Hesi Exit

Leave the catheter in place and obtain a sterile catheter. Rationale: the catheter is in the vaginal opening.

288.The nurse inserts an indwelling urinary catheter as seen in the video what action should the nurse take next?

0.4 Rationale: Calsulate using the formula, desired dose (220,000 units) over dose on hand (600,000 units) x the volume of the available dose (1 ml), 220,000/600,000 x 1 ml-0.36 0.4 ml

350.An infant is receiving penicillin G procaine 220,000 units IM. The drug is supplied as 600,000 units/ml. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth)

Use sunblock or protective clothing when outdoors.

4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT) protocol that includes methotrexate (Mexate. Trexal, MIX), an antimetabolite. Which information should the nurse provide the parents about caring for their child?

Inform her that some antianxiety medications are safe to take while breastfeeding

40. A woman with an anxiety disorder calls her obstetrician's office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman?

Serum potassium

416.An Insulin infusion for a client with diabetes mellitus who is experiencing hyperglycemic hyperosmolar..in addition to the client's glucose, which laboratory value is most important for the nurse to monitor?

eNormal sinus rhythm and complaining of chest pairn

454.The nurse is caring for several clients on a telemetry unit. Which client should the nurse assess first? The client who is demonstrating

Monitor mental status

610.After recelving lactulose, a client with hepatic encephalopathy has several loose stools What action should the nurse implement?

Monitor heart, lung, and kidney function. Notify healthcare provider of serum amylase and lipase levels. Review client's abdominal ultrasound findings.

617.A client with acute pancreatitis is compla ining of pain and nausea. Which interventions should the nurse implement (Select all that apply)

Serum creatinine

619.incaring for a client receiving the amino glycoside antibiotic gentamicin, it is most important for the nurse to monitor which diagnostic test?

Long-term care facility . Home health agency

627The daughter of an older female client tells the clinic nurse that she is no longer able to care for her mother since her mother has lost the ability to perform activities of daily living ADIS) due to aging. Which options should the nurse discuss with the daughter?

Administer 8 units of insulin aspart Sub

642.After checking the fingerstick glucose at 1630, what action should the nurse implement?

Determine how the client is cared for when caregiver is not present

651. A newly hired home health care nurse is planning the initial visit to an adult client who has had multiple sclerosis (MS) for the past 20 years and is currently bed-bound and is lifted by a hoist. And unlicensed caregiver provides care 8 hours/ daily, 5 days/week. During the initial visit to this client, which intervention is most important to the nurse to implement?

The heart will stop beating & you wil stop breathing.

A 10 year old who has terminal brain cancer asks the nurse, "What will happen to my body when I die?" How should the nurse respond?

Complete pre-infusion checklist

A 12 - lead electrocardiogram ( ECG ) indicates a ST elevations in leads V1 to V4 , for a client who reports having chest pain. The healthcare provider prescribe tissue plasminogen activator (t-PA). Prior to initiating the infusion, which interventions is most important for the nurse to implement?

Encourage popsicles and fluids of choice Rationale: specific gravity of urine is a measurement of hydration status (normal range of 1.010 to 1.025) which is indicative of fluid volume deficit when Sp Gr increases as urine becomes more concentrated.

A 12year old client who had an appendectomy two days ago is receiving 0.9 % normal saline at 50 ml/hour. The client's urine specific gravity is 1.035. What action should the nurse implement? Evaluate

Begin parenteral antibiotic therapy

A 13 years-old client with non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. The healthcare provider collects home aspirate specimens for culture and sensitivity and applies a cast to the adolescent's lower leg. What action should the nurse implement next?

Rationale . Convert the client 's weight to kg , 2.2 pound : 1 kg - 154 pounds . x kg 154/2.2-70kg. Calculate the client infusion rate, 0.1 x 70 kg 7 units/hour. Using the formula, D/H x Q 7 units/hour / 100 units x 100 ml-7ml/ hour

A 154 pound client with diabetic ketoacidosis is receiving an IV of normal saline 100 ML with regular insulin 100 units. The healthcare provider prescribes a rate of 0.1 units/kg/hour. To deliver the correct dosage, the nurse should set the infusion pump to Infuse how many ml/hour? enter numeric value only

Answer 83 Rationale: 1000 ml...-12hr Xml1hr 1000/12 83.33 83

A 16-year-old adolescent with meningococcal meningitis is receiving a continuous IV infusion of penicillin G, which is prescribed as 20 million units in a total of 2 liters of normal saline every 24 hr. The pharmacy delivers 10 million units/ liters of normal saline. How many ml/hr should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

Explain that a protruding abdomen is typical for toddlers

A 2-year-old girl is brought to the clinic for a routine assessment and all findings are within the normal limits. However, the mom expresses concern over her daughter's protruding abdomen and tells the nurse that she is worry that her child is becoming overweight. How should the nurse respond to the mother's comment?

Palpitations and shortness of breath

A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences

"His smaller size is probably due to the heart disease"

A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother.. During the assessment, the mother asks the nurse why her child is at the 5h percent..sponse is best for the nurse to provide?

.Tell all their assigned clients to stay in their rooms.

A 350-bed acute care hospital declares an internal disaster because the emergency generators malfunctioned during a city-wide power failure. The UAPs working on a general medical unit ask the charge nurse what they should do first. What instruction should the charge nurse provide to these UAPs?

Ineffective coping related to denial

A 46-year-old male client who had a myocardial infarction 24-hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which nursing problem should the nurse formulate?

Ineffective coping related to denial

A 46-year-old male client who had a myocardial infarction 24-hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at.this.time. Based on this behavior, which nursing problem should the nurse formulate?

Provide an opportunity for him to clarify his values related to the decision

A 56-years-old man shares with the nurse that he is having difficulty making decision about terminating life support for his wife. What is the best initial action by the nurse?

Administer a prescribed bronchodilator. Rationale . If the PEFR is below 50 % in as asthmatic child , there is severe narrowing of the airway, and a bronchodilator should be administered immediately. Be should be implemented after A. C will not alleviate the symptoms and D is not a priority.

A 6 -years-old who has asthma is demonstrating a prolonged expiratory phase and wheezing and has 35 % personal best peak expiratory flow rate ( PEFR ) . Based on these finding, which action should the nurse implement first?

Continue giving ORS frequently in small amounts

A 6-year-old child with acute infectious diarrhea is placed on a rehydration therapy...Which action should the nurse instruct the parents to take if the child begins to vomit?

Her mother and sister have a history of breast cancer

A 60-year-old female client asks the nurse about hormones replacement therapy (HRT) as a means preventing osteoporosis. Which factor in the client's history is a possible contraindication for the use of HRT

Further evaluation involving surgery may be needed

A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client's teaching plan?

Medicare

A 66-year-old woman is retiring and will no longer have a health insurance through her place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs?

Collect a urine specimen for routine urinalysis

A 7-year-old boy is brought to the clinic because of facial edema. He reports that he has been voiding small amounts of dark, cloudy, tea-colored urine. The parents state that their son had a sore throat 2 weeks earlier, but it has resolved. After assessing the child's vital signs and weight, what intervention should the nurse implement next?

Reposition the client with the head of the bed elevated.

A child is admitted to the pediatric unit diagnosed with sickle cell crisis. When the nurse walks into the room , the unlicensed assistive personnel ( UAP ) is encouraging the child to stay in bed in the supine position. Which action should the nurse implement?

Instructions about how much fluid the child should drink daily Rationale: It is essential that the child and family understands the importance of adequate hydration in preventing the stasis-thrombosis-ischemia cycle of a crisis that has a specific plan for hydration is developed so that a crisis can be delayed. Other choices listed are not the most important topics to include in the discharge teaching

A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge?

Cardiac rhythm and heart rate.

A child with heart failure is receiving the diuretic furosemide (Lasix) and has serum potassium level 3.0 mEa/L. Which assessment is most important for the nurse to obtain?

Bronchodilators

A client admitted to the emergency center had inspiratory and expiratory wheezing, nasal flaring, and thick, tenacious sputum secretions observed during the physical examination. Based on these assessment findings, what classification of pharmacologic agents should the nurse anticipate administering?

Establish a structured routine for the client to follow

A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?

1. Call the rapid response team to assist 2. Move the crash cart to the client room 3. Notify the client's healthcare provider 4. Inform the family of the critical situation

A client admitted to the telemetry unit is having unrelieved chest pain after receiving 3 sublingual nitroglycerin tablets and morphine 8 mg IV. The electrocardiogram reveals sinus bradycardia with ST elevation. In what order should the nurse implement the nursing actions? (Arrange first to last)

Unresponsive to painful stimuli

A client admitted with an acute coronary syndrome (ACS) receives eptifibatide, a glycoprotein (GP) IB IIA inhibitor, which important finding places the client at greatest risk?

Determine the client's vital sign.

A client arrives on the surgical floor after major abdominal surgery. What intervention should the nurse perform first?

Maternal blood pressure

A client delivers a viable infant but begins to have excessive uncontrolled vaginal..notifying the health care provider of the clients' condition, what information is most...

Discuss the importance of continuing the usual at-home activities

A client diagnosed with bipolar disorder is going home on a week-end pass. Which suggestions should give the client's family to help them prepare for the visit?

Allopurinol (Zyloprim)

A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide (Amphogel) is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention?

Initiate seizure precautions

A client experiencing withdrawal from the benzodiazepines alprazolam (Xanax) is demonstrating severe agitation and tremors. What is the best initial nursing action?

Current diagnosis of hepatitis B Rationale: prophylactic treatment of tuberculosis with isoniazid is contraindicated for persons with liver disease because it may cause liver damage. The nurse should withhold the prescribed dose and contact the healthcare provider. Other options do not provide data indicating the need to question or withhold the prescribed treatment.

A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose?

oBlood pressure 149/101

A client has a prescription for lorazepam 2mg for alcohol withdrawal symptoms. Which finding.., the client?

Drink chamomile tea at breakfast and in the evening

A client in her first trimester of pregnancy complains of nausea. Which complementary therapy should the nurse recommend?

Use a secondary port of the Normal Saline solution to administer the antibiotic. Rationale: A client in septic shock needs antibiotic administered in a timely manner to ensure maintenance of therapeutic serum level. The nurse should administer the antibiotic using a secondary port of the Normal Saline solution. No other medications should be administered using TPN tubing or solution. TPN not should be place on hold because sudden cessation will cause rapid change in serum glucose levels. Excessively delays in the administration of the antibiotics.

A client in septic shock has a double lumen central venous catheter with one liter df 0.9 % Normal Saline Solution infusing at 1 ml / hour through one lumen and TPN infusing at50 ml/hr. through one port. The nurse prepared newly prescribed IV antibiotic that should take 45 mints to infuse. What intervention should the nurse implement?

. Use a secondary port of the Normal Saline solution to administer the antibiotic. Rationale: A dient in septic shock needs antibiotic administered in a timely manner to ensure maintenance of therapeutic serum level. The nurse should administer the antibiotic using a secondary port of the Normal Saline solution. No other medications should be administered using TPN tubing or solution. TPN not should be place on hold because sudden cessation will cause rapid change in serum glucose levels. Excessivelyl delays in the administration of the antibiotics.

A client in septic shock has a double lumen central venous catheter with one liter of 0.9 % Normal Saline Solution infusing at 1 ml / hour through one lumen and TPN infusing at 50 ml/hr, through one port. The nurse prepared newly prescribed IV antibiotic that should take 45 mints to infuse. What intervention should the nurse implement?

Use a secondary port of the Normal Saline solution to administer the antibiotic. Rationale: A client in septic shock needs antibiotic administered in a timely manner to ensure maintenance of therapeutic serum level. The nurse should administer the antibiotic using a secondary port of the Normal Saline solution. No other medications should be administered using TPN tubing or solution. TPN not should be place on hold because sudden cessation will cause rapid change in serum glucose levels. Excessively delays in the administration of the antibiotics.

A client in septic shock has a double lumen central venous catheter with one liter of 0.9 % Normal Saline Solution infusing at 1 ml / hour through one lumen and TPN infusing at 50 ml/hr. through one port. The nurse prepared newly prescribed IV antibiotic that should take 45 mints to infuse. What intervention should the nurse implement?

Divalproex.

A client in the emergency center demonstrates rapid speech, flight of ideas, and reports sleeping only three hours during the past 48h. Based on these finding, it is most important the nurse to review the laboratory value for which medication?

Auscultated bilateral breath sounds Rationale: Restlessness often results from decreased oxygenation so breath sounds should be assessed first. Giving an anxiolytic such as lorazepam, might be indicated but first the client should be assessed for the cause of the restiessness. An obstruction in the urinary drainage system can cause a distended bladder that may result in restlessness, but patent airway is the priority intervention. The client should be assessed before evaluating the cardiac rhythm on the monitor

A client in the intensive care unit is being mechanically ventilated, has an indwelling urihary catheter in place, and is exhibiting signs of restiessness. Which action should the nurse take first?

Transfer the client to the surgical floor.

A client in the postanesthesia care unit (PACU) has an eight (8) on the Aldrete pestanesthesia scoring system. What intervention should nurse implement?

Lower the left arm below the level of the heart

A client is admitted for cellulitis surrounding an insect bite on the lower, right arm and intravenous (IV) antibiotic therapy is prescribed. Which action should the nurse implement before performing venipuncture?

Oatmeal with butter, artificial sweetener, and strawberries, and 6 ounces coffee

A client is admitted for type 2 diabetes mellitus (DM) and chronic Kidney disease (CKD)...which breakfast selection by the client indicates effective learning?

Thiamine (Vitamin BI) Rationale: Thiamine replacement is critical in preventing the onset of Wernickes encephalopathy, an acute triad of confusion, ataxia, and abnormal extraocular movements, such as nystagmus related to excessive alcohol abuse. Other medications are not indicated.

A client is admitted to a medical unit with the diagnosis of gastritis and chronic heavy alcohol abuse. What should the nurse administered to prevent the development of Wernicke's syndrome?

Negative pressure environment

A client is admitted to isolation with the diagnosis of active tuberculosis (TB). Which infection control measures should the nurse implement?

Negative pressure environment

A client is admitted to isolation with the diagnosis of active tuberculosis. Which infection control measures should the nurse implement?

No wheezing upon auscultation of the chest.

A client is admitted to the emergency department with a respiratory rate of 34 breaths per minute and high pitched wheezing on inspiration and expiration, the medical diagnosis is severe exacerbation of asthma. Which assessment finding, obtained 10 min after the admission assessment, should the nurse report immediately to the emergency department healthcare provider?

Persistent coughing while drinking

A client is admitted to the hospital after experiencing a brain attack, commonly referred to as a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding?

Hypokalemia

A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely?

Confusion and tremors Rationale: daily alcohol is the likely etiology for the client's pancreatitis. Abrupt cessation of alcohol can result in delirium tremens (DT) causing confusion and tremors, which can precipitate cardiovascular complications and should be reported immediately to avoid life-threatening complications. The other options are expected findings in those with liver dysfunction or pancreatitis, but do not require immediate action.

A client is admitted with acute pancreatitis. The client admits to drinking a pint of bourbon daily. The nurse medicates the client for pain and monitors vital signs q2 hours. Which finding should the nurse report immediately to the healthcare provider?

Rapid onset of decreased level of consciousness

A client is admitted with an epidural hematoma that resulted from a skateboarding accident. To differentiate the vascular source of the intracranial bleeding, which finding should the nurse monitor?

Maintain both lower extremities elevated on pillows.

A client is admitted with metastatic carcinoma of the liver, ascites, and bilateral 4+ piing edema of both lower extremities. When the client complains that the antiembolic stocking are too constricting, which intervention should the nurse implement?

Weigh every morning

A client is being discharged home after being instruction should the nurse include in this client's discharge treated for heart failure (HF). What

Weigh every morning

A client is being discharged home after being treated for heart failure (HF). What instruction should the nurse include in this discharge teaching plan?

Eat approximated the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent

A client is being discharged with a prescriptión for warfarin (Coumadin). What instruction should the nurse provide this client regarding diet?

Correct orders: (DPIA) 1. Determine when the client had last bowel movement 2. Position client supine with knees bent 3. Inspect abdominal contour 4. Auscultate all four abdominal quadrants

A client is complaining of intermittent, left, lower abdominal pain that began two days ago...implement the following interventions?

Wash hands before cleaning exit site

A client is discharged with automated peritoneal dialysis PD) to be used nightly...which instructions should the nurse include?

1000 units/hour Rationale:20000/500-40x25-1000

A client is receiving an IV solution labeled Heparin Sodium 20,000 Units in 5 % dextrose injection 500 ml at 25 mi/hour. How many units of heparin is the client receiving each hour?

Answer: 1.6 Rational: using the formula D/HxQ .200mg/250 mg x 2ml 200/250 1.6 ml

A client is receiving and oral antibiotic suspension labeled 250 mg/2ml. The healthcare provider prescribes 200mg every 6 hours. How many ml should the nurse administer at each dose? (Enter numerical value only. If rounding is required, round to the nearest tenth)

Leakage around catheter insertion site

A client is receiving continuous bladder irrigation via a triple-lumen suprapubic catheter that was placed during prostatectomy. Which report by the unlicensed assistive personnel (UAP) requires intervention by the nurse?

Level of consciousness Rationale: Colonic bacteria digest lactulose to create a drug-induces acidic and hyperosmotic environment that draws water and blood ammonia into the colon and coverts ammonia to ammonium, which is trapped in the intestines and cannot be reabsorbed into the systemic circulation. This therapeutic action of lactulose is to reduce serum ammonia levels, which improves the client's level of consciousness and metal status.

A client is receiving lactulose (Rortalac) for signs of hepatic encephalopathy. To evaluate the client's therapeutic response to this medication, which assessment should the nurse obtain?

Bowel patterns

A client is receiving mesalamine 800 mg PO TID. Which assessment is most important for the nurse to perform to assess the effectiveness of the medication?

Contraction pattern

A client is receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important time the infusion rate is increases?

Administer the Zofran after flushing the saline lock with saline Rationale: Zofran is an antiemetic administered before and after chemotherapy to prevent vomiting. The nurse should administer the antiemetic using the accepter technique for IV administration via saline lock. Zofran is not a chemotherapy drug and does not need to be administered by a chemotherapy- certified nurse.

A client is scheduled to receive an IW dose of ondansetron (Zofran) eight hours after receiving chemotherapy. The client has saline lock and is sleeping quietly without any restlessness. The nurse caring for the client is not certified in chemotherapy administration. What action should the nurse take?

Overlook the client's behavior.

A client on a long-term mental health unit repeatedly takes own pulse regardless of the circumstance. What action should the nurse implement?

Apply warm moist compresses then gently scrub eyelids with dilute baby shampoo

A client present at the clinic with blepharitis. What instructions should the nurse provide for home care?

Inability to close the affected eye, raise brow, or smile

A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the client to perform a series of movements that require use of the facial muscles. What symptoms suggest that the client has most likely experience a Bell's palsy rather than a stroke?

Administer the medication as prescribed with a glass of water

A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at bedtime. What action should the nurse take?

Baked apples topped with dried raisins

A client receiving chemotherapy has severe neutropenia. Which snack is best for the nurse to recommend to the client?

Administer prescribed morphine sulfate IV and provide oxygen at 2 L/min per nasal cannula

A client was admitted to the cardiac observation unit 2 hours ago complaining of chest pain. On admission, the client's EKG showed bradycardia, ST depression, but no ventricular ectopy. The client suddenly reports a sharp increase in pain, telling the nurse, "I feel like an elephant just stepped on my chest The EKG now shows Q waves and ST segment elevations in the anterior leads. What intervention should the nurse perform?

e Muscle cramping Rationale: SIADH causes dilution hyponatremia because of the increased release of ADH, which is treated with water restriction and demeclocycline, a tetracycline derivate that blocks the action of ADH. Signs of hyponatremia (normal 136-145), which indicate the need for increasing the dosage of demeclocycline, should be reported to the healthcare provider. The signs include: plasma sodium level less than 120, anorexia, nausea, weight changes related to fluid disturbance, headache, weakness, fatigue, and muscle cramping, AC& D are not related to hyponatremia

A client who developed syndrome of inappropriate antidiuretic hormone (SIADH) associated with small carcinoma of the lung is preparing for discharge. When teaching the client about self-management with demeclocycline (Declomycin), the nurse should instruct the client to report which condition to the health care provider?

Research indicates that mirror therapy is effective in reducing phantom limb pain Rationale: pain relief associated with mirror therapy may be due to the activation neurons in the hemisphere of the brain that is contralateral to the amputated limb when visual input reduces the activity of systems that perceive protopathic pain

A client who had a below the knee amputation is experiencing severe phantom pain (PLP) and ask the nurse if mirror therapy will make the pain stop. Which by the nurse is likely to be most helpful?

Schedule a weekly home visit to draw hCG values.

A client who had a gestational trophoblastic disease (GTD) evacuated 2 days ago is being..18 months-old child and lives in a rural area. Her husband takes the family car to work daily.. .ransportation during the day. What Intervention is most important for the nurse to implement?

Assess compliance with routine prescriptions. .Rationale: Fluid retention may be a sign that the client is not taking the medication as prescribed or that the prescriptions may need adjustment to manage cardiac function post - PTCA ( normal ejection fraction range is 50 to 75 % )

A client who had a percutaneous transluminal coronary angioplasty (PTCA) two weeks ago returns to the clinic for a follow up visit. The client has a postoperative ejection fraction ejection fraction of 30 % . Today the client has lungs which are clear , +1 pedal edema, and a Spound weight gain. Which intervention the nurse implement?

Reassess readiness for SNF transfer

A client who had a right hip replacement 3 day ago is pale has diminished breath sound over the left lower lung fields, a temperature of 100.2 F, and an oxygen saturation rate of 90 % . The client is scheduled to be transferred to a skilled nursing facility ( SNF ) tomorrow for rehabilitative critical pathway. Based on the client's symptoms, what recommendation should the nurse give the healthcare provider?

