Multichoices

The 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 (ADLs) due to aging. Which options should the nurse discuss with the daughter? SATA a. Home hospice agency b. Long-term care facility c.Home health agency

b. Long-term care facility c.Home health agency Long term care facilities and home health agencies performs ADLs. Hospice provides empathetic, attentive care for dying. C provide physical therapy to strengthen a part of the body.

A client with multiple sclerosis is receiving beta -1b interferon every other day. TO assess for possible bone marrow suppression caused by the medication, which serum laboratory test findings should the nurse monitor? SATA a. Neutrophils b. Platelet count c.RBC d.WBCs

b. Platelet count c.RBC d.WBCs

A neonate w/ congenital heart defect (CHD) is demonstrating symptoms of HF. Which interventions should the nurse include in the infants plan of care? SATA a. Administer diuretics via secondary infusion in the morning only b.Give O2 at 6L/nasal canula for 3 repeated oximetry screens below 90% c.Evaluate the heart rate for effectiveness of cardio tonic medications d. Use high energy formula 30 calories/ ounces at Q3hours feeding via soft nipples e.Ensure interrupted and frequent rest periods between procedures

b.Give O2 at 6L/nasal canula for 3 repeated oximetry screens below 90% c.Evaluate the heart rate for effectiveness of cardio tonic medications d. Use high energy formula 30 calories/ ounces at Q3hours feeding via soft nipples e.Ensure interrupted and frequent rest periods between procedures

After teaching a male client with chronic kidney disease (CKD) about therapeutic diet... which menu of foods indicates that the teaching was effective?SATA a- A slice of whole grain toast d- A bowl of cream of wheat e- Two bananas.

a- A slice of whole grain toast d- A bowl of cream of wheat Rationale: Patient with CKD have elevated serum potassium, sodium and protein levels. A and D are low in potassium, sodium and protein, Beans are rich in proteins.

A client with acute pancreatitis is complaining of pain and nausea. Which interventions should the nurse implement SATA a- Monitor heart, lung, and kidney function. b- Notify healthcare provider of serum amylase and lipase levels. c-Review client's abdominal ultrasound findings. d- Encourage an increased intake of clear oral fluids

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

A client is admitted with an exacerbation of HF secondary to COPD. Which observations by the nurse require immediate intervention to reduce the likelihood of harm to this client? SATA a. A full pitcher of water is on the bedside table b. The client is lying in a supine position bed c. Pt. uses lip pursed breathing

a. A full pitcher of water is on the bedside table b. The client is lying in a supine position bed

An OA resident of a long term care facility has a 5yr history of HTN. The client has a headache and rate the pain 5 on pain scale 0 to 10. The clients BP is currently 142/89. Which interventions should the nurse implement? SATA a. Administer a daily dose of lisinopril as scheduled b. Provide a PRN dose of acetaminophen for headaches c. Notify HCP immediately

a. Administer a daily dose of lisinopril as scheduled b. Provide a PRN dose of acetaminophen for headaches 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 the client's headache. The other options are not indicated for this situation.

The nurse requests a meal 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? SATA a. Apple Juice b. Chicken broth c.Black coffee

a. Apple Juice b. Chicken broth

A newly admitted client vomits into an emesis basin as seen in the PICTURE. The nurse should consult with the HCP before administering which of the clients prescribes medications? SATA a. Clopidogrel (Plavix), antiplatelet, give PO b. Methylprednisone (solu-medrol), a corticosteroid to be given IV c. Enoaparin (Lovenox), low molecular weight heparin to be given SQ d. Ibuprofen e.Nitroglycerin (Nitro Dur) f. Furosemide (Lasix)

a. Clopidogrel (Plavix), antiplatelet, give PO b. Methylprednisone (solu-medrol), a corticosteroid to be given IV c. Enoaparin (Lovenox), low molecular weight heparin to be given SQ d. Ibuprofen

