randoms

Which question should the nurse ask the male client diagnosed with aorto-iliac disease during the admission interview?

"Have you experienced any problems having sexual intercourse?"

When preparing the client in a short leg cast for discharge, which data indicate that the client needs further teaching?

"I can put a coat hanger down the cast to scratch gently if I have severe itching."

Which statement by the daughter of an 80-year-old female client who lives alone would warrant immediate intervention by the nurse?

"I changed my mother's furniture around.

The client is complaining of painful swallowing secondary to mouth ulcers. Which statement indicates the nurse's teaching has been effective?

"I will avoid spicy foods, tobacco, and alcohol."

A client recovering from a total hip replacement has developed a deep vein thrombosis. The health-care provider has ordered a continuous infusion of heparin, an anticoagulant, to infuse at 1200 units per hour. The bag comes with 20,000 unit of heparin in 500 mL of 0.9% normal saline. At what rate should the nurse set the pump?

30ml

A nurse is caring for an 8-year-old child who is admitted to the pediactric unit with a tentative diagnosis of acute poststreptococcal glomerulonephritis (APSGN). Diagnostic tests are ordered. Which tests will help confirm the diagnosis? Select all that apply

ASO titer . Urinalysis . Blood chemistry . Intravenous pyelogram

The client diagnosed with acute deep vein thrombosis is receiving a continuous heparin drip, an intravenous anticoagulant. The health-care provider orders warfarin (Coumadin), an oral anticoagulant. Which action should the nurse take?

Administer the Coumadin along with the heparin drip as ordered

The nurse prepares to administer digoxin (Lanoxin) to a newborn with a diagnosis of heart failure and notes that the apical rate is 140 beats per minute. Which nursing action is appropriate?

Administer the digoxin

Which psychosocial client problem would be most likely in a client with an external fixator device?

Alteration in body image

A nurse is reviewing the health history and laboratory report of a child with lead poisoning. What complications does the nurse expect in relation to lead toxicity? Select all that apply

Anemia . Proteinuria. Encephalopathy

A child is admitted to the nurse's unit with a suspected diagnosis of meningitis. The nurse should tell the parent which of the following?

Antibiotics should be started before the cerebrospinal fluid cultures are definitive because culture

Parents of a child with generalized seizures ask the nurse for information to give their child's teachers. Which of the following should be included?

As the child grows, medication dosages may need to be adjusted to control seizure activity.

The client is diagnosed with pericarditis. When assessing the client, the nurse is unable to auscultate a friction rub. Which action should the nurse implement?

Ask the client to lean forward and listen again.

The nurse is caring for a client who goes into ventricular tachycardia. Which intervention should the nurse implement first?

Assess the client for a pulse.

When caring for a client with a spica cast for a hip injury, what intervention should the nurse include in the plan of care?

Assess the client for distention and vomiting

The client is four (4) hours post-operative abdominal aortic aneurysm repair. Which nursing intervention should be implemented for this client?

Assess the client's bilateral pedal pulses

The nurse is caring for a client diagnosed with rule out nephrotic syndrome. Which intervention should be included in the plan of care?

Assess the client's sacrum for dependent edema.

Which intervention would be the most important for the nurse to implement for the client with a left nephrectomy?

Assess the intravenous fluids for rate and volume.

The hypertonicity of the muscles in an infant with cerebral palsy causes scissoring of the legs. The nurse teaches the mother that the preferred way to carry the infant is in a sitting position:

Astride one of her hips

Which referral would be most important for the client with permanent hearing loss?

Aural rehabilitation.

Which situation(s) are classified as natural disasters? Select all that apply

Blizzards, Volcanic eruptions,Communicable diseases

Six hours after major abdominal surgery a male client complains of severe abdominal pain; is pale and perspiring; has a thread, rapid pulse; and states he feels faint. The nurse checks the client's medication administration record and determines that the client can receive another injection of pain medication in an hour. What is the most appropriate action by the nurse?

