nursing process planning

The client arrives at the emergency department after a burn injury that occurred in the basement at home, and an inhalation injury is suspected. Which should the nurse anticipate as being prescribed for the client?

100% oxygen via a tight-fitting, nonrebreather face mask

An adult client with muscle spasms is taking an oral maintenance dose of baclofen (Lioresal). The nurse reviews the medication record, expecting that which dose would be prescribed?

15 mg 4 times a day

A health care provider prescribes a bolus of 500 mL of 0.9% normal saline (NS) to run over 4 hours. The drop (gtt) factor is 10 drops (gtt) per 1 mL. The nurse plans to adjust the flow rate at how many gtt per minute? Fill in the blank. Record your answer to the nearest whole number.

21

A client is complaining of pain underneath a cast in the area of a bony prominence. Which should the nurse anticipate?

A window will be cut in the cast.

The nurse notes that a client is due in hydrotherapy for a burn dressing change in 30 minutes. The nurse plans to take which action next in the care of this client?

Administer an opioid analgesic last taken 6 hours ago.

The nurse is reviewing the prescriptions of a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions should the nurse expect to note? Select all that apply.

Administer antacids, as prescribed. Encourage coughing and deep breathing. Administer anticholinergics, as prescribed

The nurse in the labor room is assisting in caring for a client in the active stage of labor. The nurse is told that the fetal patterns show a late deceleration on the monitor strip. Based on this finding, the nurse prepares for which appropriate nursing action?

Administering oxygen via face mask

In reviewing the admission assessment data and health care provider's prescriptions for a client with peptic ulcer disease, the nurse notes that the client has a history of renal disease. Based on this data, the nurse determines that which antacid should be prescribed for this client?

Aluminum hydroxide (Amphojel)

The nurse is caring for a client with kidney failure. The serum phosphate level is reported as 7 mg/dL. Which medication should the nurse plan to administer as prescribed to the client?

Aluminum hydroxide gel

The nurse reviews the phenytoin level of a client who is taking phenytoin (Dilantin). The nurse notes that the plasma drug level is 9 mcg/mL. Which does the nurse anticipate to be prescribed for the client?

An increase in the present dosage

Prednisone is prescribed for a client with diabetes mellitus who is taking NPH insulin daily. Which prescription should the nurse anticipate during therapy with the prednisone?

An increased amount of daily NPH insulin

When performing a surgical dressing change of a client's abdominal dressing, the nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse should plan to do which action in the initial care of this wound?

Apply a sterile dressing soaked with normal saline.

The nurse is preparing to assist in performing a fundal assessment on a postpartum client. The nurse understands that which is the initial nursing action when performing this assessment?

Ask the client to urinate and empty her bladder.

The nurse is preparing a subcutaneous dose of bethanechol chloride (Urecholine) prescribed for a client with urinary retention. Before giving the dose, the nurse checks to see that which medication is available on the emergency cart?

Atropine sulfate

The nurse is caring for a client diagnosed with Paget's disease. The nurse plans care, knowing that this condition usually affects which bones?

Axial skeleton including the vertebrae

The nurse is assisting in planning care for a client with a chest tube. The nurse should suggest to include which interventions in the plan? Select all that apply.

Be sure all connections remain airtight. Be sure all connections are taped and secureMonitor closely for tubing that is kinked or obstructed by the weight of the client.

A 31-week preterm labor client dilated to 4 centimeters has been started on magnesium sulfate. Her contractions have stopped. If the client's labor can be inhibited for the next 48 hours, which medication does the nurse anticipate will be prescribed?

Betamethasone

Neuroleptic malignant syndrome is suspected in a client who is taking chlorpromazine. Which medication should the nurse prepare in anticipation of the prescription to treat this adverse effect related to the use of chlorpromazine?

Bromocriptine (Parlodel)

The nurse is administering a dose of a prescribed diuretic to an assigned client. The nurse should plan to monitor the client for hypokalemia as a side effect of therapy if the client is receiving which medication?

Bumetanide

A client experiences an episode of Bell's palsy and complains about increasing clumsiness. The nurse should prepare the client for which diagnostic study (studies) to determine the cause of the complaints? Select all that apply.

Cerebral angiography Lumbar puncture (LP Computed tomography

The nurse is assisting in preparing a plan of care for a child who will be returning from surgery following the application of a hip spica cast. Which would be the priority action in the plan of care for this child on return from the procedure?

Check circulation in the feet.

The nurse plans to admit a client who has seizure precautions prescribed. Which pieces of equipment should be available at the client's bedside in the hospital room? Select all that apply.

Clean gloves Oxygen with nasal cannula setup Suction machine with oral catheter

The nurse working on an endocrine nursing unit understands that which correct concept is used in planning care?

