PN Comprehensive

nurse reinforcing teaching with client who has spinal cord injury & will need to perform intermittent urinary self catheterization at home after discharge. Which of following statements indicates that client understands procedure?

I will perform intermittent self catheterization every 2 to 3 hrs The client may initially require self-catheterization every 2 to 3 hr with the frequency eventually increasing to every 4 to 6 hr. A longer interval can result in bladder distention and increased risk for urinary tract infection.

nurse is assisting with planning recreational activities for young adult client who has an acute exacerbation of schizophrenia. Which of following activities should nurse recommend for client?

Walking with staff member The nurse should plan to encourage the client to participate in nonthreatening, noncompetitive physical activities. Walking with the staff also provides an opportunity for verbal interaction between the client and the staff.

Ours in an acute mental health facility caring for client who has schizophrenia. Client asks nurse can I vote in upcoming presidential election? Which of following responses should nurse make?

We can work together to find out how you can get a mail in ballot The nurse provides a therapeutic response by suggesting collaboration and formulating a plan of action that will result in giving the client information and addressing the client's need.

client at routine prenatal care visit asks nurse if it's common to develop vaginal yeast infections during pregnancy. Which of following responses should nurse make?

hormonal changes of pregnancy change acidity of vagina, making yeast infections more common This is an information-seeking question; therefore, the therapeutic response is an answer that provides the client with the information she is requesting.

nurse is assisting to plan teaching about secondary prevention actions for colorectal cancer for health fair for adults in community. Which of following topics should nurse recommend to include

importance of colonoscopy screening starting at age 50 yrs old Screening examinations for colorectal cancer are secondary prevention.

Results of enzyme linked immunosorbent assay testing for an 18 month old infant who has pneumocystis carinii pneumonia indicate that she is HIV-positive. When assisting with planning care, nurse should consider which of following factors?

infants mother is likely HIV positive Transmission of HIV from a woman to her infant can occur during pregnancy, delivery, or through breastfeeding. Though it is possible for the infant to acquire HIV from sexual abuse, mother-to-child transmission accounts for the majority of HIV/AIDS cases in infants.

nurse caring for toddler. Which of following objects should nurse select from playroom for this child during hospitalization?

10 piece wooden puzzle Age-appropriate toys for a toddler include puzzles, large crayons, blocks, picture books, push-pull toys, finger paints, modeling clay, and musical toys. These toys allow for manipulation and exploration and meet the child's developmental and diversional activity needs.

community health nurse contributing to plan of care for for high-risk newborns who were discharged yesterday. Which following newborns should nurse recommend to care for first?

A 4 day old newborn who has elevated Bilirubin level & requires photo therapy The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to the client's safety, the risk posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. An elevated bilirubin level can lead to kernicterus; therefore, it is imperative for the nurse to initiate phototherapy immediately to help prevent this dangerous outcome.

A nurse on the pediatric unit receives the laboratory results for several clients. Which of the following results should the nurse report to the provider?

A Client in DKA and a blood glucose of 375 The initial goal of therapy for DKA is a blood glucose level below 240 mg/dL. To accomplish this, the client should receive regular insulin via continuous IV infusion, and the nurse should monitor the blood glucose level hourly. The nurse should report the client's result so that the provider can adjust the insulin dosage.

A nurse in an urgent care center is collecting data from a group of clients who all have in odor Of alcohol on their breath and multiple injuries to the head and extremities. Which of the following clients should the nurse report first to the charge nurse?

A client who is difficult to arouse and is unable to respond to questions The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the risk posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore; the nurse should identify the client who is difficult to arouse and is unable to respond to questions as the priority to report to the charge nurse. These findings might indicate a decreased level of consciousness due to an alcohol intoxication level of 401-800 mg percent or traumatic brain injury. The greatest risk to this client is neurological sequelae of the head trauma or death due to severe alcohol intoxication.

nurse in a long-term care facility is caring for group of clients. One of clients as walking in hallway & bumping into walls & does not respond to his name. Which of following actions should nurse take first?

A company to his room The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the nurse should first escort the client back to his room to protect the client from injury due to wandering.

A nurse is caring for a child who has epistaxis. Which of the following actions should the nurse take?

Apply continuous pressure to the lower part of the child's nose With the child sitting up and breathing through his mouth, the nurse should apply continuous pressure with her thumb and forefinger to the soft lower area of the nose for 10 min. Most bleeding from the nose stops within that period.

A nurse is caring for a client who has a platelet count Of 50,000. After discontinuing the clients peripheral IV site, which of the following actions should the nurse take?

Apply pressure to the catheter removal site for 10 minutes A platelet count below 100,000/mm3 indicates thrombocytopenia, a problem that puts the client at increased risk for bleeding. By applying pressure to the site for 10 min, the nurse promotes coagulation and prevents additional blood loss.

nurse in an acute care clinic is talking with client reports that her osteoarthritis pain in her knees increasing each day. Client wants to discuss nonpharmacological approaches that will relieve her pain. Which of following interventions should nurse suggest?

Apply warm compresses to sore joints Warm packs or warm soaks, such as in a bath or hot tub, are often effective for relieving arthritic pain. The nurse should encourage the client to avoid temperatures hot enough to cause burns. She should plan for a temperature just a little warmer than body temperature for optimal comfort.

nurse On pediatric unit is assisting with plan care for preschooler who will have surgical procedure in morning. Child has been crying despite his parents presence at his bedside. Nurse should recommend engaging child in therapeutic play for care plan because it offers which following benefits?

Allows child to manipulate toy medical equipment A major function of play therapy is making potentially unmanageable situations manageable through symbolic representation, which provides children with opportunities to learn to cope. A preschooler does not have the language development to express his fear of the unfamiliar medical equipment in the hospital. The nurse encourages the child to touch the equipment to decrease the child's fear and intimidation in a safe environment using age-appropriate vocabulary. The use of toys enables children to transfer anxieties, fears, fantasies, and guilt to objects rather than people.

nurse delegates newly Licensed nurse to provide one on one observation for a client who requires suicide precautions. Which of following actions by newly licensed nurse indicates need for further reinforcement of teaching?