Maintain contact transmission precaution

A client who had a small bowel resection acquired methicillin resistant staphylococcus aureus (MRSA) while hospitalized. He treated and released, but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention

Maintain effective breathing patterns Rationale: Basic airway management (B) is the priority. Pain management (A), risk of infection (C), and prevention of injury (D) do not have the same priority as (C)

A client who had an emergency appendectomy is being mechanically ventilated, and soft wrist restrain are in place to prevent self extubation, Which outcome is most important for the nurse to include in the client's plan of care?

eAuscultate all quadrant of the abdomen.

A client who had an open cholecystectomy two weeks ago comes to the emergency department with complaints of nausea, abdominal distention, and pain. Which assessment should the nurse implement?

Perform a sterile vaginal exam Rationale: When a client in active labor suddenly expresses the urge to have a bowel movement, a sterile vaginal exam should be performed to determine if the fetus is descending

A client who has been in active labor for 12 hours suddenly tells the nurse that she has a strong urge to have a bowel movement. What action should the nurse take?

Tracheal deviation toward the left lung. Rationale: Tracheal deviation toward the unaffected left lung with absent breath sounds over the affected right lung are classic late signs of a tension pneumothorax

A client who is admitted to the intensive care unit with a right chest tube attached to a THORA-SEAL chest drainage unit becomes increasingly anxious and complain of difficulty breathing. The nurse determine the client is tachypneic with absent breath sounds in the client's right lungs fields. Which additional finding indicates that the client has developed a tension pneumothorax?

Evaluate swallow Rational: Osmotic demyelination, also known as central pontine myelinolysis, is nerve damage caused by the destruction of the myelin sheath covering nerve cells in the brainstem. The most common cause is a rapid, drastic change in sodium levels when a client is being treated for hyponatremia, a common occurrence in SIADH Difficulty swallowing due to brainstem nerve damage should be care but determining the client's risk for aspiration is most important

A client who is admitted to the intensive care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first?

Urine output 20

A client who is at 36 weeks gestations is admitted with severe preclamesia. After a 6 gram loading dose of magnesium sulfate is administered, an intravenous infusion of magnesium sulfate at a rate of 2 grams/hour is initiated. Which assessment finding warrants immediate intervention by the nurse?

Waste 0.5 ml from the pre-filled syringe and inject the medication in the ventrogluteal site. RATIONALE: The pre-filled contain 30mg/1ml, so 0.5ml should be wasted to obtain the correct dosage of 15mg for administration in the preferred IM ventrogluteal site. The nurse is responsible for calculating and preparing the

A client who is experiencing musculoskeletal pain receives a prescription for ketorolac 15mg IM q6 hours. The medication is depended in a 39mg/ml pre-filled syringe. Which action should the nurse implement when giving the medication?

Recognize signs and symptoms of hypoglycemia. Report persist polyuria to the healthcate provider Take Glucophage with the morning and evening meal.

A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client's teaching plan? (Select all that apply.)

. The body cells develop resistance to the action of insulin.

A client who is recently diagnosed with type 2 diabetes mellitus (DM) ask the nurse how this type of diabetes leads to high blood sugar. What Pathophysiology mechanism should the nurse explain about the occurrence of hyperglycemia in those who have type 2 DM?

Explain that vomiting can occur during surgery Withhold the preoperative medication

A client who is schedule for an elective inguinal hernia repair today in day surgery is eating in the waiting area. What action should be taken by the nurse who is preparing to administer the preoperative medications?

Toasted wheat bread and jelly

A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset What snack should the nurse instruct the client to take with the tetracycline?

The additive effect of multiple medications has caused the blood pressure to drop too low

A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse's decision to hold the client's scheduled antihypertensive medication?

Teach tracheal suctioning techniques

A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan?

Confusion and papilledema

A client who sustained a head injury following an automobile collision is admitted to the hospital. The nurse include the client's risk for developing increased intracranial pressure (ICP) in the plan of care. Which signs indicate to the nurse that ICP has increased?

Plan volume-controlled evenly-space meal thorough the day Rationale: It is most important for the client to learn how to eat without damaging the surgical site and to keep the digestive system from dumping the food instead of digesting it. Eating volume-control and evenly-space meals thorough the day allows the client to fill full, avoid binging, and eliminate the possibility of eating too much one time. Chewing slowly and thoroughly helps prevent over eating by allowing a filling of fullness to occur. Taking sips, rather than large amounts of fluids keeps the stomach from overfilling and allow for adequate calories to be consumed. Gas forming foods and fatty foods should be avoiding to decrease risk of dumping syndrome and flatulence.

A client who underwent an uncomplicated gastric bypass surgery is having difficult with diet management. What dietary instruction is most important for the nurse to explain to the client?

Stop the normal saline infusion.

A client who was admitted yesterday with severe dehydration is complaining of pain a 24 gauge IV with normal saline is infusing at a rate of 150 ml/hour. Which intervention should the nurse implement first?

Risk for self-directed violence related to impulsive actions

A client whose wrists are sutured from a recent suicide attempt is been transferred from a medical unit. Which nursing diagnosis is of the highest priority?

Headache and tremors Postural hypotension e Pallor and diaphoresis . Irregular heart beat

A client with Addison's crisis is admitted for treatment with adrenal cortical supplementation. Based on the client's admitting diagnosis, which findings require immediate action by the nurse? (Select all that apply)

Confirn the desired effect of the medication has been achieved.

A client with Alzheimer's disease (AD) is receiving trazodone (Desyrel), recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client's mood and sleep patterns are improved, but there is no change in cognitive ability. How should the nurse respond to this information?

Left forearm hematoma Rationale: The left forearm hematoma may be indicative an injury, such as broken bone, toilet due to the fall. Disorientation is common symptom of Alzheimer' s disease. Dislodged is not an urgent concern

A client with Alzheimer's disease falls in the bathroom. The nurse notifies the charge nurse and completes a fall follow-up assessment. What assessment finding warrants immediate intervention by the nurse?

Full bladder Rational: a pounding headache is a sign of autonomic hyperreflexia, an acute emergency that occurs because of an exaggerated sympathetic response in a client with a high level spinal cord injury. Any stimulus below the level of injury can trigger autonomic hyperreflexia, but the most common cause is an overly distended bladder. The other options are unlikely to produce the manifestation of autonomic hyperreflexia.

A client with C-6 spinal cord injury rehabilitation. In the middle of the night the client reports a severe, pounding headache, and has observable piloerection or "goosebumps". The nurse should asses for which trigger?

Urinary output of 25mL per hour

A client with HIV and pulmonary coccidioidomycosis is receiving amphotericin B. which assessment finding should the nurse report to the healthcare provider?

Provide daily care of tong insertion sites using saline and antibiotic ointment

A client with a cervical spinal cord injury (SCI) has Crutchfield tongs and skeletal traction applied as a method of closed reduction. Which intervention is most important for the nurse to include in the client's a plan of care?

Administer the analgesic as reqpested

A client with a history of chronic pain requests a analgesic. The client is alert but has difficulty describing the exact nature and location nonopioid 0 of the pain to the nurse. Which action should the nurse implement next?

.Administer the analgesic as requested

A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. What action should the nurse implement next?

Muffled heart sounds Rationale: Muffled heart sounds may indicative fluid build-up in the pericardium and is life- threatening. The other one are signs of end stage liver disease related to alcoholism but are not immediately life- threatening.

A client with a history of cirrhosis and alcoholism is admitted with severe dyspmea and ascites. Which assessment finding warrants immediate intervention by the nurse?

Redress the abdominal incision Rationale: The abdominal incision should be redressed using aseptic-techniques. The IV site should be assessed to ensure that not been dislodged and a dressing reapplied, if need it. Leaving the light on at night may interfere with the client's sleep and increase confusion. Restraints are not indicated and should only be used as a last resort to keep client from self-harm.

A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (V) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the nurse implement?

Titrate the dopamine infusion to raise the BP. Rationale: the client is experiencing cardiogenic protocol of the vasoactive secondary infusion, dopamine, to increase the blood shock and requires titration per pressure. Low hourly urine output is due to shock catheter irrigation. Pacing is not indicated glucose should be monitored but is not directly indicated at this time and does not indicate a need for based on the client's capillary blood

A client with a history of diabetes and coronary artery disease is admitted with shortness of breath, anxiety, and confusion. The client's blood pressure is 80/60 mmHg, heart rate 120 beats/minute with audible third and fourth heart sounds, and bibasilar crackles. The client's average urinary output is 5 mlhour. Normal saline is infusing at 124 ml/hour with a secondary infusion of dopamine at mcgkg/minute per infusion pump With intervention should the nurse implement?

Obtain a list of medications taken for cardiac histony

A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and palpitations. Which finding is most important for the nurse to assess to the client?

The client has asymmetrical chest wall expansion Rationale: A potential complication of thoracentesis is a pneumothorax. The symptoms of a pneumothorax are uneven, unequal movement of the chest wall. A is an expected finding after the local anesthetic effects "wear off" B is a desired result of thoracentesis and C is within normal limits.

A client with a large pleural effusion undergoes a thoracentesis . Following the procedure, which assessment finding warrants immediate intervention by the nurse?

Cinnamon applesauce RATIONALE: Dairy products and calcium fortified dairy products decrease the absorption of ciprofloxacin. Cinnamon applesauce contains no calcium, so this is the best snack selection. Since other options contains calcium, these snack should be avoided by a client who is taking ciprofloxacin.

A client with a lower respiratory tract infection receives a prescription for ciprofloxacin 500mg PO q 12hours. When the client request an afternoon snack, which dietary choice should the nurse provide?

Keep room temperature 80

A client with a new diagnosis of Raynaud's disease lives alone. Which instruction should the nurse include in the client's discharged teaching plan?

Observe the antecubital fossa for inflammation.

A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform?

Obtain a wound swab for culture and sensitivity

A client with a postoperative wound that eviscerated yesterday has an elevated temperature...most important for the nurse to implement?

The client's need for pain medication should be determined.

A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement?

.Avoid foods that caused gas before the colostomy

A client with a recent colostomy expresses concern about the ability to control flatus. Which intervention is most important for the nurse to include in the client's plan of care?

0.9 % sodium chloride solution ( normal saline )

A client with a serum sodium level of 125 mea/mL should benefit most from the administration of which intravenous solution?

Monitor the client's cardiac activity via telemetry. Rational: as insulin lowers the blood glucose of a client with diabetic ketoacidosis (DK.A), potassium returns to the cell but may not impact hyperkalemia related to acute renal failure. The priority is to monitor the client for cardiac dysrhythmias related to abnormal serum potassium levels. IV access, assessment of glucose level, and monitoring urine output are important interventions, but do not have the priority of monitoring cardiac function.

A client with acute renal failure (ARF) is admitted for uncontrolled type1 diabetes Mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is the most important for the nurse to include in this client's plan of care?

Avoid all isometric exercises, but walk regularly. Rationale: Isometric exercise can raise blood pressure for the duration of the exercise, which may be dangerous for a client with cardiovascular disease, while walking provides aerobic conditioning that improves ling, blood vessel, and muscle function.

A client with angina pectoris is being discharge from the hospital. What instruction should the nurse plan to include in this discharge teaching?

Hemoglobin client's hemoglobin to assess Rational: naproxen can cause gastric bleeding, so the nurse should monitor the for possible bleeding. Other options are not likely to be affected by the used of naproxen and are not related to the client's current symptoms

A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor?

Avoid use of nonsteroidal ant-inflammatory drugs (NSAID)

A client with atrial fibrillation receives a new prescription for dabigatran. What instruction should the nurse include in this client's teaching plan?

The family reports a great reduction in client's maniac behavior

A client with bipolar disorder began taking valproic acid (Depakote) 250 mg PO three times daily two months ago. Which finding provides the best indication that the medication regimen is effective?

Chest pain and dysrhythmia

A client with bleeding esophageal varices receives vasopressin (Pitressin) IV. What should the nurse monitor for during the IV infusion of this medication?

Place the implant in a lead container using long-handled forceps

A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed What action should the nurse take?

Dry roasted almonds. Rational: alcoholism promotes inadequate food intake and gastrointestinal loss of magnesium include green leafy vegetables and nuts and seeds. Other snacks listed provide much lower amounts of magnesium per serving.

A client with chronic alcoholism is admitted with a decreased serum magnesium level. Which snack option should the nurse recommend to this client?

Monitor abdominal girth. Report serum albumin and globulin levels. Note signs of swelling and edema.

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? (Select all that apply.)

Prepare the skin for procedure.

A client with coronary artery disease who is experiencing syncopal episodes is admitted for an electrophysiology study (EPS) and possible cardiac ablation therapy Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)?

Reduced level of pain

A client with diabetic peripheral neuropathy has been taking pregabalin (Lyrica) for 4 days. Which finding indicates to the nurse that the medication is effective?

Topical corticosteroid. Oral antihstamine Rationale: anti-inflammatory actions of topical corticosteroids and oral antihistamines provide relief from severe pruritus (itching). Other options are not indicated

A client with eczema is experiencing severe pruritus. Which PRN prescriptions should the nurse administer? (Select all that apply)

Provide only necessary information in short, simple explanations with written instructions to take home .Rationale: Simple, short explanations should be provided. Information is not retained when the recipient is anxious, and too much information can increase worry. Ethically, discharge instructions may not be postponed

A client with emphysema is being discharged from the hospital. The nurse enters the client's room to complete discharge teaching. The client reports feeling a little short of breath and is anxious about going home. What is the best course of action?

Contact the regional organ procurement agency

A client with end-stage liver failure is declared brain dead. The family wants to discontinue feeding and donate any viable organs. Which action should the nurse take?

Two FHR accelerations of 15 beats / minute x 15 seconds are recorded

A client with gestational diabetes is undergoing a non-stress test (NST) at 34-week gestation.. .s 144 beats/minute. The client is instructed to mark the fetal monitor by pressing a button each time the baby moves. After 20 minutes, the nurse evaluates the fetal monitor strip. What..

Assist the client to sharply flex her thighs up again the abdomen. Rationale: Flexing the client's thighs against the abdomen (Mc Robert's maneuver) changes the angle g the pelvis and increase the pelvic diameter, making more room for the shoulders to emerge. ABD are implemented after C

A client with gestational diabetes, at 39 weeks of gestation, is in the second stage of labor. After delivering of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first?

Report increased bruising of bleeding

A client with hypertension receives a prescription for enalapril, an angiotensin..instruction should the nurse include in the medication teaching plan?

.Total calcium 5.0 mg/d

A client with hyperthyroidism is admitted to the postoperative after subtotal thyroidectomy: Which of the client's serum laboratory values requires intervention by the nurse?

Describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider

A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included in preparing this client for this treatment?

Decrease in pulse rate

A client with hyperthyroidism is receiving propranolol (Inderal). Which finding indicates that the medication is having the desired effect?

Notify the healthcare provider

A client with hyperthyroidism who has not been responsive to medications is admitted for evaluation. What action should the nurse implement? (Click on each chart tab for additional information. Please scroll to the bottom right corner of each tab to view all information contained in the client's medical record.)

Serum potassium level of 3.1 mEaL or mmolL (ST) Rationale: The normal potassium level in the blood is 3.5-5.0 miliiqivalents per liter (mEg/L).

A client with intestinal obstructions has a nasogastric tube to low intermittent suction and is receiving an IV of lactated ringer's at 100 ml/H. which finding is most important for the nurse to report to the healthcare provider?

Observe aspiration site.

A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure?

Temporary vasodilation

A client with multiple sclerosis (MS) has decreased motor function after taking a hot bath (Uhthoff s sign). Which pathophysiological mechanism supports this response?

Schedule frequent rest periods Provide assistance to bedside commode e Teach to patch one eye when ambulating

A client with multiple sclerosis (MSy ls admitted to the medical unit. The client reports..which action should the nurse implement to reduce the client's risk for falls?

Teach family proper range of motion exercises.

A client with muscular dystrophy is concerned about becoming totally dependent and is reluctant to call the nurse to assist with activities of daily living (ADLs). To achieve maximum mobility and independence, which intervention is most important for the nurse to include in the client's plan of care?

Observe rhythm on telemetry monitor Rationale: If not treated a low little Serum magnesium level can affect myocardial depolarization leading to a lethal arrhythmia, and the nurse should assess for dysrhythmias before contacting the healthcare provider. Other choices are common in MG but do not contribute the Safety risk of low magnesium levels.

A client with myasthenia Gravis (MG) is receiving immunosuppressive therapy Review recent laboratory test results show that the client's serum magnesium level has decreased below the normal range. In addition to contacting the healthcare provider, what nursing action is most important?

Determine if the sensation feels uncomfortable. Rational: electronic stimulators, such as a transelectrical nerve stimulator (TENS) unit, have been found to be effective in reducing low back pain by "closing the gate" to pain stimuli. A tingling sensation should be felt when the power is turned on, and the nurse should assess whether the sensation is too strong, causing discomfort or muscle twitching. Decreasing the electrical signal may be indicated if the sensation is too strong. Other options are not necessary because the tingling sensation is expected.

A client with persistent low back pain has received a prescription for electronic stimulator (TENS) unit. After the nurse applies the electrodes and turns on the power, the client reports feeling a tingling sensation. How should the nurse respond?

Obtain a prescription to increase the IV rate

A client with pneumonia has an IV of lactated ringer's solution infusing at 30ml/br current labor...sodium level of 155 mEa/L, a serum potassium level of 4mEq/L... what nursing intervention is most important?

Institute coughing and deep breathing protocols

A client with pneumonia has arterial blood gases levels at: PH 7.33; Paco2 49 mm/hg: HC03 25 mEaus Pao2 95 , what intervention should the nurse implement based on these results?

Teach the client how to use a dry heating pad over the painful area

A client with polycystic kidney disease (PKD) recelving antibiotics for an infected cyst is experiencing severe pain. What action should the nurse implement?

Obtain vital signs and breath sounds. Rational: the client's baseline cardiovascular status should be determined before conducting the fluid challenge. If the client manifests changes in the vital signs and breath sounds associated with pulmonary edema, the administration of the fluid challenge should be terminate. Other options would not assure a safe administration of the medication.

A client with possible acute kidney injury (AKI) is admitted to the hospital and l is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement?

Evaluate daily blood clotting factors.

A client with rapid respirations and audible rhonchi is admitted to the intensive care unit because of a pulmonary embolism (PE). Low-flow oxygen by nasal cannula and weight based heparin protocol is initiated. Which intervention is most important for the nurse to include in this client's plan of care?

Persistent fever Rationale: Enbrel decrease immune and inflammatory responses, increasing the client's risk of serious infection, so the client should be instructed to report a persistent fever, or other signs of infection to the healthcare provider

A client with rheumatoid arthritis (RA) starts a new prescription of etanercept Enbrel) subcutaneously once weekly. The nurse should emphasize the importance of reporting problem to the healthcare provider?

Human source grafts require monitoring for signs of graft rejection

A client with severe full-thickness burns is scheduled for an allografting procedure. Which information should the nurse provide the client?

.Mucous membranes cherry red color

A client with superficial burns to the face, neck, and hands resulting from house fire...which assessment finding indicates to the nurse that the client should be monitored for carbon monoxide...

Measure blood glucose Monitor vital signs .Assessed level of consciousness Rationale: Blood glucose greater than 600 mg/dl (33.3 mmolL SD), vital sign changes in mental awareness are indicators of possible HHNS. Urine ketones are monitored in diabetic ketoacidosis. Wound culture is performed prior to treating the wound infection but is not useful in monitoring for HHNS

A client with type 2 diabetes mellitus is admitted for antibiotic treatment for a leg ulcer. To monitor the client for the onset of hyperosmolar hyperglycemic nonketotic syndrome (HHNS), what actions should the nurse take? (Select all that apply)

Fingerstick glucose assessment góh with meals Review with the client proper foot care and prevention of injury Coordinate carhohydrate controlled meals at consistent times and intervals .Teach subcutaneous injection technique, site rotation and insulin management

A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin ( HbA1c ) of 10 % . Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale with insulin aspart qóh are prescribed. What action should the nurse include in this client's plan of care?

Nausea and indigestion.

A client with urticaria due to an environmental allergies is taking diphenhydramine.. Which complaint should the nurse identify to the client as a side effect of the OTC medication?

Provide immediate defibrillation

A client's telemetry monitor indicates ventricular fibrillation (VF). What should the nurse do first?

Explore the client's decision to refuse treatment and offer support Rationale : 照 long AS the client is alert , oriented and aware of the disease prognosis sis, the healthcare team must abide by her decisions. Exploring the decision with the client and offering support provides a therapeutic interaction and allows the client to Other options are essentially arguing express her fears and concerns about her quality of life. with the client's decisions regarding her end of life treatment or diminish the opportunity for the client to discuss her feelings

A clinical trial is recommended for a client with metastatic breast cancer, but she refuses to participate and tells her family that she does not wish to have further treatments. The client's son and daughter ask the nurse to try and convince their mother reconsider this decision. How should the nurse respond?

.Establish trust with community leaders and respect cultural and family values

A community health nurse is concerned about the spread of communicable diseases among migrant farm workers in a rural community. What action should the take to promote the success of healthcare designed to address problem?

A client must be willing to accept palliative care, not curative care The healthcare provider must project that the client has 6 months or less to live

A family member of a frail elderly adult asks the nurse about eligibility requirements for hospice care. What information should the nurse provide? (Select all that apply.)

Acknowledge the client's stress and sugsest that she consider respite care. Rationale: When this amount of disclosure is offered, the client is usually seeking information focuses on the client's expression of worry, concern and stress and addresses the client's need to initiate a request for assistance with respite care

A female client comes to the clinic complaining of fatigue and inability to sleep because she is the full-time caretaker for 22-year-old son who was paralyzed by a motor vehicle collision. She adds that her husband left her because he says he can't take her behavior any more since all she does is care for their son. What intervention should the nurse implement?

Measure vital signs

A female client has been taking a high dose of prednisone, a corticosteroid, for sev months. After stopping the medication abruptly, the client reports feeling "very tired" Which nursing intervention is most important for the nurse to implement?