Clients who have hyperparathyroidism should be protected against falls.

A client with fibromyalgia has not achieved pain relief with opioid pain medication. The client has a history of diabetes mellitus and atherosclerosis. The nurse anticipates that which single medications may be selected by the health care provider to be given in conjunction with the opioid pain medication? Select all that apply.

Duloxetine (Cymbalta) Pregabalin (Lyrica) Alprazolam (Xanax)

The nurse, caring for a child with aplastic anemia, is reviewing the laboratory results and notes a white blood cell (WBC) count of 6000 cells/mm3 and a platelet count of 20,000 cells/mm3. Which nursing intervention should be incorporated into the plan of care?

Encourage quiet play activities.

The nurse prepares to assist a health care provider examine the client's skin with a Wood's light. Which action should be included in the plan for this procedure?

Darken the room for the examination.

The nurse is assisting in developing a plan of care for a pregnant client with acquired immunodeficiency syndrome (AIDS). The nurse determines that which concern is the priority for this client?

Development of an infection

A mother brings her 4-month-old infant to the well-baby clinic for immunizations. Which immunizations should be administered to this infant?

Diphtheria, tetanus, acellular pertussis (DTaP), Haemophilus influenzae type b (Hib), inactivated poliovirus vaccine (IPV), pneumococcal vaccine (PCV)

A client with active tuberculosis (TB) demonstrates less-than-expected interest in learning about the prescribed medication therapy. Which technique would the nurse ultimately need to employ in order to encourage participation?

Directly observed therapy

The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. The nurse notes that the client has a history of arthritis and has been taking acetylsalicylic acid (aspirin). The nurse reports the information to the health care provider and anticipates that the provider will prescribe which?

Discontinue the aspirin 48 hours before the scheduled surgery.

A nurse planning care for a client with hepatitis plans to meet the client's safety needs by performing which action?

Monitoring prothrombin and partial thromboplastin values

The nurse is caring for a client who has had an open reduction with internal fixation (ORIF) with a posterior approach. The client has been prescribed hip precautions. The nurse plans to implement which in the care of the client? Select all that apply.

Ensure the client doesn't sit or stand for long periods of time. Ensure the client doesn't cross the legs past the midline of the body. Ensure the client uses assistive/adaptive devices with activities of daily living

The nurse is working with an older client and family about discharge following hospitalization. When initiating discussions with the group, the nurse understands that older persons usually prefer which?

To live independently, but close to their children

A health care provider has written a prescription for calcium carbonate for the client with hypocalcemia. The nurse preparing to administer the medication schedules the medication to be given at which time?

Two hours after meals

A client with new onset migraine headaches is being seen in the clinic. The client has a history of hypotension and diabetes mellitus. The nurse predicts that the client will experience undesirable cardiac side effects if the health care provider prescribes which medications? Select all that apply.

Verapamil (Calan) 2. Propranolol (Inderal

The nurse is assigned to care for a client with systemic lupus erythematosus (SLE). The nurse plans care considering which factor regarding this diagnosis?

it is an inflammatory disease of collagen contained in connective tissue

The nurse assists in developing a plan of care for the child with meningitis. Which should be the priority client problem for a child with a meningitis diagnosis?

neurological dysfunction

A health care provider prescribes laboratory studies on an infant born to a human immunodeficiency virus-(HIV-) positive woman to determine the presence of HIV infection. Which laboratory study should the nurse expect to be prescribed?

p24 antigen assay

The nursing student is developing a plan of care for the hospitalized client with bulimia nervosa. The nursing instructor intervenes if the student documents which incorrect intervention in the plan?

Observe for excessive exercise.

The nurse is reviewing a health care provider's prescription for a child who was just admitted to the hospital with a diagnosis of Kawasaki disease. Which prescription should the nurse anticipate being part of the treatment plan?

Immune globulin

The nurse in the delivery room is caring for a newborn delivered 10 minutes ago. The nurse assists to prepare which medications that will be prescribed to be given within the first hour of life? Select all that apply.

Erythromycin eye drops Phytonadione (vitamin K

The nurse is reviewing the laboratory results of several clients receiving pharmacologic therapy. Which laboratory test results indicate a therapeutic value and that the nurse can safely administer the medication as prescribed? Select all that apply.

Gentamicin 8 mcg/mL Theophylline (Theo-24) 10 mcg/mL Carbamazepine (Tegretol) 10 mcg/mL

The nurse is assigned to collect data from a Hispanic-American client during the hospital admission. On initial meeting of the client, the nurse should plan to do which?

Greet the client with a handshake.

Which is the best rationale for using group therapy as an accepted way of treatment of clients in the milieu?

Group therapy provides a social mechanism in which a client can relate to peers and validate thoughts and feelings in a realistic environment.