Ambulates client's roommate while client sleeps One-on-one observation requires constant supervision of the client. The client might wake up and engage in self-injurious behavior while the newly licensed nurse is caring for the other client.

nurse in an urgent care center reviewing laboratory results for several clients who have benefit stations of influenza. Which of following clients should nurse report to provider in mediately?

An infant who is wbc count is 24,000 The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. This WBC count is high and indicates infection and possibly sepsis, which poses the greatest risk to the client. The provider must initiate blood, urine, and spinal fluid cultures and begin antimicrobial therapy.

A nurse is caring for a client who has regular occupational exposure to sunlight and comes to the clinic for evaluation of several skin lesions. Which of the following findings should alert the nurse to the possibility of malignant melanoma?

And irregularly shaped brown lesion with light blue areas on the neck Malignant melanoma, the leading cause of death from skin cancer, is a neoplasm of dermal or epidermal cells. Exposure to sunlight increases the risk, with fair-skinned people at the greatest risk. Malignant melanoma commonly starts in exposed skin areas like the back, scalp, face, and neck, and metastasizes readily to other areas. Manifestations include a change in the color, size, or shape of a skin lesion, with irregular borders in hues of tan, black, or blue.

nurse facilitating a group discussion with preschool teachers about child abuse. Which of following data should nurse use as common example of suggestive finding?

Arm cast for spiral fracture of forearm Spiral fractures occur from twisting of an extremity. In most instances, spiral fractures of the arm result from an abusive injury.

A nurse is assisting with developing a plan of care for a client who has GERD. The nurses should suggest monitoring the client for which of the following complications?

Aspiration Aspiration is a common complication of GERD, which results when the esophageal sphincter malfunctions, allowing gastric acid and undigested food to back up into the esophagus. This places the client at risk for aspiration. GERD causes effortless, uncontrolled regurgitation, whether the client is in an upright position or reclining. The most common results of regurgitation are heartburn and indigestion; however, aspiration is also possible. Therefore, the nurse should monitor the client for crackles in the lung fields, which is an indication of aspiration.

A nurse is observing a client who has schizophrenia and is in the day room when another client asks him if two items of clothing match. He replies a match. I like matches. They are the givers of light, the light of the world. God will light the world. Let your light shine on. The nurse should identify these statements as which of the following speech alterations?

Associative looseness The nurse should identify that this client is demonstrating associative looseness, a pattern of disordered speech that reflects haphazard and illogical thoughts that lead from one to another.

nurse is assisting with admission of client who has a urinary tract infection & history of Myelomeningocele. After admission history is complete, which of following actions should nurse recommend?

Attach a latex allergy alert identification band Myelomeningocele, a serious complication of spina bifida, is a neural tube defect in which the spinal cord and meninges are in a cerebrospinal fluid-filled sac at birth. Clients who have neural tube defects are at risk for latex allergy; therefore, the nurse should avoid the use of common medical products containing latex, such as latex gloves, for this client.

nurse caring for client who spent past several minutes mumbling about being doomed to die & now pacing in an increasingly agitated & angry manner. Which of following actions nurses priority?

Attempt to reduce environmental stimuli The nurse should apply the least restrictive priority-setting framework. This framework assigns priority to nursing interventions that are least restrictive to the client, as long as those interventions do not jeopardize the client's safety. Least restrictive interventions promote the client's safety without using restraints. The nurse should only use physical or chemical restraints when the safety of the client, staff, or others is at risk. Therefore the nurse should first attempt to calm the client by decreasing environmental stimuli. The nurse should walk with the client to a quiet area that places distance between him and other clients and from objects he could use to hurt himself or others. The nurse should ensure that the area is visible to other staff members in case more restrictive measures become necessary.

A nurse is caring for a client who has a deep partial and full thickness burns and requires a topical anti-microbial drug. The nurse should reinforce with the client that the goal of this medication therapy is to reduce which of the following outcomes?

Bacterial growth Topical antimicrobial medications (particularly broad-spectrum antimicrobials) help prevent bacteria from entering the body when a client has an impairment of the protective covering of the skin, as with burns. It creates a protective barrier, along with the dressing, between bacteria and the exposed body tissues. This therapy helps prevent infection.

A nurse is reinforcing discharge teaching with a client who had a TIA. The nurse should instruct the client to monitor which of the following parameters at home?

Blood pressure A temporary disturbance of the blood supply to the brain causes TIAs, which are brief alterations in neurologic function. The most common causes are atherosclerotic plaque in the carotid arteries and hypertension; therefore, the client should track his BP regularly to promote hypertension management and reduce the risk of cerebrovascular accident.

A nurse in a prenatal clinic is collecting data from several clients. which of the following client reports should the nurse identify as an expected physiologic adaptation to pregnancy?

Breast tenderness Breast tenderness is common during the first and third trimesters of pregnancy. The nurse should explain to the client that this is expected and that she should wear a well-fitting, supportive bra to help alleviate the tenderness.

nurse on mental health unit is caring for client who has depression. Which of following actions should nurse take to foster therapeutic environment for this client?

Build trust with client by sitting quietly with him. The nurse should build trust with the client to convey interest in the client's concerns. Offering self by sitting with the client and the use of silence are actions that promote trust which encourages the client to speak more openly about issues and concerns.

nurse beginning her shift & reviewing medication administration records for her clients. She notes dosage of medication above safe range & sees that nurse administered that dosage during previous shift. Which of following actions should nurse take?

Call provider to clarify dosage After collecting data from the client to check for adverse effects of the medication, the nurse should notify the provider of her observations to determine the next action.

A nurse is collecting data from a toddler who has aids. The nurse should identify which of the following findings as an indication infection?

Candidiasis Candidiasis, or oral thrush, results from the overgrowth of Candida albicans, an opportunistic fungus that commonly infects the oral cavity of clients who have immature or compromised immune systems. Candidiasis appears as a cheesy, white plaque that looks like milk curds on the buccal mucosa and tongue. Thrush is often the initial opportunistic infection in an HIV-positive child who is developing AIDS.

A nurse response to a call from an assistive personnel that a client has had a seizure and is unconscious. Which of the following data should the nurse collect first?