'***A male client is admitted for the removal of an internal fixation that was inserted for the fracture ankle. During the admission history, he tells the nurse he recently received vancomycin for MRSA wound infection. Which action should the nurse take? SATA a. Collect multiple site screening culture for MRSA b.Place the client on contact transmission precautions c. Continue to monitor for client sign of infection d.Obtain sputum specimen for culture sensitivity

a. Collect multiple site screening culture for MRSA b.Place the client on contact transmission precautions c. Continue to monitor for client sign of infection

*tq*The nurse is developing an educational program for OA who are being d/c with new antihypertensives medications. The nurse should ensure that the educational materials include which characteristics? SATA a. Contains a list w/ definitions of unfamiliar terms b.Uses common words w/ few syllables c. Uses pictures to help illustrate complex ideas d.Written a 12 grade reading

a. Contains a list w/ definitions of unfamiliar terms b.Uses common words w/ few syllables c. Uses pictures to help illustrate complex ideas. Rational:During the aging process OA experience sensory or cognitive changes, such as decreased visual or hearing acuity, slower thought or reasoning processes

The nurse is caring for a client who is experiencing a tonic-clonic seizures. What actions should the nurse implement? SATA a. Ease the client to the floor b. Loosen restrictive clothing c. Note duration of the seizure d. Place pillows around surrounding

a. Ease the client to the floor b. Loosen restrictive clothing c. Note duration of the seizure

The patho mechanism are responsible for ascites r/t liver failure? SATA a. Fluids shifts from intravascular to interstitial area d/t decreased serum protein b. Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen c. Increased circulating aldosterone levels that increase sodium and water retention d.Bleeding results from low clotting factors

a. Fluids shifts from intravascular to interstitial area d/t decreased serum protein b. Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen c. Increased circulating aldosterone levels that increase sodium and water retention Rationale: Failed liver decreases albumin production. Since albumin is the primary sources of protein creating intravascular osmotic pressure, decreased serum protein allows a fluid shift into the interstitial space. Pressure increases in the portal circulation when venous return from the upper GI tract cannot flow freely into sclerosed liver, which cause a pressure gradient to further increase fluid shifts into the abdomen. A failing liver ineffectively inactivates steroidal hormones, such as aldosterone resulting in sodium and water retention.

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? SATA a. Graves' disease, an autoimmune condition, affects thyroid stimulating hormone receptors. b. T3 and T4 hormone levels are increased c.Large protruding eyeballs are a sign of hyperthyroid function d.Pt. will be Hyperglycemic

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

During a left femoral artery aortogram, the HCP inserts an arterial sheath and initiate. Through the sheath to dissolve an occluded artery. Which interventions should the nurse implement? SATA a. Instruct the client to keep the left leg straight b.Observe the insertion site for hematoma c. Circle 1st noted drainage on the dressing d. Keep HOB 60 deg angle

a. Instruct the client to keep the left leg straight b.Observe the insertion site for hematoma c. Circle 1st noted drainage on the dressing

An older female who ambulate with a quad cane prefer to use. a wheel chair bc she has a halting and unsteady gait at times. Which interventions should the nurse implement? SATA a. Move personal items within client's reach b. Lower bed to the lower possible position c. Raise all bed rails when the client is resting d. Give directions to call for assistance e. Assist client to the bathroom in 2 hours.

a. Move personal items within client's reach b. Lower bed to the lower possible position d. Give directions to call for assistance e. Assist client to the bathroom in 2 hours.

An older male adult resident of long term care facility is hospitalized for cardiac catherization 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? SATA a. Notify the HCP of the clients change in mental status b. Apply soft restraints so that the operative sites is protected c.Include q2 hours reorientations in the plan of care.

a. Notify the HCP of the clients change in mental status c.Include q2 hours reorientations in the plan of care. R: Pt. condition reflects mental changes that could be related to post procedure stress, sundowners syndrome, or cerebral complications, the nurses should inform the HCP of the clients change in mental status for safety, q2hr orientation evaluation and reorientation should be included in plan of care.

