Boogyyy boogyy

A nurse is measuring a client for knee-high antiembolic stockings to help prevent venous stasis. Which of the following actions should the nurse take?

Measure from the heel to the popliteal space

A nurse is preparing an injection using a single dose glass ampule. Which of the following actions should the nurse take?

Tap the top of the ampule, place a gauze pad or unwrapped alcohol swab around the ampule neck, and break off the top with a forward motion away from the hands.

A nurse is providing teaching for a client who has an ileal conduit following bladder cancer. Which of the following statements by the client indicates a need for the nurse to provide additional teaching?

"I need to catheterize the stoma several times a day."

A nurse is reinforcing teaching about alcohol withdrawal with a client who has a history of alcohol use disorder. Which of the following client statements indicates an understanding of the teaching.

"I should expect hand tremors to start less than 24 hrs after I stop drinking"

A nurse observes a client sitting alone in her room crying. As the nurse approaches her, the client states "I'm feeling sad. I don't want to talk now" Which of the following responses should the nurse make?

"I'll stay with you a few minutes."

A nurse is caring for a 9-year-old child who has a new diagnosis of diabetes mellitus and tells the nurse that he is eager to return to school and participate in sports. The mother tells the nurse that she is afraid to let her take part in physical activities at school. Which of the following responses should the nurse make?

"Tell me more about how you are feeling about your daughters activities."

A nurse is contributing to the development of a pamphlet about breast cancer awareness for a local health fair. Which of the following information provided by the nurse needs to be corrected?

"Use the palm of your hand to feel for lumps using a patting motion."

A nurse is reinforcing teaching with a middle aged client about hypertension. Which of the following information should the nurse include in the teaching?

"diuretics are the first type of medication to control hypertension."

A nurse is caring for a client who has multiple traumas following a motor vehicle crash. The client's partner, who was driving the vehicle, blames herself for the accident. Which of the following responses should the nurse make?

"tell me more about your feelings about what happened to your wife"

A nurse is preparing to administer penicillin IM to an adult client. Which of the following angles should the nurse use for injection into the clients ventrogluteal muscle?

90 degrees

A nurse in a providers office is collecting data from a client who has ovarian cancer. Which of the following manifestations should the nurse expect?

Abdominal bloating

A nurse in a mental health facility is caring for a client who becomes upset and breaks a chair when a visitor does not arrive. The client remains agitated following the inital verbal attempts to calm him down. Which of the following interventions should the nurse implement first?

Administer an antianxiety medication.

A nurse is reviewing a provider's admission orders for a client who has acute heart failure. For which of the following prescriptions should the nurse obtain clarification?

Ambulate three times daily

A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymosis. While the client waits for the x-ray technician, which of the following actions should the nurse take (Select all that apply).

Apply ice to the ankle, Apply compression bandage, Elevate the foot.

Before administering client medications, the nurse must identify the client. Which of the following methods of identification should the nurse use?

Ask the clients full name and date of birth.

A nurse is administering meperidine 100mg IM for a client who is admitted with a pelvic fracture. Following the injection which of the following data is priority for the nurse to check?

Asses for signs of overdose

A nurse is preparing to administer a soapsuds enema to an adult client which of the following actions should the nurse take?

Assist the client to left sims position

A nurse is caring for a client who is experiencing menopausal changes and request information about the use of herbal therapies to relieve her discomfort. Which of the following statements should the nurse make?

Black cohosh

A client tells the nurse that he suspects that he grinds his teeth at night along with giving the client dental referral, the nurse should explain that the client should see a dentist for this problem, which she should document as which of the following disorders?

Bruxism-Condition in which you grind your teeth.

A nurse is caring for a client who has heart failure. The client states she has recently been bothered by a non-productive cough. Which of the following medications should the nurse associate with the non-productive cough?

Captopril

A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurses priority?

Check the child's weight daily.

A nurse is caring for a client who has a depressive disorder is in alcohol withdrawl, and reports a recent job loss. Which of the following should be the priority nursing intervention?

Determine the presence and degree of suicidal risk

A nurse is reinforcing teaching for a client who has type 1diabetes mellitus about foot car. Which of the following client statements should indicate to the nurse an understanding of the instructions?