Check airway patency The nurse should apply the ABC priority-setting framework. This framework emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is, therefore, the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority-setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority-setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. The priority data the nurse should collect is to check the client's airway patency. The nurse should establish and maintain the client's airway to prevent respiratory arrest and hypoxia.

nurse reinforcing teaching with client who has hypothyroidism & taking levothyroxine. Nurse should instruct client to report which of following manifestations to provider?

Chest pain Chest pain can result if a client takes too much levothyroxine. It is important to increase the dosage gradually to prevent rapid changes in cardiac output that can cause tachycardia and angina, especially for clients who have longstanding hypothyroidism or cardiovascular disorders.

nurse reinforcing teaching with an assistive personnel about dietary restrictions for client who is taking phenelzine to treat depression. APs selection of which of following foods for clients lunch indicates an understanding of instructions?

Chicken salad Phenelzine is an MAOI. Clients taking MAOIs must avoid foods that contain tyramine due to a dangerous food-drug interaction. Foods high in tyramine include those that are processed and aged, such as luncheon meats and cheeses. This menu selection does not contain food high in tyramine; therefore, it is the best choice.

nurse caring for client during Her first prenatal visit & notes that she is lactose intolerant. Which of following foods should nurse include on list of calcium sources for this client?

Collard greens Collard greens are a good source of lactose-free calcium. One cup of collard greens provides approximately the same amount of calcium as the equivalent volume of 240 mL (8 oz) of milk. They also contain folic acid, which is a nutrient women should consume during pregnancy to prevent birth defects.

The healthcare facilities leadership team is implementing a new computerized charting system. Before the implementation date, which of the following actions should the charge nurse take first?

Collect the staff input about planning and implementing the change The charge nurses should apply the nursing process priority-setting framework. The nurses can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, he must first collect adequate data. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. Therefore, the charge nurses should collect data about the situation by gathering the staff's input, and collaborate about implementing the change smoothly and efficiently.

nurse preparing to administer medications to client who is unconscious. Nurse should bring medication administration record to clients bedside & perform which of following verification procedures?

Compare medical record number & name on medication administration record with clients identification band The Joint Commission requires the use of two client identifiers when administering medications. The nurse should compare the medical record number and name on the MAR with the client's identification band.

A nurse is caring for a client who has a new diagnosis of acute systemic lupus erythematosus And is to begin medication therapy. Which of the following types of medications should the nurse expect to administer?

Corticosteroids Corticosteroids, such as prednisone, are the treatment of choice for acute systemic manifestations of SLE because of their rapid anti-inflammatory action.

nurse reviewing medical record of client who has requesting prescription for sildenafil citrate. Which of following data in clients record should nurse identify contradiction for use of this medication?

Current use of nitro to treat heart failure Taking any nitrates, such as nitroglycerin, is a contraindication for sildenafil, a medication that treats erectile dysfunction. Taking it concurrently with nitrates can cause life-threatening hypotension.

nurse assisting with admission of client to medical unit & ask him if he has advanced directives. Client states I have document with me name of someone who can make healthcare decisions for me I am not able to. Should identify that client referring to which of following documents?

DPA A durable power of attorney for health care document, or health care proxy, names a surrogate who can make health care decisions for the client if he is unable to do so.

nurse collecting data from client who has aids & taking zidovudine. Which of following findings priority for nurse to report to provider?

Decreased hemoglobin The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the priority finding for the nurse to report to the provider is a decreased hemoglobin level. Zidovudine can cause severe anemia and neutropenia from bone marrow suppression resulting in hematologic toxicity.

nurse reinforcing teaching for a client who has coronary artery disease about the difference between angina pectoris & myocardial infarction. Which following manifestations should nurse identify as indications Of myocardial infarction?

Diaphoresis, dizziness, anxiety, impending doom, nausea, & vomiting Nausea and vomiting is correct. Nausea, vomiting, and epigastric distress are common manifestations of MI. Diaphoresis and dizziness is correct. Diaphoresis (sweating), dizziness, fatigue, and anxiety are common manifestations of MI. Anxiety and feelings of doom is correct. Anxiety and feelings of doom and fear are common manifestations of MI.

A nurse is caring for a client who is taking acarbose to treat type two diabetes. Which of the following should the nurse monitor for adverse effects?

Diarrhea The most common adverse effects of acarbose, an alpha-glucosidase inhibitor, are gastrointestinal. They include diarrhea, abdominal distention and cramping, and flatulence.

A nurse is reinforcing teaching with the parents of an infant who has a cleft palette. The parents asked the nurse how long they should wait before he should have corrective surgery. The nurse should explain that the parents should wait no longer than 6 to 12 months to prevent which of the following outcomes?

Difficulty with language acquisition Infants who have a cleft palate can have difficulty acquiring language because they need to use the palate for vocalizing sounds. With the cleft in the palate, these infants could develop poor speech habits.

nurse reinforcing discharge teaching with client who has new prescription for metoprolol. Which of following instructions should nurse include?

Do not stop taking his medication abruptly, count your radial pulse daily, change positions slowly "Do not stop taking this medication abruptly." is correct. Clients who stop taking metoprolol abruptly increase their risk for angina, hypertension, and myocardial infarction. They should reduce the dosage gradually over 1 to 2 weeks. "Count your radial pulse daily." is correct. The client should count his radial pulse daily and report a heart rate slower than 60/min. "Change positions slowly." is correct. Metoprolol can cause orthostatic hypotension. To prevent injury, the client should move slowly from lying down or sitting to standing.

A nurse is collecting data from a preschooler who has recurrent and persistent otitis media. When obtaining the child's history from a parent? The following questions should the nurse ask?

Does anyone smoke around four in the same house as your child? Otitis media is an infection of the middle ear. Passive smoking promotes adherence of respiratory pathogens to the lining of the middle ear space. It also prolongs the inflammation and impedes drainage from the ear.

nurse is caring for a client who has MRSA infection. A dietary assistant asks nurse what precautions are necessary for entering clients room with lunch tray. Which of following instructions should nurse give dietary assistant?

