This b is never ending MSH

While caring for a client with full thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this find it to the healthcare provider the nurse should evaluate which laboratory value?

Neutrophil count

In providing discharge teaching to a client with chronic obstructive pulmonary disease (COPD), which instruction is most important for the nurse to emphasize?

Notify the healthcare provider of any change in sputum color

A client tells the clinic nurse about experiencing burning on urination and assessment reveals that the client had sexual intercourse four days ago what a person who is casually met. Which action should the nurse implement?

Obtain a specimen of urethral drainage for culture

Which nursing problem has the highest priority one planning care for a client with Ménière's disease?

Potential for injury related to vertigo

The nurse is performing an initial assessment of an adult client. Which finding indicates that the nurse should evaluate the client for a pulse deficit?

Dorsalis pedis pulse volume is +1

During the preoperative assessment the nurse learned that a client has a history of venous thromboembolism (VTE). To reduce the risk for this problem developing again in the post operative period, which instruction should the nurse emphasize when teaching the client

Early ambulation

A client was the benign prosthetic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions

Monitor urinary stream for a decrease in output

The nurse is providing home care instructions to a client who had an acute anterior wall myocardial infarction (MI) one week ago. The client has a new prescription for daily low-dose aspirin. In teaching the client about this medication it is most important for the nurse to emphasize the need to call the healthcare provider regarding which problem?

Bruising

Which admission assessment findings should the nurse document related to a client who has been diagnosed of Cushing's syndrome?

Central-type obesity, with thin extremities

A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the post anesthesia unit. Before selecting which medication to administer, which action should the nurse implement?

Compare the clients pain scale rating with the prescribed dosing.

An older client who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and eats only half of the food on the meal tray. The clients family expresses concern about the clients nutritional status. How should the nurse respond to the families concern?

Demonstrates the use of visual scanning during meals to the client and family

A client with a newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?

Describe the use of an elimination diet to find trigger foods

While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences on the clients fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take?

Discuss approaches to chronic pain control with the client

An IV infusion of normal saline 250 mL with KCI 130 mEq to be administered over 4 hours is prescribed for a postoperative client. The nurse should regulate the infusion pump to deliver how many mL per hour?

63

The family suspects that acquired immune deficiency syndrome (AIDS) dementia is occurring in their son who is human immunodeficiency virus (HIV) positive. Which symptom confirms there suspicions?

A change has recently occurred in his hand writing

Following an ileal conduit urinary diversion a client voices several concerns. Which finding indicates to the nurse that the client is experiencing a complication?

A dark purplish colored stoma

A client with a right ulnar fracture and cast placement reports an increase in arm pain. Which action should the nurse take first?

Administer a PRN analgesic

A client with chronic myelogenous leukemia (CML) who has been on long-term corticosteroidtherapy develops oral candidiasis . The client tells the nurse that the pain makes it difficult to chew or swallow. Which action should the nurse implement first?

Administer a topical analgesic

Which action should the nurse implement to reduce the risk of vesicant extravasation in the client who is receiving intravenous chemo therapy?

Administer an anti-emetic before starting the chemotherapy

A client with stage IV bone cancer is admitted to the hospital for pain control. Client verbalizes continuous, severe pain of 8 on a 1 to 10 scale which intervention should the nurse implement?

Administer opioid and non-opioid medication simultaneously

A young client with osteoarthritis of both knees tells the nurse that desire to continue daily walks in the park with friends. How should the nurse respond?

Advise less weight bearing to prevent joint destruction

An overweight young adult client who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. The client reports feeling very weak and jittery. Which actions should the nurse implement? Select all that apply

Assess skin temperature and moisture Measure pulse and blood pressure Check fingerstick glucose level

The nurse is preparing a client with an excaberation of systemic lupus erythematosus (SLE) for discharge. Which instruction is most important to the nurse to include in the discharge teaching?

Avoid extreme environmental temperatures

The nurse is teaching a client how to collect a sputum specimen. What steps should the nurse instruct the client to follow in collecting sputum?

Breathe deeply, followed by coughing up the sputum

The nurse is providing discharge teaching to an elderly client hospitalized for treatment of venous leg ulcers. Which instruction should the nurse include in the teaching plan? Select all that apply

Eat a diet that is high in protein and vitamins A and C Keep legs elevated when sitting or lying down Inspect ankles daily for areas of darkening skin

A client who had surgery yesterday is becoming increasingly anxious. The clients respiratory rate has increased and 38 breaths per minute. The client has a nasogastric tube to low intermittent section with 500 mL of yellow green drainage over the last 4 hours. The clients arterial blood gases (ABG) indicate a decrease CO2 and an increased serum pH? Which serum laboratory value should the nurse monitor first?

Electrolytes

An adult client who had bariatric surgery two months ago has developed a post operative stricture. For the past week, the client has experienced nausea, vomiting, and anorexia, and is admitted to the hospital for fluid resuscitation. At this time the client denies feeling any pain. Which intervention should the nurse implement?