The nurse wants to ensure that the emergency department is prepared for a disaster and is creating an action plan for educating the staff. Which actions should the nurse plan in order to adequately prepare the staff? Select all that apply.

Identify specific nursing roles during a disaster. Test the disaster plans before a disaster occurs. Begin educating staff on roles at the time of a disaster. Encourage each nurse to create a personal emergency preparedness plan

The nurse has obtained ribavirin (Virazole) in powder form from the pharmacy to give to a child with respiratory syncytial virus (RSV). The nurse understands that the medication will be administered by which route?

Inhalation

The nurse has assisted with the insertion of a Levin tube for gastrointestinal (GI) decompression. Which settings will the health care provider prescribe? Select all that apply.

Low Intermittent

A client has been diagnosed with pernicious anemia. In planning care for the client, the nurse anticipates that the client will be treated with which?

Vitamin B12

The nurse is assisting in planning discharge instructions to the mother of a child following orchiopexy, which was performed on an outpatient basis. Which is the priority in the plan of care?

Wound care

A client rings the call bell and complains of pain at the site of an intravenous (IV) infusion. The licensed practical nurse (LPN) inspects the site and determines that the client has developed phlebitis. The LPN should plan to avoid which action in the care of this client?

Prepare to start a new line in a proximal portion of the same vein.

The nurse is providing care to a Cuban-American client who is terminally ill. Numerous family members are present most of the time, and many of the family members are very emotional. Which nursing action is most appropriate?

Request permission to move the client to a private room, and allow the family members to visit.

The nurse is assisting with developing a plan of care for a client who is experiencing hematological toxicity as a result of chemotherapy. The nurse should suggest including which in the plan of care?

Restricting fresh fruits and vegetables in the diet

Which equipment should the nurse plan to have at the bedside when initiating a clear liquid diet in a postoperative client who has had general anesthesia?

Suction equipment

A client arrives at the emergency department with an acetaminophen (Tylenol) overdose. Acetylcysteine is prescribed to be administered to the client immediately. The nurse prepares to administer the medication by which route?

Orally

The nurse caring for a client diagnosed with placental abruption should plan which action?

Prepare the client for a cesarean birth.

The nurse is planning care for a child with hemolytic-uremic syndrome (HUS). The child has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to include which intervention in the care of the child?

Restriction of fluids, as prescribed

The nurse is caring for a client taking an oral hypoglycemic agent (sulfonylurea) has just been diagnosed with a urinary tract infection. The health care provider plans to treat the infection with sulfamethoxazole. The nurse expects that because of medication interactions, the health care provider will prescribe a prescription in which manner?

Lower dose of the oral hypoglycemic

The spouse of a client with acute kidney injury secondary to heart failure asks the nurse how this could happen. The nurse plans to base a response in part on the fact that which statement is true?

The kidneys generally require and receive about 20% to 25% of the resting cardiac output.

The nurse is planning to reinforce instructions to the Hispanic-American client about nutrition and dietary restrictions. When developing the plan for the instructions, the nurse is aware of which related fact?

This ethnic group views food as a primary form of socialization.

The nurse is caring for a client following segmental resection of the upper lobe of the left lung. The nurse notes 700 mL of grossly bloody drainage in the chest tube drainage system during the first hour following surgery. Which statement represents the nurse's accurate interpretation of this finding?

This finding requires further data collection.

A client with new onset migraine headaches is being seen in the clinic. The client has a history of hypotension and diabetes mellitus. The nurse predicts that the client will experience undesirable cardiac side effects if the health care provider prescribes which medications? Select all that apply.

Verapamil (Calan) Propranolol (Inderal)

The nurse prepares to give a bath and change the bed linens on a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which should the nurse incorporate in the plan during the bathing of this client?

Wearing a gown and gloves

HomeHistoryHelpCalculator Review Mode Question 45 of 50 Previous ▲▼ GoNextStopBookmarkRationaleStrategyReferenceSubmit The nurse employed in a long-term care facility is planning the client assignments for the shift. Which client should the nurse assign to the unlicensed assistive personnel (UAP)

a client who requires 24 hour urine collection

The nurse is planning to reinforce dietary teaching about foods that are low in potassium to a client receiving a potassium-retaining diuretic. The nurse should be sure to include which food on a list of foods that have low potassium content?

White bread

The nurse is asked to assist with preparing a client who will be receiving a total parenteral nutrition (TPN) solution via a central line. The nurse plans to obtain which essential piece of equipment for this procedure?

electronic infusion pump

The nurse is assisting in developing a plan of care for a client in the fourth stage of labor who received an epidural. Which problem is most likely to occur during this stage?

urinary retention caused by the loss of sensation to void in Rapid bladder feeling

In planning activities for the depressed client, especially during the early stages of hospitalization, which is best?

encourage the client to participate in a structured daily program of activities

The nurse prepares the plan of care for a client with late-stage Alzheimer's disease who resides in a long-term care facility. Which would be priority concerns to include? Select all that apply.