Don gloves when entering room & use hand sanitizer when exiting Clients who have a MRSA infection require contact precautions. In addition to the use of standard precautions and meticulous hand hygiene, contact precautions require that any staff who will have contact with the client's environment don gloves prior to entering the room. Additional precautions, such as a gown, are required for contact with the client, and a mask and goggles if secretions from the infected area could spray into the worker's face. Delivering the tray would require contact with the environment; therefore, the dietary assistant must wear gloves.

nurse contributing to plan of care for client who had stroke & to receive feeding via a gastrostomy tube. Which of following actions should nurse recommend to take prior to initiating each feeding?

Elevate head of bed Clients who have a brain injury are typically unable to swallow effectively and thus cannot protect their airway from aspiration. Even though this route bypasses the nasopharynx, it is still possible for the client to cough or vomit enteral formula into the oral cavity. Consequently, the nurse should take actions to prevent aspiration, such as elevating the head of the bed, prior to initiating the feeding.

nurse collecting data fromclient who is taking varenicline for smoking cessation . Which of following findings is nurses priority?

Erratic Behavior The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. The greatest risk to the client is the development of neuropsychiatric effects that can progress to depression and suicide. Therefore, the highest priority finding is erratic behavior.

A nurse is reviewing the laboratory data of a client who reports manifestations that suggests systemic lupus erthematosus. The nurse should expect an increase in which of the following parameters for a client who has SLE?

Erythrocyte sedimentation rate SLE is a chronic systemic autoimmune disease that causes skin, heart, lung, and kidney inflammation. Like most autoimmune diseases, a series of exacerbations and remissions is typical. Most clients who have an exacerbation of SLE have an increased ESR.

A nurse is discussing the fire safety with newly hired nurses. Which of the following identify as the priority if a fire occurs in the health care facility?

Evacuate clients from the unit The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. The greatest risk during a fire is injury to clients; therefore, the nurse's priority action is to evacuate clients from the unit. The nurse should follow the RACE protocol when responding to a fire - Rescue, Activate, Confine, and Extinguish.

A nurse is caring for an older adult client who has an in the canal hearing aid. The client states that the hearing aid is making a whistling sound. The nurse should identify which of the following factors as a source for this sound?

Excessive wax In the ear canal Factors that can make a hearing aid whistle are a poor seal with the ear mold, an ear infection, excessive wax in the ear canal, improper fit, or a malfunction.

A new resident provider asks the nurse for an access code to review a clients online record. The resident is not scheduled to attend the Facility's orientation computer class until next week. Which of the following actions should the nurse take?

Explained that it is against policy to share access codes and refer the resident to his supervisor Staff should never share access codes and passwords nor allow people who do not have their own access code to use the system. Doing so is a breach of federal guidelines for data security and client confidentiality.

nurse talking with a group of clients at a senior center about risk factors for osteoporosis. Which of following statements should the nurse include?

Extended periods of immobility increase your risk for osteoporosis Osteoporosis is a disorder of weakened bones due to a loss of bone mass and a change in bone structure. Immobility can result in osteoporosis; therefore, weight-bearing exercise, such as walking, is one way for the client to help prevent osteoporosis.

nurse participating in community health fair is providing information to a client who has a BP of 150/90 during blood pressure screening. Which of following actions should nurse take?

Give client a written record of his blood pressure to bring to his provider When a client has an elevated reading at a hypertension screening, the nurse should encourage him to see his provider for further evaluation within 2 months. To help facilitate this process, the nurse should give him a written record of the BP at the screening to share with his provider.

nurse caring for client who has dehydration. Which of the following laboratory values should nurse expect for this client?

Hematocrit 55% An elevated hematocrit indicates dehydration. Other manifestations of dehydration are a weak pulse, tachycardia, hypotension, slow capillary refill, elevated BUN, increased urine specific gravity, and decreased urine output.

A nurse is reinforcing teaching with a client about how to use an albuterol MDI. After removing the cap from the inhaler and shaking the canister, the nurse should instruct the client to take the following steps in which order?

Hold the mouthpiece 1 to 2 inches in front of your mouth, tilt your head back slightly and open your mouth wide, depress the canister while taking a slow deep breath, and hold your breath for 10 seconds The client should hold the mouthpiece 2 to 4 cm (1 to 2 in) from his mouth, tilt his head back slightly, and then open his mouth. Next, he should depress the medication canister while taking a deep breath to facilitate delivery of the medication through the airway. After holding his breath for 10 seconds, the client should resume his usual breathing pattern.

A nurse is assisting with the care of a client who has Addison's disease and comes to the emergency department reporting nausea, vomiting, diarrhea, and of abdominal pain. To prevent addisonian crisis, the nurse should expect that the provider will prescribe which of the following medications?

HydroCortisone Addison's disease causes adrenal gland hypofunction and inadequate production of glucocorticoids. Acute adrenal insufficiency is life-threatening, with severe fluid and electrolyte imbalances. Without treatment, sodium levels fall and potassium levels increase. Rapid infusion of IV fluids, such as 0.9% sodium chloride, and IV administration of high dose corticosteroids, such as hydrocortisone, to correct the glucocorticoid deficiency are essential.

nurse reviewing laboratory report for client who has CDK. nurse finds following laboratory test results: potassium 6.8, calcium 7.4, hemoglobin 10.2, & phosphate 4.8. Which of following findings priority for nurse to report to provider?

Hyperkalemia The nurse should apply the urgent versus nonurgent priority-setting framework. Using this framework, the nurse should consider urgent needs the priority need because they pose more of a threat to the client. The nurse may also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which finding is the most urgent. Therefore, hyperkalemia which can cause life-threatening cardiac dysrhythmias is the priority for the nurse to report to the provider.

A nurse in a substance use disorder program is interacting with the client. Which of the following statements indicates that the client is using intellectualization as a way of coping with the anxiety of admission?

I have read that problems with substance can have a variety of predisposing factors The nurse should identify this response as a use of intellectualization. Intellectualization is an attempt to use intellectual processes to avoid expressing the emotions that stem from stressful situations.

nurse in providers office is talking with an older adult client reports having trouble sleeping. Which of following statements should nurse identify as possible causes for patients sleeping difficulties?

I often have a cup of coffee with my dessert before going to bed The client should avoid beverages that contain caffeine in the late afternoon and evening because caffeine stimulates the CNS and can result in sleep disturbances. Caffeine is also a diuretic and can cause nighttime awakenings for urination.

