardial infarction in the past
The nurse is caring for a client with cholecystitis. The client is a poor historian and is unable to tell the nurse when the symptoms started. Which assessment finding indicates to the nurse that the condition is chronic rather than acute?
The client has light colored stools and dark amber urine
The nurse is caring for a client with cholecystitis. The client is a poor historian and is unable to tell the nurse when the symptoms started. Which assessment finding indicates to the nurse that the condition is chronic rather than acute?
The client has light-colored stools & dark amber urine
Eight hours after presenting to the emergency department with complaints of substernal chest pain, a client's lab results demonstrate that myoglobin levels have not risen. Nurse's interpretation
The client has not experiences a myocardial infarction
The nurse has completed teaching about dietary recommendations for a client with diverticulitis. Which notation will the nurse include in the client's chart about the client's response to the teaching?
The client identified and verbalized understanding of five dietary recommendations for diverticulitis
The nurse has completed teaching about dietary recommendations for a client with diverticulitis. Which notation will the nurse include in the client's chart about the client's response to the teaching?
The client identified and verbalized understanding of five dietary recommendations for diverticulitis.
The nurse is caring for a client who is at risk for developing gastritis. Which finding from the client's history leads the nurse to this conclusion?
The client takes naproxen sodium (Naprosyn) 500mg daily for arthritis pain
The nurse is caring for a client who is hospitalized with an exacerbation of Crohn's disease. What does the nurse expect to find during the physical assessment?
The client's bowel sounds are hyperactive in all quadrants
A nurse is monitoring a client undergoing exercise electrocardiography (stress test). Which assessment finding necessitates that the test be stopped?
The client's electrocardiogram (ECG) indicates significant ST segment depression
The nurse is caring for a client with Crohn's disease & colonic strictures. Which assessment finding indicates to the nurse that a dangerous complication has developed?
The client's temperature is 100.0F (37.8 C)
The client with obstructive jaundice asks the nurse why his his skin so itchy. Which is the nurse's best response?
The itching is caused by the accumulation of bile salts in the skin
The client w/ obstructive jaundice asks the nurse why his skin is so itchy. Which is the nurse's best response?
The itching is caused by the accumulation of bile salts in the skin"
The nurse is caring for an older adult client with a pulmonary infection. Which nursing action is a priority with this client?
The nurse assesses the clients level of consciousness
The nurse assesses the client receiving oxygen via a partial rebreather mask. The nurse will intervene for which assessment finding?
The oxygen flow rate is 2 L/min
In assessing a client's wound, which finding assists the nurse in determining that the wound is infected?
The wound is inflamed/ The wound has an odor/ There is heavy exudate
Which action is highest priority for the nurse to teach the client with a tracheostomy to decrease the risk for aspiration?
Thicken all liquids
When initiating treatment for GERD with metoclopramide (Reglan), what is essential for the nurse to teach the client?
This med will make you feel tired
Reviewing a clients lab results, the nurse correlates in which values as risk factors for atherosclerosis
Total cholesterol/Triglycerides/Low density cholesterol/Homocysteine
The nurse evaluates the results of which lab test as diagnostic for acute coronary syndrome in the client with unstable angina
Troponin T
Which laboratory value is indicative of a myocardial infarction?
Troponin T = 0.8 ng/mL
The client with a history of stable angina describes a recent increase in the number of attacks and the intensity of the pain. The nurse correlates this with which condition
Unstable angina
An older client was prescribed an antihistamine. Which medical problem may be aggravated by this medication?
Urinary retention
Which nursing intervention will best assist a client who is bedridden to keep skin intact?
Use lift/ draw sheet to move client
The nurse is caring for a client who has a new small-bore nasoduodenal tube for feedings. Which intervention will most effectively prevent clogging of the tube?
Using a 60-mL syringe to irrigate the tube with warm water before & after administration of medications
The nurse is caring for a client who has a new small bore nasoduodenal tube for feedings. Which intervention will most effectively prevent clogging of the tube?
Using a 60mL syringe to irrigate the tube with warm water before and after administration of medications
Which nursing intervention is best for the nurse to use to enhance healing of a 1 week old partial thickness wound?
Using papain- urea (Accuzyme) cream as ordered
The client is 24 hours postoperative after a tracheostomy has been performed. The nurse finds the client cyanotic, with the tracheostomy tube lying on his chest. What is the nurse's first action?
Ventilates with resuscitation bag with mask
When measuring the client's pulse oximetry, the nurse finds that the client has a reading of 85% down from 92% 1 hour ago. What will the nurse do first?
Verify assessment and apply nasal cannula oxygen
The client is scheduled to undergo a thoracentesis. What will be the nurse priority intervention?
Verify the informed consent has been by the client
Which instruction is best for the nurse to teach the client who has furuncle in his axilla?
Wash with antibacterial soap and apply warm compress and antibiotic cream
Client has bruising on the arms. What's important question to ask
What medications are you taking
The nurse monitors for which complication in a client taking a nonselective beta-blocking agent
Wheezing
How often will the nurse change a transparent film dressing for protection of a small, clean, lightly draining wound?
When seal breaks and exudate leaks
The nurse is caring for an adult client with possible cholecystitis. Which laboratory findings lead the nurse to believe that this diagnosis is correct?
White blood cell count, 13000/mm...Alanine...aminotransferase (ALT), 66 IU/L.....Alkaline phosphatase (ALP), 106 U/L
The nurse is caring for a client who recently underwent total colectomy and placement of a continent ileostomy. Which instruction will the nurse include in the teaching plan for the client?
You can add a few drops of deodorant solution inside the pouch to minimize odor.
The nurse is to insert a nasogastric tube for a client with upper GI bleeding. Which instructions will the nurse give to the client before starting the procedure?
You may take some sips of water when I begin to insert the tube into your nose
Client with rash beneath her breast expresses she may have breast cancer. Nurse's best response
You need to keep that area dry
The nurse reviews a health teaching for a client with Crohn's disease. Which instructions will the nurse provide for the client?
You should have a colonoscopy every few years
The nurse has completed the teaching session for a client with a new colostomy. Which feedback statement by the nurse is the most appropriate?
You were able to clean the stoma well today. Now you need to practice putting on the appliance.
The nurse incorporates which information into the teaching plan for the client with severe esophageal varices who is scheduled for transjugular intrahepatic portal systemic shunt (TIPS) insertion?
You will receive sedation, but the procedure may still be painful