When conducting diet teaching for a client who is on a postoperative soft diet, which foods should eat? SATA a. Pasta, noodles, rice b. Egg, tofu, ground meat c.Mashed potatoes, pudding, milk d. Brussel sprouts, blackberries, seeds

a. Pasta, noodles, rice b. Egg, tofu, ground meat c.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.

During discharge teaching, an overweight client heart failure (HF) is asked to make a grocery list for the nurse to review. Which food choices included on the client's list should the nurse encourage? SATA a. Plain, air-popped popcorn b. Natural whole almonds c. saltine crackers

a. Plain, air-popped popcorn b. Natural whole almonds

The nurse is caring for a one week old infant who has a ventriculoperitoneal (VP) pump shunt that was placed 2 days ago after birth. Which findings are an indication of a postoperative complications? a. Poor feeding and vomiting b. Leakage of CSF from the incisional site d. Abdominal distention e. WBC Count of 1000/mm3

a. Poor feeding and vomiting b. Leakage of CSF from the incisional site e. WBC Count of 1000/mm3 R:A, B and D are sign of postoperative complications. Shunt malfunction is most often caused by mechanical obstruction, which can result from ventricular exudate, distal end thrombosis or displacement, and/or infection. CNS infection is usually manifested by poor feeding, vomiting, elevated temperature, decreased responsiveness and seizure activity. Incisional leakage should be tested for glucose, an indication of CSF, which place the infant at risk for infection. Abdominal distention is a manifestation of peritonitis or a postoperative ileus from distal catheter placement. C is not a result of a shunt obstruction and E is a normal finding for one-week-old neonate.

The nurse is preparing ti d/c an OA femalr client whi is at risk for HYPOcalcemia nurse include w/ this clients d/c teaching? SATA a. Report any muscle twitching or seizure b. Take vitamin D w/ calcium daily c. Low fat yogurt is a good source of calcium d. Keep a diet record to monitor calcium intake e. Avoid seafood particularly shellfish

a. Report any muscle twitching or seizure b. Take vitamin D w/ calcium daily c. Low fat yogurt is a good source of calcium d. Keep a diet record to monitor calcium intake Rationale: Twitching and seizure are signs of low calcium. (A) Vit D supplement with calcium to enhance calcium absorption, especially in older adults. Dairy product should be included in the diet. Keeping a food record is a good healthcare practice. Foods high in calcium are recommended to maintain normal calcium level and it is important to verify if the client has allergy to shellfish.

An OA male who had an abdominal cholecystectomy has become increasingly confused and disoriented over the past 24hrs. He is found wandering into another clients room and is return to his room by the UAP. What actions should the nurse take? SATA a. Report mental status change to the HCP b.Assess the clients breath sounds and oxygen saturation c. Review the clients most recent serum electrolyte values d.Assign the UAP to reassess the clients risk for falls

a. Report mental status change to the HCP b.Assess the clients breath sounds and oxygen saturation c. Review the clients most recent serum electrolyte values

The nurse is assessing 3 month old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which findings? SATA a. Restlessness b. Clenched fist c. Increased pulse rate d. Increased Respiratory rate e. Increased temperature

a. Restlessness b. Clenched fist c. Increased pulse rate d. Increased Respiratory rate

A client with multiple sclerosis (MS) is admitted to the medical unit. The client reports... which action should the nurse implement to reduce the client's risk for falls? SATA a. Schedule frequent rest periods b. Provide assistance to bedside commode c. Teach to patch one eye when ambulating d.Wear fuzzy socks around home

a. Schedule frequent rest periods b. Provide assistance to bedside commode c. Teach to patch one eye when ambulating

After removing a left femoral arterial sheath, which assessment finding warrant immediately interventions by the nurse? SATA a. Unrelieved back and flank pain b. cool and pale left leg and foot c.Left groin egg size hematoma d. tenderness over insertion

a. Unrelieved back and flank pain b. cool and pale left leg and foot c.Left groin egg size hematoma