Call the practitioner, report the client's symptoms, and obtain further orders

The client diagnosed with acute pancreatitis has developed a pseudocyst that ruptures. Which procedure should the nurse anticipate the HCP ordering?

Chest tube insertion

The client with a right open fractured elbow has a long arm cast and is complaining of unrelenting severe pain and feeling as if the fingers are asleep. Which complication should the nurse suspect that the client is experiencing?

Compartment syndrome

The nurse is caring for the client recovering from intestinal surgery. Which assessment finding would require immediate intervention

Complaints of chills and feeling feverish.

A two year-old child is brought to the provider's office with a chief complaint of mild diarrhea for two days. Nutritional counseling by the nurse should include which statement?

Continue with the regular diet and include oral rehydration fluids

In children with meningitis, there is the potential for many complications occurring from damage to the nervous system. Which of the following is/are the most common, nonlethal complication(s)?

Cranial nerve deficits.

The nurse understands that which are characteristics of anthrax? Select all that apply.

Cutaneous lesions become a black eschar . Gastrointestinal anthrax causes bloody diarrhea . Flulike symptoms are a sign of pulmonary anthrax . Person-to-person transmission of inhalation disease does not occur . A person can become infected through skin contact, ingestion, or inhalation of the bacillus

The mother of a 2 month-old baby calls the nurse 2 days after the first DTaP, IPV, Hepatitis B and HIB immunizations. She reports that the baby feels very warm, cries inconsolably for as long as 3 hours, and has had several shaking spells. In addition to referring her to the emergency room, the nurse should document the reaction on the baby's record and expect which immunization to be most associated with the findings the infant is displaying?

DTaP

Which potential complication should the nurse assess for in the client with infective endocarditis who has embolization of vegetative lesions from the mitral valve?

Decreased urine output.

The client with chronic alcoholism has chronic pancreatitis and hypomagnesemia. What should the nurse assess when administering magnesium sulfate to the client?

Deep tendon reflexes.

Which endocrine disorder would the nurse assess for in the client who has a closed head injury with increased intracranial pressure?

Diabetes insipidus

A client is ordered lisinopril (Zestril) for treatment of hypertension. He asks the nurse about possible adverse effects. The nurse should teach him about which common adverse effects of angiotensin-converting enzyme (ACE. inhibitors? Select all that apply

Dizziness . Headache. Hypotension

Which instruction should the nurse discuss with the female client with viral conjunctivitis?

Do not share towels or linens.

A client is admitted to the hospital with the diagnosis of a right-sided brain attack (CVA.. The client is right handed. Which task will be most difficult for this client?

Dressing every morning

When assessing the integumentary system of the client with anorexia nervosa, which finding would support the diagnosis?

Dry, brittle hair.

When conducting rounds at change of shift, the nurse assesses the client with a fractured humerus. Which data would warrant immediate intervention by the nurse?

Edema under the dressing that caused the nails to be white.

The nurse administers 2 units of salt-poor albumin to a client with portal hypertension and ascites. The nurse explains to the client that this is administered to:

Elevate the circulating blood volume

The client diagnosed with diabetes mellitus type 2 is admitted to the hospital with cellulitis of the right foot secondary to an insect bite. Which intervention should the nurse implement first?

Elevate the right foot on two (2) pillows

The nurse is caring for the client one (1) day postoperative sigmoid colostomy operation. Which independent nursing intervention should the nurse implement?

Encourage the client to discuss his or her feelings

Which nursing instruction should the nurse discuss with the client who is receiving glucocorticoids for Addison's disease?

Encourage the client to wear a Medic Alert bracelet and carry a card in the wallet.

A client is transferred from the emergency department to the locked psychiatric unit after attempting suicide by taking 200 acetaminophen (Tylenol) tablets. The client is now awake and alert but refuses to speak with the nurse. In this situation, the nurse's first priority is to:

Ensure safety by initiating suicide precautions.

The nurse is preparing the postoperative nursing care plan for the client recovering from a hemorrhoidectomy. Which intervention should the nurse implement?