Cheek feet daily for bruises or sores

A nurse is reinforcing teaching with a client who has schizophrenia. Which of the following statements by the client demonstrates concrete thinking?

Concrete thinking is reasoning that's based on what you can see, hear, feel, and experience in the here and now. It's sometimes called literal thinking, because it's reasoning that focuses on physical objects, immediate experiences, and exact interpretations.

A nurse is preparing to reinforce teaching with a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following actions is the nurses priority in contributing to this plan?

Determine what the client knows about managing her diabetes

A nurse is caring for a client who has benign prostatic hyperplasia. Which of the following findings should the nurse expect?

Difficulty starting the flow of urine.

A nurse is collecting data from a client who reports a sudden onset of shortness of breath, fatigue, and dizziness. Electrocardiography indicates the client is experiencing atrial fibrillation. Which of the following medications should the nurse expect to administer?

Digoxin

A nurse is preparing to administer a vaginal cream to a client. The nurse should instruct the client to lie in which of the following positions while in bed?

Dorsal Recumbent

A nurse is preparing to administer ear drops to a 2 year old child. The nurse should pull the auricle in which of the following directions when instilling medication?

Down and Back

A nurse is preparing to administer digoxin to a client who has left sided heart failure. Which of the following clinical manifestations should the nurse expect to see in this client? Select all that apply?

Dyspnea ,Crackles ,Oliguria, Decreased Oxygen Saturation levels

A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. To focus on affective learning with this client, which of the following interventions should the nurse use?

Explore the client's feelings about dietary modifications.

A nurse is collecting data from a client who reports taking several herbal supplements. Which of the following supplements should the nurse tell the client can increase anticoagulation effects and thus increase risk for bleeding?

Fever few

A nurse is collecting a medication history from a client who takes herbal supplements and is scheduled for surgical procedure in 10 days. The nurse should inform the client that which of the following dietary supplements increases the risk of bleeding?

Fever few- generally used to treat migraines

A nurse is developing a therapeutic relationship with a client. The nurse should perform which of the following actions during the working phase of a therapeutic relationship?

Instruct the client about methods to achieve goals

A nurse is planning to care for a client who has cystitis. Which of the following interventions should be included in the plan of care?

Instruct the client to avoid drinking caffeinated beverages.-it irritates the mucosa of the bladder resulting in painful spasms.

A nurse is reinforcing teaching with a client who has fibromyalgia about strategies to help reduce her manifestations. Which of the following interventions should the nurse include?

Limit caffeine consumption

A nurse is preparing medication for a client when another client has an emergency. Which of the following actions should the nurse take?

Lock the medication in a room and finish preparing it after returning from the emergency.

A nurse is collecting data from a client who reports persistent vomiting , dizziness, palpitations, and numbness and tingling in his fingers and toes, and around his mouth. The nurse notes the clients respirations are slow shallow. The nurse should suspect that the client has developed which of the following acid-base-imbalances?

Metabolic alkalosis

A nurse is assisting in the post-dialysis plan of care for a client who is receiving hemodialysis treatment for chronic kidney disease. Which of the following interventions should the nurse include in the plan of care?

Monitor client for bleeding. -monitor for at least 1 hour after the procedure because heparin is administered during the hemodialysis treatment.

A nurse is reinforcing teaching with a client who has diabetes mellitus type 1 about sick-day management. Which of the following is the priority action for the nurse to recommend to the client?

Monitor glucose levels every four hours

A nurse in a clinic is caring for a client who heart failure and is taking digoxin, Which of the following statements by the client indicates the client is experiencing digoxin toxicity?

My vision seems yellow.

A nurse is preparing to administer the hepatitis B vaccine to a client. Which of the following techniques should the nurse use to locate the deltoid muscle?

Place one finger across the acromion process and measure 3 finger breadths below to the midpoint and center of the lateral aspect of the upper arm.

A nurse in a clinic is collecting data from a client who reports wrist pain caused by carpal tunnel syndrome. The nurse should expect which of the following findings?