Ask the client to discuss "do not resuscitate" with her healthcare provider

A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining of shortness of breath. The client tells the nurse that she wants "no heroic measures" taken if she stops breathing, and she asks the nurse to document this in her medical record. What action should the nurse implement?

Encourage the client to continue expressing her fears and concerns Rational: the nurse should show support for the client by encouraging her to continue expressing her concerns. A diagnosis has not yet been made, so it is too early to discuss treatment options. Other options dismiss the client's feelings or are premature given that the diagnosis is not yet made.

A female client is extremely anxious after being informed that her mammogranm was abnormal and needs to be repeated. Client is tearful and tells the nurse her mother died of breast cancer. What action should the nurse take?

Report the client's jaw pain to the healthcare provider.

A female client is taking alendronate, a bisphosphate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

Explore the client 's reasons for wanting to be discharged .

A female client on the mental health unit frequently asks the nurse when she can be discharged. Then, becoming more anxious, she begins to pace the hallway. What intervention should the nurse implement first?

Has she taken a bath since the raped occurred? RATIONALE. The priority action is collected the forensic evidence, so asking if the has taken a bath since the rape occurred is the most important information to obtain. Other options are used by law enforcement to determine the perpetrator and are not vital in providing client care at this time.

A female client presents in the Emergency Department and tells the nurse that she was raped last night. Which question is most important for the nurse to ask?

Take on an empty stomach with a full glass of water

A female client receives a prescription for alendronate sodium (Fosamax) to treat her newly diagnose osteoporosis. What instruction should the nurse include in the client's teaching plan?

Digitally check the client for a fecal impaction

A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amount of liquid stool. Which action should the nurse implement?

Have you noticed any changes in your fingernails?

A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the nurse to ask?

760 Rationale: 1L-1000ml Subtract the emesis, 1 cup (8 oz) 240ml 1000-240-760 ml

A female client reports that she drank a liter of a solution to cleanse her intestines..mmediately. How many ml of fluid intake should the nurse document? Whole number

Rented movies and borrowed books to use while passing time at home

A female client with breast cancer who completed her first chemotherapy treatment today at an out-patient center is preparing for discharge. Which behavior indicates that the client understands her care needs

Advise the client to empty her bladder fully when she first voids

A female client with chronic urinary retention explains double voiding technique to the nurse by stating she voids partially, hold the remaining urine in her bladder for three minutes, then voids again to empty her bladder fully. How should the nurse respond?

Advise the client to empty her bladder fully when she first voids

A female client with chronic urinary retention explains double voiding technique to the nurse by stating she volds partilly, hold the remaining urine in her bladder for three minutes, then voids again to empty her bladder fully, How should the nurse respond?

Therapeutic exercise included in daily routine.

A female client with rheumatoid arthritis (RA) comes to the clinic complaining of joint pain and swelling. The client has been taking prednisone (Deltasone) and ibuprofen (Motrin Extra Strength) every day. To assist the client with self-management of her pain, which information should the nurse obtain?

creatinine clearance 25 mL / minute

A female client with severe renal impairment is receiving enoxaparin (UevenRx) 30 ma SUBQ BID Which laboratory value due to enoxaparin should the nurse report to the healthcare provider?

.Request the mother to leave the room

A gravida 2 para 1, at 38-weeks gestation, scheduled for a repeat cesarean section in one week, is brought to the labor and delivery unit complaining of contractions every 10 minutes. While assessing the client, the client's mothers enter the labor suite and says in a loud voice, "I've had 8 children and I know she's in labor. I want her to have her cesarean section right now!" what action should the nurse take?

How many departments can use this equipment?

A group of nurse-managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organization's budget. Which question is most important to consider when analyzing the cost-benefit for this piece of equipment?

Plan an interdisciplinary staff meeting to develop strategies to enhance client care

A health care provider continuously dismisses the nursing care suggestions made by staff nurses. As a result. .dealing with the healthcare provider. What action should the nurse- manager implement?

Pulse increase of 10 beats/minute

A low-risk primigravida at 28-weeks gestation arrives for her regular antepartal clinic visit. Which assessment finding should the nurse consider within normal limits for this client?

Allow several minutes for the client to respond

A male Korean-American client looks away when asked by the nurse to describe his problem. What is the best initial nursing action?

.Be sure to take the multivitamin and the medication at least two hours apart for best absorption and effectiveness

A male client has received a prescription for orlistat for weight and nutrition management. In addition to the medication, the client states he plans to take a multivitamin. What teaching should the nurse provide?

Hyperextended with neck supported by a rolled towel.

A male client is admitted with burns to his face and neck. Which position should the nurse place the client to prevent contract?

Turkey salad sandwich.

A male client is discharged from the intensive care unit following a myocardial infarction, and the healthcare provider low-sodium diet. Which lunch selection indicates to the nurse that this client understands the dietary restrictions?

Surgeon needs to see client immediately to evaluate the situation

A male client is having abdominal pain after a left femoral angioplasty and stent, and is asking for additional pain medication for right lower quadrant pain (9/10), two hours ago, he received hydrocodone/acetaminophen 7.5/7.50 mg his vital signs are elevated from a previous hour: temperature 97.8 F, heart rate 102 beats/ minute, respiration 20 breaths/minutes. abdomen is swollen, the groin access site is tender, peripheral pulses are present, but left is greater than right. Preoperatively, clopidrogel was prescribed for a history of previous peripheral stents. Another nurse is holding manual pressure on the femoral arterial access site which may be leaking into the abdomen. What data is needed to make this report complete?

Monitor urine output hourly.

A male client is returned to the surgical unit following a left nephrectomy and is medicated with morphine. His dressing has a small amount of bloody drainage, and a Jackson- Pratt bulb surgical drainage device is in place. Which interventions is most important for the nurse to include in this clients plan of care?

Asses for contraindications for thrombolytic therapy

A male client notifies the nurse that he feels short of breath and has chest pressure radiating down his left arm. A STAT 12-lead electrocardiogram (ECG) is obtained and shows ST segment elevation in leads II, II, aVE and V4R. The nurse collects blood samples and gives a normal saline bolus. What action is most important for the nurse to implement?

Send stool sample to the lab for a guaiac test

A male client receives a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, what action should the nurse implement?

Schedule the client for the chest radiograph . Obtain sputum for acid fast bacillus (AFB) testing * Place a mask on the client until he is moved to isolation.

A male client recently released from a correctional facility arrives at the clinic with a cough, fever, and chills. His history reveals active tuberculosis (TB) 10 years ago. What action should the nurse implement? (Select all that apply)

Serum calcium

A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab is important for the nurse to review before contacting the health care provider?

Stroke

A male client reports to the clinic nurse that he has been feeling well and is often dizzy" his blood pressure is elevated. Based on this findings, this client is at a greatest risk for which pathophysiological condition?

Teach client to listen to music or audio books while driving Rationale: Desensitization is component in the treatment plan for clients with panic attacks which is best approached with anxiety-reducing strategies, such as listening to audio book (B) during situation that precipitate symptoms (A) is a flooding technique that requires professional guidance.

A male client returns to the mental health clinic for assistance with his anxiety reaction that is manifested by a rapid heartbeat, sweating, shaking, and nausea while driving over the bay bridge. What action i the treatment plan should the nurse implement?

Encourage the client to obtain a complete physical exam since these symptoms are consistent with an ulcer

A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and a dull growing pain that is relieved when he eats. What is the best response by the nurse?

Determine the client's responsiveness and respirations Rationale: Activities, such as brushing teeth, can mimic the waveform of Vi, so first he client should be assessed (A) to determine if the alarm is accurate. The crash cart can be brought to the room by someone else and defibrillation (B) delivered as indicated by the client's rhythm. Based on as assessment of the client, CPRG as summoning the emergency response team (D) may be indicated.

A male client was transferred yesterday from the emergency department to the telemetry unit because he had ST depression and resolved chest pain. When his EKG monitor alarms for ventricular tachycardia (VT). what action should the nurse take ke first? first?

Serum lithium level of 1.6 mEa/L or mmoll (SI)

A male client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the healthcare provider?

Fresh horseradish

A male client who was admitted with an acute myocardial infarction receives a cardiac diet with sodium restriction and complains that his hamburger is flavorless. which condiment should the nurse offer?

Hypocapnia reduces ICP

A male client who was hit by a car while dodging through traffic is admitted to the emergency department with intracranial pressure (ICP). A computerized tomography (CT) scan reveals an intracranial bleed. After evacuation of hematoma, postoperative prescription include intubation with controlled mechanical ventilation to PacO2.what is the pathophysiological basis for this ventilator settings?

After I squeeze the inhaler and swallow, I always feel a slight wave of nausea, bit it goes away

A male client with COPD smokes two packs of cigarettes per day and is admitted to the hospital for a respiratory infection. He complains that he has trouble controlling respiratory distress at home when using his rescue inhaler. Which comment from the client indicates to the nurse that he is not using his inhaler properly?

Observe for changes in level of consciousness. Rationale: Based on the client's history of drinking, he may be exhibiting sing of hepatic involvement and encephalopathy. Changes in the client's level of consciousness should be monitored to determine if he able to maintain consciousness, so neurological assessment has the highest priority

A male client with a long history of alcoholism is admitted because of mild confusion and fine motor tremors. He reports that he quit drinking alcohol and stopped smoking cigarettes one month ago after his brother died of lung cancer. Which intervention is most important for the nurses to include in the client's plan of care?

Ask the client about his expected goals for the hospitalization Rationale: Palliative care measures provide relief or control of symptoms, so it is important for the nurse to determine the client's goals for symptom control while receiving treatment in the hospital. Although home care is available the client may not be legible for palliative care at home. Radiation therapy is an effective positive care measure used to manage symptoms and would be appropriate unless the radiation conflicts with the client goals.

A male client with cancer is admired to the oncology unit and tells the nurse that he is in the hospital for palliative care measures. The nurse notes that the client's admission prescription include radiation therapy. What action should the nurse implement?

Suggest the use of alternative sources of protein such as dairy products and nuts

A male client with cancer who has lost 10 pounds during the last months tells the nurse that beef, chicken, and eggs, which used to be his favorite foods, now they taste "bitter". He complains that he simply has no appetite. What action should the nurse implement?

Ecchymosis and hematemesis

A male client with cancer, who ts recelving antineoplastic drugs,is admitted to the..what findings is most often manifest this condition?

Raise the head of the bed to a Fowler's position and support his arms with a pillow

A male client with cirrhosis has ascites and reports feeling short of breath. The client is in semi Fowler position with his arms at his side. What action should the nurse implement?

Stroke secondary to hemorrhage

A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him feel bad. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?

Assign a UAP to assist the client with a warm shower early in the morning

A male client with rheumatoid arthritis is schedule for a procedure in the morning The..u.nable to complete the procedure because of early morning stiffness. Which intervention...mplement?

Encourage him to use an electric razor Rationale: This client is at risk for bleeding based on his platelet count (normal 150,000 to 400,000/ mm3). Safe practices, such as using an electric razor for shaving, should be encouraged to reduce the risk of bleeding

A male client's laboratory results include a platelet count of 105,000/ mm3 Based on this finding the nurse should include which action in the client's plan of care?

Auscultate bowel sounds in all four quadrants

A male client, who is 24 hours postoperative for an exploratory laparotomy, complains that he is "starving" because he has had no "real food" since before the surgery. Prior to advancing his diet, which intervention should the nurse implement?

Graves' disease, an autoimmune condition, affects thyroid stimulating hormone receptors T3 and T4 hormone levels are increased Large protruding eyeballs are a sign of hyperthyroid function

A middle-aged woman, diagnosed with Graves' disease, asks the nurse about this condition. Which etiological pathology should the nurse include in the teaching plan about hyperthyroidism? (Select all that apply)

Notify the healthcare provider and obtain a tracheostomy tray

A mother brings her 3-year-old son to the emergency room and tells the nurse the he has had an upper respiratory infection for the past two days. Assessment of the child reveals a rectal temperature of 102 F. he is drooling and becoming increasingly more restless. What action should the nurse take first?

This hernia is a normal variation that resolves without treatment. Rational: an umbilical hemia is a normal variation in infants that occurs due to an incomplete fusion of the abdominal musculature through the umbilical ring that usually resolves spontaneously as the child leans to walk. Other choices are ineffective and unnecessary.

A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus, and tells the nurse the quarter is supposed to fix her child's hemia. Which explanations should the nurse provide?

Withhold this dose

A mother calls the nurse to report that at 0900 she administered a PO dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine, what instruction should the nurse provide to this mother

Instruct the mother to take the teen to the emergency room

A n adolescent's mother calls the clinic because the teen is having recurrent vomiting and..Ccombative in the last 2 days. The mother states that the teen takes vitamins, calcium, mag..With aspirin. Which nursing intervention has highest priority?

Participated actively in all treatments regimens Rationale: indicates active participation by the client, which is required for treatment to be successful. The best plan of care should incorporate the valued and treatments of both cultures and in this case there is no apparent cultural cl between the two forms of treatment. The client has already identify he's cultural values (A).(B) Only considers one of the two treatment modalities desired by the client the client has already chosen how he wishes to assimilate his cultural with the prescribed medical treatment (D).

A native-American male client diagnosed with pneumonia, states that in addition to his prescribed medical treatment ofⅣ antibiotics he wishes to have a spiritual cleaning performed. Which outcome statement indicates that the best plan of care was followed?

Give O2 at 6 L / nasal cannula for 3 repeated oximetry screens below 90 % Evaluate heart rate for effectiveness of cardio tonic medications Use high energy formula 30 calories/ounce at Q3 hours feeding via soft nipples Ensure Interrupted and frequent rest periods between procedures

A neonate with a congenital heart defect (CHD) is demonstrating symptoms of heart failure (HF). Which interventions should the nurse include in the infant's plan of care?

Ask the new person to move belonging to accommodate others

A new member joins the nursing team spreads books on the table, puts items on two chairs, and sits on a third chair. The members of the group are forced to move closer and remove their possessions from the table what action should the nurse leader take?

Determine if she can ask for support from family, friend, or the baby's father

A new mother tells the nurse that she is unsure if she will be able to transition into parenthood. What action should the nurse take?

Clopidogrel (Plavix), an antiplatelet agent, given orally Methytprednisolone isalumcdrol), a corticosteroid, to be given IV Enoxaparin (lexengs),a low-molecular weight heparin to be given subcutaneous

A newly admitted client vomits into an emesis basin as seen in the picture. The nurse should consult with the healthcare provider before administering which of the client's prescribes medications?

I'll change your assignment, but let's talk about you a nurse should respond to this kind of client.

A newly graduated female staff nurse approaches the nurse manager and request reassignment to another client because a male client is asking her for a date and making suggestive comments. Which response is best for the nurse manager to provide?

Hypernatremia

A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants immediate intervention by the nurse?

Condition of hair, nails, and skin Rationale: the assessment of hair, nails, and skin is most effective of long-term nutritional status, which is important in the healing

A nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual nutritional status?

Marinating pain level below 4 when implementing outpatient pain clinic strategies .Rationale: An outpatient pain clinic provides the interdisciplinary services needed to manage chronic pain. Also the client has a terminal disease and is being discharge hone, hospice and health care are not indicating at this time. Short term counseling is not an option.

A nurse is planning discharge care for a male client with metastatic cancer. The client tells the nurse that he plans to return to work despite pain, fatigue, and impending death. Which goals is most important to include in this client's plan of care?

Allow the infant to rest before feeding

A nurse is preparing to feed a 2-month-old male infant with heart failure who was born with congenital heart defect. Which intervention should the nurse implement?

Contact the healthcare provider immediately to report the laboratory value regardless of the advice

A nurse plans to call the healthcare provider to report an 0600 serum potassium level of 2 mEg/L or mmol/L (SI), but the charge nurse tells the nurse that the healthcare provider does not like to receive early morning calls and will make rounds later in the morning. What action should the nurse make?

Allow time for the behavior and then redirect the clients to other activities

A nurse receive a shift report about a male client with Obsessive compulsive disorder (OCD). The nurse does morning rounds and reaches the client while he is repeatedly washing the top of the same table. What intervention should the nurse implement?

Stabilize the victim's neck and roll over to evaluate his status

A nurse stops at the site of a motorcycle acident and finds a young adult male lying face down in the road in a puddlie of water. It is raining, no one is available to send for help, and cell phone is in the about 50 feet away. What action should the nurse take first?

Chest discomfort one hour after consuming a large, spicy meal Rationale: Emergency triage involves quick assessment to prioritize the need for further evaluation and care. Those with trauma, chest pain, respiratory distress, or acute neurological changes are priority. In this example, while clients with other conditions require attention, the client with chest discomfort is at greatest risk and is a priority

A nurse who is working in the emergency department triage area is presented with four clients at the same time. The client presented with which symptoms requires the most immediate intervention by the nurse?

place the id bands on the infant and mother

A nurse who works in the nursery is attending the vaginal delivery of a term infant. What action should the nurse complete prior to leaving the delivery room?

mother with an infected episiotomy

A nurse with 10 years experience working in the emergency room is reassigned to the perinatal unit to work an 8 hour shift. Which client is best to assign to this nurse?

A client taking corticosteroids who has become disoriented in the last two hours. Rational meeting the client's psychosis can occur during need for safety is a priority corticosteroids therapy, places the client at risk for intervention. Mania and injury, so the patient taking corticosteroids should be seen first.

A nurse working on an endocrine unit should see which client first?

Skills of staff and client acuity

A nurse-manager is preparing the curricula for a class for charge nurses. A staffing formula based on what data ensures quality client care and is most cost-effective?

Administer Naxclone IV

A postoperative female client has a prescription for morphine sulfate 10 mg IV q3 hours for pain. One dose of morphine was administered when the client was admitted to the post anesthesia care unit (PACU) and 3 hours later, the client is again complaining of pain. Her current respiratory rate is 8 breaths/minute. What action should the nurse take?

Catheterize for residual urine after next voiding

A postpartal client complains that she has the urge to urinate every hour but is only able to void a small amount. What interventions provides the nurse with the most useful information?

Continue with the plan of care for this client Rationale: continue with the plan. Diuresis in 24 to 48h after birth is a sign of improvement in the preeclamptic client. As relaxation of arteriolar spasms occurs, kidney perfusion increases. With improvement perfusion, fluid is drawn into the intravascular bed from the interstitial tissue and then cleared by the kidneys

A preeclamptic client who delivered 24h ago remains in the labor and delivery ecovery room. She continues to receive magnesium sulfate at 2 grams per hour. Her total input is limited to 125 ml per hour, and her urinary output for the last hour was 850 ml. What intervention should the nurse implement?

.Ask the older brother how he felt during the incident.

A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to child, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. What action should the nurse take?

Continue to monitor the client's blood pressure hourly

A primigravida a 40-weeks gestation with preeclampsia is admitted after having a seizure in the hot tub at a midwife's birthing center. Based on documentation in the medical record, which action should the nurse implement? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client's medical record.)

Administer Oxygen via face mask

A primigravida client is 36 weeks gestation is admitted to labor and delivery unit because her membranes ruptured 30minutes ago . Initial assessment indicates 2cm dilation , 50 % effaced, -2 station, vertex presentation greenish colored amniotic fluid, and contractions occurring 3-5 minutes with a low FHR after the last contraction peaks:

Encourage the client to eat finger foods.

A resident of a long-term care facility, who has moderate dementia, is having difficulty eating in the dining room. The client becomes frustrated when dropping utensils on the floor and then refuses to eat. What action should the nurse implement?

Sitting up and leaning forward

A school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In what position should the nurse place the child?

The child should avoid eating homemade cookies and cupcakes during parties

A school-aged child was recently diagnosed with celiac disease. Which instruction should the nurse give the classroom teacher?

Administered Nebulized Epinephrine

A toddler presents to the clinic with a barking cough, strider, refractions with respiration, the child's skin is pink with capillary refill of 2 seconds. Which intervention should the nurse implement?

Obtain a pulse oximeter reading

A toddler with a history of an acyanotic heart defect is admitted to the pediatric intensive...rate of 60 breaths/ minute, and a heart rate of 150 beats/minute. What action should the nurse take?

Ensure the transparent dressing has no tears that might create vacuum leaks

A vacuum-assistive closure (VAC) device is being use to provide wound care for a client has stage III pressure ulcer on a below-the- knee (BKA) residual limb. Which intervention should the nurse implement to ensure maximum effectiveness of the device?

Encourage screening for a peptic ulcer

A woman just learned that she was infected with Heliobactet pylori. Based on this finding, which health promotion practice should the nurse suggest?

Uncontrollable drooling

A woman who takes pyridostigmine for myasthenia gravis (MG) arrives at the emergency department complaining of extreme muscle weakness. Her adult daughter tells the nurse that since yesterday her mother has been unable to smile, which assessment finding warrants immediate intervention by the nurse?

Shock

A young adult client is admitted to the emergency room following a motor vehicle collision. The client's head hit the dashboard. Admission assessment include: Blood pressure 85/45 mm Hg, temperature 98.6 F, pulse 124 beat/minute and respirations 22 breath/minute. Based on these data, the nurse formulates the first portion of nursing diagnosis as "Risk of injury" What term best expresses the "related to" portion of nursing diagnosis?

Last menstrual period was 7 weeks ago Rationale: Acute lower abdominal pain in A young adult female can be indicative of an ectopic pregnancy, which can be life threatening. Since the clients last menstrual period was seven weeks ago a pregnancy test to be obtained to ruled out ectopic pregnancy, which can result in intra-abdominal hemorrhage caused by a ruptured Fallopian tube. Although the severity of pain requires treatment, the most significant finding is the clients last menstrual period. Other options the most important concerns

A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider?

infuse sodium chloride 0.9 % ( normal saline )

A young adult male is admitted to the emergency department with diabetic ketoacidosis (DKA). His pH is 7.25, Hco3 is 12 mEg/L or 12 mmol/L (SI), and blood glucose 310 mg/dl 17.2 mmol/L (Si). Which action should the nurse implement?

Evaluate the urine osmolality and the serum osmolality values.

A young adult male was admitted 36 hours ago for a head injury that occurred as the result of a motorcycle accident. In the last 4 hours, his urine output has increased to over 200 ml/H. Before reporting the finding to the healthcare provider, which intervention should the nurse implement?