Risk for injury Risk for infection Risk for aspiration Impaired verbal communication

A client is being evaluated as a potential kidney donor for a family member. The donor asks the nurse why a different team of people other than the team working with the potential recipient is doing the evaluation. Which response should the nurse give to the client?

It will avoid a conflict of interest by the team evaluating the recipient and the team evaluating the donor is avoided.

An adolescent client is admitted to the inpatient unit after medical stabilization for an overdose of acetaminophen (Tylenol). The history identifies that her boyfriend broke up with her 2 weeks ago and that she hasn't been eating well, resulting in a loss of 15 pounds. The nurse assists in developing a plan of care that includes which interventions? Select all that apply.

Making nutritious snacks available anytime Providing meals on an isolation tray that contains plastic utensils Ensuring that her diet consists of bland, easy-to-digest foods and beverages

Which is the primary goal that should be included in the plan of care for a child who has cerebral palsy?

Maximize the child's assets and minimize the limitations.

The nurse is employed at a drug abusers' residential treatment center. The nurse is preparing for the arrival of a new client and prepares to explain to the client that the emphasis of the center is on group and social interaction and that rules and expectations are mediated by peer pressure. The most likely focus of therapy of this residential center is which?

Milieu therapy

The nurse develops a plan of care for a client following a lumbar puncture. Which interventions should be included in the plan? Select all that apply.

Monitor the client's ability to void. Maintain the client in a flat position. Monitor the client's ability to move the extremities. Inspect the puncture site for swelling, redness, and drainage

A client has undergone total hip replacement of the right hip, which was damaged by osteoarthritis. Which action should be included in the postoperative plan of care?

Partial weight bearing on the operative leg is usually permitted 72 hours postoperatively.

The nurse is assisting with care for a pregnant client in labor who will be delivering twins. The nurse prepares to monitor the fetal heart rates by performing which?

Placing external fetal monitors so that each fetal heart rate is monitored separately

The nurse is assisting in developing a plan of care for a client receiving warfarin sodium (Coumadin). The nurse selects which problem as the priority in caring for this client?

Potential for injury

The nurse is admitting a client with acute pericarditis who reports chest pain. When planning the client's care, which position should the nurse encourage the client to assume to alleviate the chest pain? Select all that apply.

Sitting up and leaning forward Head of bed elevated to 45 degrees

The nurse should anticipate that which medication is the most likely to be prescribed prophylactically for a child with spina bifida (myelomeningocele) who has a neurogenic bladder?

Sulfisoxazole

The nurse has reinforced home care instructions to a client who had a permanent pacemaker inserted. Which educational outcome has the greatest impact on the client's long-term cardiac health?

The ability to take an accurate pulse in either the wrist or neck

A hospitalized client who recently experienced the loss of a spouse is grieving. The client progresses well and is approaching discharge. Which is an appropriate outcome for this client?

The client verbalizes stages of grief and plans to attend a community grief group.

The nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days ago. On review of the client's record, the nurse notes that the admission was a voluntary admission. Based on this type of admission, the nurse should expect which?

The client will participate in the treatment plan.

The nurse is working with a victim of rape in a clinic setting and assists in developing a plan of care for the client. Which is an inappropriate short-term initial goal?

The client will resolve feelings of fear and anxiety related to the rape trauma.

A client has an intravenous infusion (IV) started before surgery for a right below-the-knee amputation. In addition to the intravenous infusion, blood is drawn and a surgical skin preparation is done. The nurse anticipates that the client is likely to experience which psychosocial problem in the preoperative period?

anxiety

The nurse is developing a plan of care for a client who is scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery?

have the client void immediately before surgery

The nurse is caring for a hospitalized child with a history of seizures who is receiving oral phenytoin sodium (Dilantin). Which should be included in the plan of care for this child?

provide oral hygiene, especially care of the gums

The nurse is asked to assist another health care member in providing care to a client who is placed in a modified Trendelenburg's position. The nurse interprets that the client is likely being treated for which condition?

shock

The nurse is preparing for the admission of a client with a prescription for seizure precautions. Which supplies will the nurse make available to this client? Select all that apply.

suction machine oxygen administration padding for side rails prescribed Diazepam (Valium)

The licensed practical nurse employed in the ambulatory clinic is assisting a registered nurse with preparing to administer a dose of intravenous immune globulin (IVIG). The licensed practical nurse ensures that which medication is readily available before the medication is administered?

Epinephrine (Adrenalin)