Encourage small frequent meals

When preparing a client for an abdominal paracentesis which action should the nurse implement before the procedure is initiated?

Encourage the client to empty the bladder

The nurse is caring for a client with lung cancer who has a constant, dry cough, and is exhausted from coughing. Which medication should the nurse administer to this client?

Guaifenesin with codeine

The nurse calls the healthcare provider because a client diagnosed with an abdominal aortic aneurysm (AAA) is reporting of low back pain. Which additional information about the client would be important for the nurse to tell the healthcare provider?

Hematocrit and blood pressure

A client with diabetes mellitus is admitted with an upper respiratory infection. Which changes in blood glucose management should the nurse tell the client to expect?

Higher doses of insulin

A client who has developed acute kidney injury (AKI) due to an aminoglycoside antibiotics has moved from oliguric phase to the diuretic phase of AKI. Which parameters are most important for the nurse to plan to carefully monitor?

Hypovolemia and electrocardiographic changes

An older client with cirrhosis of the liver and hepatic cell is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan?

Improved level of consciousness

The nurse reveals the results of an abdominal computerized tomography (CT) scan for a client with severe colicky abdominal pain and vomiting. The results indicate a strangulated hernia of the small intestines and surgery as planned. After placing the client on nothing by mouth(NPO) precautions and obtaining vital signs, which prescription should the nurse implement first?

Insert anasogastric (NG) tube and attach a low intermittent section

Which intervention should the nurse include in the teaching plan for a client with pruritus?

Instruct the client to keep fingernails trimmed short

A client experiences ABO incompatibility reaction after multiple blood transfusions. Which findings should the nurse report immediately to healthcare provider?

Lower back pain and hypotension

The nurse is developing a plan of care for a client undergoing peritoneal dialysis. Which nursing intervention has the highest priority?

Main accurate intake and output record

An adult woman with Graves' disease is admitted with severe dehydration and malnutrition. She is currently restless and refusing to eat. Which action is most important for the nurse to implement?

Maintain a patent intravenous site

Which information should the nurse include in the teaching plan of a client diagnosed with a Gastroesophageal reflux disease (GERD)?

Minimize symptoms by when wearing loose comfortable clothing

A client with draining skin lesions of the lower extremity is admitted with possible methicillin resistant staphylococcus aureus (MRSA). Which nursing intervention should the nurse include in the plan of care

Monitor the clients white blood cell count Institute contact precautions for staff and visitors Send wound drainage for culture and sensitivity

During an annual well woman examination, a postmenopausal client who expresses concern about her risk for heart disease describes herself as a moderate drinker. When the nurse asked the woman to quantify her statement, the client reports that she drinks for glasses of wine daily. Which information should the nurse provide this client?

Reduce intake of wine to one glass daily can help lower the risk for cardiac disease

Nurse determines that a client who arrives in the pre-operative holding area before surgery is allergic to bananas. Which action should the nurse implement prior to taking the client into the operative area?

Replace latex containing devices in the OR with alternate synthetic materials

The client is admitted with history of hypertension and an acute myocardial infarction two years ago. The client reports "I am feeling weak and tired so I cannot exercise at all. I feel out of breath when I walk even a short distance. Since I cannot exercise I am gaining weight my shoes are even getting tight." The cardiac monitor display sinus tachycardia. Which cue would most likely lead the nurse to further assess the client for other symptoms of right sided heart failure

Report of tight shoes

During a routine assessment at an outpatient clinic, the nurse notes that the client has abdominal obesity and a high waist hip ratio, what a body mass index of 32. Which action should the nurse take in response to these findings?

Screen for a family history for diabetes mellitus Discuss the importance of a regular exercise program Measure the clients BP in both arms

While caring for a client with Guillian Barr syndrome (GBS) the nurse performs a neurological assessment every four hours. Which assessment finding Lawrence immediate intervention by the nurse?

Sensory loss at T8

This is admitting a client with possible tuberculosis. The client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB?

Sputum culture positive for mycobacterium tuberculosis

The nurse observes that a newly admitted client with Parkinson's disease exhibits a mask like facial appearence. Which additional nursing assessment takes priority in response to this finding

Swallowing ability

A client is recovering from an episode of urinary tract calculi. During discharge teaching the client asks about dietary restrictions in discussing fluid and take the nurse should include which type of fluid limitation?

Tea and hot chocolate

A client is a history of asthma reports having episodes of bronchoconstriction and increased mucus production while exercising. Which action should the nurse implement?

Teach client to use pursed lip breathing when episodes occur

A client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling experienced worsened at night. Which client teaching should the nurse provide?

Wear braces on both wrists during the night

Which instruction should the nurse include in the discharge teaching plan of a client who has started treatment for newly diagnosed diabetes insipidus?

Weigh yourself every day at the same time