The nurse is managing the care of a client w/ Cushings syndrome. Which interventions should the nurse delegate to the UAP? SATA a. Weigh the client and report any weight gain b.Report any client complain of pain or discomfort c.Note and report the clients food and liquid intake during meals and snacks d.Evaluate the client for sleep disturbances

a. Weigh the client and report any weight gain b.Report any client complain of pain or discomfort c.Note and report the clients food and liquid intake during meals and snacks

After teaching a male client w/ chronic kidney disease (CKD) about therapeutic diet... which menu of foods indicates that the teaching was effective? SATA a.A slice of whole grain toast b. A bowl of cream of wheat c. 2 bananas

a.A slice of whole grain toast b. A bowl of cream of wheat

After several hours of non productive coughing, a client presents to the ER complaining of chest tightness and SOB. History includes stage COPD and DM. while completing the pulmonary assessment the nurse hears wheezing and poor air movement bilaterally which actions should nurse implement? a.Administer PRN medication treatment b. Obtain 12 lead electrocardiogram c.Monitor continues oxygen saturation d.Apply Oxgen NC

a.Administer PRN nebulizer treatment b. Obtain 12 lead electrocardiogram c.Monitor continues oxygen saturation R:

The home care nurse provide self care instructions for a client chronic venous insufficiency cause by DVT. Which instructions should the nurse include in the clients d/c teaching plan? SATA a.Avoid prolonged standing or sitting b. Use recliner for long periods of sitting c.Continue wearing elastic stocking d. Maintain bed flat while sleeping

a.Avoid prolonged standing or sitting b. Use recliner for long periods of sitting c.Continue wearing elastic stocking

A client w/ T2 DM is admitted for frequent HNNKS and Hemoglobin HbA1c of 10% insulin glargine 10 Units SQ once a day at bedtime and a sliding scale w/ insulin aspart q6h are prescribed. What actions should the nurse include in this clients plan of care? SATA a.Finger glucose assessment q6h w/ meals b.Review w/ the client proper foot care and prevention of injury c.Coordinate carbohydrate controlled meals at consistent times and intervals d.Teach SQ injection techniques, site rotations and insulin management. e.Do not contaminate the insulin glargine w/ insulin aspart so that it is available for IV use

a.Finger glucose assessment q6h w/ meals b.Review w/ the client proper foot care and prevention of injury c.Coordinate carbohydrate controlled meals at consistent times and intervals d.Teach SQ injection techniques, site rotations and insulin management.

When conducting diet teaching for a client who was diagnosed with a myocardial infarction, which snack foods should the nurse encourage the client to eat? SATA a.Fresh turkey slices and berries b.raw unsalted almonds and apples c. Bagel and bacon

a.Fresh turkey slices and berries b.raw unsalted almonds and apples

**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? SATA a.Headache and tremors b.Postural hypotension c.Pallor and diaphoresis d.Irregular heart beat e. hypotension

a.Headache and tremors b.Postural hypotension c.Pallor and diaphoresis d.Irregular heart beat

An adult man reports that he recently experienced an episode of chest pressure and breathlessness when he was jogging in the neighborhood. He express concerns bc both of his deceased parents had a heart disease and his father was a diabetic. He lives with his male partner, is vegetarian, and take atenolol which maintain his BP at 138/74. Which risk factors should the nurse explore further with the client? SATA a.History HTN b. Family health history c. vegetarian diet

a.History HTN b. Family health history Rationale: Based on the client's family history and medication for management of hypertension, the nurse should further explore these risk for ischemic heart disease.

