Exam 8
telemetry with newly dx atrial fibrillation; warfarin; instruct client to do when taking med
avoid injury to prevent bruising be careful using a razor or fingernail clippers report any change in color of urine or stool
primigravid; early labor; exposed to rubella at 14 weeks; after birth, assess for what complication
cardiac disorders
healthy adolescent new onset diabetic ketoacidosis and receiving IV and oral fluids; monitor intake because quick replacement may result in
cerebral edema
childs iron deficiency anemia is related to frequent infections
children with iron deficiency anemia are more susceptible to infection than are other children
nursing goal immediately following surgery; cataract removed
client describes methods to prevent an increase in intraocular pressure
internal medicine; 4 phone calls; chronic pancreatitis; contact first
client reporting increased thirst and hunger
9 yr old; ED; extensive burns in restaurant fire; important intervention
conduct wound assessment
assigning a room for client with hep A; dx would be appropriate roommate
congestive heart failure
long term peritoneal dialysis at home; reduced outflow from cath; to determine if cath is obstructed, what should the nurse ask the client
constipation
administering colchicine to client who is experiencing exacerbation of gouty arthritis; monitor for what adverse reaction
diarrhea
nurse manager appropriately behaves as autocrat in which situation
directing staff activities if client experiences a cardiac arrest
PCA to manage postop pain; do when assisting with PCA
document the clients response to pain meds
4th postpartum day; primiparous; breast engorgment; to relieve; intervention before nursing her baby
express sm. amount of breast milk
multigravid at 32 wks experienced hemolytic disease of newborn in previous pregnancy; prepare client for frequent antibody titer evaluations from where
maternal blood
health teaching about physiologic changes expected during postpartum period; bottle feeding; effective
my menstrual flow should resume in approx. 6-10 weeks
accompanying client to mall to shop; neighbor of nurse approaches and tries to engage in conversation; most appropriate response by nurse to neighbor
now is not a good time to talk, I will telephone you later
client fell and fractured neck of femur; documenting site; where
under ball looking bone
ED complaining of visual changes and severe headache; BP 210/120; denies having HTN; emergency intervention; most common cause of malignant hypertension
untreated hypertension
prescription to admin IM injection to neonate;what site should nurse select
vastus lateralis
overdosed on phencyclidine (PCP); cautious about which behavior
violent behavior
osteoporosis about alendronate sodium; take the medication
with a full glass of water and remain upright for 30 min
ED with elevated blood alcohol level; driving wrong side of road; vitals are stable and he has a headache; do first
work through personal feelings related to substance use/abuse
dx with peripheral artery disease is being d/c; statement indicates need for further education
I should wipe any injury with iodine on a cotton ball
new mother; care of neonate after circumcision with a gomco clamp; statement indicates need additional instructions
I will remove any yellowish crusting gently with water
released from restraints; I'll never get that angry and lose it again, those restraints were the worst things that ever happened to me"
I'd like to talk with you about your experience
dexamethasone for 2 weeks; deficient knowledge when comment is made
If I forget a dose, it's no big deal, i'll just take it when I remember it
UAP psychiatry; balance in therapeutic milieu; further teaching
controlling clients helps them feel more comfortable
L&D at 30 weeks; hx of cesarean birth and reports severe abdominal pain that started less than 1 hr ago; better after vomit; loses consciousness; fetal HR is 100; priority intervention
prepare the client for immediate surgery
oncology unit; RN, LPN, UAP; client for RN
52 yr old with lung cancer admitted for acute dyspnea
outpatient addiction; now he drinks at home from the time he comes home from work until bed; priority first to last make comments
I hear how confused and frustrated you are it can happen that as one person sobers up, the spouse deteriorates what have you tried to do about your husbands behaviors what do you think you could do to have your husband come in for evaluation
wearing a back brace after spinal fusion; effective teaching
I should wear a thin cotton undershirt under the brace
statement about heart sounds is correct
S1 is the loudest at the apex, and S2 is the loudest at the base
special therapy using needles inserted in specific areas along channels in skin
acupuncture
dx ovarian cancer; spread to outside of pelvis; wants palliative care instead of aggressive therapy; priority nursing dx
acute pain
hemodialysis treatments; BP 200/100, HR 110, RR 36, o2 sat 89%; intervention
administer oxygen
long leg cast how to use crutches properly while descending a staircase; transfer body weight to the unaffected leg and then
advance both crutches
nurse manager; include what items as part of personnel budget
anticipated overtime payments for staff
male; impotence; which medication is a contributing factor
antihypertensives
initial assessment of post op client; IV infusion is different from solution ordered by physician; first action