A female client who has we currency Cystitis asked the nurse about preventing future episodes. Which of the following statements should the nurse provide for the reinforcement of teaching?

I prefer tub baths to showering Cystitis is an inflammation of the bladder lining that commonly occurs with a urinary tract infection (UTI). Women who are at risk for UTIs should avoid tub baths because they increase the risk for infection. The nurse should remind the client to take showers instead of tub baths.

A nurse is reinforcing teaching with the parent of a child who has type one diabetes how to manage the child's disorder during illness, such as cold. Which of the following statements by the parent indicates an understanding of the teaching?

I'll check his blood glucose more often The parent should check the child's blood glucose every 3 hr during an illness because it tends to rise, even if the child eats less food.

nurse caring for client who's taking warfarin. Which of following laboratory values should nurse recognize as an effective response to medication?

INR 3.0 Warfarin is an anticoagulant that prevents thrombus formation in susceptible clients. The INR measures its effectiveness. For most clients taking warfarin, an INR of 3.0 indicates effective therapy.

A nurse is reviewing the use of side rails with an assistive personnel. Which of the following statements by the AP indicates that further instruction is required?

If the patient seems confused, I will raise all four side rails so that he doesn't hurt himself Raising all four side rails can put the client at greater risk for injury. He might try to climb over the side rails, which could result in a fall or injury.

During client care staff meeting, charge nurse discusses potential problems with data security that affect confidential client information. Which of following environments should charge nurse identify as an acceptable area for discussing client information?

In unit medication room Nurses should only discuss clients' information in areas where no one else can overhear the discussion. A unit medication room is a nonpublic area where nurses can privately discuss client information that pertains to the client's care.

A nurse is reinforcing teaching with a client who has hyperthyroidism about managing this disorder. Which of the following recommendations should the nurse include?

Increase her caloric intake with meals Clients whose thyroid hormone levels are high have increased protein, lipid, and carbohydrate metabolism, resulting in the loss of protein stores and a negative nitrogen balance. Even with an increased appetite, it is often difficult to meet energy demands, and weight loss is common. Muscle weakness and wasting can develop without adequate caloric and protein intake.

A nurse is assisting with the admission of a client who has manifestations that suggest tuberculosis. Which of the following actions is the nurses priority?

Initiate airborne precautions The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client, and in this case, to other clients and staff. When there are several risks to safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat. Clients who have or might have tuberculosis require airborne isolation precautions immediately because of the highly communicable nature of the infection. Airborne precautions prevent transmission of pathogens that remain infectious in the air, including Mycobacterium tuberculosis, the bacterium that causes tuberculosis.

charge nurse coordinating evacuation of clients from facility following a bomb threat. Which of following actions should nurse take when implementing evacuation process?

Instruct clients who are able to ambulate to leave Clients who are able to ambulate should leave first in an evacuation process because it quickly reduces the number of clients who require evacuation assistance.

A nurse is caring for a client who takes more friend to treat chronic a fib and has early manifestations of Alzheimer's disease. The clients partner asked the nurse if the client would benefit from taking ginkgo biloba. Which of the following responses should the nurse make?

It is likely that ginkgo biloba will interfere with the effectiveness of his other medications Some experts believe that ginkgo biloba can delay the mental deterioration of Alzheimer's disease if the client takes it in the early stages. Research, however, has not demonstrated this, and more importantly, ginkgo biloba increases the client's risk for bleeding when taken with warfarin.

nurse reinforcing teaching with family of child who has autism spectrum disorder. Which of following statements indicates that family understands instructions?

It will help our child if we structure our daily routine Children who have autism spectrum disorder benefit from a structured routine. A structured environment can help minimize the anxiety the child might have with sudden schedule changes and socialization requirements, as well as satisfy his preference for ritualistic behavior.

A nurse at a long-term care facility hears an AP talking with an older adult client who has dementia with periods of confusion. Which of the following statements indicates that the AP requires further instructions?

It's almost time for your appointment. Let me do your hair for you and brush your teeth When a client who has dementia has periods of confusion, the AP should allow the client additional time to complete activities that she is able to perform independently. Insisting on completing the task for her, or attempting to hurry her, can provoke agitation. The AP should encourage independence and provide assistance only if the client asks for or needs it.

A nurse is reinforcing teaching with the school-age child has just had a fiberglass cast application follow a lower extremity fracture. Which of the following instructions should the nurse reinforced with the child and his parents about care during the first 48 hours?

Keep the cast above the level of your heart Immediately following the injury, and for at least the first 48 hr, the child should keep the affected limb above the level of the heart to help prevent edema and pain and to promote venous return.

nurse on antepartum unit caring for client who is at 28 wks of gestation & reports dizziness when lying on her back. Into which of following positions should nurse assist client?

Lateral A lateral, or side-lying position, promotes uteroplacental blood flow and thus helps relieve the symptoms of supine hypotension, including faintness, dizziness, and breathlessness.

provider tells a client who reports practicing Hinduism that at 12 wks gestation she needs more protein in her diet & suggest eating more meat. After provider leaves examination room, client tells nurse that eating animal products will cause her to miscarry. Which of following responses should nurse make?

Let's discuss other foods that are also high in protein that you could substitute for meat Many cultures have beliefs about food that the nurse should respect. Discussing nonanimal protein sources can help the client identify those that do not conflict with her religious and cultural beliefs.

Nurse is collecting data from a 66-year-old client during a routine physical examination at her first clinic visit and she does not have her medical records. When the nurse asks if she has received the pneumococcal immunization, the client replies I am not sure but it's been at least five years since I've had any immunizations. Which of the following responses should the nurse make?

Let's go ahead with giving you this immunization The Centers for Disease Control and Prevention recommends this immunization for people who are 65 years old and older. If the client did receive this immunization more than 5 years ago, the nurse should administer another one because the client is over 65.

nurse caring for client who has terminal illness. Family wants to care for client at home. Which of following statements indicates that nurse understands family centered care?

Let's set up meeting with the doctor to discuss your options for home care With family-centered care, the nurse considers the health of the family as a unit; therefore, the client and family help determine their outcomes and goals. Setting up a meeting to discuss this with the provider will give them a sense of autonomy and foster the family-centered nursing environment.

nurse in rehabilitation facility is observing an AP help client transfer from bed to wheelchair. Which of following actions indicate to nurse that AP understands how to perform this task?