Ask the client if he is worried about becoming schizophrenic at the age his mother was diagnosed.

A young adult male who is being seen at the employee health care clinic for an annual assessment tell the nurse that his mother was diagnosed with schizophrenia when she was his age and that life with a schizophrenic mother was difficulty indeed. Which response is best for the nurse to provide?

Altered consciousness within the first 24 hours after injury

A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma?

Altered consciousness within the first 24 hours after injury

A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative ofa developing epidural hematoma?

Explain that counseling will be provided to give her information about her cancer risk Rational: BRACA1or BRACA2 genetic mutation indicates an increased risk for developing breast or ovarian cancer and genetic counseling should be provided to explain the increased risk (A)to the client along with options for increased screening or preventative measures. (B) Is completed by the genetic counselor before the client undergoes genetic testing, a positive BRACAltest is not arn indicator of the presence of cancer and (C and D) are not appropriate responses prior to genetic counseling.

A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond?

Determine the mother's basic skill level in providing care. Rational: Although the mother states she is a capable caregiver, the client is manifesting disuse syndrome complications, and the mother's skill in providing basic care should be determined. Further assessment is needed before implementing other nursing actions.

A young boy who is in a chronic vegetative state and living at home is readmitted to the hospital with pneumonia and pressure ulcers. The mother insists that she is capable of caring for her son and which action should the nurse implement next?

Determine current sexual practice Rationale: First a history should be obtained including practices that might be related to the infertility, such as douching, daily ejaculation or the male partner's exposure to heat, such as frequent sauna or work environment which can decrease sperm production (A B or C) may be indicated after a complete assessment is obtained

A young couple who has been unsuccessful in conceiving a child for over a year is seen in the family planning clinic. During an initial visit, which intervention is most important for the nurse to implement?

One whole-wheat bagel with cream cheese, two strips of bacon, sik ounces of orange juice.

A-12-years old boy has a body mass index (BMI) of 28, a systolic pressure and a glycosylated hemoglobin ( HBAC ) of 7.8 % , which selection indicated that his mother understands the management of his diet?

Maintain strict aseptic technique.

A16-year-old male is admitted to the pediatric intensive care unit after being involved in a house fire. He has full thickness burns to his lower torso and extremities. Before a dressing change to his legs, which intervention is most important for the nurse to implement?

Thready brachial pulse.

A2-year-old is bleeding from a laceration on the right lower extremity that occurred as the result of a motor vehicle collision. The nurse is selecting supplies to start an IV access. Which assessment finding is most significant in the nurse's selection of catheter size?

The client will be restricted from eating seafood

A35 years old female client has just been admitted to the post anesthesia recovery unit following a partial thyroidectomy. Which statement reflects the nurse's accurate understanding of the expected outcome for the client following this surgery?

Malignancy

A59-year-old male client comes to the clinic and reports his concern over a lump that, "just popped up on my neck about a week ago." In performing an examination of the lump, the nurse palpates a large, nontender, hardened left subclavian lymph node. There is not overlying tissue inflammation. What do these findings suggest?

Palpate at the radial pulse site with the pads of two or three fingers.

Aclient has an intravenous fluid infusing in the right forearm. To determine the client's distal pulse rate most accurately, which action should the nurse implement?

. Simethicone (Mylicon

Aclient refuses to ambulate, reporting abdominal discomfort and bloating caused by too much gas buildup" the client's abdomen is distended. Which prescribed PRN medication should the nurse administer?

Creatinine 4 mg/dl (354il/L ST)

Aclient with osteoporosis related to long-term corticosteroid therapy receives a prescription for calcium carbonate. Which client's serum laboratory values requires intervention by the nurse?

Report the client's jaw pain to the healthcare provider.

Afemale client is taking alendronate, a bisphosphate, for postmenopausal osteoporosils. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

Prepare the cdient for intubation

Afemale client who was mechanically ventilated for 7 days is extubated. Two hours later..,productive cough, and her respirations are rapids and shallow. Which intervention is most important?

Blood pressure 170/98

After a routine physical examination, the healthcare admits a woman with a history of Systemic Lupus Erythematous (SLE) to the hospital because she has 3+ pitting ankle edema and blood in her urine. Which assessment finding warrants immediate intervention by the nurse?

Encourage a low-carbohydrate and high-protein diet peripherally

After a sudden loss of consciousness, a female client is taken to the ED and initial assessment indicate that her blood glucose level is critically low. Once her glucose level is stabilized, the client reports that was recently diagnosed with anorexia nervosa and is being treated at an outpatient clinic. Which intervention is more important to include in this client's discharge plan?

Capillary refill of 8 seconds

After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse?

Ask the client about gastrointestinal pain

After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?

Encouraging liberal fluid intake

After administering an antipyretic medication. Which intervention should the nurse implement?

.Place one hand on top of the other and interlace the fingers

After applying an alcohol-based hand rub to the palms of the hand and rubbing the hand together, what action should the nurse do next?

Bilateral Wheezing.

After changing to a new brand of laundry detergent, an adult male reports that he has a fine itchy rash. Which assessment finding warrants immediate intervention by the nurse?

Chest physiotherapy should be performed twice a day before a meal.

After diagnosis and initial treatment of a 3 year old with Cystic fibrosis, the nurse provides home care instructions to the mother, which statement by the child's mother indicates that she understands home care treatment to promote pulmonary functions?

Initiate intravenous fluid as prescribed .Rationale: Venous blood return to the heart and drains from the subclavian vein into the superior vena cava. The X-ray findings indicate proper placement of the CVC, so prescribed intravenous fluid can be started. A and B are not indicated at this time. The catheter should be secure immediate following insertion (C)

After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the x-ray findings that indicate the CVC tip is in the client's superior vena cava. Which action should the nurse implement?

Listen with the bell at the same location

After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an $3 heart sound is present, what action should the nurse take first?

.An older man whose sheets are damped each time he is turned. Rational: a Braden score of less than 18 indicates a risk for skin breakdown, and clients with such score require intensive nursing care. Constant moisture places the client at a high risk for skin breakdown, and interventions should be implemented to pull moisture away from the client's skin. Other options may be risk factors but do not have as high a risk as constant exposure to moisture.

After receiving the Braden scale findings of residents at a long-term facility, the charge nurse should to tell the unlicensed assistive personnel (UAP) to prioritize the skin care for which client?

Epinephrine Injection, USP IV

After receiving the first dose of penicillin, the client begins wheezing and has trouble breathing. The nurse notifies the healthcare provider immediately and received several prescriptions. Which medication prescription should the nurse administer first?

Unrelieved back and flank pain. Cool and pale left leg and foot Left groin egg-size

After removing a left femoral arterial sheath, which assessment finding warrant immediately interventions by the nurse? (Select all that applied.)

Apply light pressure over the area.

After repositioning an immobile client, the nurse observes an area of hyperemia To assess for blanching, what action should the nurse take?

Administer PRN nebulizer treatment. Obtain 12 lead electrocardiogram. Monitor continuous oxygen saturation.

After several hours of non-productive coughing, a client presents to the emergency room complaining of chest tightness and shortness of breath. History includes end stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. While completing the pulmonary assessment, the nurse hears wheezing and poor air movement bilaterally. Which actions should the nurse implement? (Select all that apply.)

Hold oral intake until swallow evaluation is done.

After six days on a mechanical ventilator, a male client is extubated and place on oxygen via face mask . He is awake and cooperative . but complaining of a severe sore throat. While sipping water to swallow a medication, the client begins coughing, if strangled. What intervention is most important for the nurse to implement?

A slice of whole grain toast A bowl of cream of wheat

After teaching a male client with chronic kidney disease (CKD) about therapeutic diet...which menu of foods indicates that the teaching was effective? Select all that apply

The client voluntarily grants permission for the procedure to be done The client is competent to sign the consent without impairment of judgment The client understands the risks and benefits associated with the procedure

After the nurse witnesses a preoperative client sign the surgical consent form, the nurse signs the form as a witness. What are the legal implications of the nurse's signature on the client's surgical consent form? (Select all that apply)

Notify the healthcare provider of the client's lack of understanding. Rational: the nurse is only witnessing the signature, and is not responsible for the client's understanding of the procedure. The healthcare provider needs clarify any questions and misconceptions. Explaining the procedure again is the healthcare provider's legal responsibility. The other options are not indicated.

After the risk and benefits of having a cardiac catheterization are reviewed by the healthcare provider, an older adult with unstable angina is scheduled for the procedure. When the nurse presents the consent form for signature, the client asks how the wires will keep a heart heating during the procedure. What action should the nurse take?

Hypotension

Amale client arrives at the clinic with a severe sunburn and explains that he did not use sun screen because it was an overcast day. Large blisters are noted over his back and chest and his shirt is soaked with serosanguinous fluid. Which assessment finding warrants immediate intervention by the nurse?

New onset of purple skin lesions

Amale client who was diagnosed with viral hepatitis A 4 weeks ago returns to the clinic complaining of weakness and fatigue. Which finding is most important for the nurse to report to the healthcare provider?

Evaluate daily serial renal laboratory studies for progressive elevations

Amale client with impaired renal function who takes ibuprofen daily for chronic arthritis.gastrointestinal (Gi) bleeding. After administering IV fluids and a blood transfusion, his blood pressure is 100/70, and his renal output is 20 m/hour. Which intervention should the nurse include in hours?

Instilf beractant 100 mg/kg in endotracheal tube.

Amale infant born at 28-weeks gestation at an outlying hospital is being prepared for transport to a respiration are 92 breaths/minute and his heart rate is 156 beats/minute. Which drug is the transport administration to this infant?

Provide the man and his mother with a copy of the Patient's Bill of Rights

Aman expresses concern to the nurse about the care his mother is receiving while hospitalized. He believes that her care is not based on any ethical standards and ask what type of care he should expect from a public hospital. What action should the nurse take?

Determine type of chemical exposure. Rational: once the type of chemical is determined, poison control should be called even if the chemical is unknown. If lavage is recommended by poison control, intubation and nasogastric tube may be needed as directed by poison control. Altered sensorium, such as lethargy, may occur if hydrocarbons are ingested

Amother runs into the emergency department with s toddler in her arms and tells the nurse that her child got into some cleaning products. The child smells of chemicals on hands, face, and on the front of the child's clothes. After ensuring the airway is patent, what action should the nurse implement first?

Apply counter-pressure to the sacral

Amultigravida, full-term, laboring client complains of "back labor". Vaginal examination reveals that the client 's 3 cm with 50 % effacement and the fetal head is at - 1 station , what should the nurse implement?

Reinforce the importance of annual papanicolaeu (Pap) smears.

An 18-year-old female client is seen at the health department for treatment of condylomata acuminate (perineal warts) caused by the human papillomavirus (HPV). Which intervention should the nurse implement?

Your blood pressure is a little high. You need to have it rechecked within one weelk

An African-American man come into the hypertension screening booth at a community fair. The nurse finds that is blood pressure is 170/94 mmHg. The client tells the nurse that he has never been treated for high blood pressure. What response should the nurse make?

1000, 1600, 2200, 0400

An IV antibiotic is prescribed for a client with a postoperative infection. The medication is to be administered in 4 divided doses. What schedule is best for administering this prescription?

Document the ongoing wound healing.

An Unna boot is applied to a client with a venous stasis ulcer. One week later when the Unna boot is removed during a follow-up appointment, the observes that the ulcer site contains bright red tissue. What action should the nurse take in response to this finding?

Rationale: 4mg x 0.5 ml-2/6-0.33 ml

An adolescent receives a prescription for an injection of s-matriptan succinate 4 mg subcutaneously for migraine headache. Using a vial labeled, 6 mg/0.5 ml, how many ml should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest hundredth.) 0.33 ml

Describes life without purpose

An adolescent with major depressive disorder the past 12 days. Which assessment finding requires immediate follow-up? has been taking duloxetine (Cymbalta) for

Magnesium hydroxide (Maalox)

An aduit female client with chronic kidney disease (CKD) asks the nurse if she can continue... Medications. Which medication provides the greatest threat to this client?

36 %

An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full thickness burns to all surfaces of both lower extremities. What percentage of body surface area should the nurse document in the electronic medical record (EMR)?

Imibalance nutrition Rationale: The client's nutritional status has the highest priority at this time, and finger foods are often provided, so the client who is on the maniac phase of bipolar disease can receive adequate nutrition.

An adult client is exhibit the maniac stage of bipolar disorder is admitted to the psychiatric unit. The client has lost 10 pounds in the last two weeks and has no bathed in a week "I'm trying to start a new business and "I'm too busy to eat". The client is oriented to time, place, person but not situation. Which nursing problem has the greatest priority?

Send family to the waiting area while the client's history is taking Rationale To protect the client privacy, the family member should be asked wait outside while the client's history is taks.

An adult client present to the clinic with large draining ulcers on both lower legs that are characteristics of Kaposi's sarcoma lesions. The client is accompanied by two family member. Which action should the nurse take?

Obtain a prescription for an anticholinergic medication Rationale: Antipsychotic medications have an extrapyramidal side effects one of which is difficult to swallowing the nurse should obtain a prescription for an anticholinergic medication which is used for the treatment of extrapyramidal symptoms. Other options are not warranted actions based on the symptoms presented

An adult client with schizophrenia begin treatment three days ago with the Antipsychotic risperidone. The client also received prescription for trazodone as needed for sleep and clonazepam as needed for severe anxiety. When the client reports difficulty with swallowing, what action should the nurse take?

Assist client in identifying goals for the day Rationale: clients with severe depression have low energy and benefit from structured activities because concentration is decreased. The client participate in care by identifying goals for the day is the most important intervention for the client's first day at the unit.

An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client ran one year ago, his spouse states that the client no longer runs, bur sits and watches television most of the day. Which is most important for the nurse to include in this client's plan of for today?

Compulsion

An adult female client is admitted to the psychiatric unit because of a complex handwashing ritual she performs daily that takes two hours or longer to complete. She worries about staying clean and refuses to sit on any of the chairs in the day area. This client's handwashing is an example of which clinical behavior?

Ask the dlient If she has had any recent thoughts of harming herself

An adult female client is admitted to the psychiatric unit with a diagnosis of major depressive...medication therapy, nurse notices the client has more energy, is giving her belongings. mood. Which intervention is best for the nurse to implement?

Ask the client if she has had any recent thoughts of harming herself

An adult female client is admitted to the psychiatric unit with a diagnosis of major depressive...medication therapy, the nurse notices the client has more energy, is giving her belongings.mood. Which intervention is best for the nurse to implement?

Explore client's readiness to discuss the situation.

An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. What action should the nurse take first?

Lethargy Rationale: Lethargy is the earliest sign of ICP along with slowing of speech and response to verbal commands. The most important indicator of increase ICP is the client's level or responsiveness or consciousness. B and C are very late signs of ICP

An adult male client is admitted to the emergency room following an automobile collision in which he sustained a head injury. What assessment data would provide the earliest that the client is experiencing increased intracranial pressure (ICP)?

Explain the reason for using only non-narcotics.

An adult male is admitted to the emergency department after falling from a ladder. While waiting to have a computed tomography (CT) scan, he requests something for a severe headache. When the nurse offers him a prescribed does of acetaminophen, he asks for something stronger. Which intervention should the nurse implement?

nausea and projectile vomit Rationale: Projective vomiting is indicative of increasing intracranial pressure, which can lead to ischemic brain damage or death, so this finding warrants immediate intervention. Rebound abdominal tenderness may indicate internal bleeding. Diminished breath sound may be related to pain. Rib pain with inspiration may indicate rib fracture.

An adult male is brought to the emergency department by ambulance following a motorcycle accident. He was not wearing a helmet and presents with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse?

.Be alert for possible cross-sensitivity to cephalosporin agents.

An adult male reports the last time he received penicillin he developed a severe maculopapular rash all over his chest. What information should the nurse provide the client about future antibiotic prescriptions?

Determine if the client has an executed living will

An adult male who lives alone is brought to the Emergency Department by his daughter who is unresponsive. Initial assessment indicated that the client has minimal respiratory effort, and his pupils are fixed and dilated. At the daughter's request, client is intubated and..Which nursing intervention has the highest priority?

Install a bed exit safety monitoring device

An adult male who was admitted two days ago following a cerebrovascular accident (CVA) is confused and experiencing left-side weakness. He has tried to get out of bed several times, but is unable to ambulate without assistance. Which intervention is most important for the nurse to implement?

History of hypertension. Family heath history

An adult man reports that he recently experienced an episode of chest pressure and concern because both breathlessness when he was jogging in the neighborhood. He expresses of his deceased parents had heart disease and his father was a diabetic. He lives with his male partner, is a vegetarian, and takes atenolol which maintain his blood pressure at 138/74. Which risk factors should the nurse explore further with the client? Select all that apply

Assign staff to monitor what the client eats. Rationale: clients with an eating disorder have an unhealthy obsession with food. The client's continued weight loss, despites indication that the client has consumed 100 % of the diet , should raise questions about the client 's intake of the food provided, so the client should be observed during meals to prevent hiding or throwing away food. Other options may be accurate but ineffective and unnecessary scheduled to begin

An adult who is 5 feet 5 inches (165.1 cm) tall and weighs 90 1b. (40.8 Kg) is admitted with a diagnosis of chronic anorexia. The client receives a regular diet for 2 days , and the client 's medical records indicates that 100 % of the diet provided has been consumed. However the client's weight on the third day morning after admission is 89 1b. (40.4 Kg). What action should the nurse implement?

Encourage the client to describe the pain.

An adult woman who is seen in the clinic with possible neuropathic pain of the right leg rates her pain as a 7 on a 10 point scale. What action should the nurse take?

They decrease the risk for joint trauma

An elderly client with degenerative joint disease asks if she should use the rubber jar openers that are available. The nurse's response should be based on which information about assistive devices?

Destruction of joint cartilage.

An elderly female client with osteoarthritis reports increasing pain and stiffness in her right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of her symptoms?

Ensure proper alignment of the leg in traction.

An elderly female is admitted because of a change in her level of sensorium. During the evening shift, the client attempts to get out bed and falls, breaking her left hip. Buck's skin traction is applied to the left leg while waiting for surgery. Which intervention is most important for the nurse to include in this client's plan care?

Delirium

An elderly male client is admitted to the mental health unit with a sudden onset of global disorientation and is continuously conversing with his mother, who died 50 years ago. The nurse reviews the multiple prescriptions he is currently taking and assesses his urine specimen, which is cloudy, dark yellow, and has foul odor. These findings suggest that his client is experiencing which condition?

Decrease prevalence of glaucoma in the population.

An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. What effect is the nurse likely to note as a result of this increases in glaucoma surgeries?

Irritability and a high-pitched cry

An infant born to a heroin-addicted mother is admitted to the neonatal care unit. What behaviors can...to exhibit?

Determine the infant's blood sugar level

An infant is placed in a radiant warmer immediately after birth. At one hour of age, the nurse finds the infant tachypneic, and hypotonic. What is the first action that the nurse should take?

Digoxin.

An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is irritable and diaphoretic with jugular vein distention. Which prescription should the nurse administer first?

Notify healthcare provider to prepare for pericardiocentesis Rationale: Cardiac tamponade is pressure on the heart that occurs when blood or fluid builds up in the space between the heart muscle (myocardium) and the outer covering sac of the heart (pericardium). In this condition, blood or fluid collects in the pericardium, the sac surrounding the heart. This prevents the heart ventricles from expanding fully. The excess pressure from the fluid prevents the heart from working properly. As a result, the body does not get enough blood

An older adult client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant, heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

Increase ventilator rate. Rationale: This client is experience respiratory acidosis. Increasing the ventilator rate depletes CO2 a, which returns the PH toward normal. Report findings is important but only after increasing ventilator rate.

An older adult female admitted to the intensive care unit (ICU) with a possible stroke is intubated with ventilator setting of tidal volume 600 , P102 40 % , and respiratory rate of 12 breaths/minute. The arterial blood gas (ABG) results after intubation are PH 7.31 . PaCO2 60 , PaO2 104 , SPO2 98 % , HCO3 23. To normalize the client 's ABG finding, which action is required?

Restrict daily fluid intake. Rationale: the client is exhibiting signs of cox pulmonale, a complication of COPD that causes the right side of the heart to fail. Restricting fluid intake to 1000 to 2000 ml/day, eating a high-calorie diet at small frequent meals with foods that are high in protein and low in sodium can help relive the edema and decrease workload on the right-side of the heart.

An older adult male is admitted with complications related to chronic obstructive pulmonary disease (COPD). He reports progressive dyspnea that worsens on exertion and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide?

. Report mental status change to the healthcare provider Assess client's breath sounds and oxygen saturation Review the client's most recent serum electrolyte values Rationale: The healthcare provider should be informed of changes in the client's condition (B) because this behavior may indicate a postoperative complication. Diminished oxygenation (C) and electrolyte imbalance (E) may cause increased injury if the client climbs confusion in the older adult. Raising all four bed rails (A) may lead to further over the rails and falls and restrains should not be applied until other measures such as re-orientation are implemented. The nurse should assess the client's increased risk for falls, rather than assigning this to the UAP (D)

An older adult male who had an abdominal cholecystectomy has become increasingly confused and disoriented over the past 24 hours. He is found wandering into another client's room and is return to his room by the unlicensed assistive personnel (UAP). What actions should the nurse take? (Select all that apply).

Administer a daily dose of lisinopril as scheduled. Provide a PRN dose of acetaminophen for headache Rational: the client' routinely scheduled medication, lisinopril, is an antihypertensive medication and should be administered as scheduled to maintain the client's blood pressure. A PRN dose of acetaminophen should be given for client's headache.