The nurse is preparing a client who had a below the knee (BKA) amputation for dc to home. Which recommendations should the nurse provide-this client? SATA a.Inspect the skin for redness b. Wash the stump with soap and water c.Use residual limb shrinker d. avoid range of motion exercises

a.Inspect the skin for redness b. Wash the stump with soap and water c.Use residual limb shrinker 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 interacting w/ a female client who is diagnosed w/ postpartum depression. Which finding should the nurse document as an objective sign of depression? SATA a.Interacts w/ flat affect b.Avoids eye contacts c.Has disheveled appearance d.Reports feeling sad

a.Interacts w/ flat affect b.Avoids eye contacts c.Has disheveled appearance

A client with T2 DM is admitted for antibiotics treatment for a leg ulcer. To monitor the client for the onset of HNNS, What action should the nurse take? SATA a.Measure blood glucose b.Monitor VS c. Assessed LOC d. Check urine for ketones

a.Measure blood glucose b.Monitor VS c. Assessed LOC. Rationale: Blood glucose greater than 600 mg/dl (33.3 mmol/L SI), 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.

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? SATA a.Notify the food services department of the allergy b.Enter the allergy information in the clients record c.Add egg allergy to the clients allergy arm band d. Document the statement in the nurses notes.

a.Notify the food services department of the allergy b.Enter the allergy information in the clients record c.Add egg allergy to the clients allergy arm band R: The dietary department needs to screen menu selections for foods that are prepared with eggs. The client's chart should be clearly marked but the statement does not need to be documented in the nurse's note or included in the intake record. Allergy identification on the arm band is a universal location where allergies are noted while client is hospitalized.

Following an esophagogastroduodenoscopy (EGD) a male client is drowsy and difficult to arouse, and his respirations are slow and shallow. Which actions should the nurse implement? SATA a.Prepare the medication reversal agent b. Check oxygen saturation level c.Apply oxygen via nasal cannula d. Begin cardiopulmonary resuscitation

a.Prepare the medication reversal agent b. Check oxygen saturation level c.Apply oxygen via nasal cannula

The mother of a child recently diagnosed with asthma attacks asks the nurse how to help protect her child from having asthmatics attacks, which instructions should the nurse provide the mother? SATA a.Stay indoors when grass is being cut b.Close car windows and use air conditioner c.Avoid sudden changes in temperature d.Keep away from pets with long hair e.stay indoors at all times

a.Stay indoors when grass is being cut b.Close car windows and use air conditioner c.Avoid sudden changes in temperature d.Keep away from pets with long hair

**After the nurse witnesses a pre operative client sign the surgical consent form, The nurse signs the form as a witness. What are the legal implications of the nurses signature on the clients surgical consent form? SATA a.The client voluntarily grants permission for the procedure to be done b.The client is competent to sign the consent without impairment of judgement c.The client understands the risks and benefits associated with the procedure d. The surgeon has explained to the client why the surgery is necessary

a.The client voluntarily grants permission for the procedure to be done b.The client is competent to sign the consent without impairment of judgement c.The client understands the risks and benefits associated with the procedure R: informed consent is required for any invasive procedure. The nurses signature as a witness to the clients signature on surgical consent indicates that the client voluntary gives consent for the scheduled procedure.

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 chemo theraphy and wants to stop all treatments but knows her husband will sign the consent form for more treatments. The nurses response should include which information? SATA a.The husband cannot sign the consent for the client, her signature is required b.The clients specific wishes should be discussed with her HCP c.The Health care team will formulate a plan if care to keep the client comfortable d. Pt. needs to seek 2nd medical opinion b4 stopping chemo

a.The husband cannot sign the consent for the client, her signature is required b.The clients specific wishes should be discussed with her HCP c.The Health care team will formulate a plan if care to keep the client comfortable Rationale: An adult client who is mentally competent has the autonomy and the client's right to make her own decision regarding her treatment.