Lock brakes on bed & wheelchair before moving client. Prior to starting the transfer, the AP should make sure that both the wheelchair and the bed are stationary and will not shift when the client moves into the chair.

nurse is collecting data from a client who has tuberculosis & prescription for EthAmbutol. Nurse should inform client that he is likely to develop which of following alterations as an adverse effect of this medication?

Loss of red\green color discrimination Ethambutol is an antitubercular medication that impairs ribonucleic acid synthesis. A common adverse reaction is the loss of red/green color discrimination due to optic neuritis. The nurse should notify the provider of this finding and expect a prescription to discontinue the medication.

A nurse is contributing to the plan of care for a client who is receiving mechanical ventilation. Which of the following recommendations should the nurse make?

Maintain the head of the bed at 30° The nurse should recommend that the client's head of the bed remain elevated at 30 to 45 degrees to decrease the risk for ventilator-acquired pneumonia.

nurse caring for an infant who is experiencing dehydration. Which of following data related to hydration status is nurses priority to collect?

Measure clients weight daily The nurse should apply the urgent versus non-urgent priority-setting framework. Using this framework, the nurse should consider urgent findings the priority because they more readily indicate the degree of threat to the client. The nurse may also need to use nursing knowledge to identify which finding is the most critical. Daily weights are the most sensitive indicator of fluid balance in clients of all ages. Daily weights are especially critical for infants and children because fluid accounts for a greater portion of body weight.

nurse caring for client who has chronic phantom limb pain following & above the knee amputation. Which of following medication prescriptions should nurse verify with provider?

Meperidine Opioids are more effective for residual limb pain rather than phantom limb pain; additionally, meperidine is not recommended for chronic pain because using it long-term can cause accumulation of a toxic metabolite.

nurse going to medical surgical unit caring for client who developed deep, rapid respirations. Arterial blood gas Analysis: pH 7.25, PaCO2 morning 40, HCO3 18. Which of following should nurse identify & report to provider?

Metabolic acidosis A pH of 7.25 indicates acidosis. If the cause is respiratory, the pH and PaCO2 values deviate in opposite directions. Since the PaCO2 is within the expected range, despite the low pH, the cause must be metabolic. Therefore, the nurse correctly reports to the provider that the client has metabolic acidosis.

nurse reinforcing discharge teaching to client who does not speak same language as nurse. Clients neighbor, who speaks to clients native language & nurses, arrives to drive client home. Which of following actions should the nurse take?

Obtain services of an interpreter Federal mandates require that a professional medical interpreter translate the client's health care information into the client's native language.

A nurse is talking with the parent of a four month old infant about growth and development. Which of the following statements indicates that the parent needs further instruction?

My baby loves to play with pillows in her crib Parents should never place pillows in their infant's crib. They pose a suffocation hazard.

nurse assisting with plan of care for client who is post operative following hip arthroplasty. In clients medical record, nurse notes history of COPD. Which of following oxygen delivery method should nurse recommend to use this client?

Nasal cannula A nasal cannula delivers precise concentrations of oxygen; therefore, it is an appropriate device for a client who has COPD and requires a precise percentage of inspired oxygen.

nurse in an urgent care center is collecting data from an infant who has laryngotracheobronchitis. Which of following findings should nurse report to provider as an indication of impending airway obstruction?

Nasal flaring Acute laryngotracheobronchitis, or croup, causes dyspnea and swelling of the upper airway. Indications of impending airway instruction include tachycardia, tachypnea, increasing restlessness, flaring nares, and intercostal retractions.

nurse is preparing to care for a client who is in balanced skeletal traction to stabilize her femur fracture. Which of following actions should nurse recommend for clients plan of care?

Offer client a diet high in fluid and fiber A client who is immobile is at risk for constipation. The nurse should encourage a diet high in fluid and fiber to promote gastrointestinal function.

A nurse is reinforcing teaching with the parent of a client who has severe reactive airway disease about Glucocorticoid therapy. The parent asks why her child has to inhale the medication instead of taking it Orally. Which of the following information should the nurse provide to the parent?

Oral glucocorticoids are more likely to slow linear growth in children Chronic use of oral glucocorticoids in high doses by children can result in decreased linear growth. Inhaled glucocorticoids deliver the anti-inflammatory agent directly to the local target area (the client's airways), resulting in a decreased risk for adrenal suppression.

nurse is assisting with care of client who had precipitous delivery. nurse should identify collection which of following data as a priority during the fourth stage of labor?

Palpating clients fundus The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. A precipitous delivery is one that follows labor of less than 3 hr. Regardless of the cause of the rapid delivery, uterine atony can result, causing postpartum hemorrhage. The nurse should palpate the fundus and massage as needed to monitor for and reduce the risk of hemorrhage.

A nurse is caring for a client who has a pseudomembranous colitis do to CDIff. Which of the following interventions is the nurses priority?

Performing hand hygiene before and after contact with the client The nurse should apply the safety and risk reduction priority-setting framework when caring for this client. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. C. difficile is a spore-forming, gram-positive anaerobic bacillus that produces two virulent exotoxins that attack the lining of the intestine. The toxins destroy cells and produce pseudomembranes, patches (plaques) of inflammatory cells, and decaying cellular debris on the interior surface of the colon. The spores spread easily by contact with body fluids and inanimate objects. The greatest risk to this client, as well as to the nurse and others, is injury from infection transmission; therefore, the priority intervention is hand hygiene.

A nurse is reinforcing teaching with a client who has a new prescription for a Doxycycline. The nurse should reinforce to the client the need to monitor for which of the following adverse effects of this medication?

Photosensitivity An adverse effect of doxycycline, a tetracycline antibiotic, is photosensitivity. The skin reacts abnormally to light, especially ultraviolet radiation or sunlight. Prevention involves avoiding direct exposure to sunlight and ultraviolet light, wearing protective clothing outdoors, and using sunscreen.

nurse at a long-term care facility notes that a client who has dementia is having problems with orientation. Which of following actions should nurse take to improve clients level of orientation?