Positive phalen's sign

A nurse is reinforcing teaching with a client who has a respiratory infection. The nurse should have the client lie on his left side with pillows elevating the right side of his chest to help mobilize secretions from which of the following lung segments?

Posterior segment of the right lower lobe

A nurse is assisting in the planning of preventative care for a client who is restless following a traumatic brain injury with increased intracranial pressure. Which of the following is an appropriate nursing action?

Put them in a room with reduced stimulation

A nurse is caring for a client who is exhibiting manic behavior. The client reports recent personal stressors including the loss of her mother and a divorce. Which of the following is the nurses priority action?

Preventing self-directed violence

A nurse is assisting with the care of a client who is receiving heparin by IV infusion. Which of the following medications should the nurse have available in the event of an overdose?

Protamine sulfate

A nurse is collecting data on a client who has end-stage kidney disease (ESKD). Which of the following is an expected finding?

Pruritis

A client receiving a cleansing enema reports mild cramping. After a few minutes he ask the nurse to stop the enema and allow him to go to the bathroom. Which of the following actions should the nurse take?

Stopping or slowing the enema solution flow temporarily prevents cramping

A nurse is reinforcing teaching with a parent of a child who has acute group A b-hemolytic streptococci. Which of the following instructions should the nurse include in the teaching?

Replace the child's toothbrush after 24 hours on antibiotics

A nurse is preparing to administer digoxin to a client who has heart failure. For which of the following findings should the nurse withhold the medication and report to the provider?

Reports of blurred vision

A nurse is collecting data about a client pulmonary system. While auscultating the clients lungs, the nurse hears continuous gurgling, low pitched sounds over the trachea and bronchi. Which of the following terms should the nurse use to document this finding?

Rhonchi

A nurse is talking with a client who is about to start taking nitroglycerin oral, sustained-release capsules. Which of the following instructions should the nurse include?

Swallow the capsule whole.

A nurse is reviewing the admission prescriptions for a client who has benign prostatic hyperplasia. Which of the following medications should the nurse expect to administer?

Silodsosin

A nurse is reinforcing discharge teaching with a client who has AIDS. Which of the following statements should the nurse make regarding home infection control?

Soak sponges used for cleaning in a bleach solution after use

A nurse is reviewing the medical record of a client and identifies serum potassium 6.8mEq/L. Which of the following medications should the nurse expect to administer?

Sodium polystyrene -TX hyperkalemia removes excess potassium through bowel

A nurse is caring for a client who has acute osteomyelitis. The client ask the nurse to explain how she developed the infection. The nurse should respond that which of the following organisms is the most common cause?

Staphylococcus aureus

A nurse is reinforcing teaching with a client who has schizophrenia. Which of the following statements by the client indicates an understanding of the relapse prevention plan?

Take medications as prescribed?

A nurse is caring for a client who states "I am not going to take my medications anymore." Which of the following responses should the nurse make?

Tell me more about this decision

A nurse is collecting data on a client who is postoperative following transurethral resection of the prostate (TURP). The nurse should recognize which of the following findings is the priority?

The client has bright red urine in his urinary catheter.

A nurse is assisting with the care of a client who has recently undergone a stem cell transplant. Which of the following isolation precaution should the nurse take?

The client is not permitted to have fresh flower or potted plants

A nurse is emptying a clients urinal when she notices the urine is dark amber, cloudy, and has an unpleasant odor. The nurse should identify that these findings are likely to be the result of which of the following?

Urinary tract infection

A nurse is reinforcing teaching with a client about the olinguric phase of acute kidney injury. Which of the following information should the nurse include in the teaching?

Urine output is less than 400mL per 24 hours

A nurse is caring for a client who is 1-day postoperative following a transurethral resection of the prostate (TURP) and has a continuous bladder irrigation in place. Which of the following actions should the nurse take? (Select all that apply)

Use sterile techniques when preparing the irrigation solution. Make sure the drainage rubbing is patent and without obstruction. Notify the surgeon if the urine is bright red or has large clots.

A nurse is assisting int he plan of care for aclient who has a suspected myocaridal infarction. Which of the following medications should the nurse plan to administer first?

oxygen