An older adult resident of a long-term care facility has a 5-year history of hypertension. The client has a headache and rate the pain 5 on a pain scale 0 to 10. The client's blood pressure is currently 142/89. Which interventions should the nurse implement? (Select all that apply)

.Multiple organ dysfunction syndrome (MODs)

An older client is admitted to the intensive care unit with severe abdominal pain, abdominal distention, and absent bowel sound. The client has a history of smoking 2 O packs of cigarettes daily for 50 years and is currently restless and confused. Vital signs are: temperature 96 F, heart rate 122 beats/minute, respiratory rate 36 breaths/minute, mean arterial pressure(MAP) 64 mmHg and central venous pressure (CVP) 7 mmHg. Serum laboratory findings include: hemoglobin 6.5 grams/dl, platelets 6o, 000, and white blood cell count (WBC) 3,000/mm3. Based on these findings this client is at greatest risk for which pathophysiological condition?

Ask the client to describe the changes that have ocurred

An older female client tells the nurse that her muscles have gradually been getting weak.what is the best initial response by the nurse?

Move personal items within client's reach .Lower bed to the lower possible position Give directions to call for assistance eAssist client to the bathroom in 2 hours. Rationale: A dlient who needs assistive devices, such as quad-cane is at risk for fails. Precautions that should implement include ensuring that personal items are within reach the bed is in the lowest position and directions are given to call assistance to minimize the risk for falls. Frequently assisting the client to the bathroom help ensure this client does not go the bathroom by herself, thereby decreasing the possibility of falling.

An older female who ambulate with a quad-cane prefer to use a wheel chair because she has a halting and unsteady gait at times. Which interventions should the nurse implement? (Select all that apply)

Notify the healthcare provider of the client's change in mental status. Include q2 hour's reorientation in the client's plan of care.

An older male adult resident of long-term care facility is hospitalized for a cardiac catheterization that occurred yesterday. Since the procedure was conducted, the client has become increasingly disoriented. The night shift nurse reports that he attempted to remove the sandbag from his femoral artery multiple times during the night. What actions should the nurse take? (Select all that apply.)

Palpate the client's suprapubic area for distention Rationale: the client is exhibiting classic signs of an enlarge prostate gland, which restricts urine flow and cause bothersome lower urinary tract symptoms (LUTS) and urinary retention, which is characterized by the client's voiding patterns and perception of incomplete bladder emptying.

An older male client arrives at the clinic complaining that his bladder always feels full. He complains of weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating his urine stream. Which action should the nurse implement?

Ask the wife to stop and assess the client's swallowing reflex

An older male client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side. When entering the room, the nurse finds the client's wife tearful and trying unsuccessfully give him a drink of water. What action should the nurse take?

Start an intravenous (TV) infusion of normal saline

An older male client with a history of type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first?

Identify pills in the bag.

An older male client with history of diabetes mellitus, chronic gout, and osteoarthritis comes to the clinic with a bag of medication bottles. Which intervention should the nurse implement first?

Completely stop cigarette/ cigar smoking

An older male client with type 2 diabetes mellitus reports that has experiences legs pain when walking short distances, and that the pain is relieved by rest. Which client behavior indicates an understanding of healthcare teaching to promote more effective arterial circulation?

Obtain a prescription for DNR

An older male who is admitted for end stage of chronic obstructive pulmonary disease (COPD) tells the nurse The client provides the nurse with a living will and DNR. What action should the nurse implement?

Begin manual ventilation immediately.

An unconscious client is admitted to the intensive care unit and is placed on a ventilator. The ventilator alarms continuously and the client 's oxygen saturation level is 62 % , what action should the nurse take first?

Assign a practical nurse (LPN) to determine if an apical radial deficit is present

An unlicensed assistive personnel (UAP) assigned to obtain client vital signs reports to the charge nurse that a client has a weak pulse with a rate of 44 beat/ minutes. What action should the charge nurse implement?

Tell the client that the nurse will be back to talk to her after medications are given

An unlicensed assistive personnel (UAP) informs the nurse who is giving medications that a female client is crying. The client was just informed that she has a malignant tumor. What action should the nurse implement first?

Review the client's serum calcium level

An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasms when taking the blood pressure using th e same arm. After confirming the presence of spams what action should the nurse take?

Note date and time of the behavior. Discuss the issue privately with the UAP. Plan for scheduled break times Evaluate the UAP for signs of improvement.

An unlicensed assistive personnel UAP leaves the unit without notifying the staff. In what order should the unit manager implement this intervention to address the UAPs behavior? (Place the action in order from first on top to last on bottom.)

Ensure that the infant's crib mattress is firm

Anurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. What information is most important for the nurse to include?

Have a meconium aspirator available at delivery

Artificial rupture of the membrane of a laboring reveals meconium-stained fluid, what is... the priority?

. Inclnde oatmeal with stewed pruned for breakfast as often as possible. Increase fluid intake by keeping water glass next to recliner. Recommend seeking help with regular shopping and meal preparation. Rational older adult are at higher risk for chronic constipation due to decreased gastrointestinal muscle tone leading to reduce motility. Oatmeal with prunes increases dietary fiber and bowel stimulation, thereby decreasing need for laxatives. Increased fluid intake also decreases constipations. Assistance with food preparation might help the client eat more fresh fruits and vegetables and result on less reliance on microwaved and fast foods, which are usually high in sodium and fat with little fiber. Laxatives can be reduced gradually by improving the diet, without resorting to using enemas

Assessment by the home health nurse of an older client who lives alone indicates that client has chronic constipations. Daily medications include furosemide for hypertension and heart failure and laxatives. To manage the client's constipation, which suggestions should the nurse provide? (Select all that apply)

Inform the anesthesia care provider

At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?

Remove sequential compression devices.

At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the client's medical record. Based on date contained in the record, what action should the nurse take before assisting the client with ambulation:

Place a wedge under the client's right hip. Rationale: Hypotension from pressure on the vena cava is a risk for the full-term client. Placing a wedge under the right hip will relieve pressure on the vena cava. Other options will either not relieve pressure on the vena cava or would not allow the client the remaining her position of choice.

At 40 week gestation, a laboring client who is lying is a supine position tells the nurse that she has finally found a comfortable position. What action should the nurse take?

Anxiety

At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." What is the priority nursing diagnosis for this client?

Have the client vocalize the instructions provided.

AutoRecovered me An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction & lens implantation. Which intervention is most important for the nurse to implement to ensure the client's compliance with self-care?

Do not get pregnant for at least 3 months

Awoman just received the Rubella vaccine after a delivery of a normal new born, has two children at home, ages 13 months and 3 years. Which instruction is most important to provide to the client?

Offer to provide the influenza vaccination to the student while she is at the clinic Rationale: person with asthma are at increased risk related to influenza and should receive the influenza vaccination prior to or during influenza season. Waiting until the start of the next season places the student at risk for the current season. The vaccination does not increase risk for persons with asthma but the nasal spray may result in increased wheezing after receiving that form of the vaccination.

Ayoung adult female college student visits the health clinic in early winter to obtain birth control pills. The clinic nurse asks if the student has received an influenza vaccination. The student stated she did not receive vaccination because she has asthma. How should the nurse respond?

Use two foms of contraception while taking this drug

Azithromycin is prescribed for an adolescent female who has lower lobe pmeumonia and recurrent chlamydia. What information is most important for the nurse to provide to this client?

An open sterile Foley catheter kit set up on a table at the nurse waist level

Based on principles of asepsis, the nurse should consider which circumstance to be sterile?

Continue to monitor the progress of labor.

Based on the information provided in this client's medical record during labor, which should the nurse implement? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client's medical record.)

Ensure that the knot can be quickly

Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?

Direct the nurse to continue the surgical hand scrub for a 5 minute duration

Before preparing a client for the first surgical case of the day, a part-time scrub nurse the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide?

Fall prevention measures.

Diagnostic studies indicate that the elderly client has decreased bone density. In providing client teaching, which area of instruction is most important for the nurse to include?

47

Dopamine protocol is prescribed for a male dlient who weigh 198 pounds to maintain the mean arterial pressure (MAP) greater than 65 mmHg. His current MAP is 50 mmHg, so t he nurse increases the infusion to 7 mg / kg / minute . The infusion is labeled dextrose 5 % in water (D5W) 500 ml with dopamine 400 mg. The nurse should program the infusion pump to deliver how many ml/hour?

Lie on the left or right side when sleeping or resting

During a 26-week gestation prenatal exam, a client reports occasional dizziness...What intervention is best for the nurse to recommend to this client?

Prepare a woman for a bone density screening Rationale: A bone density screening is a fast, noninvasive screening test for osteoporosis that can be explained by the PN. There is no additional preparation needed

During a Woman's Health fair, which assignment is the best for the Practical Nurse (PN) who is working with a register nurse (RN)

Prepare for the endotracheal tube to be repositioned

During a cardiopulmonary resuscitation of an intubated client, the nurse detects a palpable pulse throughout the two minutes cycle chest compression and absent breath sounds over the left lung. What action should the nurse implement?

Dialysis would need to be resumed if chronic rejection becomes a reality

During a clinic visit, a client with a kidney transplant ask, "What will happen if chronic rejection develops?" which response is best for the nurse to provide?

Check the client for lacerations or fractures

During a home visit, the nurse observed an elderly client with diabetes slip action should the nurse take first?

Instruct the client to keep the left leg straight Observe the insertion site for a hematoma Circle first noted drainage on the dressing

During a left femoral artery aortogram, the healthcare provider inserts an arterial sheath and initiate. Through the sheath to dissolve an occluded artery. Which interventions should the nurse implement?

Instruct the client to keep the left leg straight Observe the insertion site for a hematoma Circle first noted drainage on the dressing

During a left femoral artery aortogram, the healthcare provider inserts an arterial sheath and initiate...through the sheath to dissolve an occluded artery. Which interventions should the nurse implement

Discuss the concerns expressed by the client about the vaccination. Rationale: the nurse should first address the concerns identified by the client, before taking other actions, such as obtaining information about past vaccinations, exposure to the flu, or reviewing the informed consent form.

During a routine clinic visit, an older female adult tells the nurse that she is the flu season is coming soon, but is reluctant to obtain the vaccination. What action should the nurse take first?

1. Assess the client's skin and circulation for impairment related to the restrains 2. Evaluate the client's restrains mentation to determine need to continue 3. Assigu unlicensed assistive personnel to remove restrains and remain with client 4. Contact the client's surgeon and primary healthcare provider

During change of shift, the nurse reports that a male client who had abdominal surgery yesterday increasingly confused and disoriented during the night. He wandered into other clients rooms, saying that there are men in his room trying to hurt him. Because of continuing disorientation and the client's multiple attempts to get of bed, soft restrains were applied at 0400. In what order should the nurse who is these interventions? (Arrange from first action on top to last on the bottom). receiving report implement

Report weight gain of 2 pounds (0.9kg) in 24 hours

During discharge teaching, the nurse discusses the parameters for weight monitoring with a client who was recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge?

Respiratory apnea of 30 seconds

During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate firs?

Respiratory apnea of 30 seconds

During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate first?

Stop the transfusion start a saline

During the infusion of a second unit of packed red blood cells, the client's temperature increases from 99 to 101.6 f. which intervention should the nurse implement?

Document the finding in the infant's record.

During the initial newborn assessment, the nurse finds that a newborn's heart rate is irregular. Which intervention should the nurse implement?

Instruct the scrub nurse to re-drape the client

During the intraoperative phase of care, the circulating nurse observes that the client is not adequately client's privacy. What is the best initial nursing action for the nurse to implement?

Hemophilic Influenza Type B (tiß) vaccine

During well-baby, 6-month visit, a mother tells the nurse that her infant has had fewer ear infections than her 10-year-old daughter. The nurse should explain that which vaccine is likely to have made the difference in the siblings' incidence of otitis media?

Restrict unvaccinated children from attending school until measles outbreak is resolved.

Fallowing an outbreak of measles involving 5 students in an elementary school, which action is most important for the school nurse to take?

Transfuse packed red blood cells

Following a gun shot wound to the abdomen, a young adult male had an emergency bowe.. Multiple blood products while in the operating room. His current blood pressure is 78 / 52.He is being mechanically ventilated , and his oxygen saturation is 87 % . His laboratory values. Grams/ di (70 mmol/LSI), platelets 20,000/mm 3 (20 x 109/L(Sl units), and white blood cells, Based on these assessments findings, which intervention, should the nurse implements first?

"I have a headache that gets worse when I sit up"

Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse that the client is experiencing a complication?

eFat embolism

Following a motor vehicle collision (MCV), a male adult in severe pain is brought to the emergency department via ambulance. His injured left leg is edematous, ecchymotic around the impact of injury on the thigh, and shorter than his right leg. Based on these findings, the client is at greatest risk for which complication?

Oliguria signals tubular necrosis related to hypoperfusion

Following a motor vehicle collision, an adult female with a ruptured spleen and a blood pressure of 70/44, had an emergency splenectomy. Twelve hours after the surgery, her urine output is 25 ml/hour for the last two hours. What pathophysiological reason supports the nurse's decision to report this finding to the healthcare provider?

Prepare medication reversal agent Check oxygen saturation level Apply oxygen via nasal cannula

Following an esophagogastroduodenoscopy (EGD) a male client is drowsy and difficult to arouse, and his respiration are slow and shallow. Which action should the nurse implement? Select all that apply

The mucosal barrier, sucralfate (Carafate), for a client diagnosed with peptic ulcer disease. Rationale: Carafate coats the mucosal lining prior to eating a meal

Following breakfast, the nurse is preparing to administer 0900 medications to clients on a medical floor. Which medication should be held until a later time?

Review with the client the need to avoid foods that are rich in milk and cream

Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse?

Decrease abdominal girth

Following insertion of a Leveen shunt in a client with cirrhosis of the liver, which assessment finding indicates to the nurse that the shunt is effective?

Reduce the risk for injuny

Following routine diagnostic test, a client who is symptom-free is diagnosed with Paget's disease. Client teaching should be directed toward what important goal for this client?

Advise the client that assignments are not based on clients requests

Following surgery, a male client with antisocial personality disorder frequently requests that a specific nurse be assigned to his care and is belligerent when another nurse i assigned. What action should the charge nurse implement?

Tented skin turgor

For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a bedridden, older client with infectious gastroenteritis. Which finding requires the nurse to take further action?

eNotify the healthcare provider of the vomiting. Rational: transdermal scopolamine is used to prevent nausea and vomiting from anesthesia and surgery. The nurse should notify the healthcare provider if the medication is ineffective. The patch should be applied behind the ear and should remain in place to reduce the nausea and vomiting. Nausea and vomiting are no side effects of the medication.

Four hours after surgery, a client reports nausea and begins to vomit. The nurse notes that the client has a scopolamine transdermal patch applied behind the ear. What action should the nurse take?

Insensible loss of body fluids contributes to the hemoconcentration of serum solutes Rationale: Fever causes insensible fluid loss, which contribute to fluid volume and results in hemoconcentration of sodium (serum sodium greater than 150 mEa/L). Dehydration, which is manifested by dry, sticky mucous membranes, and flushed skin, is often managed by replacing lost fluids and electrolytes with IV fluids that contain varying concentration of sodium chloride. Although other options are consistent with fluid volume deficit, the physiologic response of hypernatremia is explained by hem concentration.

If the nurse is initiating IV fluid replacement for a child who has dry, sticky mucous membranes, flushed skin, and fever of 103.6 F. Laboratory finding indicate that the child has a sodium concentration of 156 mEaL. What physiologic mechanism contributes to this finding?

Document the extend of the bruising in the medical record

In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the fracture site, and recognizes that hematoma formation at the bone fragment site has occurred. What action should the nurse implement?

Hematocrit of 28 % . Rational: although physiologic anemia is expected in pregnancy, a hematocrit of 28 % is below pregnant norms and could signify iron - deficiency anemia . Other options are normal finding pregnancy

In assessing a client at 34-weeks' gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid , a hematocrit of 28 % , a heart rate of 92 beats per minute, and a systolic murmur. Which finding requires follow-up?

Ensure that no dependent loops are present in the tubing.

In assessing a client twelve hours following transurethral resection of the prostate (TURP), the nurse observes that the urinary drainage tubing contains a large amount of clear pale pink urine and the continuous bladder irrigation is infusing slowly. What action should the nurse implement?

Photograph the lesion with a ruler placed next to the lesion Rationale: An ulcer extends into the dermis or subcutaneous tissue and is likely to increase in size and depth, so assessment should include photograph with measuring device to document the size of the lesion.

In assessing a pressure ulcer on a client's hip, which action should the nurse include?

Document the assessment data

In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths minute. What action should the nurse implement?

Anxiety related to fear of suffocation.

In assessing an older female client with complication associated with chronic obstructive pulmonary disease (COPD), the nurse notices a change in the clien appearance. Her face appears tense and she begs the nurse not to leave her alone. Her pulse rate is 100, and respirations are 26 per min. What is the primary nursing diagnosis?

Glucose

In caring for a client with Cushing syndrome, which serum laboratory value is most important for the nurse to monitor?

Observe the amount and dose of morphine in the PCA pump syringe

In caring for a client with a PCA infusion of morphine sulfate through the right cephalic vein, The nurse assesses that the client in lethargic with a blood pressure of 90/60, pulse rate of 118 beats per minute, and respiratory rate of 8 breaths per minutes. What assessment should the nurse perform next?

Place personal religious artifacts on the body Attach identifying name tags to the body Follow cultural beliefs in preparing the body

In caring for the body of a client who just died, which tasks can be delegate to the unlicensed assistive personnel (UAP)? (Select all that apply)

avoid smoking in the house

In conducting a health assessment, the nurse determines that both parents of a child with asthma smoke cigarettes. What recommendation is best to the nurse to recommend to the parents?

Orthopnea Rationale: If the client is orthopneic, the nurse needs to adapt the insertion position that does not place the client in a supine position (the head of the bed should be elevated as much as possible).

In determine the client position for insertion of an indwelling urinary catheter, it is most important for the nurse to recognize which client condition?

Peripheral vasodilation Rationale: Toxins released by bacteria in septic shock create massive peripheral vasodilation and increase microvascular permeability at the site of the bacterial invasion.

In early septic shock states, what is the primary cause of hypotension?

Observe both lower extremities for redness and swelling Rationale: Intermittent compression devices (ICDs) are used to reduce venous stasis and prevent venous thrombosis in mobile and postoperative clients and its effectiveness best assessed by observing the client's lower extremities for early signs of thrombophlebitis

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

An immobile client receiving low molecular weight heparin ql2 h. Rationale: A describe the most stable client. The other ones are at high risk for bleeding problems and require the assessment skills.

In making client care assignment, which client is best to assign to the practical nurse (PN) working on the unit with the nurse?

Evaluate closet proximal pulse. Rationale: A primary focus of care for a client with an AKA is monitoring for signs of adequate tissue perfusion, which include evaluating skin color and ongoing assessment of pulse strength.

In monitoring tissue perfusion in a client following an above the knee amputation (aka), which action should the anurse include in the plan of care?

infectious process

In planning strategies to reduce a client's risk for complications following orthopedic surgery, the nurse recognizes which pathology as the underlying cause of osteomyelitis?

Enable clients to become active participants in controlling the disease process

In preparing a diabetes education program, which goal should the nurse identify as the primary emphasis for a class on diabetes self-management?

Enable clients to become active participating in controlling the disease process Rational e: The primary goal of diabetic self- management education is to enable the client to become an active participant in the care and control of disease process, matching levels of self management to the abilities of the individual client. The goal is to place the client in a cooperative or collaborative role with healthcare professional rather than (A)

In preparing a diabetes education program, which goal should the nurse identify as the primary emphasis for a class on diabetes self-management?

1. Talk to the physician as a group in a non-confrontational manner. | 2. Document concerns and report them to the charge nurse. 3. Submit a written report to the director of nursing. 4. Contact the hospital's chief of medical services. 5. File a formal complaint with the state medical board. . Rational: nurses have both an ethical and legal responsibility to advocate for clients' physical and emotional safety. Talking with the physician in a non- confrontational manner is the first step in conflict resolution. If this is not effective, the organizational chain of ineffective, a formal complaint with the state medical board should be implemented.

Nurses working on a surgical unit are concerned about the physicians treatment of clients during invasive procedures, such as dressing changes and insertion of IV lines. Clients are often crying during the procedures, and the physician is usually unconcerned or annoyed by the client's response. To resolve this problem, what actions should the nurses take? (Arrange from the first action on the top of the list on the bottom)

.Ask the nurse to return home and get her prescription eyeglasses for work.

On a busy day, one hour after the shift report is completed, the charge nurse learns that a female staff nurse who lives one hour away from the hospital forgot her prescription eye glasses at home. What action should the charge nurse take?

Encourage use of analgesics before position change

One day following a total knee replacement, a male client tells the nurse that he is unable to transfer because it is too painful. What action should the nurse implement?

Neurovascular and circulation compromise related to compartment syndrome.

One day following an open reduction and internal fixation of a compound fracture of the leg, a male client complains of"a tingly sensation" in his left foot. The nurse determines the client's left pedal pulses are diminished. Based on these finding, what is the client's greatest risk?

. Teach need for dietary and supplementary vitamin D3 Rationale: Burn injury results in the acute loss of bone as well as the development of progressive vitamin D deficiency because burn scar tissue and adjacent normal- appearing skin cannot convert normal quantities of the precursors for vitamin D3 that is synthesized from ultraviolet sun rays which is needed for strong bones. Clients with a history of full thickness burns should increase their dietary resources of vitamin D and supplemental D3 (B). range of motion (A) and muscle strengthening exercises (D) do not treat he underlying causes of the bone pain and weakness unprotected sunlight (C) should be avoided.

One year after being discharged from the burn trauma unit, a client with a history of 40 % full - thickness burns is admitted with bone pain and muscle weakness , which intervention should the nurse include in the clients plan of care?

Have the child lie with the ear up for one to two minute after installation.

Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis media. An antipyrine and benzocaine-otic also prescribed for pain and inflammation. What instruction should the nurse emphasize concerning the installation of the antipyrine/benzocaine otic solution?

Evidence of hypoventilation

Progressive kyphoscoliosis leading to respiratory distress is evident in a client with muscul. Which finding warrants immediate intervention by the nurse?

Assist the client in developing a goal of managing the pain

Several months after a foot injury, and adult woman is diagnosed with neuropathic pain. The client describes the pain as severe and burning and is unable to put weight on her foot. She asks the nurse when the pain will "finally go away." How should the nurse respond?

