Exam 4

A hospitalized client has a platelet count of 78,000/mm3 (78 × 109/L). What action by the nurse is best?

A private room, Strict hand washing, Avoiding exposure to people who are sick

An older adult client in the clinic reports a decrease in hearing over a week. What initial action by the nurse is most appropriate?

Assess for cerumen buildup.

The family of a neutropenic client reports that the client appears confused. What action by the nurse is the priority?

Assess the client for infection

A nurse admits a client who is experiencing an exacerbation of heart failure. What action would the nurse take first?

Assess the client's respiratory status

A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important?

Assessing the IV site every hour

A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment would the nurse complete first?

Heart rate and rhythm

A client presents to the emergency department in a sickle cell crisis. What intervention by the nurse takes priority?

administer oxygen

A nurse teaches a client with Cushing's disease. Which dietary requirements would the nurse include in this client's teaching? (Select all that apply.) a. Low calcium b. Low carbohydrate c. Low protein d. Low calories e. Low sodium

b, d, e

A client is having a radioisotopic imaging scan. What action by the nurse is most important? a. Assess the client for shellfish allergies. b. Place the client on radiation precautions. c. Sedate the client before the scan. d. Teach the client about the procedure.

d

A client does not understand why vision loss due to glaucoma is irreversible. What explanation by the nurse is best?

"Because eye pressure was too high, the tissue died."

A nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement would the nurse include in this patient's teaching?

"Do not take this medication within 1 hour of taking an antacid."

After teaching a client who is prescribed adalimumab (Humira) for severe ulcerative colitis, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?

"I will take this medication with my breakfast each morning."

A nurse teaches a client who has a history of heart failure. Which statement would the nurse include in this client's discharge teaching?

"Weigh yourself daily while wearing the same amount of clothing."

A patient is prescribed 250 mL of normal saline to infuse over 4 hours via gravity. The facility supplies gravity tubing with a drip factor of 15 drops/mL. At what rate (drops/min) will the nurse set the infusion to deliver? (Record your answer using a whole number.) _____ drops/min

16

A nurse cares for a clientwho is prescribed 5 mg/kg of infliximab (Remicade) intravenously. The clientweighs 110 lbs and the pharmacy supplies infliximab 100 mg/10 mL solution. How many milliliters would the nurse administer to this patient? (Record your answer using a whole number.) ____ mL

25ml

A nurse prepares to administer 12 mg/kg of 5-fluorouracil chemotherapy intravenously to a clientwho has colon cancer. The clientweights 132 lbs. How many milligrams would the nurse administer? (Record your answer using a whole number.) _____ mg.

720mg

A client has a platelet count of 25,000/mm3 (25 × 109/L). What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

C) Help the patient choose soft foods from the menu. D) Shave the male patient with an electric razor. E) Use a lift sheet when needed to reposition the patient.

A client with peptic ulcer disease is in the emergency department with increasing pain over the last several days. The client's blood pressure when lying down was 122/80 mm Hg and when standing was 98/52 mm Hg. What action by the nurse is most appropriate?

Call the Rapid Response Team.

A client has a platelet count of 9000/mm3 (9 × 109/L). The nurse finds the client confused and mumbling. What action takes priority?

Calling the Rapid Response Team (at risk for spontaneous bleeding)

A nurse is caring for four clients with leukemia. After hand-off report, which client should the nurse see first?

Client who had two bloody diarrhea stools this morning

The following data relate to a client who is 2 hours postoperative after an esophagogastrostomy:Physical AssessmentVital SignsPhysician OrdersSkin dryUrine output 20 mL/hrRestlessPulse: 128 beats/minBlood pressure: 88/50 mm HgRespiratory rate: 22Oxygen saturation: 99%Normal saline at 75 mL/hrMorphine sulfate 2 mg IV push every 1 hr PRN painIntake and output every hourVital signs every hourVancomycin (Vancocin) 1 g IV every 8 hrWhat action by the nurse is best?

Consult the surgeon about increased IV fluids.

A nurse is evaluating a client who is being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan?

Decreased orthostatic light-headedness and dizziness

A client receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what action by the nurse is most important?

Double-checking the client and blood product identification

A nurse assesses a client who is experiencing diabetic ketoacidosis (DKA). What manifestations would the nurse expect to assess? (Select all that apply.)

Dry skin, Abdominal pain, Kussmaul respirations

A client hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL (61 mmol/L). What medication does the nurse prepare to administer?

Epoetin alfa (Epogen)

A nurse assesses a client who is hospitalized with an exacerbation of Crohn's disease. Which clinical manifestation would the nurse expect to find?

High-pitched, rushing bowel sounds in the right lower quadrant

A client is taking timolol (Timoptic) eyedrops. The nurse assesses the client's pulse at 48 beats/min. What action by the nurse takes priority?