Establish a rapport with the client to decrease embarrassment of assessing site

The male client is considering a vasectomy for birth control. Which information should the nurse teach the client?

Explain that initially an alternate form of birth control will be required.

Which risk factor would the nurse expect to find in the client diagnosed with pancreatic cancer?

Exposure to industrial chemicals.

The client is two (2) hours postoperative right-ear mastoidectomy. Which assessment data should be reported to the health-care provider?

Facial drooping.

A 31-year-old client is seeking contraceptive information. Before responding to the client's questions about contraceptives, the nurse obtains a health history. What factor in the client's history indicates to the nurse that oral contraceptives are contraindicated?

Has a history of borderline hypertension

Which assessment technique should the nurse use to assess the client's optic nerve?

Have the client read the Snellen chart.

Which question should the nurse ask when assessing the client for an endocrine dysfunction?

Have you had any unexplained weight loss?"

The client has been diagnosed with hemorrhoids. Which statement from the client indicates that further teaching is needed?

I must take a laxative every night and have a stool daily."

The client has recently been diagnosed with irritable bowel syndrome (IBS). Which intervention should the nurse teach the client to reduce symptoms?

Instruct the client to avoid drinking fluids with meals.

Before administering an MMR (measles, mumps, and rubella) vaccine to a 15-month-old child, which question should the nurse ask the mother of the child?

Is your child allergic to any antibiotics?'

Which information should the nurse teach the client regarding sports injuries?

Keep the injury immobilized and elevated for 24 to 48 hours.

A child arrives at the pediatric emergency department, having had a generalized seizure at home and a recent sore throat and mild fever. During the nurse's assessment, the child begins to have generalized tonic-clonic seizure activity. The drug of choice and method of administration the nurse expects the physician to order are which of the following?

Lorezapam given intravenously or diazepam given directly into a vein.

The client with peripheral venous disease is scheduled to go to the whirlpool for dressing change. Which is the nurse's priority intervention?

Medicate the client 30 minutes before going to whirlpool.

The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which overall imbalance?

Metabolic alkalosis

The client has just had a pericardiocentesis. Which interventions should the nurse implement? Select all that apply

Monitor vital signs every 15 minutes for the first hour. Assess the client's heart and lung sounds. Record the amount of fluid removed as output. Evaluate the client's cardiac rhythm

The nurse is caring for a client in a sickle cell crisis. Which is the pain regimen of choice to relieve the pain?

Morphine, a narcotic analgesic, every two (2) to three (3) hours PRN.

Which vaccination would the nurse recommend to the postpubertal male to preventorchitis?

Mumps vaccination.

Which signs/symptoms would the nurse expect to find in the client diagnosed with an insulinoma?

Nervousness, jitteriness, and diaphoresis.

A client with type 1 diabetes is diagnosed with diabetic ketoacidosis and initially treated with intravenous fluids followed by an IV bolus of regular insulin. The nurse anticipates that the practitioner will prescribe a continuous infusion of:

Novolin R insulin

The nurse is caring for the client on strict bed rest. Which intervention is priority when caring for this client?

Perform active range of motion exercises.

Which intervention should the nurse implement for the client who has had an ileal conduit?

Report to the health-care provider any decrease in urinary output.

The nurse is told in report that the client has aortic stenosis. Which anatomical position should the nurse auscultate to assess the murmur?

Second intercostal space, right sternal notch

The nurse is teaching basic cardiopulmonary resuscitation (CPR) to individuals in the community. Which is the order of basic CPR? List in order of performance

Shake and shout, Perform head tilt chin lift. Look, listen, and feel for breathing. Give two (2) rescue breaths. Begin cardiac compressions.

The nurse is teaching the client diagnosed with Type 2 diabetes mellitus about diet. Which diet selection indicates the client understands the teaching?

Smoked turkey sandwich, celery sticks, and unsweetened tea.