The nurse is teaching a client with atrial fibrillation about a newly prescribed medication, dronedarone. Which information should the nurse include in client interactions? SATA a- Discontinue medication when palpitation subside. b- Avoid eating grapefruit or drinking grapefruit juice. c- Report changes in the use of daily supplements d- Notify your health care provider if your skin looks yellow

b- Avoid eating grapefruit or drinking grapefruit juice. c- Report changes in the use of daily supplements d- Notify your health care provider if your skin looks yellow Rationale: Side effects can increase if the client consume grapefruit. OTC medications or herbal should be reported for possible drugs interactions. Hepatic injury can occur, and the client should report sign of jaundice or itching, or right upper quadrant pain.

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? SATA a- Administer a PPD test b- Schedule the client for the chest radiograph c- Obtain sputum for acid fast bacillus (AFB) testing d- Place a mask on the client until he is moved to isolation.

b- Schedule the client for the chest radiograph c- Obtain sputum for acid fast bacillus (AFB) testing d- Place a mask on the client until he is moved to isolation. Rationale: Client with history of TB a chest x-ray and sputum are indicated. The client sign and symptoms indicate the pt should wear mask to protect others.

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? SATA a. Maintain current caloric intake b. Avoid use of alcohol as a sleep aide at bedtime c. Start a weight loss program

b. Avoid use of alcohol as a sleep aide at bedtime c. Start a weight loss program

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? SATA a.Seeds, spices, lettuce b. Fortified whole wheat cereals, whole grain pasta, brown rice c.Spinach, kale, dried raisins and apricots

b. Fortified whole wheat cereals, whole grain pasta, brown rice c.Spinach, kale, dried raisins and apricots

During the transfer of a client who had a major abdominal surgery this morning, the PACU nurse reports that the client, who is awake and responsive continues to report pain and nausea after receiving morphine 2 mg IV and Ondansetron 4 mg IV 45 mins ago. Which elements of SBAR communications are missing from the report given by the PACU nurse? SATA a.BAckground b.Assessments c.Recommendations d.Rationales

b.Assessments c.Recommendations d.Rationales

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? SATA a. RBC b. WBC c. Sputum Culture and sensitivity

b. WBC c. Sputum Culture and sensitivity

A family member of a frail elderly adult ask the nurse about eligibility requirements for hospices care. What information should the nurse provide? SATA a. A family must agree for the need of hospice care b.A client must be willing to accept palliative care, not curative care c. The HCP must project that the client has 6 months to live

b.A client must be willing to accept palliative care, not curative care c. The HCP must project that the client has 6 months to live

The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing actions should the nurse assign to the PN? SATA a. Call the doctor b.Administer a dose of insulin per sliding scale for a client with type 2 DM c.Obtain post operative VS for a client one day following unilateral knee arthroplasty d.perform daily surgical dressing change for a client who had an abdominal hysterectomy.

b.Administer a dose of insulin per sliding scale for a client with type 2 DM c.Obtain post operative VS for a client one day following unilateral knee arthroplasty d.perform daily surgical dressing change for a client who had an abdominal hysterectomy.

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? SATA a. assess house b.Assess the client for self care ability c. Provide pain medications instructions d. Teach care of ostomy to care provider

b.Assess the client for self care ability c. Provide pain medications instructions d. Teach care of ostomy to care provider

Assessment by the home health nurse of an older client who lives alone indicates furosemide for HTN and HF and laxatives. To manage the clients constipation, which suggestions should the nurse provide? SATA a. Report constipation to HCP r/t cardiac medication side effects b.Include oatmeal w/ stewed pruned for breakfast as often as possible c. Increase fluid intake by keeping water glass next to recliner d. Recommend seeking help with regular shopping and meal preparation

b.Include oatmeal w/ stewed pruned for breakfast as often as possible c. Increase fluid intake by keeping water glass next to recliner d. 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.

