Unit 8-18
The nurse reviews the medication history of a client admitted to the hospital and notes that the client is taking leflunomide (Arava). During data collection, the nurse asks which question to determine medication effectiveness?
"Do you have any joint pain?"
A client is being discharged from the ambulatory care unit following cataract removal, and the nurse provides instructions regarding home care. Which statement by the client indicates an understanding of the instructions?
"I will wear my eye shield at night and my glasses during the day."
A client with myasthenia gravis is being discharged on pyridostigmine bromide (Mestinon). The nurse reinforces medication instructions with the client and makes which statement to the client?
"Take the medication before activities such as eating."
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
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 reinforcing client education regarding symptoms of testicular cancer. The nurse encourages the client to report which symptoms as being associated with testicular cancer? Select all that apply.
A grainy mass palpated in a testicle An enlargement of one of the testes
The nurse is reviewing the postoperative prescriptions for a client who had a transsphenoidal hypophysectomy. Which health care provider's prescription noted on the record indicates the need for clarification?
Apply a loose dressing if any clear drainage is noted.
The nurse is caring for a client with a burn injury to the lower legs. Silver sulfadiazine (Silvadene) is prescribed to be applied to the sites of injury. Which indicates the appropriate method to apply this medication?
Apply to cleansed, debrided wounds as prescribed.
The nurse notes that the medical record of a client with cirrhosis states that the client has asterixis. To verify this information the nurse should take which action?
Ask the client to extend the arms.
The nurse is caring for a client who is receiving hydralazine (Apresoline). The nurse evaluates the effectiveness of the medication by monitoring which client parameters?
Blood pressure
During admission data collection, the nurse asks the client to run the heel of one foot down the lower anterior surface of the other leg. The nurse notices rhythmic tremors of the leg being tested and concludes that the client has interference in which area?
Balance and coordination
The nurse is assisting in collecting subjective and objective data from a client admitted to the hospital with tuberculosis (TB). The nurse should expect to note which finding?
Complaints of night sweats
The nurse is assisting in performing a confrontation test on a client seen in the clinic. The nurse understands that this test is performed to check which client ability?
The ability to demonstrate effective peripheral vision
A client has been diagnosed with pyelonephritis. The nurse interprets that which health problem has placed the client at risk for this disorder?
Diabetes mellitus
The nurse educator is asking the nursing student to recall the signs/symptoms of hypothyroidism. The nurse educator determines that the student understands this disorder if which are included in the student's response?
Dry skin Constipation Cold intolerance
The nurse is interpreting the laboratory results of a client who has a history of chronic ulcerative colitis. Which result indicates a complication of ulcerative colitis?
Hemoglobin 10.2 g/dL
A client with multiple sclerosis is receiving diazepam (Valium), and the home care nurse reinforces instructions to the client regarding the side effects of the medication. The nurse tells the client that which is a side effect of this medication?
Incoordination
A client with hiatal hernia chronically experiences heartburn after meals. Which should the nurse teach the client to avoid?
Lying recumbent after meals
The nurse reinforces instructions to the client prescribed to take cyclosporine (Sandimmune) oral solution. Which instruction should the nurse provide?
Mix the concentration with chocolate milk.
The nurse is caring for a client who has a cast applied to the left lower leg. On data collection, the nurse notes the presence of skin irritation from the edges of a cast. Which nursing intervention is appropriate?
Petal the cast edges with adhesive tape.
The nurse is preparing to administer eardrops to an infant. How should the nurse administer the eardrops?
Pull down and back on the ear, and direct the solution toward the wall of the canal.
The nurse is assisting in caring for a client who has just returned from the postanesthesia care unit after radical neck dissection. The nurse monitors the portable wound suction for which types of drainage expected in the immediate postoperative period?
Serosanguineous
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 diplopia has been taught to use an eye patch to promote better vision and prevent injury. The nurse determines that the client understands how to use the patch if the client states that he or she will do which?
Wear the patch continuously, alternating eyes each day.
A client who will undergo thyroidectomy at a later date has been started on medication therapy with potassium iodide (SSKI). As the licensed practical nurse (LPN) prepares to administer a scheduled dose, the client states that there is a burning sensation and a brassy taste in the mouth. Which action should the LPN take?
Withhold the medication and notify the RN.