The client is diagnosed with hereditary spherocytosis. Which treatment/procedure would the nurse prepare the client to receive?

Splenectomy.

The 72-year-old client tells the nurse that food does not taste good anymore and that he has lost a little weight. Which information should the nurse discuss with the client?

Suggest using extra seasoning when cooking

A nurse administers albuterol to a child with asthma. For what common side effect should the nurse monitor the child?

Tachycardia

The nurse is preparing a teaching care plan for the client diagnosed with nephritic syndrome. Which intervention should the nurse include?

Take diuretics as needed to treat the dependent edema in ankles.

The nurse is aware that epinephrine and norepinephrine are secreted by which endocrine gland?

The adrenal medulla.

Which laboratory data indicate the client's pancreatitis is improving?

The amylase and lipase serum levels are decreased.

The unlicensed nursing assistant is applying elastic compression stockings to the client. Which action by the assistant would warrant immediate intervention by the nurse?

The assistant is putting the stockings on while the client is in the chair.

The nurse is teaching a community class to people with Type 2 diabetes mellitus. Which explanation would explain the development of Type 2 diabetes?

The cells become resistant to the circulating insulin

Which behavior by the male client would make the nurse suspect the client has a hearing loss? Select all that apply

The client becomes irritable very easily. The client has difficulty making decisions. The client's wife reports that he ignores her.

The nurse is caring for clients on a cardiac floor. Which client should the nurse assess first?

The client diagnosed with mitral valve prolapse with an audible S3.

The nurse is assessing the client's sensory system. Which result would indicate an abnormal stereognosis test?

The client is unable to identify a key in the hand with both eyes closed

The nurse is caring for the client recovering from a percutaneous renal biopsy. Which data indicate that the client is complying with client teaching?

The client lies flat in the supine position for 12 hours.

Which outcome should the nurse identify for the client diagnosed with fluid volume excess?

The client will have no adventitious breath sounds

Which is the primary goal of care for a client diagnosed with sickle cell anemia?

The client will live as normal a life as possible.

The nurse is caring for clients on a medical floor. Which client will the nurse assess first?

The client with essential hypertension who has epistaxis and a headache.

The nurse is administering a beta blocker to the client diagnosed with essential hypertension. Which data would cause the nurse to question administering the medication?

The client's apical pulse is 56.

The nurse has been assigned to train the unlicensed nursing assistant about prioritizing care. Which client should the nurse instruct the unlicensed nursing assistant to see first?

The elderly woman who needs assistance ambulating to the bathroom

The nurse is teaching the client diagnosed with colon cancer who is scheduled for a colostomy the next day. Which behavior indicates the best method of applying adult teaching principles?

The nurse repeats the information as indicated by the client's question

Which referral would be most appropriate for the client diagnosed with thoracic outlet syndrome?

The physical therapist.

The nurse is performing a physical assessment on a toddler. Which of the following actions should be the first?

Use minimal physical contact

The nurse is planning to teach a client about home modifications to reduce the risk of falls. Which recommendation(s) should be included in the teaching plan? Select all that apply.

Use nightlights during nighttime . Place handrails in bathtubs and showers . Check staircase railings for secureness and sturdiness

The nurse is assisting with a synchronized cardioversion on a client in atrial fibrillation. When the machine is activated, there is a pause. What action should the nurse take?

Wait until the machine discharges.

Which discharge instruction should the nurse teach the client diagnosed with varicose veins who has received sclerotherapy?

Walk 15 to 20 minutes three (3) times a day.

The nurse is teaching the client with peripheral vascular disease. Which intervention should the nurse discuss with the client? Select all that apply

Wear comfortable, well-fitting shoes. Keep the area between the toes dry.

A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status?

Weighing the client daily at the same time each day

Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students?

Whitish oval specks sticking to the hair

The mother of a 3 month-old infant tells the nurse that she wants to change from formula to whole milk and add cereal and meats to the diet. What should be emphasized as the nurse teaches about infant nutrition?

Whole milk is difficult for a young infant to digest