Post a large calendar on bulletin board Posting a large calendar in a central location will assist this client with orientation.

nurse assigned to care for several clients who are post operative. Nurse should identify client taking which of following medications at risk for delayed wound healing?

Prednisone to treat persistent arthritis exacerbations Prednisone is a corticosteroid that is associated with delayed wound healing. Clients who have arthritis often require high doses of prednisone to help resolve exacerbations.

A nurse is caring for a client who is postoperative following a laparotomy and has an indwelling urinary catheter and a Jackson Pratt drain in place. Which of the following findings should indicate that the client is developing a postoperative complication?

Pulse ox of 85% Clients who have had abdominal surgery should have an oxygen saturation above 95%. A client whose oxygen saturation is 85% has hypoxemia and requires immediate intervention.

A nurse is reinforcing teaching with the Parent of a child who has a new prescription of iamotrigine For a seizure disorder. The nurse should instruct the parents that which of the following adverse effects is the priority to report to the provider?

Rash The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the greatest risk to this client is injury from Stevens-Johnson syndrome or toxic epidermal necrolysis, which are life-threatening reactions that manifest initially as a rash in the first 2 to 8 weeks of treatment with lamotrigine. The nurse should instruct the parents to report a rash immediately to the provider.

A nurse is reviewing the medical history of a client who has presbyopia. With which of the following activities should the nurse expect the client to have difficulty?

Reading the newspaper With presbyopia, the lens is unable to change shape to focus on objects close up. Presbyopia develops with aging, beginning in middle age, and results from the decreased elasticity of the lens.

A nurse is planning to delegate the post operative care of a client following an appendectomy. Which of the following actions should the nurse assigned to an assistive personnel?

Record urinary output after emptying the indwelling urinary catheter Emptying an indwelling urinary catheter and recording I&O is within the scope of practice for an AP. This task is routine and has a predictable outcome; therefore, the nurse may delegate this task to an AP.

nurse reinforcing discharge teaching with client who has had transient ischemic attack. Which of following instructions should nurse include?

Reduce dietary sodium A temporary disturbance of the blood supply to the brain causes TIAs, which are brief alterations in neurologic function. The most common causes are atherosclerotic plaque in the carotid arteries and hypertension; therefore, the client should limit sodium intake to help control hypertension and prevent future TIAs.

A nurse is collecting data from a client who has an abdominal aortic aneurysm. Which of the following findings should indicate to the nurse that the AAA is expanding?

Report of sudden severe back pain An aortic aneurysm is a weak spot in the wall of the aorta that allows the aorta to expand and increase in diameter. Sudden and increasing lower abdominal and back pain indicates that the aneurysm is extending downward and pressing on the lumbar sacral nerve roots.

A newly licensed nurse in an urgent care center is caring for a client who has bruises that the nurse suspects are due to child abuse. Which of the following actions should the nurse take?

Report the suspected abuse to local authorities The nurse should initiate the process of removing the child from the abusive environment by following the facility's protocol for reporting the situation to child protective services or local law enforcement.

A nurse is collecting data from a client who has an acute visual disturbance and describes it as a curtain pulled over his visual field with occasional flashes of light. The nurse should notify the provider that this client might have which of the following disorders?

Retinal detachment The retina is the thin layer of light-sensitive tissue on the back of the wall of the eye. Retinal detachment is a medical emergency in which the retina of the eye peels away from its underlying layer of support tissue. Without immediate treatment, the entire retina can detach, leading to permanent vision loss. Manifestations include a sudden onset of decreased peripheral or central vision, dark floaters, flashes of light, and a shadow or curtain over a part of the visual field.

A nurse is reinforcing teaching about self a ministration of NPH insulin with a client who has type two diabetes. Which of the following instructions should the nurse include?

Rotate injection sites within the same area To prevent lipodystrophy, the client should rotate injection sites, making them about 2.5 cm (1 in) apart, within the same anatomical area.

A charge nurse in a long-term care facility notes that several staff members are linked in completing an annual mandatory educational session about extremity restraint safely. Which of the following actions should the nurse plan take?

Send an email to each nonadherent employee that includes a link to upcoming educational sessions E-mail provides a simple yet efficient way for the charge nurse to inform nonadherent employees about options they have for achieving adherence without embarrassing anyone with a public announcement. In addition, including the appropriate link in the e-mail facilitates adherence by helping each employee identify an upcoming session that coordinates with his work schedule.

charge nurse in skilled nursing facility notes several recent conflicts among staff on different shifts. Which of following strategies should charge nurse plan to use to resolve these conflicts?

Set up series of meetings for all staff members to discuss issues The charge nurse is using the conflict resolution strategy of collaboration by involving the staff to communicate and work together to devise and implement win-win solutions.

A nurse is reinforcing teaching with a client about treatment options for profound sensorineural hearing loss. The client should include which of the following information about the function of cochlear implants?

Transmits impulses directly to the auditory nerve endings Cochlear implants work by directly stimulating nerve endings in the cochlea.

A nurse is reinforcing teaching with the client who is going to have an EEG in the morning. Which of the following information should the nurse provide to the client?

Shampoo your hair before the procedure, and don't put any styling products on it afterward An electroencephalogram (EEG) is a painless test that records the electrical activity of the brain. For the test, the technician attaches electrodes to the scalp to record the tiny electrical charges the nerve cells in the brain release. So that the electrodes will adhere to the scalp, the client's hair has to be clean and free of oil and hair-care products.

nurse reinforcing teaching about body mechanics with assistive personnel. Which of following instructions should nurse include?

Sit with your back supported, keep your knees at hip level, & use an ergonomically designed computer keyboard Using lumbar support in a straight-back chair helps maintain good posture and prevent back pain.

nurse on a mental health unit is caring for client who has antisocial personality disorder & becoming increasingly loud & belligerent. Which of following approaches should nurse use to manage clients behavior?

Speak to client with clear calm caring statements To remain in control of the situation, the nurse should use clear, calm statements that are nonthreatening to the client. The nurse should also set limits for clients who exhibit potentially violent behavior.

nurse collecting data from school age child who has celiac disease. Which of following findings should nurse expect?