A client w/ cirrhosis of the liver is admitted w/ complications r/t end stage liver disease. Which interventions should the nurse implement? SATA a. provide low diet in phosphorus b.Monitor abdominal girth c.Report serum albumin and globulin levels d.Note signs of swelling and edema

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

While monitoring a client during a seizure, Which interventions should the nurse implement? SATA a. insert an oral padded tongue blade b.Move obstacles away from the client c.Monitor physical movements d.Observe for a patent airway e.Record the duration of the seizure

b.Move obstacles away from the client c.Monitor physical movements d.Observe for a patent airway e.Record the duration of the seizure

In caring for the body of a client who just dies; which tasks can be delegated to UAP? SATA a. Confirm the clients wishes for tissue donations b.Place personal religious artifacts on the body c.attach identifying name tags to the body d. Follow cultural beliefs in preparing the body

b.Place personal religious artifacts on the body c.attach identifying name tags to the body d. Follow cultural beliefs in preparing the body

While assessing a clients chest tube (CT), the nurse discovers bubbling in the water seal chamber of the chest tube collection device. The clients vital signs are: BP of 80/40 mmhg, HR 120 beats/min, RR 32 breaths/mins, oxygen saturation 88%. Which interventions should the nurse implement?SATA a. Administer a nebulizer treatment b.Provide supplemental oxygen c.Auscultate bilateral lung fields d.Reinforce occlusive CT dressing

b.Provide supplemental oxygen c.Auscultate bilateral lung fields d.Reinforce occlusive CT dressing

A client who is newly diagnosed w/ T2 DM receives a prescription for metformin ( Glucophage) 500mg PO 2x daily. What information should the nurse include in this clients teaching plan? SATA a. Take additional dose for signs of hyperglycemia b.Recognize s/s of hypoglycemia c. Report persist polyuria to the HCP d.Take glucophage w/ the morning and evening meal

b.Recognize s/s of hypoglycemia c. Report persist polyuria to the HCP d.Take glucophage w/ the morning and evening meal

To reduce the risk of symptoms exacerbation for a client with multiple Sclerosis (MS), Which instructions should the nurse include in the clients d/c plan? SATA a.feedrightaway b.Space activities to allow for rest periods c.Take warm baths before starting exercise

b.Space activities to allow for rest periods c.Take warm baths before starting exercise

The nurse is caring for a group of clients with the help of LPN and an experienced UAP. WHich procedures can the nurse delegate ti the UAP? SATA a. Start blood transfusion for client who had a below the knee amputation b.Take postoperative VS for a client who has an epidural following knee arthroplasty c.Collect the sputum specimen for a client w/ a fever of unknown origin d.Ambulate a client who had a femoral popliteal by pass graft yesterday

b.Take postoperative VS for a client who has an epidural following knee arthroplasty c.Collect the sputum specimen for a client w/ a fever of unknown origin d.Ambulate a client who had a femoral popliteal by pass graft yesterday

An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, which nursing care intervention should the nurse include in the clients plan of care? SATA a. Encourage pt to out weight on legs b.Teach the client to use incentive spirometer q2hrs while awake. c. Remove the urinary catheter as soon as possible and encourage voiding

b.Teach the client to use incentive spirometer q2hrs while awake. c. Remove the urinary catheter as soon as possible and encourage voiding

A client with asthma is experiencing severe pruritus. Which PRN prescriptions should the nurse administer? SATA a. Topical scabicide b.Topical corticosteroids c.Oral antihistamine

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

When conducting diet teaching for a client who was diagnosed w/ hypoparathyroidism, which foods should the nurse encourage the client to eat? SAta a. Nuts b.Yogurt c.Processed cheese

b.Yogurt c.Processed cheese

The nurse is ready to insert an indwelling catheter as seen in the picture. At this point in the procedure, what actions should the nurse take before inserting the catheter? SATA b. Collect Ureine sample c. Gently palpate the client's bladder for distention d. Hold the catheter 3 - 4 inches (7.5 - 10 cm) from its tip e. Secure the urinary drainage bag to the bed frame

c. Gently palpate the client's bladder for distention d. Hold the catheter 3 - 4 inches (7.5 - 10 cm) from its tip e. Secure the urinary drainage bag to the bed frame