Infuse a rapid IV normal saline bolus

Sublingual nitroglycerin is administered to a male dient with unstable angina who complains crushing chest pain. Five minutes later the client becomes nauseated and his bloods pressure drops to 60/40. Which intervention should the nurse implement

Medicate as needed for pain and anxiety.

Ten years after a female client was diagnosed with multiple sclerosis (MS), she is admitted to a community palliative care unit. Which intervention is most important for the nurse to include in the client's plan of care?

Three days postoperative colon resection receiving transfusion of packed RBCs.

The RN is assigned to care for four surgical clients. After receiving report, which client should the nurse see first? The client who is

Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation

The charge nurse in a critical care unit is reviewing clients' conditions to determine who is stable enough to be transferred. Which client status report indicates readiness for transfer from the critical care unit to a medical unit?

Rationale: The RN should deal with the client with command hallucinations and these can be very dangerous if the client's acts on the commands, especially if the command is a homicidal in nature. Other client present low safety risk

The charge nurse is making assignment on a psychiatric unit for a practical nurse (PN) and newly license register nurse (RN). Which client should be assigned to the RN?

A 30 year old depressed client who admits to suicide ideation. RATIONALE: A client who is suicidal requires psychological assessment, communication and knowledge beyond the educational level of a practical nurse (RN) Other clients could be cared for by the PN or the UAP, with supervision by the registered nurse.

The charge nurse is planning for the shift and has a registered nurse (RN) and a practical nurse (PN) on the team. Which client should the charge nurse assign to the RN?

Picking up the second glove

The charge nurse observes the practical nurse (PN) apply sterile gloves in preparation for performing a sterile dressing change. Which action by the PN requires correction by the charge nurse?

.An 82-year-old client with Alzheimer's disease newly-fractures femur who has a Foley catheter and soft wrist restrains applied

The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse (RN)?

Diabetic ketoacidosis and titrated IV insulin infusion

The charge nurse of the Intensive Care Unit is making assignments for the permanent staff and one RN who was floated from a medical unit. The client with which condition is the best to assign to the float nurse?

Laceration

The client with which type of wound is most likely to need immediate intervention by the nurse?

Arterial endothelium injury causes inflammation Macrophages consume low density lipoprotein (LDL), creating foam cells Foam cells release growth factors for smooth muscle cells Smooth muscle grows over fatty streaks creating fibrous plaques Vessel narrowing results in ischemia

The development of atherosclerosis is a process of sequential events. Arrange the pathophysiological events in orders of occurrence. (Place the first event on top and the last on the bottom)

Offer to go with the family members to view the body

The family of a client who just died arrives on the nursing unit after receiving telephone notification of the death. Several family members state they would like to view the body. How should the nurse respond?

.Obtain a detailed report from the nurse transferring the client.

The father of 4-year-old has been battling metastatic lung cancer for the past 2 years. After discussing the remaining options with his healthcare provider, the client requests that all treatment stop and that no heroic measures be taken to save his life. When the client is transferred to the palliative care unit, which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care?

Tell the staff to keep all clients and visitors in the client rooms with the doors closed

The fire alarm goes off while the charge nurse is receiving the shift report. What action should the charge nurse implement first?

Irregular pulse

The health care provider prescribes atenolol 50 mg daily for a client with angina pectoris...to the health care provider before administering this medication?

Administer the medication via the oral route as prescribed

The healthcare provider changes a client 's medication prescription from Ⅳ to PO administration and double the dose. The nurse notes in the drug guide that the prescribed medication, when given orally, has a high first-pass effect and reduce bioavailability What action should the nurse implement?

Ask for a full explanation from the interpreter of the witnessed discussion

The healthcare provider explains through an interpreter the risks and benefits of a scheduled surgical procedure to a non-English speaking female client. The client gives verbal consent and the healthcare provider leaves, instructing the nurse to witness the signature on the consent form. The client and the interpreter then speak together in the foreign language for an additional 2 minutes until the interpreter concludes, "she says it is OK." What action should the nurse take next?

Roasted turkey canned vegetables Rationale: Foods allowed on a low-fiber diet includes roasted or baked turkey and canned vegetables the foods in the other options are not low in fiber

The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection would indicate to the nurse the client understands they prescribed diet?

Hemoglobin A1C ( HbA1C ) reading less than 7 %

The healthcare provider prescribes acarbose (Precose), an alpha-glucosidase inhibitor, for a client with Type 2 diabetes mellitus. Which information provides the best indicator of the drug's effectiveness?

75

The healthcare provider prescribes an IV solution of isoproterenol (Isupre) 1 mg in 250 ml of DsW at 300 mcghour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only.)

Give the prescribed antiemetic

The healthcare provider prescribes carboprost tromethamine (Hemabate) 250 mcg IM for a multigravida postpartum client who is experiencing heavy, bright red vaginal bleeding. Prior to administering this medication, which interventions should the RN implement?

0.4

The healthcare provider prescribes celtazidime (Eortax) 35 mg every 8 hours IM for an concentration of 100 mg/ml. How many ml should the nurse administered for each dose? infant. The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a (Enter numeric value only. If rounding is required, round to the nearest tenth)

Answer 12 Rationale: 144/2.2- 65kg 18units/kg/br kg x 18units/kg/br- 1170 units/hr 25000 units heparin/250 ml of D5W 100 units heparin per ml of solution Formula D / H x A : X

The healthcare provider prescribes heparin protoćol at18 units/kg/hr for a client with a possible pulmonary embolism. This client weighs 144 pounds. The available solution is labeled, heparin sodium 25,000 units in 5 % dextrose 250 ml , the nurse should program the pump to deliver how many ml/hr? Enter numeric value only. If rounding is require round to the nearest whole number.)

Aspirin content.

The healthcare provider prescribes oxycodone/ aspirin 1 tab PO every 4h as needed for pain, for a client with polycystic kidney disease. Before administering this medication, which component of the prescription should the nurse question?

Yogurt and/or buttermilk.

The healthcare provider prescribes the antibiotic Cefdinir (cephalosporin) 300mg PO every 12 h for a client with postoperative wound infections. Which feeds should the nurse encourage this client to eat?

.Yogurt and/or buttermilk.

The healthcare provider prescribes the antibiotic cephradine 500mg PO every 6 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat?

Avoid prolonged standing or sitting Use recliner for long period of sitting continue wearing elastic stocking

The home care nurse provide self-care instruction for a client chronic venous deep vein thrombosis.

Cloudy dialysate output and rebound abdominal pain

The home health nurse is assessing a male client who has started peritoneal dialysis (PD) 5 days ago. Which assessment finding warrants immediate intervention by the nurse?

. The husband cannot sign the consent for the client, her signature is required . The client's specific wishes should be discussed with her healthcare provider e The healthcare team will formulate a plan of care to keep the client comfortable

The husband of a client with advanced ovarian cancer wants his wife to have every treatment available. When the husband leaves, the client tells the nurse that she has had enough chemotherapy and wants to stop all treatments but knows her husband will sign the consent form for more treatment. The nurse's response should include which information?

Explain that memory loss and confusion are common with vitamin B12 deficiency

The husband of an older woman, diagnosed with pernicious anemia, calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobalamin two days ago. He tells the nurse that he is worried that she might be getting Alzhelmer's disease. What action should the nurse take?

Remove the heating pads and place a soft blanket over the client's leg aned feet.

The leg of a client who is receiving hospice care have become mottled in appearance. When the nurse observes the unlicensed assistive personal (UAP) place a heating pad on the mottled areas, what action should the nurse take?

Instruct the mother to change the child's diaper more often.

The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence o watery stools. Which nursing intervention should the nurse implement?

Brain damage with CP is not progressive but does have a variable course

The mother of a child with cerebral palsy (CP) ask the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

Is your son sleepy and difficult to feed?

The mother of a one-month-old boy born at home brings the infant to his first well...was born two weeks after his due date, and that he is a "good, quiet baby" who almost..hypothyroidism, what question is most important for the nurse to ask the mother?

Stop using the ointment and encourage complete drying of the feet and wearing clean socks.

The mother of an adolescent tells the clinic nurse, "My son has athlete's foot , I have been applying triple antibiotic ointment for two days, but there has been no improvement. What instruction should the nurse provide?

CPT should be performed more frequently, but at least an hour before meals. Rationale: CPY with inhalation therapy should be performed several times a day to loosen the secretions and move them from the peripheral airway into the central airways where they can be expectorated. CPT should be done at least one hour before meals or two hours after meals.

The mother of the 12- month-old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day, and has also experiences a loss of appetite. What instruction should the nurse provide?

White blood cell (WBC) count Sputum culture and sensitivity

The nurse administers an antibiotic to a client with respiratory tract infection. To evaluate the medication's effectiveness, which laboratory values should the nurse monitor? Select all that apply

Elevated liver function tests Rationale: Elevated liver function enzymes are a serious side effect of antivirals and should be reported. A decrease white blood count is a consistent finding with shingle B and (C and D) are side effects that affect that are of less priority than A.

The nurse administers an oral antiviral to a client with shingles. Which finding is important for the nurse report to the health care/provider?

Examine the genitalia as the last part of the total exam. |

The nurse ask the parent to stay during the examination of a male toddler's genital area. Which intervention should the nurse implement?

Dyspnea, cough, and fatigue.

The nurse assesses a 78-year-old male client who has left sides heart failure. Which symptoms would the nurse expect this client to exhibit?

Antibiotics

The nurse assesses a client with new onset diarrhea. It is most important for the nurse to question the client about recent use of which type of medication?

Avoid use of alcohol as a sleep aide at bedtime e Start a weight loss program

The nurse assesses a female client with obstructive sleep apnea syndrome (OSAS) who is 5 feet tall 152 cm) and weighs 155 pounds (70 kg), the client's 24 hour diet history includes: no breakfast, cheeseburger and fries for lunch; lasagna, chocolate ice cream and a cola drink for dinner, and 2 glasses of wine in the evening before going to bed for a total caloric intake of 3500 calories. What instructions should the nurse provide? (Select all that apply)

Discussed effective use of the stockings with the client UAF Rational: antiembolism stockings are designed to fit securely and should be applied so that there are no bands of the fabric constricting venous return. The nurse should discuss the need for correct and effective use of the stockings with both the client and UAP to improve compliance. Other options do not correct the incorrect application of the stockings.

The nurse assigned unlicensed assistive personnel (UAP) to apply antiembolism stockings to a client. The nurse and UAP enters the room, the nurse observes the stockings that were applying by the UAP. The UAP states that the client requested application of the stockings as seen on the picture, for increased comfort. What action should the nurse take?

Discussed effective use of the stockings with the client on UAF Rational: antiembolism stockings are designed to fit securely and should be applied so that there are no bands of the fabric constricting venous return. The nurse should discuss the need for correct and effective use of the stockings with both the client and UAP to improve compliance. Other options do not correct the incorrect application of the stockings.

The nurse assigned unlicensed assistive personnel (UAP) to apply antiembolism stockings to a client. The nurse and UAP enters the room, the nurse observes the stockings that were applying by the UAP. The UAP states that the client requested application of the stockings as seen on the picture, for increased comfort. What action should the nurse take?

Administer a prescribed analgesia for pain.

The nurse caring for a 3-month-old boy one day after a pylorotomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should the nurse take?

Large amounts of fluid and electrolyte replacement.

The nurse caring for a client with acute renal fluid (ARF) has noted that the client has voided 800 ml of urine in 4 hours. Based on this assessment, what should the nurse anticipate that client will need?

Flex the client's head with chin to the chest and insert.

The nurse caring for a client with dysphagia is attempting to insert an NG tube, but the client will not swallow and is not gagging. What action should the nurse implement to facilitate the NGT passage into the esophagus?

.Place a washcloth in the sink while cleaning the dentures

The nurse delegates to an unlicensed assistive personnel (UAP) denture care for a client th...daily leaving. When making this assignment, which instruction is most important for the nurse to do?

Cries frequently during the interview

The nurse delegates to an unlicensed assistive personnel (UAP) denture care for a client th...daily leaving. When making this assignment, which instruction is most important for the nurse to do?

Pupis reactive to accommodation

The nurse determines that a client's pupils constricts as they change focus from a far object. What documentation should the nurse enter about this finding?

Frequency of laxative use for chronic constipation

The nurse discovers that an electrolyte imbalance, what disease has an elevated serum magnesium elderly client with no history of cardiac or renal level. To further investigate the cause of this information is most important for the nurse to obtain from the client's medical history?

.Evaluate the client's mood, cognition and orientation. Rational: the mental status exam assesses the client for abnormalities in cognitive functioning, potential thought processes, mood and

The nurse ends the assessment of a client by performing a mental status exam. Which statement correctly describes the purpose of the mental status exam?

Place the side rails in an up position

The nurse enters a client's room and observe the unlicensed assistive personnel (UAP) making an occupied bed as seen in the picture. What action should the nurse take first?

Reposition the restraint tie onto the bedframe

The nurse enters a client's room and observes the client's wrist restraint secured as seen in the picture. What action should the nurse take?

Evaluate the oxygen saturation

The nurse enters a client's room to administer scheduled daily medications and observes the client leaning forward and using pursed lip breathing. Which action is most important for the nurse to implement first?

Position a firm wedge to support pelvis and thorax at 30 degree tilt.

The nurse finds a client at 33 weeks gestation in cardiac arrest. What adaptation to cardiopulmonary resuscitation (CPR) should the nurse implement?

Participation of community leaders in planning the program Rationale: When developing a culturally-competent health promotion project, the participation of stakeholders and community leaders is most important. A and B might be useful background information, but t-first the program should be developed. D may be useful fulfilling the plan developed by the health care team and the community leaders if funding for this assistance is included in the budget.

The nurse has received tunding to design a health promotion project for African- American women who are at risk for developing breast cancer. Which resource is most important in designing this program?

Auscuitate for irregular heart rate. Rational: Chronic kidney failure (CKF) is a progressive, irreversible loss of kidney functions, decreasing glomerular filtration rate (GFR), and the kidney's inability to excrete metabolic waste products and water, resulting in fluid overload, elevated pulse, elevated BP and electrolytes imbalances. The most important action for the nurse to implement is to auscultate for irregular heart rate (D) due to the decreased excretion of potassium by the kidneys. (A, B, and C) are not as important as monitoring for fatal cardiac dysrhythmias related to hyperkalemial

The nurse identifies an electrolyte imbalance, an elevated pulse rate, and elevated BP for a client with chronic kidney disease. Which is the most important action for the nurse to take?

Offer the client oral fluids Rationale: Increasing oral fluid intake reduces the risk of problems associated with immobility, so the UAP should be instructed to offer the client oral fluids every two hours, or whenever turning he client. It is not necessary to empty the urinary bag or feed the client every two hours. Assessment is a nursing function, and UAPs do not have the expertise to perform assessment of breath sounds

The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized elderly client with an indwelling urinary catheter every two hours. What additional action should the nurse instruct the UAP to take each time the client is turned?

Clamp the tubing and instruct the client to breathe deeply before continuing

The nurse is administering a 750 ml cleansing enema to an adult client. After approximately150 ml of enema has informed, the client states, 'stop I can't hold anymore." What action should the nurse take?

Assess the client for self-care ability .Provide pain medication instructions Teach care of ostomy to care provider

The nurse is arranging home care for an older client who has a new colostomy following a large bowel resection three day. The clients plan to live with a family member. Which action should the nurse implement? Select all that apply

"I couldn't get my son's socks and shoes on this morning"

The nurse is assessing a 4-year-old boy admitted to the hospital with the diagnosis of possible nephrotic syndrome. Which statement by the parents Indicates a likely correlation to the child's diagnosis?

Rebound tenderness in the upper quadrants

The nurse is assessing a client with a small bowel obstruction who was hospitalized hours ago. Which assessment finding should the nurse report immediately to the healthcare provider?

Wait 1 minute and palpate the systolic pressure before auscultating again.

The nurse is assessing a female client's blood pressure because she reported feeling dizzy. The blood pressure cuff is inflated to 140 mm hg and as soon as the cuff is deflated a korotkoff sound is heard. Which intervention should the nurse implement next?

:Moderate of foul-smelling lochia.

The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection?

Long distance runner since high school.

The nurse is assessing a middle-aged adult who is diagnosed with osteoarthritis. Which factor in this client's history is a contributor to the osteoarthritis?

Oral temperature of 100.6 F Rationale: A temperature greater than 100.4 F (38 C) (B), which is indicative of endometriosis (infection of the lining of the uterus), should be reported to the health care provider. (A and D) are findings that are within normal limits in the postpartum period. Fundal deviation to one side (C) is an expected finding related to a full bladder, so the nurse should encourage the client to void

The nurse is assessing a postpartum client who is 36 hours post-delivery. Which finding should the nurse report to the healthcare provider?

Fetal heart rate of 200 beats/minute

The nurse is assessing a primigravida a 39-weeks gestation during a weekly prenatal visit. Which finding is most important for the nurse to report to the healthcare provider?

The hemoglobin A1C was 6.5g/100 ml last week

The nurse is assessing an older adult with type 2 diabetes mellitus. Which assessment finding indicates that the client understands long- term control of diabetes?

Contractions of the sternocleidomastoid muscle

The nurse is assessing the thorax and lungs of a client who is having respiratory difficulty. Which finding is most indicative of respiratory distress?

A 10-year-old who is receiving chemotherapy and the infusion pump is beeping Rationale: an infiltration of a caustic agent can cause tissue damage and children are at greater risk for fluid volume imbalances

The nurse is assigned to care for clients on a medical unit. Based on the notes taken during the shift report, which client situation warrants the nurse's immediate attention?

Supplemental feedings with formula Rationale: Infant sucking at the breast increases prolactin release and proceeds a feedback mechanism for the.p milk, the nurse should explain that supplemental bottle formula feeding minimizes the infant's time at the breast and decreases milk supply . B promotes milk production and healing after delivery . C support milk production. C is recommended routine for breast feeding that promote adequate milk supply

The nurse is assisting a new mother with infant feeding. Which information should the nurse provide that is most likely to result in a decrease milk supply for the mother who is breastfeeding?

.Obtain a clean catch mid-stream specimen

The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the child's dietary restrictions. Which foods are contraindicated for this child?

Foods sweetened with aspartame

The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the child's dietary restrictions. Which foods are contraindicated for this child?

Murmur

The nurse is auscultating a client's heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio first to select the option that applies)

High pitched or fine crackles.

The nurse is auscultating a client's lung sounds. Which description should the nurse use to document this sound?

-Murmur

The nurse is auscultating is auscultating a client's heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio file to select the option that applies.)

Disconnect the NG suction so the client can ambulate in the hallway

The nurse is caring a client with NG tube. Which task can the nurse delegate to the UAP?

Start chest compressions with assisted manual ventilations Administer epinephrine 0.01 mg/kg intraosseous (O) Apply pads and prepare for transthoracic pacing Review the possible underlying causes for bradycardia

The nurse is caring for a 4-year-old male child who becomes unresponsive as his heart rate decreases to 40 beats/minute. His blood pressure is 88/70 mmHg, and his oxygen saturation is 70 % while receiving 100 % oxygen by non - rebreather face mask . In what sequence, from first to last, should the nurse implement these actions? (Place the first action on top and last action on the bottom.)

Complain of headaches and stiff neck

The nurse is caring for a client following a myelogram. Which assessment finding should the nurse report to the healthcare provider immediately?

Place client in Trendelenburg position on the left side.

The nurse is caring for a client immediately after inserting a PICC line. Suddenly, the client becomes anxious and tachycardiac, and loud churning is heard over the pericardium upon auscultation. What action should the nurse take first?

Confirm the necessity for continued use of the CVC

The nurse is caring for a client receiving continuous IV fluids through a single lumen central venous catheter (CVC). Based on the CVC care bundle, which action should be completed daily to reduce the risk for infection?

Measure hourly urinary output

The nurse is caring for a client who had gastric bypass surgery yesterday. Which intervention is most important for the nurse to implement during the first 24 postoperative hours?

Couvey to the client that birth is imminent.

The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first?

.Jaundice

The nurse is caring for a client who is taking a macrolide to treat a bacterial infection. Which finding should the nurse report to the healthcare provider before administering the next dose?

Increase the oxygen flow via nasal cannula if dyspnea is present.

The nurse is caring for a client with hypovolemic shock who is receiving two units of packed red blood cells (RBCs) through a large bore peripheral IV. What action promotes maintenance of the client's cardiopulmonary stability during the blood transfusion?

Take postoperative vital signs for a client who has an snidual following knee arthroplasty Collect a sputum specimen for a client with a fever of unknown origin Ambulate a client who had a femoral-popliteal bypass graft yesterday

The nurse is caring for a group of clients with the help of a licensed practical nurse (LPN) and an experienced unlicensed assistive personnel (UAP). Which procedures can the nurse delegate to the UAP? (Select all that apply)

Poor feeding and vomiting Leakage of CSF from the incisional site Abdominal distention

The nurse is caring for a one week old infant who has a ventriculoperitoneal (VP) shunt that was placed days after birth. Which findings are an indication of a postoperative complication?

Notify nursing supervisor and hospital chaplain of the child's impending death.

The nurse is caring for a toddler with a severe birth anomaly that is dying. The parents... holding the child as death approaches. Which intervention is most important for the nurse?

Determine the availability of two units of packed cells in the blood bank for client B

The nurse is caring for four clients.. postoperative hemoglobin of 8.7 mg/dl; client C newly admitted with potassium...an appendectomy who has a white blood cell count of 15,000mm3. What intervention..

Compress the drip chamber

The nurse is changing a client 's IV tubing and closes the roller clamp on the new tubing setup when the bag of solution is...which action should the nurse take to ensure adequate filling of the drip chamber?

1. Drape the client in a recumbent position for privacy 2. Open the urinary catheterization tray 3. Don sterile gloves using aseptic technique 4. Use forceps and swaps to clean the urinary meatus

The nurse is collecting a sterile urine specimen using a straight catheter tray for culture... .(Arrange from first action to last).