assess the client, call physician, then hang the ordered solution
schizophrenia is mute, cant perform ADLs and stares out window for hours; first priority
assist the client with feeding
nurse and NA caring for a group of adolescents; task delegate to NA
assisting adolescent dx with paraplegia with a meal
arm cast reports severe pain in affected extremity and decreased sensation and motion; swelling in fingers increased; priority
call HCP
primiparous; 20 hrs after giving birth; starting postpartum exercises; instructions most appropriate
flex the knees while supine then inhale deeply and exhale while contracting the abdominal muscles
liquid oral iron supplements; child; most important information to provide
give the medicine via a dropper or through a straw
receiving shift report on a group of clients; nurse see first
heart failure who has a PaO2 of 75 and O2 sat of 90% on a nonrebreather mask
heat and cold treatments; manage arthritis; knowledge deficit
heat producing liniments can be used with other heat devices
depression; hospitalized for 3 days; tranylcypromine sulfate; tyramine foods reaction
hypertensive crisis
diabetes for 10 years; nurse gives usual dose of insulin at 7 am, at 1030 the client has light headedness and sweating; report and recommend intervention for
hypoglycemia
correctional facility wearing handcuffs; 2 officers socializing with nursing staff; best action
insist that the officers stay in the room at all times
asthma; focused assessment to detect
inspiratory and expiratory wheezing
family stage intervention for alcoholic adolescent; successful when adolescent
is motivated to enter an alcohol rehab program
cell cycle nonspecific alkylating agent thiotepa 60 mg weekly for 4 weeks by bladder instillation; chemo; how does thiotepa exert its therapeutic effect
it interferes with DNA replication and RNA transcription
admin moderate sedation to client with COPD; next action based on principle that
it may be necessary to raise the head of this clients bed
teaching adolescent with seizure disorder; valporic acid; immediately report what s/s to HCP
jaundice
stage IV parkinsons is admitted to ED with heart failure; no CPR;LPN says the client shouldnt have come to the hospital because they have an advance directive; RN response
just because the client has an advance directive doesnt mean that we shouldnt treat reversible conditions such as heart failure
neonate is returned to mothers room from nursery; mother undress baby and check diaper; nurse respond
let me know if you need any assistance or supplies for you or the baby
fecal impaction should watch for
liquid or semiliquid stools
medication appropriate to admin if prescribed to client experiencing symptoms of early alcohol withdrawal
lorazepam
prenatal record; gravida 2 para 0111; pregnant twice, what else does this info reveal
one pregnancy resulted in an abortion and one resulted in a preterm neonate who is living
ovarian cancer to a group; topic priority
ovarian cancer s/s are often vague until late in development
activity restriction and sexual dysfunction; tests completed and dx L5-S1; assessment findings should be expected
pain radiating down the right leg
assessing pregnant client using leopolds maneuvers; actions appropriate for this
palpate the clients upper abdomen using both hands note the shape and consistency of the palpated part note the mobility of the palpated part
mother asks the nurse again what caused her childs phenylketonuria (PKU); why does she keep asking
parents of a chronically ill child commonly require a long time to work through the grieving process for their childs disease
teaching a client with emphysema how to do pursed lip breathing; expected outcome
prolonged exhalation
one on one teaching the client doesnt make eye contact; culturally sensitive strategy would be appropriate
provide detailed written information
12 yr old with CF treated for pneumonia; HCP calling in telephone order for ampicillin; take what actions
repeat the prescription to the HCP ask the HCP to confirm that the prescription is correct as understood by nurse
sexual contact with someone whom she suspects has genital herpes; information should nurse give
report any difficulty urinating
new nurse asked to start IV on antepartum client; isn't familiar with IV pumps used; should
review the units procedure manual
diazepam 10 mg IV for status epilepticus; statement about diazepam is true
should be administered no faster than 5 mg/min in adult
custody of clients daily kardex and care plan; to give change of shift report; steps to maintain confidentiality
shred the documents or place them in a container to protect confidentiality
lab value will require intervention in client receiving lithium
sodium 130
suspicious of staff members; help establish therapeutic relationship; plan
spend brief intervals with the client each day
bowel resection; 7 days postop for removal of staples; mid incision pain; incision is separating; priority
stop the staple removal, cover the incision, report the findings to the physician
following cesarean birth for abruptio placentae; multigravid; I feel like such a failure; nurse consider when responding
the clients feeling of grief is a normal reaction
L&D area; believes membranes have ruptured; when getting hx what should nurse ask first
the time of membrane rupture