Steatorrhea (Oily Stool known as: fatty stool) Foul, fatty, frothy stools, known as steatorrhea, are a manifestation of celiac disease, a malabsorption syndrome.

A nurse is reinforcing teaching with a client about a surgical procedure that she will undergo later in the day. The client states that no one has spoken to her about the procedure before. Which of the following actions should the nurse take?

Stop reinforcing the teaching and check with the surgeon about informed consent The client's statement indicates that she has not given informed consent; therefore, the nurse should stop reinforcing the teaching and notify the surgeon.

A nurse is reinforcing teaching with a client who has a new prescription for sertraline. Client asked nurse if we should continue to take St. John's wort for depression. Which of following instructions should nurse to give client?

Stop taking herbal supplement while taking medication Taking the antidepressant sertraline and the herbal supplement St. John's wort together puts the client at risk for serotonin syndrome.

A nurse is monitoring a client who is receiving a transfusion of packed red blood cells. Which of the following actions should the nurse take first when suspecting a transfusion reaction?

Stop the infusion The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. For this client, it could be a life-threatening event such as circulatory collapse. Therefore, the first action the nurse should take is to stop the infusion to prevent any further administration of blood.

nurse on pediatric mental health unit caring for school age child. Which of following questions or statements should nurse make to foster rapport & engage him in conversation?

Tell me about your favorite video game The nurse uses the therapeutic communication technique of exploring to encourage the child to respond with more than just the name of the game. This type of communication fosters rapport and encourages communication.

A nurse is caring for a client who has borderline personality disorder and is expressing concern about needing prolonged hospitalization. Which of the following statements should the nurse make ?

Tell me what concerns you most about being hospitalized Clients who have borderline personality disorder have a difficult time identifying their feelings. The nurse uses open-ended therapeutic communication with this response which allows the client to focus on concerns about hospitalization and encourages verbalization of feelings.

nurse is collecting data from client who's receiving clozapine to treat schizophrenia. The nurse should identify that an increase in which of following parameters is an early indication of agranulocytosis?

Temperature Antipsychotic medications, such as clozapine, can cause agranulocytosis, which is the depletion of WBCs. This increases the client's risk for infection. Fever is an early indication that the client should have a WBC count checked to detect agranulocytosis.

A nurse is evaluating the injection site for a client who had a Mantoux skin test 48 hours ago. The nurse finds 10 mm of induration with slight redness. Which of the following conclusions should the nurse make?

The client has had an exposure to tuberculosis A Mantoux test is a skin test that determines exposure to tuberculosis. The nurse should look at the test site and palpate the area to determine if the injection site is raised and feels hard to the touch (induration) and record the results in millimeters to represent the size of the raised bump. Redness alone does not determine a positive result.

nurse assisting to prepare for the transfer of client from post anesthesia care unit following a sub total thyroidectomy. Which of following equipment should nurse have available at patient's bedside?

Tracheostomy tray With the laryngeal edema that is common post thyroidectomy, respiratory distress could result in airway obstruction. Emergency intubation can be difficult due to laryngeal swelling, and endotracheal intubation can increase the risk for hemorrhage by increasing tension on the incision during insertion. The nurse should have a tracheostomy tray available for this client.

nurse caring for an adolescent client who gave birth to stillborn preterm fetus. Client is crying & says to nurse why did this happen to me? Which of following responses should nurse make?

This must be so difficult for you This therapeutic response shows empathy and encourages the client to continue to express her feelings.

nurse reinforcing teaching with parent of toddler whos undergoing insertion of tympanostomy tubes. Which of following statements should nurse include?

Tubes should stay in place until they fall out on their own Tympanostomy tubes allow for drainage from and ventilation to the middle ear. They usually fall out on their own 6 to 12 months after insertion.

A nurse is talking with a parent of a preschooler. The parent reports that her child grows upset at night and does not go to bed at a consistent time. Which of the following instructions should the nurse give the parent?

Use a stable relaxing routine such as a bath and bedtime story before bed Routines are reassuring to preschoolers because they allow them to anticipate their environment and adapt appropriately. These actions help the child settle down prior to bedtime. They also provide for parental-child interaction prior to bed.

nurse is preparing to administer 10 units of insulin glargine & 4 units of NPH insulin subcutaneously to a client. Which of following actions should nurse take?

Use separate syringes for administering insulin glargine & NPH insulin The nurse should not mix insulin glargine with any other insulin. The nurse should administer the NPH insulin and insulin glargine separately.

nurse at family planning clinic preparing to give presentation to clients about to use diaphragm. Which of the following information should nurse plan to include in session?

Use spermicidal jelly whenever you use your diaphragm A diaphragm is a barrier device that helps prevent pregnancy. Use of a diaphragm alone is not 100% effective in preventing pregnancy, but the use of spermicidal jelly with it increases the effectiveness of the device.

A nurse is reinforcing teaching with a client who has type two diabetes. The client states I eat pasta every day. I can't imagine giving it up. Which of the following responses should the nurse make?

You don't have to give up pasta; just adjust the amount you eat The American Diabetes Association recommends individualizing carbohydrate restriction for each client. A careful evaluation of the client's usual dietary practices and modifications is an important part of helping clients manage this disorder.

nurse reinforcing teaching with client who is scheduled for LASIK surgery which of following information should nurse include?

Your procedure will only take 10 to 15 minutes per eye LASIK is a type of refractive laser eye surgery performed to correct myopia, hyperopia, and astigmatism, which are common causes of nearsightedness. The procedure typically takes 10 to 15 min per eye.

nurse is reinforcing teaching with client who has come to family planning clinic requesting an IUD. Which of following information should nurse reinforced with client?

Your risk for ectopic pregnancy increases with an IUD MY ANSWER An IUD is a family planning device the provider inserts through the cervix into the uterus to prevent pregnancy. The IUD works by changing the lining of the uterus and fallopian tubes, making fertilization in the uterus more difficult. Consequently, an IUD increases the risk for ectopic pregnancy.

hospice nurse visiting with family member of a client. family member states that client has insomnia almost nightly. Which of following practices should nurse identify as contributing to clients insomnia?

client watches television in her bed during day To promote sleep, the client should avoid watching television in bed. She should be in bed only for sleep or sexual activities.