Clear fluid leaking from the nose

The nurse is completing a head to be assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the nurse?

20 pack-year history of cigarette smoking Rationale: Cigarette smoking (2 packs/day x 310 years 20 packs-year) increases the risk of osteoporosis. BMI of 30 or greater falls in the category of obesity which increase weight bearing that is protective against osteoporosis. C contain estrogens, and are also protective against development of osteoporosis. D is not related to the development of osteoporosis

The nurse is conducting health assessments. Which assessment finding increases a 56- year-old woman's risk for developing osteoporosis?

"What practices do you believe will help you heal?

The nurse is conducting the initial assessment of an ill client who is from another culture....What response should the nurse provide?

Place a client's locked wheelchair on the client's strong side next to the bed. RATIONALE: Placing the wheelchair on the client's strong side offers the greatest stability for the transfer. Holding the client arm's length or pulling from the opposite site of the bed reflect poor body mechanism. Using a gait belt offers additional safety for the client but should be done after the wheelchair has be put into the proper place and the wheels have been locked and before the client has assumed a standing position

The nurse is demonstrating correct transfer procedures to the unlicensed assisted personnel (UAP) working on a rehabilitation unit. The UAPs ask the nurse how to safely move a physically disabled client from the wheelchair to a bed. What action should the nurse recommended?

. Exercise at least three times weekly

The nurse is developing a plan of care for a middle-aged woman who is diagnosed with type 2 diabetes melitus (DM), To lower her blood glucose and increase her serum high-density lipoprotein (HDL) levels, which instruction is most important for the nurse to provide?

Literacy level

The nurse is developing a teaching program for the community. What population characteristic is most influential when choosing strategies for implementing a teaching plan?

Contains a list with definitions of unfamiliar terms Uses common words with few Syllables Uses pictures to help illustrate complex ideas

The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational materials include which characteristics? Select all that apply

Increase fluid intake to 3,000 ml / daily

The nurse is developing the plan of care for a client with pneumonia and includes the nursing diagnosis of Ineffective airway clearance secretions." Which intervention is most important for the related to thick pulmonary plan of care? include in the client's

Fever and dysuria.

The nurse is evaluating a client's symptoms, and formulates the nursing diagnosis, "high risk for injury due to possible urinary tract infection." Which symptoms indicate the need for this diagnosis?

Baked pork chop , applesauce , corn on the cob , 2 % milk , and key - lime pie

The nurse is evaluating the diet teaching of a client with hypertension. What dinner selection indicates that the client understands the dietary recommendation for hypertension?

Ineed to have regular pap smears

The nurse is evaluating the health teaching of a female client with condyloma acuminate. Which statement by the client indicates that teaching has been effective?

Too much salt can cause the kidneys to retain fluid Rationale: Excessive salt intake can contribute to primary hypertension by causing renal salt retention which influence water retention that expands blood volume and pressure (ACD) are not believed to contribute to primary hypertension

The nurse is explaining the need to reduce salt intake to a client with primary hypertension. What explanation should the nurse provide?

Interacts with a flat affect .Avoids eye contact . Has a disheveled appearance.

The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an obiective signs of depression? (Select all that apply)

Muscle spasms of the back and neck Rationale: An extra pyramidal symptom (EPS) characterized by abnormal muscle spasms of the neck (A) requires immediate intervention because it can cause difficulty antipsychotic medication medications swallowing and jeopardize the airway. Though (A, B and C) are also EPS caused by used to manage schizophrenia (D) has the highest priority to insure client safety is (A)

The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention?

Suggest enrolling the client in adult daycare instead of rotating among family.

The nurse is making a home visit to a male client who is in the moderate stage of Alzheimer's diseases. The client's wife is exhausted and tells the nurse that the family plans to take turns caring for the client in their home, each keeping him for two weeks at a time. How should the nurse respond?

Weigh the client and report any weight gain. Report any client complaint of pain or discomfort. Note and report the client's food and liquid intake during meals and snacks.

The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply)

During acute illness

The nurse is planning a class for a group of clients with diabetes mellitus about blood glucose monitoring. In teaching the class.as.awhole the nurse should emphasize the need to check glucose levels in which situation?

Monitor blood pressure frequently

The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care?

Provide a family tour of the preoperative unit one week before the surgery is scheduled.

The nurse is planning preoperative teaching plan of a 12-years old child who is scheduled for surgery. To help reduce the child anxiety, which action is the best for the nurse to implement?

Place the oximeter clip on the ear lobe to obtain the oxygen saturation reading Rationale: Pulse oximeter clips can be attached to the earlobe to obtain an accurate measurement of oxygen saturation. Other options will not provide the needed assessment

The nurse is planning to assess a client's oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client has a bilateral below-the-knee amputation and pedal pulses that are weak and threaty. What action should the nurse take?

Reposition the infant every 2 hours. Rational: An infant, who is receiving phototherapy for hyperbilirubinemia, should be repositioned every two hours. The position changes ensure that the phototherapy lights reach all.of the body surface areas.

The nurse is preparing a 4-day-old I infant with a serum bilirubin level of 19 mg/dl (325 micromol/L) for discharge from the hospital. When teaching the parents about home phototherapy, which instruction should the nurse include in the discharge teaching plan?

Push the undiluted Dextrose slowly through the currently infusion IV

The nurse is preparing a 50 ml dose of50 % dextrose IV for a clien with insulin...medication?

Monitor for an elevated temperature Rationale: The client should be instructed to monitor or elevated temperature because immunosuppressant agents which are prescribed to reduce rejection after transplantation, place the client at risk for infection. The client should recognize sign of liver rejection, such as sclera jaundice and increasing abdominal girths, but fever may be the only sign of infection. A is not as important and monitoring for signs of infection.

The nurse is preparing a client for discharge from the hospital following a liver transplant. Which instruction is most important for the nurse to include in this client's discharge teaching plan?

Inspect skin for redness Use a residual limb shrinker Wash the stump with soap and water Rationale: Several actions are recommended for home care following an amputation. The skin should be inspected regularly for abnormalities such as redness, blistering, or abrasions. A residual limb shrinker should be applied over the stump to protect it and reduce edema. The stump should be washed daily with a mild soap and carefully rinse and dried. The client should avoid cleansing with alcohol because it can dry and crack the skin Range of motion should be done daily

The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendations should the nurse provide this client? (Select all that apply)

Recommend weigh bearing physical activity

The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation?

Avoid crowds for first two months after surgery. Rationale: Cyclosporine immunosuppression liver transplantation and can increase the risk for infection, therapy is vital in the success of which is critical in the first two months after surgery. Fever is often.

The nurse is preparing a discharge teaching plan for a client who had a liver transplant. Which instruction is most important to include in this plan'?

Names 3 home safety hazards to be resolve immediately. Rational: a major teaching goal for an elderly client with osteoporosis is maintenance of safety to prevent falls. Injury due to a fall, usually resulting in a hip fracture, can result in reduced mobility and associated complications. Oth goals are also important when teaching clients who have osteoporosis, but they do not have the priority of preventing falls, which relates to safety

The nurse is preparing a teaching plan for an older female client diagnosed with osteoporosis. What expected outcome has the highest priority for this client?

Determine if the clamp on the IV tubing is released Rational: When the pump immediately beeps, it is often because the IV tubing clamp is occluding the flow, so the clamp should be checked first to ensure that it is open. If the alarm is not eliminated after the tubing clamp is released, flushing the IV site with saline is a common practice to clean the needle or to identify resistance due to another source. Local signs of infiltration to select another vein, but the pump's beeping-this early in the procedure is likely due to a mechanical problem. If beeping continues after verifying that the clamp may indicate the need is released the placement or threading of the tubing through the pump should be verified

The nurse is preparing an intravenous (IV) fluid infusion using an IV pump. Within 30 seconds of turning on the machine, the pump's alarm beeps "occlusion". What action should the nurse implement first?

Avoid straining at stool, bending, or lifting heavy objects. Rationale: after cataract surgery, the client should avoid activities which increase pressure and place strain on the suture line.

The nurse is preparing an older client for discharge following cataract extraction. Which instruction should be include in the discharge teaching?

Peak and through levels has not been drawn since the tobramycin was started

The nurse is preparing dose # 7 of an IV piggyback infusion of tobramycin for a 73 - year- ol client with... Infected pseudomonas aeruginosa. Which assessment data warrants further intervention by the nurse?

Divide the medication into two injection with volumes under Iml Rationale: IM injection for children under 3 of age should not exceed 1ml. divide the dose into smaller volumes for injection in two different sites.

The nurse is preparing to administer 1.6 ml of medication IM to a 4 month old infant. Which action should the nurse include?

Check the TPN solution for cloudiness

The nurse is preparing to administer an infusion of amino acid-dextrose total parenteral nutrition (TPN) through a central venous catheter (CVC) line. Which action should the nurse implement first?

e Check the TPN solution for cloudiness

The nurse is preparing to administer an infusion of amino acid-dextrose total parenteral nutrition (TPN) through a central venous catheter (CVC) line. Which action should the nurse implement first?

Decreases the amount of HCL secretion by the parietal cells in the stomach

The nurse is preparing to administer histamine 2-receptor antagonist to a client with peptic ulcer disease. What is the primary purpose of this drug classification?

Report any muscle twitching or seizures Take vitamin D with calcium daily Low fat yogurt is a good source of calcium Keep a diet record to monitor calcium intake

The nurse is preparing to discharge an older adult female client who is at risk for bw...nurse include with this client's discharge teaching?

Development progress from head to rump

The nurse is presenting information about fetal development to a group of parents with... when discussing cephalocaudal fetal development, which information should the nurse gives the parents?

.Report fresh blood in the urine

The nurse is reinforcing home care instructions with a client who is being discharged following.,prostate (TURP). Which intervention is most important for the nurse to include in the

Inability of the SA node to initiate an impulse at the normal rate Rationale: A prolonged PRI reflects an increased amount of time for an impulse to travel from the SA node through the AV node and is characteristic of a first degree heart block

The nurse is reviewing a client's electrocardiogram and determines the PR interval (PRI) is prolonged. What does this finding indicate?

It blocks the effects of histamine, causing decreased secretion of acid

The nurse is teaching a client about the antiulcer medications ranitidine which was... statement best describes the action of this drug?

Keeps the irrigating container less than 18 inches above the stoma

The nurse is teaching a client how to perform colostomy irrigations. When observing the client's return demonstration, which action indicated that the client understood the teaching?

Avoid eating grapefruit or drinking grapefruit juice. Report changes in the use of daily supplements . Notify you heal care provider if your skin

The nurse is teaching a client with atrial fibrillation about a newly prescribed medication, dronedarone. Which information should the nurse include in client interactions? (Select all that apply)

Protect joint function

The nurse is teaching a group of clients with rheumatoid arthritis about the need to modify daily activities. Which goal should the nurse emphasize?

Observe him as he demonstrates self-injection technique in another diabetic adolescent . Rational: watching the adolescent perform the procedure with another adolescent provides peer support the most information regarding his skill with self-injection. Other options do not provide information about the effectiveness of nurse's teaching.

The nurse is teaching a male adolescent recently diagnosed with type Idiabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate do you effectiveness of the teaching?

Apply downward manual pressure at the suprapubic regions Rationale: The Crede Method is used for those cdients with atonic bladders, which is a concomitant of demyelinating disorders like multiple sclerosis. The client is applying pressure in the wrong region (umbilical Are) and should be instructed to apply pressure at the suprapubic are.

The nurse is teaching a male client with multiple sclerosis how to empty his bladder using the Crede Method. When performing a return demonstration, the client applies pressure to the umbilical areas of his abdomen. What instruction should the nurse provide?

Hold the newborn in an upright position Rationale: the mother should be instructed to hold the infant during feedings in a sitting or upright position to prevent aspiration. Impaired sucking is compensated by.theuse.of special feeding appliances and nipples such as the habeman feeder that prevents aspiration by adjusting the flow of mild according to the effort of the neonate. Squeezing the nipple base may introduce volume that is greater than the neonate can coordinate swallowing. The preferred positon of an infant after feeding is on the right side to facilitate stomach emptying. Sucking difficulty impedes the neonate's intake of adequate nutrient needed for weight gain and water should be provided after the feeding to cleanse the oral cavity and not fill up the neonate's stomach.

The nurse is teaching a mother of a newborn with a cleft lip how to bottle feed her baby using medela haberman feeder, which has a valve to control the release of milk and a slit nipple opening. The nurse discusses placing the nipple's elongated tip in the back of the oral cavity. What instructions should the nurse provide the mother about feedings?

Postmenopausal women need an intake of at least 1,500 mg of calcium daily.

The nurse is teaching a postmenopausal client about osteoporosis prevention. The client reports that she smokes 2 packs of cigarettes a day and takes 750 mg calcium supplements daily. What information should the nurse include when teaching this client about osteoporosis prevention?

headache, photophobia, and nuchal rigidity Rationale: Headache, photophobia, and nuchal rigidity are classic signs of meningeal infection, so this client should immediately be referred to the health care provider. AC D do not have priority of B

The nurse is triaging clients in an urgent care clinic. The client with which symptoms should be referred to the health care provider immediately?

Delegate care of the crying client to an unlicensed assistant Rationale: According to the simple triage and Rapid Treatment (START) protocol of triage, the nurse should determine which client fit the objective of providing the greatest good for the greatest number of people who are most likely to survive. Delegating the care of the crying person to an unlicensed assistant allow the nurse to care for the injured who require intervention based on their ability to breath, maintain circulation and follow simple commands. A and

The nurse is triaging victims of a tornado at an emergency shelter. An adult woman who has been wandering and crying comes to the nurse. What action should the nurse take?

I. Open the sterile catheter kit close to the client's perineum. 2. Don sterile gloves and prepare to sterile field 3, Cleanse the urinary meatus using the solution, swabs, and forceps provided 4. Place distal end of the catheter sterile specimen cup and insert catheter into meatus

The nurse is using a straight urinary catheter kit to collect a sterile urine specimen from a female client. After positioning am prepping this client, rank the actions in the sequence they should be implemented. (Place to first action on the top on the last action on the bottom.)

Affirm that the UAP is using and effective strategy to reduce the client's anxiety. Rationale: Reduction is an effective technique is managing the anxiety of client with Alzheimer's disease, so the nurse should affirm the UAP is using an effective strategy (A). Nurse assertive communication and offering more choices (B) may increase. an agitation (C) is not indicated since the UAP is using redirection, an effective strategy

The nurse makes a supervisory home visit to observe an unlicensed assistive personnel (UAP) who is providing personal care for a client with Alzheimer's disease. The nurse observes that whenever the cdient gets upset, the UAP changes the subject. What action should the nurse take in response to this observation?

Evacuate each infant with mother via wheelchair

The nurse manager is conducting an in-services education program on the fire evacuation of the newborn recovery. What intervention should the nurse manager disseminate to the staff?

Engage the client in a non-threatening conversation.

The nurse note a depressed female client has been more withdrawn and non- communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

Elevate the presenting part off the cord.

The nurse note a visible prolapse of the umbilical cord after a client experiences spontaneous rupture of the membranes during labor. What intervention should the nurse implement immediately?

Auscultate the client 's bowel sounds

The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete?

Allow the UAP to complete the procedure, then discuss the painless comment privately with the UAP

The nurse observes a newly hired unlicensed assistive personnel (UAP) performinga fingestick to obtain a client's blood glucose. Prior to sticking the client's finger, the UAP explains the procedure and tell the client that it I painless. What action should the nurse take?

Remind the client to hold his breath after inhaling the medication

The nurse observes an adolescent client prepare to administer a prescribed corticosteroid medication using a metered dose inhaler as seen in the picture. What action should the nurse take?

Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.

The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement?

Explain that the hand rub can be completed in less than 2 minutes

The nurse observes an unlicensed assistive personnel (UAP) using an alcohol-based clean..tray to the room. The UAP rub both hands thoroughly for 2 minutes while standing at the..should the nurse take?

.The client's previous GCS score

The nurse performs a prescribed neurological check at the beginning of the shift on a client who was admitted to the hospital with a subarachnoid brain attack (stroke).O The client's Glasgow Coma Scale (GCS) score is 9. What information is most important for the nurse to determine?

Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours.

The nurse plans to collect a 24- hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?

Ensure that the scale is calibrated before a weight is obtained

The nurse plans to use an electronic digital scale to weight a client who is able to stand. Which intervention should the nurse implement to ensure that measurement of the client's weight is accurate?

Open the roller clamp on the tubing.

The nurse prepares an intravenous solution and tubing for a client with a saline lock, as seen in the video. Which nurse takes next

Affective

The nurse provides feeding tube instructions to the wife of a client with end stage cancer. The client's wife performs a return demonstration correctly, but begins crying and the nurse, "Ijust don't think I can do this every day." The nurse should direct further teaching strategies toward which learning domain?

Heat loss

The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn's survival?

Apple juice Chicken broth.

The nurse requests a meals tray for a client follows Mormon beliefs and who is on clear liquid diet following abdominal surgery. Which meal item should the nurse request for this client? (Select all that apply)

Diaphoresis

The nurse reviews the signs of hypoglycemia with the parents of a child with Type I diabetes mellitus. The parents correctly understand signs of hypoglycemia if they include which symptoms?

Narrow therapeutic index.

The nurse should observe most closely for drug toxicity when a client receives a medication that has which characteristic?

Avoid grapefruits and its juice

The nurse should teach the client to observe which precaution while taking dronedarone?

Inflammation of the mucous membrane & bronchospasm

The nurse should teach the parents of a 6 year-old recently diagnosed with asthma that the symptom of acute episode of asthma are due to which physiological response?

Move the device one to two inches away from the mouth

The nurse teaches an adolescent male dlient how to use a metered dose inhaler. Seen in the picture. What instruction should the nurse provide?

Answer: 12160 Rationale: 4ml x 67kg x 40 (bsa)-12,160 ml

The nurse uses the parkland formula (4ml x kg x total body surface area 24 hours fluid replacement) to calculate the 24-hours IV fluid replacement for a client with 40 % burns who weighs 76kg . How many ml should the client receive ? ( Enter numeric value only.)

Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills.

The nurse who is working on a surgical unit receives change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse?

Assist cardiac nurses with their assignments Rationale: When receiving staff from another specialty unit, the charge nurse should allow the nurse to assist where possible (D) without taking a client assignment so that the nurse is not asked to perform unfamiliar skills ( A , B , C ) are likely to involve skills the nurse is not accustomed to performing

The nurse who works in labor and delivery is reassigned to the cardiac care unit for the day because of a low census in labor and delivery. Which assignments is best for the nurse to give this nurse?

A family member of a client with dementia who has been missing for five hours

The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first?

Observe the amount of urine in the client's urinary drainage bag

The nurses observes that a postoperative client with a continuous bladder irrigation has a large blood clot in the urinary drainage tubing. What actions should the nurse perform first?

Supervised a newly hired graduate nurse during an admission assessment

The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (LPN), and unlicensed assistant personnel (UAP). Which task should the charge nurse assign to the RN?

e Supervised a newly hired graduate nurse during an admission assessment

The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (LPN), and unlicensed assistant personnel (UAP). Which task should the charge nurse assign to the RN?

Supervise a newly hired graduate nurse during an admission assessment

The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?

Fluid shifts from intravascular to interstitial area due to decreased serum protein Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen Increased circulating aldosterone levels that increase sodium and water retention

The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply

Viral meningitis whose temperature changed from 101 F to 102 F.

The practical nurse (PN) is assigned to work with three registered nurses (RN) who are caring for neurologically compromised clients. The client with which change in status is best to assign to the PN?

Inform him that the nurse is busy admitting a new client and will talk to him later. Rational: the psychiatric nurse must set limits with antisocial behavior so that appropriate behavior is demonstrated. Interrupting a conversation is rude and inappropriate, so telling the client that they can talk later is the best course action Other options may cause the client to become address the client's behavior. The nurse should not involve this client with newly | angry and they do not admitted client's admission procedure.

The psychiatric nurse is talking to a newly admitted client when a male client diagnosed with antisocial behavior intrudes on the conversation and tells the nurse, "T have to talk to you right now! It is very important!" how should the nurse respond to this client?

Vitamin supplements for high-risk pregnant women.

The public nurse health received funding to initiate primary prevention program in the community. Which program the best fits the nurse's proposal?

Perform bilateral chest auscultation

The rapid response team's detects return of spontaneous circulation (ROSC) after 2 min of continuous chest compressions. The client has a weak, fast pulse and no respiratory effort, so the healthcare provider performs a successful oral, intubation. What action should the nurse implement?

Remind the client to keep his appointments to have his cholesterol level checked.

To evaluate the effectiveness of male client's new prescription for ezetimibe, which action should the clinic nurse implement?

.Palpate the client's brachial pulse

To obtain an estimate of a client's systolic B/P. What action should the nurse take first?

Dress each wound separately Rational: each wound should be dressed separately using a new pair of sterile gloxe to avoid auto contamination (the transfer of microorganisms form one infected wound to a non-infected wound). The other choices do not prevent auto contamination

To prevent infection by auto contamination during the acute phase of recovery from multiple burns, which intervention is most important for the nurse to implement?

Review the staff nurse job description to ensure that it is clear, accurate, and recurrent. Rationale: Role ambiguity occurs when there is inadequate explanation of job descriptions and assigned tasks, as well as the rapid technological changes that produce uncertainty and frustration. A and D may be implemented if the nurse manager is concerned about role overload, which is the inability to accomplish the tasks related to one's role. C is not related to ambiguity

To reduce staff nurse role ambiguity, which strategy should the nurse manager implemented?

Review the staff nurse job description to ensure that it is clear, accurate, and current

To reduce staff nurse role ambiguity, which strategy should the nurse-manager implement

Evaluate both client's pain using a standardized pain scale

Two clients ring their call bells simultaneously requesting pain medication. What action should the nurse implement first?

Notify the food services department of the allergy Enter the allergy information in the client's record. Add egg allergy to the client's allergy arm band.