Hold the eyedrops and notify the provider

A client is scheduled for a total gastrectomy for gastric cancer. What preoperative laboratory result would the nurse report to the surgeon immediately?

International normalized ratio (INR): 4.2

A client has a sickle cell crisis with extreme lower extremity pain. What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)?

Keep the lower extremities warm.

A client is going on a cruise who is diagnosed with Meniere's disease. What medication would the nurse expect the provider to prescribe?

Maybe: Try scopolamine (Transderm Scop).

A nurse assesses a client with Cushing's disease. Which assessment findings would the nurse correlate with this disorder? (Select all that apply.)

Mood Face, Petechiaee, muscle atrophy

A client has Hodgkin's lymphoma. For what manifestations should the nurse assess the patient? (Select all that apply.)

Night sweats, Persistent fever, Weight loss

The nurse is caring for a client with peptic ulcer disease who reports sudden onset of sharp abdominal pain. On palpation, the patient's abdomen is tense and rigid. What action takes priority?

Notify the health care provider immediately.

A client is in the preoperative holding area waiting cataract surgery. The client states, "I forgot to tell you that I took my clopidogrel medication last night." What action by the nurse is most important?

Notify the surgeon immediately.

A nurse reviews the chart of a client who has Crohn's disease and a draining fistula. Which documentation would alert the nurse to urgently contact the provider for additional prescriptions?

Potassium of 2.6

A nurse is preparing to hang a blood transfusion. What action is most important?

Putting on a pair of gloves

A client has returned to the nursing unit after an open Nissen fundoplication. The nurse notes bright red blood in the NG tube. What action would the nurse take first?

Take a full set of vital signs.

The nurse assesses a client's oral cavity who isdiagnosed with Crohns, and makes the discovery shown in the photo below:What action by the nurse is most appropriate?

Teach the client about cobalamin therapy.

A nurse assesses a client who is prescribed 5-fluorouracil (5-FU) chemotherapy intravenously for the treatment of colon cancer. Which assessment finding would alert the nurse to contact the health care provider?

White blood cell (WBC) count of 1500/mm3

A client is being taught about drug therapy for Helicobacter pylori infection. What assessment by the nurse is most important?

Willingness to adhere to drug therapy

A nurse caring for a client with sickle cell disease (SCD) reviews the client's laboratory data. What finding should the nurse report immediately to the health care provider? a. Creatinine: 2.9 mg/dLb. Hematocrit: 30%c. Sodium: 147 mEq/Ld. White blood cell count: 12,000/mm3

a

The nurse is caring for a client who had an esophagectomy. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assisting with position changes and getting out of bedb. Keeping the head of the bed elevated to at least 30 degreesc. Reminding the client to use the spirometer every 4 hoursd. Taking and recording vital signs per hospital protocole. Titrating oxygen based on the clients oxygen saturations

a, b, d

A client has a gastrointestinal hemorrhage and is prescribed two units of packed red blood cells. What actions would the nurse perform prior to hanging the blood? (Select all that apply.) a. Ask a second nurse to double-check the blood. b. Prime the IV tubing with normal saline. c. Prime the IV tubing with dextrose in water. d. Take and record a set of vital signs. e. Teach the client about reaction manifestations.

a, b, d, e

A client had cataract surgery. What instructions would the nurse provide? (Select all that apply.) a. Call the doctor for increased pain. b. Do not bend over from the waist. c. Do not lift more than 10 pounds. d. Sexual intercourse is allowed. e. Use stool softeners to avoid constipation.

a,b,c,e

A client had an upper gastrointestinal hemorrhage and now has a nasogastric (NG) tube. What task can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Lavaging the tube with ice waterb. Performing frequent oral carec. Re-positioning the tube every 4 hoursd. Taking and recording vital signs

b Clients with NG tubes need frequent oral care both for comfort and to prevent infection. Lavaging the tube is done by the nurse. Re-positioning the tube, if needed, is also done by the nurse. The UAP can take vital signs, but this is not a comfort measure.

A client with Ménière's disease is in the hospital when the client has an attack of this disorder. What action by the nurse takes priority? a. Assess vital signs every 15 minutes.b. Dim or turn off lights in the client's room.c. Place the client in bed with the upper siderails up.d. Provide a cool, wet cloth for the client's face.

c

A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure? a. "I have been drinking more water than usual." b. "I am awakened by the need to urinate at night." c. "I must stop halfway up the stairs to catch my breath." d. "I have experienced blurred vision on several occasions."

c

A nurse is caring for four clients. After reviewing today's laboratory results, which client should the nurse see first? A. Client with a international normalized ratio of 2.8B. Client with a platelet count of 128,000/mm3C. Client with a prothrombin time (PT) of 28 seconds.D. Client with a red blood cell count of 5.1 millon/L

c