Two days after admission a male client remembers that he is allergic to eggs and informs the nurse of the allergy. Which actions should the nurse implement? (Select all that apply)

Initiate a hearing and vision screening program for first-graders Rationale: Community care occurs at primary, secondary, and tertiary levels of prevention. Primary prevention involves interventions to reduce the incidence of disease. Secondary prevention includes screening programs to detect disease. Tertiary prevention provides treatment directed toward clinically apparent disease. Secondary prevention focuses on screaming children for a specific disease processes such as hearing and vision screening. The other options are not examples of secondary prevention.

What action should the school nurse implement to provide secondary prevention to a school-age children?

The technique is intended to maintain straight spinal alignment.

What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning?

.Manage the airway

What is the nurse's priority goal when providing care for a 2-year-old child experiencing seizure...?

.Achieve satisfactory pain control.

What is the primary goal when planning nursing care for a client with degenerative joint disease (DID)?

Initiate the dosage lockout mechanism on the PCA pump

What is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PCA) pump?

Manage the airway

What isthe nurse 's priority goal when providing care for a 2 - year - old child experience

Deltoid Rationale: The acromion process is a parameter identified for the deltoid site.

When administering an immunization in an adult client, the nurse palpates and administer the injection one inch below the acromion process into the center of the muscle mass. The nurse should document that the vaccine was administered at what site?

Stridor

When administering ceftriaxone sodium (Rocephin) intravenously to a client before..most immediate intervention by the nurse?

Sitting upright. Rationale: The anterior fontanel closes at 9 months of age and may bulge when venous return is reduced from the head, but a bulging anterior fontanel is most significant if the infant is sitting up and may indicated an increase in cerebrospinal fluid.

When assessing a 6-month old infant, the nurse determines that the anterior fontanel is bulging. In which situation would this finding be most significant?

A collapsed lung

When assessing a male client, the nurse notes that he has unequal lung expansion. What conclusion regarding this finding is most likely to be accurate? The client has

.The gallbladder is normal

When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely explanation for failure to locate the gallbladder by palpation?

.Check for a distended bladder

When assessing a multigravida the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first?

Check for a destined bladder Rationale: a fundus that is dextroxexted (up to the right) and elevated above the umbilicus is indicative of bladder distension/urine retention.

When assessing a multigravida the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first?

Review the client's use of over the counter (OTC) medications.

When assessing and adult male who presents as the community health clinic with a history of hypertension, the nurse note that he has 2+ pitting edema in both ankles. He also has a history of gastroesophageal reflex disease (GERD) and depression. Which intervention is the most important for the nurse to implement?

Recompress the wound suction device and secure to plug Rationale: The plug of a wound suction device, such as a Hemevac, should be closed after compressing the device to apply gentle suction in a closed surgical wound to facilitate the evacuation of subcutaneous fluids into the device. Compressing the device and securing the plug should restore function of the closed wound device. A small amount of drainage should be marked on the dressing, but replacing the dressing is not necessary and the nurse should not remove the device. Other options are not indicated.

When assessing the surgical dressing of a client who had abdominal surgery the previous day, the nurse observes that a small amount of drainage is present on the dressing and the wound's Hemovaç suction device is empty with the plug open. How should the nurse respond?

To reduce abdominal pressure on the diaphragm

When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention?

.Neurologically stable without indications of an increased ICP

When caring for a client with traumatic brain injury (TBI) who had a craniotomy for increased intracranial pressure (ICP), the nurse assesses the client using the Glasgow coma scale (GCS) every two hours. For the past 8 hours the client's GCS score has been 14. What does this GCS finding indicate about the client?

Notify the healthcare provider

When changing a diaper on a 2-day-old infant, the nurse observes that the baby's legs are... this finding, what action should the nurse take next?

Refer child to the family healthcare provider

When checking a third grader's height and weight the school nurse notes that these measurements have not changed in the last year. The child is currently taking daily vitamins, albuterol, and methylphenidate for attention deficit hyperactivity disorder (ADHD). Which intervention should the nurse implement?

Pasta, noodles, rice. Egg, tofu, ground meat. . Mashed, potatoes, pudding, milk. Rational: a client's postoperative diet is commonly progressed as tolerated. A soft diet includes foods that are mechanically soft in texture (pasta, egg. ground meat, potatoes, and pudding. High fiber foods that require thorough chewing and gas forming foods, such as cruciferous vegetables and fresh fruits with skin, grains and seeds are omitted.

When conducting diet teaching for a client who is on a postoperative soft diet, which foods should eat? (Select all that apply)

Pasta, noodles, rice. Egg, tofu, ground meat. Mashed, potatoes, pudding, milk. Rational: a client's postoperative diet is commonly progressed as tolerated. A soft diet includes foods that are mechanically soft in texture (pasta, egg. ground meat, potatoes, and pudding. High fiber foods that require thorough chewing and gas forming foods, such as cruciferous vegetables and fresh fruits with skin, grains and seeds are omitted.

When conducting diet teaching for a client who is on a postoperative soft diet, which foods should eat? (Select all that apply)

Yogurt. Processed cheese.

When conducting diet teaching for a client who was diagnosed with hypoparathyroidism, which foods should the nurse encourage the client to eat?

Fortified whole wheat cereals, whole-grain pasta, brown rice Spinach, kale, dried raisins and apricots Rationale: Nutritional anemia in pregnancy should be supplemented with additional iron in the diet. Foods that are high in iron content are often protein based, whole grains (D), green leafy vegetables and dried fruits (E). (A, B, and C) are not iron rich sources

When conducting diet teaching for a client who was diagnosed with nutritional anemia in pregnancy, which foods should the nurse encourage the client to eat? (Select all that apply)

Give a dose of regular insulin per sliding scale

When development a teaching plan for a client newly diagnosed type 1 diabetes, the nurse should explain that an increase thirst is an early sing of diabetes ketoacidosis (DKA), which action should the nurse instruct the client to implement if this sign of DKA occur?

Place cardiac monitor leads on the client's chest. Rationale: Before further interventions can be done, the client's heart rhythm must be determined. This can be done by connecting the client to the monitor. A or C are not a first line drug given for any of the life threatening, pulses dysrhythmias

When entering a client's room, the nurse discovers that the client is unresponsive and pulseless. The nurse initiate CPR and Calls for assistance. Which action should the nurse take next?

Color characteristics of each stool.

When evaluating a client's rectal bleeding, which findings should the nurse document?

Get a blood pressure cuff.

When finding a client sitting on the floor, the nurse calls for help from the unlicensed assistive personnel (UAP). Which task should the nurse ask the UAP to do?

. Ask the family to ldentify a specific spokespersor

When five family members arrive at the hospital, they all begin asking the nurse questions regarding the prognosis of their critically ill mother. What intervention should the nurse implement first?

Reflection

When gathering for a group therapy session at 1400 hours, a female client complains to the nurse that a smoking break has not been allowed all day. The nurse responds that 15 minute breaks were called over the unit intercom after breakfast and after lunch. The nurse is using what communication technique in responding to the client?

Identify a command center where activities are coordinated

When implementing a disaster intervention plan, which intervention should the nurse implement first?

.Hold the thermometer in place.

When obtaining a rectal temperature with an electronic thermometer, which action is most important for the nurse to perform?

A woman who takes naproxen (Naprosyn) and reports a recent onset of dark, tarry stools

When organizing home visits for the day, which older client should the home health nurse plan to visit first?

Explain that the client may be placed in five positions

When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which approach should the nurse use?

Withhold food and fluid intake. Rational: The pathophysiologic processes in acute pancreatitis result from oral fluid and ingestion that causes secretion of pancreatic enzymes, which destroy ductal tissue and pancreatic cells, resulting in auto digestion and fibrosis of the pancreas. The main focus of the nursing care is reducing pain caused by pancreatic destruction through interventions that decrease GI activity, such as keeping the client NPO. Other choices are also important intervention but are secondary to pain management.

When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority?

Report any signs of cloudy urine output

When preparing a client for discharge from the hospital following a cystectomy and a urinary diversion to treat bladder cancer, which instruction is most important for the nurse to include in the client's discharge teaching plan?

Schedule an appointment for an out-patient psychosocial assessment.

When preparing to discharge a male client who has been hospitalized for an adrenal crisis, the client expresses concern about having another crisis. He tells the nurse that he wants to stay in the hospital a few more days. Which intervention should the nurse implement?

Low fat Rationale: A client with cholecystitis is at risk of gall stones that can be move biliary tract and cause pain or obstruction. Reducing dietary fat decrease stimulation of the gall bladder, so bile can be expelled, along with possible stones, into the biliary tract and small intestine

When providing diet teaching for a client with cholecystitis, which types of food choices the nurse recommend to the client?

As a routine part of each healthcare encounter Rationale: Universal screening for IPV is a vital means to identify victims of abuse in relationship. The suspicious of different clinicians vary greatly, so screening would not be implemented consistently. The client should be screened regardless of the presence of injury. Although history of abuse is difficult to confirm, screening should occur regardless, and this incident may know may be initial case of abuse.

When should intimate partner violence (IPV) screening occur?

.Wear long sleeves and pants Rationale: Lyme disease is it tick bone disorder and is transmitted to a child via a tick bite. Keeping the skin covered reduces the risk of being bitten by a tick. Other options are not reduce the risk for tick bites.

When teaching a group of school-age children how to reduce the risk of Lyme disease which instruction should the camp nurse include?

Correct order: (PADD) 1. Place stethoscope in suprasternal area to auscultate for bronchial sounds 2. Auscultate bronchovesicular sounds from side to side the first and second intercostal spaces 3. Displace female breast tissue and apply stethoscope directly on chest wall to hear vesicular sounds 4. Document normal breath sounds and location of adventitious breath sounds

Which action should the nurse implement with auscultating anterior breath sounds? (Place the first action on top and last action on the bottom)

Identify the source and amount of bleeding. Rationale: the nursed should first assess the client to determine the action that should be taken. Patient safety is the priority; other options are not priority.

Which action should the nurse take first? The nurse walks into a client's room and notices bright red blood on the sheets and on the floor by the IV pole.

Inspect for symmetrical shoulder height.

Which action should the school nurse take first when conducting a screening for scoliosis?

1. Place stethoscope in suprasternal area to auscultate from bronchial sounds 2. Auscultate bronchovesicular sounds from side to side of the first and second intercostal spaces 3. Displace female breast tissue and apply stethoscope directly on chest wall to hear vesicular sounds 4. Document normal breath sounds and location of adventitious breath sounds

Which actions should the nurse implement with auscultating anterior breath sounds? (Place the first action on top and last action on the bottom.)

Sudden dysphagia

Which assessment finding for a client who is experiencing pontine myelinolysis should the nurse report to the healthcare provider?

Expresses an understanding of the procedure.

Which assessment finding indicates to the nurse a client's readiness for pulmonary function tests?

Cold sensitivity

Which assessment finding of a postmenopausal woman necessitates a referral by the nurse to the healthcare provider for evaluation of thyroid functioning?

Distal pulse intensity Rationale: Distal pulse intensity assesses the blood flow through the extremity and is the most important assessment because it provides information about adequate circulation to the extremity.

Which assessment is more important for the nurse to include in the daily plan of care for a client with a burned extremity?

Bagel with jelly and skim milk

Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis?

Antintectives

Which class of drugs is the only source of a cure for septic shock?

Began to show signs of improvement in affect

Which client behavior indicates the highest risk for the client acting on these suicidal The nurse is planning care for a client who admits having suicidal thoughts?

An adult client who cannot sleep due to constant pain.

Which client is at the greatest risk for developing delirium?

Who is confused and frequently forgets to go to the bathroom

Which client should the nurse assess frequently because of the risk for overflow incontinence? A client

Body mass index

Which information is more important for the nurse to obtain when determining a client's risk for (OSAS)?

Avoid exposure to respiratory infections

Which instruction is most important for the nurse to provide a client who is being discharge following treatment for Guillan-Barre syndrome?

Remain upright after taking the medication.

Which instruction is most important for the nurse to provide a client who receives a new plan of care to treat osteoporosis?

Eat small meal throughout the day to avoid a full stomach.

Which instruction should the nurse provide a pregnant client who is complaining of heartburn?

Place the client on fall precautions

Which intervention is most important for the nurse to include in the plan of care for an older woman with osteoporosis?

Assess IV site frequently for signs of extravasation

Which intervention should the nurse implement during the administration of vesicant chemotherapeutic agent via an IV site in the client's arm?

Place wet cloths on the burned areas for short periods of time.

Which intervention should the nurse implement for a client with a superficial (first degree) burn?

Reduce risks factors for infection

Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)?

Minimize the amount of stimuli in the room

Which intervention should the nurse include in the plan of care for a child with tetanus?

Monitor temperature regularly

Which intervention should the nurse include in the plan of care for a client with leukocytosis?

Reduce risk factors for infection

Which interventions should the nurse include in a long-term plan of care for a client with COPD?

A business and professional women's group.

Which location should the nurse choose as the best for beginning a screening program for hypothyroidism?

Intravenous administration of thyroid hormones Rationale: The high mortality of myxedema coma requires immediate administration of IV thyroid hormones (A). (B) Is contraindicated, because eves small doses can cause profound somnolence lasting longer than expected. (C) Is administered to clients diagnosed with adrenal insufficiency (Addisonian crisis) and (D) to clients who have had an overdose of warfarin.

Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma?

Assess fundal tone and lochia flow

Which nursing intervention has the highest priority for a multigravida who delivered..

Muscle pain

Which problem reported by a client taking lovastatin requires the most immediate fallow up by the nurse?

Aural migraine headaches.

Which problem, noted in the client's history, is important for the nurse to be aware of prior to administration of a newly prescribed selective serotonin reuptake inhibitor (SSRI)?

Capillary hydrostatic pressure exceeds colloid osmotic pressure, producing interstitial edema

Which statement is accurate regarding the pathological changes in the pulmonary system associated with acute (adult) respiratory distress syndrome (ARDS)?

Eosinophils

Which type of Leukocyte is involved with allergic responses and the destruction of parasıtic

. Provide supplemental oxygern .Auscultate bilateral lung fields Reinforce occlusive CT dressing

While assessing a client's chest tube (CT), the nurse discovers bubbling in the of the chest tube collection device. The client's vital signs blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32 s / minutes , oxygen saturation 88 % . interventions should the nurse implement?

Promptly remove the arterial catheter from the radial artery

While assessing a radial artery catheter, the client complains of numbness and pain distal to the insertion site . What interventions should the nurse implement

Measure the client's oral temperature Rationale: The strong odor from the urine and skin that is warm to the touch may indicate that the client has a urinary tract infection. Assessing the client's temperature provides objective information regarding infection that can be reported to the healthcare provider. Urine should be obtained via a clean catch, not the bed pan where it has been contaminated. The drainage on the dressing is normal and does not require direct conservation at this time. An indwelling catheter should be avoided if possible because it increases the risk of infection.

While assisting a client who recently had a hip replacement into a bed pan, the nurse notices that there is a small amount of bloody drainage on the surgical dressing, the client's skin is warm to the touch, and there is a strong odor from the urine. Which action should the nurse take?

Place a portable toilet next to the bed

While assisting a male client who has muscular dystrophy (MD) to the bathroom, the nurse observes that he is awkward and clumsy. When he expresses his frustration and complains of hip discomfort, which intervention should the nurse implement?

T4 levels in newborns

While attempting to stablish risk reduction strategies in a community, the nurse notes that the regional studies have indicated... .ersons with irreversible mental deficiencies due to hypothyroidism. The nurse should seek funding to implement which screening measure?

Culture for sensitive organisms. RATIONALE: A client who has a postoperative dressing with purulent drainage from the wound is experiencing an infection. The nurse should review the client's laboratory culture for sensitive organisms (C) before reporting to the healthcare provider. (A, B and D) are not indicated at this time.

While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?

Use a water soluble lubricant on affected oral and nasal mucosa

While caring for a toddler receiving oxygen (02) via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement?

Measure the area of swelling and crackling. Rational: a crackling sensation, or crepitus, indicates subcutaneous emphysema, or air leaking into the skin. This area should be measured and the finding documented. Other options are not indicated for crepitus

While changing a client's chest tube dressing, the nurse notes a crackling sensation when gentle pressure is applied to the skin at the insertion site. What is action for the nurse to take?

Does your pain occur when walking short distances?

While completing an admission assessment for a client with unstable angina, which closed questions should the nurse ask about the client's pain?

Contact the medical records department supervisor

While in the medical records department, the nurse observes several old medical records with names visible in waste container. What action should the nurse implement?

e Administer a nebulizer Treatment Rationale: The client needs an immediate medicated nebulizer treatment. Sitting in an upright position with head and arms resting on the over-bed table is an ideal position to promote breathing because it promotes lung expansion. Other actions me be accurate but not yet indicated.

While making rounds, the charge nurse notices that a young adult client with asthma who was admitted yesterday is sitting on the side of the bed and leaning over the bed-side-table. The client is currently receiving at 2 litters/minute via nasal cannula. The client is wheezing and is using pursed-lip breathing. Which intervention should the nurse implement?

. Move obstacle away from client .Monitor physical movements Observe for a patent airway . Record the duration of the seizure

While monitoring a client during a seizure, which interventions should the nurse implement? (Select all that apply)

Psoriasis

While performing a skin inspection for a female adult client, the nurse observes a rash that is well circumscribed, has silvery scales and plaques, and is located on the elbows and knees. These assessment findings are likely to indicate which condition?

Attempt to distract the client with general conversation

While receiving a male postoperative client's staples de nurse observe that the client's eyes are closed and his face and hands are clenched. The client states, "I just hate having staples removed". After acknowledgement the client's anxiety, what action should the nurse implement?

.Notify the employee health nurse.

While removing an IV infusion from the hand of a client who has AIDS, the nurse is struck with the needle. After washing the puncture site with soap & water, which action should the nurse take?

Pull up a chair and sit beside the client's bed

While taking vital signs, a critically ill male client grabs the nurse's hand and ask the nurse not to leave. What action is best for the nurse to take?

Ask the client what he is thinking about at his time

While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action should the nurse take?

Ask the client when a family member last visited her.

While the nurse is conducting a daily assessment of an older woman who resides ina iong-term facility, the client begins to cry and tells the nurse that her family has stopped calling and visiting. What action should the nurse take first?

"We need to stay focused on the topic."

While the school nurse is teaching a group of 14-year-olds, one of the participants remarks, "You are too young to be our teacher! You're not much older than we are!" How should the nurse respond

Raise the client's legs and feet

While undergoing hemodialysis, a male client suddenly complains of dizziness. He is alert and oriented, but his skin is cool and clammy. His vital signs are: heart rate 128 beats/minute, respirations 18 breaths/minute, and blood pressure 90/60. Which intervention should the nurse implement first?

Submit a referral for an evaluation by a physical therapist

While visiting a female client who has heart failure (HF) and osteoarthritis, the home health nurse determines that the client is having more difficulty getting in and out bed than she did previously. Which action should the nurse implement first?

Cleanse the foot with soap and water and apply an antibiotic ointment

and pierced the bottom of the child's foot. Which action should the nurse implement pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the first?

Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour

client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement?

Ventricular arrhythmias.

client with history of bilateral adrenalectomy is admitted with a week, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse?

.Background .Assessment Recommendation Rationale: BCD are correct. The current situation is reported regarding the client's nausea and pain (A). Based on SBAR communication, critical information about the client's clinical history (B), and assessment (C) such as pain scale or vital signs related to client's response to medication, are not included, nor are any recommendations for further follow-up (D). (E) Is not a component of SBAR communication

continues to report pain and nausea after receliving morphine 2 mg IV and ondansetron 4 mg lV anesthesia care unit (PACU) nurse reports that the client, who is awake and responsive During the trenster of a cient who had major abdominal surgery this morning, the post 45 mints ago. Which elements of SBAR communication are missing from the report given by the PACU nurse? (Select all that apply)

Crutches with 4 point gait.

due to generalized weakness, but is able to bear weight on both legs. To assist with A client with a chronic health problem has difficulty ambulating short distance ambulation and provide the greatest stability, what assistive device is best for this client?

Restlessness Clenched Fist Increased pulse rate Increased respiratory rate.

e nurse is assessing a 3-month-old infant who had a pxlorotomy yesterday. This child should be medicated for pain based on which findings? Select all that apply

Repeated fasting blood sugar (FBS) is 132 mg/di or 74 mmolL (SI)

fasting blood sugar During an annual physical ( FBS ) is determined to be 140 mg / dl or 7.8 examination, an older woman's mmoVL ( SI ) . Which obtained during a follow-up visit 2 weeks later is most indicative that the client has additional finding diabetes mellitus (DM)?

Diminished left lower lobe sounds

female client with acute respiratory distress syndrome (ARDS) is chemically paralyzed and sedated while she is on as assist - control ventilator using 50 % F102 . Which assessment finding warrants immediate intervention by the nurse?

Collect multiple site screening culture for MRSA Place the client on contact transmission precautions Continue to monitor for client sign of infection.

for the fracture ankle. During the admission history, he tells the nurse he recently A male client is admitted for the removal of an internal fixation that was inserted received vancomycin (vancomycin) for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which action should the nurse take? (Select all that apply)

.An older cient post-stroke who is aphasic with right-sided hemiplegia

in preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse (PN)?

Determine which side of the body is weak.

nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, ptosis, mouth drooping and, aspiration pneumonia. What is the priority nursing assessment that should be done before administering this medication?

Maternal pulse rate of 162 beats peř min

terbutaline sulfate 8.35 mg is gives subcutaneously. Based on which finding should the A client at 30 aweek gestation is admitted due to preterm labor. A prescription of nurse withhold the next dose of this drug?

Assess the surroundings for noise and distractions.

to An older male comes to the clinic with a family member. When the nurse attempts to take the client's health history, he does not respond to questions in a clear manner. What action should the nurse implement first?

Determine client's pulse, blood pressure, and respirations

transferred to the Postanesthesia Care Unit (PACU). Which intervention should the nurse After a colon resection for colon cancer, a male client is moaning while being implement first?

Inform her that some antianxiety medications are safe to take while breastfeeding

woman with an anxiety disorder calls her obstetrician's office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman?