EXIT

A client presents to the labor and delivery unit with a report of leaking fluid that is greenish-brown vaginal discharge. Which action should the nurse take first?

Begin continuous fetal monitoring.

Which is the best approach for the nurse to use when interviewing a client about intimiate partner violence?

Begin with questions that are less sensitive in nature

A child is diagnosed wtih acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen?

Bone marrow transplantation

A client who is admitted with complications related to hypopituitarism is diphoretic and hypotensive. Which assessment finding warrants immediate intervention by the nurse?

Bradycardia

A pediatric client is taking the beta-adrenergic blocking agen propranolol. In developing a teaching plan, the nurse should teach the parents to report which sign of exchange?

Bradycardia

Which instruction should the nurse delegate to an unlicensed assistive personnel (UAP)?

Bring sterile chest drainage unit from central supply to the unit

The nurse is providing discharge teaching to the parents of a 13-month-old child who underwent repair for an atrial septal defect. The healthcare provider prescribes aspirin and an antibiotic for the first 6 months postoperatively to prevent infective endocarditis (IE). What information is most important for the nurse to discuss with the parents about hte child's recovery and prevention of IE?

Brust the child's teeth every day and ensure the child receives regular dental followup

Two days prior to discharge from the rehabilitation facility, the nurse is traching a client who is recovering from Guillain-Barre syndrome about home care. Which actions should the nurse include when providing discharge teaching to the client and spouse? (SATA)

- Develop nutritional plan - Review safe transfer strategies - Help identify community support

A newly admitted client vomits into an emesis basin as seen in the picture. The nurse should consult with the healthcare provider before adminsitering which of the client's prescribed medications? (SATA)

- Enoxaparin, a low-molecular weight heparin, subcutaneously - Ibuprofen, an NSAID - Clopidogrel, an antiplatelet agent, by mouth

When conducting an admission assessment, the nurse notes that an adult female client has developed two new allergies since her last admission. The client describes herself has lactose intolerant and states that she is unable to eat eggs. Which intervention should the nurse implement? (SATA)

- Enter new allergy information in the client's electronic medical record. - Notify the dietary department of the client's egg intolerance - Ask the client to describe her reaction to milk and eggs.

The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing actions should the nurse assign to the PN? (SATA)

- perform daily surgical dressing chagne for a client who had an abdominal hysterectomy - Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus - Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty.

An older client's daughter calls the home health nurse and reports that her mother has become forgetful and is very confused at night. The daughter states that her mother's behavior changed suddenly a few days ago and is not getting worse. Which actions should the nurse take? (SATA)

-Encourage increased intake of high protein foods -Instruct daughter to check her mother's temperature -Ask if the mother is experiencing any pain with urination

The nurse assesses a client being treated for herpes zoster (shingles). Which assessments hsould the nurse include when evaluating the effectiveness of treatment? (SATA)

-Functional ability -Skin Integrity -Pain scale

An older client is admitted to the stroke unit after recovery from the acute phase of an ischemic cerebral vascular accident (CVA). Which interventions should the nurse include in the plan of care during convalesence and rehabilitiation? (SATA)

-Measure neurological vital signs every 4 hours. -Encourage family members to participate in client's care

A client newly diagnoses with diabetes mellitus suddenly becomes confused and weak. Which interventions should the nurse implement?

-Obtain blood pressure and pulse rate -CHeck the client's current fingerstick blood glucose -Give the client 4 ounces of orange juice

A male client is admitted for the removal of an internal fixation device that was inserted for a fractured ankle. During the client's admission history, he tells the nurse that he recently received vancomycin for a methicillin-resistant staphylococcus aureus (MRSA) wound infection. Which actions should the nruse take? (SATA)

-Place the client on contact transmission precautions -Continue to monitor the client for signs of infection -Collect multiple site screening cultures for MRSA

When conducting diet teaching for a client who was diagnosed with myocardial infarction, which snack foods should th enurse encourage the client to eat? (SATA)

-Raw unsalted almonds and apples -Fresh turkey slices and berries

A client with Type 1 diabetes mellitus and a large draining ulcer of the right foot is admitted with a suspected staphylococcus aureus infection. Which intervention should the nurse implement?

-Send wound drainage for culture and sensitivity -Monitor the client's WBCs -Institute contact precautions for staff and visitors.

A client with type 2 diabetes mellitus, is admitted with hyperosmolar hyperglycemia syndrome (HHS). Which laboratory values provide the nurse with findings that are consistent with HHS? (SATA)

-Serum osmolarity of 85mOsm/kg -Blood glucose of 650mg/dL -Urine negative for ketones

The nurse is arranging home care for an older client who has a new colostomy following a large bowel resection three days ago. The client plans to live with a family member. Which actions should the nurse implement? (SATA)

-Teach care of ostomy to care provider -Provider pain medication instructions -Assess the client for self-care ability

The nurse is preparing to mix two medications from two different multidose vials, A and B. In which order should these actions be implemented when drawing the solutions from the vials?

-Verify the drug and dose with the label on the vial -Inject the volume of air to be aspirated from each vial -Aspirate the desired volume from vial A -Aspirate the desired volume from vial B

After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment findings should the nurse report to the healthcare provider? (SATA)

-WBC -Swollen lymph nodes in groin -Core body temperature

The nurse is providing lifestyle change education for a client to slow the progression of coronary artery disease. Which statement(s) made by the client should the nurse recognize as needed additional education?

-Walk 30 minutes/day -use a salt substitute -Keep a food diary

The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which information in the client's admission assessment is relevant to the nurse's plan for taking the blood pressure reading? (SATA)

-blurred vision -frequent syncope

A male client with a history of mitral valve prolapse is admitted because of fever and dyspnea on exertion, and is diagnosed with acute infective endocarditis. During the admission assessment, the nurse observes multiple areas of petechiae on the client's skin. Which interventions should the nurse include in the client's plan of care? (SATA)

-report changes in pre-existing murmurs -maintain record of fluid intake and output -monitor cardiac rhythm via telemetry -schedule rest periods between activities

The healthcare provider prescribes a fluid challenge of 0.9% sodium chloride 1L to be infused intravenously over 4 hours. The IV administration set delivers 10gtt/mL. How many gtt/minute should the nurse regulate the infusion?

42 gtt/minute

After administering a 12 ounce can of nutritional supplement, 3 teaspoons of medication, and 120mL of water, the nurse should document the client's fluid intake as how many mL?

495 mL 1oz=30mL 1tsp=5mL

The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention?

A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby

Which situation indicates a need for the nurse to discuss the use of mitten restraints with the healthcare provider?

A disoriented client removed the mesh wrapped IV line for the second time.

The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first?

A family member of a client with dementia who has been missing for five hours.

The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?

A tuna fish sandwich with chips and ice cream

The nurse is providing education about disease transmission to a client with human immunodeficiency virus (HIV) who is pregnant. Which action should the nurse recognize as the cleitn demonstrating an understanding of the disease transmission?

Acknowledge the risk of HIV transmission through breast milk.

A young male client is admitted to rehabilitation following a right above-knee amputation (AKA) for a severe traumatic injury. He is in the commons room and anxiously calls out to the nurse, stating that his "right food is aching." The nurse offers reassurance and support. Which addtional intervention is most important for the nurse to implement?

Administer a prescription for gabapentin, a neuroleptic agent

A client's morning assessment includes bounding peripheral pulses, weight gain of 2 pounds (0.91kg), pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for the nurse to include in this client's plan of care?

Administer prescribed diuretic

The nurse is caring for a client who has chronic obstructive pulmonary disease (COPD) and chest pain related to a recent fall. What nursing intervention requires the greatest caution when caring for a client with COPD?

Administering narcotics for pain relief

A client is diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide is schedules to begin at 0730. Which client medication should the bring to the healthcare provider's attention?

Allopurinol Aluminum hydroxide may decrease the effects of allopurinol. Allopurinol must be adminstered at least 3 hours before or after aluminum hydroxide.

A nurse working on an endocrine unit should see which client first?

An adult with blood sugar of 384mg/dL and a urine output of 350 in the last hour.

An antacid is prescribed for a client with gastroesophageal reflux (GERD). The client asks the nurse, "How does this help my GERD?" Which is the best response by the nurse?

Antacids will neutralize the acid in your stomach Antacids provide symptomatic relief from heartburn, hyperacidity, acid indigestion, GERD and upset stomach associated with these conditions. Antacids act by neutralizing excess hydrochloric acid (HCl) in gastric juice and inhibit the proteolytic enzyme pepsin. When taken FREQUENTLY, it can make problem worse because it leave the body quickly, and body increases acid accumulation. Antacids cannot be used for patients with kidney disease or increased Ca in blood.

A parent asked the nurse how to care for their 4 year old child after receiving the haemophilus infuenzae Type B (Hib) conjugate vaccine. Which instruction should the nurse provide?

Apply a cool pack to the injection site to reduce discomfort.

A client who gave birth 48 hours ago has decided to bottle feed the infant. During the assessment, the nurse observes that both breasts are swollen, warn and tender on palpation. Which instruction should the nurse provide?

Apply ice to the breasts for comfort.

After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?

As the client about GI pain

A client tells the nurse about working out with a personal trainer and swimming three times a week in an effort to lose weight and sleep better. The client states that it still is taking hours to fall asleep at night. What action should the nurse implement?

Ask the client for a description of the exercise schedule that is being followed.

A young adult male who is being seen at the employee health clinic for an annual assessment tells the nurse that his mother was diagnosed with schizophrenia when she was his age and that life with a schizophrenic mother was difficult indeed. Which response is best for the nurse to provide?

Ask the client if he is worried about becoming schizophrenic at the age his mother was diagnosed.

A client presses the call bell and requests pain medication for a severe headache. To assess the quality of the client's pain, which approach should the nurse use?

Ask the client to describe the pain Provoking (P) - what brings the pain on? aggravating factors? Quality (Q) - describe the pain. how does it feel like? Region/Radiation (R) - where is the pain? does it spread anywhere else? Severity (S) - how severe is the pain? At its worst? Most of the time? Time (T) - when did it start? Is it constant or intermittent?

A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to the child, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older botehr becomes withdrawn when asked about what happened. What action should the nurse take?

Ask the older brother how he felt during the incident.

A nurse receives report on a client who is four hours post-total abdominal hysterectomy. The previous nurse reports that it was necessary to change the client's perineal pad hourly, and that it is again saturated. The previous nurse also reports that the client's urinary output has decreased. What action should the nurse implement first?

Assess for weakness or dizziness

A client with chronic kidney disease has an arteriovenous (AV) fistula in the left forearm. Which observation by the nurse indicates that the fistula is patent?

Assessment of bruit on the left forearm Access the vascular with a stethoscope to detect a bruit or "swishing" sound that indicates patency. Palpate the vascular access to feel for a thrill or vibration that indicates arterial and venous blood flow and patency.

The nurse who works in labor and delivery is reassigned to the cardiac unit for the day because of a low census in labor and delivery. Which assignment is best for the charge nurse to give this nurse?

Assist cardiac nurses with their assignments

The nurse is caring for an older adult client who is admitted to the surgical unit following a partial gastrectomy. In addition to frequent position changes, which postoperative intervention is most beneficial for the nurse to perform in preventing respiratory complications?

Assist to a chair the day after surgery when condition is stable.

While removing staples from a client's postoperative wound site, the nurse observes tha tthe client's eyes are closed and client's face and hands are clenched. The client states, "I just hate having staples removed." After acknowledging the client's anxiety, which action should the nurse implement?

Attempt to distract the client with general conversation

The nurse identifies an electrolyte imbalance, a weight gain of 4.4lbs in 24 hours and an elevated central venous pressure for a client with full thickness burns. Which intervention should the nurse implement?

Auscultate for irregular heart rate

A female client with a history of heart failure (HF) arrives at the clinic after wht she describes as a very long trip. Following the initial physical assessment and chart review, which priority action should the nurse implement?

Auscultate lung and heart sounds B-type Natriuretic peptide normal <100

A client with dyspnea is being admitted to the medical unit. To best prepare for the client's arrival, the nurse should ensure that the client's bed is in which position?

B - high fowlers

A nurse who is working the emergency department triage area is presented with four clients at the same time. The cleint presenting with which symptoms requires the most immediate intervention by the nurse?

Chest discomfort one hour after consuming a large, spicy meal

A client with a lower respiratory tract infection receives a prescription for ciprofloxacin 500mg PO every 12 hours. When the client requests an afternoon snack, which dietary choice should the nurse provide?

Cinnamon applesauce calcium disrupts the intestinal absorption of ciprofloxacin, which then diminishes the antibacterial effects of the drug. **should not consume calcium-rich foods for 2-6 hours before you take cipro. (MV contain Zn, Mg, Al, Fe)

The nurse implements a tertiary prevention program for type 2 diabetes in rural health clinic. Which outcome indicates that the program was effective?

Client who developed disease complications promtly received rehabilitation

The nurse is caring for a client who reports right calf pain and shortness of breath. Which intervention should the nurse implement first?

Collect a blood sample for D-dimer test used to detect blood clotting problems. High levels indicates blood clot D-dimer is protein you rbody makes to break down clots normal d-dimer is <0.50, a positive >0.50

The nurse is providing care for a client with schizophrenia who receives haloperidol decanoate 75mg IM every 4 weeks. The client begins developing puckering and smacking of the lips and facial grimacing. Which intervention should the nurse implement?

Complete abnormal involuntary movement scale (AIMS) tardive dyskinesa (TD), condition where your face, body or both make sudden, irregular movements which you cannot control.

A young adult visits the clinic reporting symptoms associated with gastritis. Which information in the client's history is most important for the nurse to address in the teaching plan?

Consumes 10 or more drinks of alcohol every weekend. inflammation of the stomach lining

while the nurse is assessing the older adult client's fall risk, the client reports living at home alone and never faling. Which action should the nurse take?

Continue to obtain client data needed to complete the fall risk survey.

The nurse is evaluating the chest drainage system of a client with a chest tube inserted to treat a left hemothorax. Which finding requires intervention by the nurse?

Continuous bubbling in the water-seal chamber

While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?

Culture for sensitive organisms.

A client who is scheduled for a bronchoscopy in the morning is anxious and asking the nurse numerous questions about the procedure. In preparing the client for procedure, which intervention has the highest priority?

Deny client's request for a midnight snack NPO status, stomach needs to be empty to prevent aspiration.

A client present with a right proximal tibial fracture after a motor vehicle collision. Which assessment should the nurse recognize as needing immediate action?

Description of numbness in toes.

The nurse assesses a client who had bilateral total knee replacements (TKR) four hours ago. The nurse notes that the dressing on the client's right knee is now saturated with serosanguinous drainage. What action should the nurse implement?

Determine is the wound drainage device is functioning correctly.

Prior to surgery, written consent must be obtained. Which is the nurse's legal responsibility with regard to obtaining written consent?

Determine that the surgical consent form has been signed and is included int he client's record.

A client arrives for an annual physical exam and complains of having calf pain. The client's health history reveals peripheral arterial disease. Which question should the nurse ask the client about expected findings related to chronic arterial symptoms?

Does the calk pain occur when walking short distances?

A client with multiple burn injuries is being treated in the burn trauma unit just hours after the injuries occurred. The healthcare provider instructs the nurse to avoid auto contamination when performing dressing changes. Which intervention is most important for the nurse to implement?

Dress each would separately.

In caring for a client following a head injury, the nurse plans to assess for rhinorrhea so that a sample can be tested for the presence of cerebrospinal fluid (CSF). At which location should the nurse observe for this finding?

Ear or the nose. Rhinorrhea, or a runny nose, happens when excess fluid drains from the nose.

What might the nurse suggest to client with fibrocystic breasts in an attempt to help relieve her symptoms?

Eliminate caffeine from your diet. (may worsen the tenderness and pain that is associated with fibrocystic condition)

The nurse instructs a client in use of an incentive spirometer. The client performs a return demonstration as seen in the video. What action should the nurse take in response to the return demonstration?

Emphasize the need to inhale slowly into the spirometer

A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and a dull gnawing pain that is relieved when he eats. Which is the best response by the nurse?

Encourage the client to obtain a complete physical exam, since these symptoms are consistent with an ulcer

A middle-aged client, admitted to a critical care unit several weeks ago because of serious injuries sustained in a motot vehicle accident, is currently in stable condition. Based on the client's age and recent life-threatening crisis, which intervention should the nurse implement?

Encourage the client to reflect on personal goals and priorities

A male client with cirrhosis has jaundice and pruritis. He tells the nurse that he has been soaking in hot baths with no relief to his discomfort. Which action should the nurse take?

Encourage the client to use cooler water and apply calamine lotion after soaking.

A 2-month old infant with hypertrophic pyloric stenosis is receiving parenteral fluids for rehydration and decompression of the stomach while waiting for surgical repair. To maintain normal growth and development of the child during this period, which action should the nurse include in the plan of care?

Ensure placement of the nasogastric tube with an abdominal xray.

The mother of a 2-day old infant girl expresses concern about a "flea bite" type rash on her daugher's body. The nurse identifies a pink papular rask with vesicles superimposed over the thorax, back, buttocks, and abdomen. Which explanation should the nurse offer?

Erythema toxicum is a pink papular rash on which vesicles are often superimposed. Common newborn rash that will resolve after several days.

A client is recovering in the critical care unit following a cardiac catheterization. IV nitroglycerin and heparin are infusing. The client is sedated but responds to verbal instructions. After changing positions, the client complains of pain at the right groin insertion site. What action should the nurse implement?

Evaluate the integrity of the IV insertion site.

An adult client is admitted to the emergency department after falling from a ladder. While waiting to have a computed tomography (CT) scan, the client requests something for a severe headache. When the nurse offers a prescribed dose of acetaminophen, the client asks for something stronger. Which intervention should the nurse implement?

Explain the reason for using only non-narcotic

The nurse identifies several nursing problems for client who is immobile and who has been experiencing fecal incontinence and diarrhea for several days. The client's spouse is the primary caregiver, which problem has the highest priority?

Fluid volume deficit

A client with type 2 diabetes mellitus and hypertension is admitted with cellulitis of the right leg due to an imbedded thorn from gardening. The client is receiving an intravenous infusion for antibiotic administration and is on bedrest with right leg elevated on a pillow. Which finding requires immediate follow-up by the nurse?

Flushed, dry skin

The nurse is wearing personal protective equipment (PPE) while caring for a client. When exiting the client's room, which PPE should be removed first?

Gloves

An adolescent who was diagnosed with diabetes mellitus type 1 at the age of 9, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of ketoacidosis?

Had a cold and ear infection for the past two days.

The nurse is auscultating a client's lung sounds. Which description should hte nurse use to document this sound?

High pitched wheeze

After several months of chronic fatigue, morning stiffness, and joint pain, a young adult is diagnosed with rheumatoid arthritis, and the healthcare provider prescribes prednison. Which education should the nurse provide the client with regard to taking prednisone?

If sequential doses are missed, notify the healthcare provider. Missing a couple of doses can not only send your body into an adrenal shock, but the inflammatory problem for which you are seeking treatment will also return.

An older client is brought to the emergency department (ED) with a sudden onset of confusion that occurred after experiencing a fall at home. The client's daughter, who has power of attorney, has brought the client's prescriptions. Which information should the nurse provide first when reporting to the healthcare provider using SBAR?

Increasing confusion of the client

A client with acute asthma is manifesting inspiratory and expiratory wheezes and a decreased forced expiratory volume. Which prescribed drug class should the nurse administer first to the client?

Inhaled short-acting beta-2 agonists albuterol, levalbuterol, metaproterenol, terbutaline

When preparing to administer an intravenous medication through a client's triple lumen central venous catheter, the nurse observes that there are no continuous intravenous fluids infusing. What action should the nurse take?

Initiate an infusion of 0.9% normal saline solution

When admitting a clinet with a diagnosis of transient ischemic attack (TIA), which intervention is most important for the nurse to include in the client's plan of care?

Initiate neurological monitoring every 2 hours.

A client at 12-weeks gestation is admitted to the antepartum unit with a diagnosis of hyperemesis gravidarum. Which action is most important for the nurse to implement?

Initiate prescribed intravenous fluids.

A client with syndrome of inappropriate antidiuretic hormon secretion (SIADH) is admitted with hyponatremia. Which intervention is most important for the nurse to include in the plan of care to protect the client from injury?

Initiate seizure precautions

After an older client receives treatment for drug toxicity, the healthcare provider prescribes a 24-hour creatinine clearance test. Prior to starting the urine collection, the nurse notes that the client's serum creatinine is 0.3mg/dL. Which action should the nurse implement?

Initiate the urine collection as prescribed.

The nurse is planning care for a client with chronic kidney disease who is a resident of a long-term nursing facility. The client is anuric and has hemodialysis 3 times a week. Which intervention should the nurse include in the client's plan of care?

Initiate toileting schedule

The nurse is providing discharge education for a client who is post mastectomy with an axillary lymph node dissection. Which information should the nurse provide the client to help prevent the complication of lymphedema?

Instruct on wasy to avoid infection or trauma to the affected arm

An unlicensed assistive personnel (UAP) is assigned to ambulate a client with influenza who has droplet precautions implemented. The UAP requests a change in assignment, stating the reason of having not been fitted yet for N95 respirator mask. Which action should the nurse take?

Instruct the UAP that a standard face mask is sufficient for the provision of care for the assigned client.

A new nurse preparing to irrigate an intravenous catheter is a attaching a 24-gauge needle. Which action should the charge nurse implement?

Instruct the nurse to remove the needle.

The healthcare provider prescribes a sepsis protocol for a client with multi-organ failure caused by a ruptured appendix. Which intervention is most important for the nurse to include in the plan of care?

Keep head of bed raised 45 degrees.

The nurse administers morphine sulfate IV to a client with pancreatitis, who is experiencing extreme periumbilical pain and abdominal distention. Which additional intervention should the nurse implement?

Maintain IV at 125mL/hr

Which intervention should the nurse include in the plan of care for a child with tetanus?

Minimize the amount of stimuli in the room

A client with metabolic syndrome plans to begin an exercise program. What instruction is most important for the nurse to provide this client?

Monitor blood pressure and heart rate as exercise activity is increased

The nurse is reviewing the plan of care for a newly admitted client who is intoxicated on admission. Which findings should the nurse include as indicators to begin implementing the detoxification medication protocol?

Mood lability, poor hand coordination, fever, drowsiness

A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell. The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take?

Most the client to a private room, keep the door closed, and initiate droplet precautions.

The nurse is reviewing the diagnostic tests prescribed for a client with a positive skin test. Which subjective findings reported by the clients supports the diagnosis of tuberculosis?

Mucopurulent cough and night sweats

The nurse completes auscultation of the thoracic region on an adolescent client. Which finding is considered normal for this client?

No adventitious sounds

A client who experiences a cerebrovascular accident (CVA) is aphasic and has a left sided paralysis. Which nurse should be responsible for coordinating the progression of this client's care?

Nurse care manager

A client presents to the labor and delivery unit, screaming, "the baby is coming!" which action shoudl the nurse implement first?

Observe the perineum

A client arrives to the emergency department reporting an intermittent fever and night sweats for the past 3 weeks and has developed a productive cough containing small amounts of blood. Which intervention should the nurse prioritize?

Obtain sputum sample

The nurse is caring for a preterm newborn with nasal flaring, grunting, and sternal retractions. After administering surfactant, which assessment is most important for the nurse to monitor?

Oxygen saturation Lungs are not fully developed and cannot provide enough oxygen, causing breathing difficulties. Surfactant is made up of proteins and fats, which helps keep the lungs inflated and prevents them from collapsing. A baby normally begins producing surfactant sometime between weeks 24-28 of pregnancy.

A client who is receiving radiation treatment for laryngeal cancer has developed xerstomia and mucositis. The nurse determines the client has an imbalanced nutritional intake and is consuming less than the body requirements. What factor is most likely cause for this problem?

Pain when eating Xerostomia is the condition of not having enough saliva to keep the mouth wet, dry mouth. Mucositis is when your mouth or gut is sore and inflamed. Chemo and radiation.

The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program?

Participation of community leaders in planning the program

The nurse is demonstrating correct transfer procedures to the unlicensed assistive personnel (UAP) working on a rehabilitation unit. The UAP asks the nurse how to safely move a physically disabled client from the wheelchair to a bed. Which action should the nurse recommend?

Place the client's locked wheelchair on the client's strong side next to the bed.

A client who underwent an uncomplicated gastric bypass surgery is having difficulty with diet management. Which dietary instruction is most important for the nurse to explain to the client?

Plan volume-controlled, evenly-spaced meals throughout the day.

A client is receiving enoxaparin 30mg SQ BID. In assessing for adverse effects of the medication, which serum laboratory value is most important for the nurse to monitor?

Platelet count 150k-450k If platelet count falls below 100,000, should be d/c

The nurse is planning an educational session for new parents on ways to prevent sudden infant death syndrome (SIDS). Which information is most important to provide parents of newborns and infants?

Position the infant in a supine position while sleeping

A male client approaches the nurse with an angry expression on his face and raises his voice saying, "My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!" The nurse recognizes that the client is using which defense mechanism?

Projection attributing one's own feelings, desires, or qualities to another person.

A client is hospitalized two days before a scheduled aortic valve replacement with severe shortness of breath and weakness. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?

Provide a bedside commode for toileting.

when assessing an IV site that is used for fluid replacement and medication administration, the client complains of tenderness when the arm is touched above the site. Which additional assessment finding warrants immedicate intervention by the nurse?

Red streak tracking the vein Phlebitis is an inflammation of the vein, damaged vein wall or blood cloth that blocks a vein - warm, tenderness, visible red "streaking" on the skin along the vein.

An older client with a long history of coronary artery disease (CAD), hypertension (HTN), and heart failure (HF) arrives in the Emergency Department (ED) in respiratory distress. The healthcare provider prescribes furosemide IV. Which therapeutic response to furosemide should the nurse expect in the client with acute HF?

Reduced preload Furosemide reduces preload by diuresis in 20-60 minutes. Preload is the initial stretching of the cardiac myocytes (muscle cells) prior to contraction. It is related to ventricular filling. Afterload is the force or load against which the heart has to contract to eject the blood.

When providing client care, the nurse identifies a problem and develops a related clinical question. Next, the nurse intends to gather evidence so that the decision-making process in response to the problem and clinical question is evidence-based. When gathering evidence, which consideration is most important?

Relevance to the situation

A client with urge incontinence was treated with onabotulinumtoxin A injections and is now experiencing urinary retention. Which action should the nurse include in the client's plan of care?

Remind the client to practice pelvic floor (kegel) exercises regularly

The nurse is feeding an older adult admitted with aspiration pneumonia. The client is weak and begins coughing while attempting to dring through a straw. Which intervention should the nurse implement?

Request thick nectar liquids for the client

The nurse is caring for a 3-year old child who is two hours postoperative from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction?

Right foot is cool to touch and appears pale and blanched. arterial occlusion, hematoma.

A client is diagnosed with Meneire's disease. Which problem should the nurse identify as most important in the plan of care?

Risk for injury related to vertigo inner ear (labyrinth) problem that can cause dizzy spells, vertigo, and hearing loss. balance disorder.

A female client with dementia who needs assistance with meals and activities of daily living often screams at the staff and threatens to hit those who come near her. Which nursing problem should be included in the treatment plan?

Risk for other-directed violence

The laboratory findings for a client with chronic kidney disease (CKD) include elevated blood urea nitrogen (BUN) and serum creatinine levels. The client reports feeling fatigued and is unable to concentrate during the morning assessments. Based on these findings, which action should the nurse implement?

Schedule frequent rest periods

An older client with systemic inflammatory response syndrome (SIRS) has a temperature of 101.8F, heart rate of 110 beats/min, and respiratory rate of 24 breaths/min. Which addtional finding is most important to report to the healthcare provider?

Serum creatinine of 2.0 (0.7-1.2) levels above 5 in adults, or 2 in children indicate severe kidney disorder.

Which laboratory finding for an adult client is most critical for the nurse to report to the healthcare provider?

Serum glucose 62mg/dL (70-100) Na - 142 (135-145) K - 3.9 (3.5-5) BUN - 18 (6-20)

A client is admitted with a diagnosis of urolithiasis. Which finding is most important for the nurse to report to the healthcare provider?

Serum potassium is elevated Urolithiasis - kidney stones

When assessing recently delivered, multigravida client, the nurse finds that her vaginal bleeding is more than expected. Which factor in this client's history is related to this finding?

She is gravida 6, para 5

The nurse is completing the admission assessment of a 3-year-old who is admitted with bacterial meningitis and hydrocephalus. Which assessment finding is evidence that the child is experiencing increased intracranial pressure (ICP)?

Sluggish and unequal pupillary responses.

A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing several side effects since taking the drug. Which side effect should the nurse report to the healthcare provider?

Somnambulism (sleepwalking) Ramelteon - Melatonin receptor agonists - CNS depressant used to treat insomnia.

The nurse should withhold which medication if the client's serum potassium level is 6.2mEq/L?

Spironolactone Potassium-sparing diuretic, prevents your body from absorbing too much salt and keeps your potassium. It is also used to treat heart failure, high blood pressure, low K, fluid retention, cirrhosis of the liver, high aldosterone levels in your body (helps regulate the salt and water balance in your body)

A male client who is participating in an anger management assignment asks if he can make a leather belt in occupational therapy. The client begins pounding the leather vigorously with a mallet to imprint designs on the belt. Which defense mechanisms is the client using?

Sublimation redirecting negative feelings or impulses into positive ones.

The nurse is providing care for a client with severe peripheral disease (PAD). The client reports a history of rest ischemia, with leg pain that occurs during the night. What action should the nurse take in response to this finding?

Suggest dangling the legs when pain begins.

The nurse should recognize which pathophysiological process describes the role of the immune system in cancer?

T help cells bind to antigens and destroy the cell

The nurse is preparting a client discharge who was hospitalized with an acute flare of systemic lupus erythematosis (SLE) symptoms. Which instruction is most important for the nurse to include?

Take prescribed cortisone accurately

A client is scheduled for a spiral computed tomography (CT) scan with contrast to evaluate for pulmonary embolism. Which information in the client's history requires follow-up by the nurse?

Takes metformin for type 2 diabetes. Metformin should be stopped before the CT scan with contrast and resumed 2 days later. Contrast can slow down how quickly your kidneys work, which can cause a buildup of metformin in your body.

A client who recently underwent a tracheostomy is being preparted for discharge to home. Which instruction is most important for the nurse to include in the discharge plan?

Teach tracheal suctioning techniques

An older client who care for her husband at home has just learned that she needs to have a knee replacement surgery. She tells teh nruse she is concerned about her inability to provide care to her husband while she recovers from surgery and attends physical therapy. She has a friend who can drive her to and from appointments once she is discharged, but cannot provide the care her husband needs. How should the nurse respond to the client?

Tell her to consider hiring a private nurse during the postoperative convalescence.

The nurse identifies the presences of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. Which action should the nurse implement immediately?

Test the fluid on the dressing for glucose CSF

A client fell in the bathroom when left unattended by the unlicensed assistive personnel (UAP). Which information should the nurse include in the client's health record?

The client fell sustaining a fracture to the left hip.

After receiving report on an inpatient acute care unit, which client should the nurse assess first?

The client with bowel obstructiondue to a volvulus who is experiencing abdominal rigidity. a loop of intestine twists around itself and the mesentery that supplies it, causing a bowel obstruction can be recurrent and resolve spontaneously, but can also be acute and cause partial or complete bowel obstruction

The nurse is developing a plan of care for a client who reports tingling of the feet and who is newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of care for this client?

The client's skin on the lower legs will be intact at the next clinic visit.

The nurse is caring for a 24 month old toddler who has sensory sensitivity, difficulty engaging in social interactions, and has not spoken two-word phrases. Which assessment should the nurse administer?

The modified checklist for Autism in Toddlers (M-CHAT)

After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to the practical nurse?

Validate prescribed intravenous flow rates

The nurse is caring for a child who takes methylphenidate extended release for the treatment of attention deficit hyperactivity disorder (ADHD). Which assessment finding indicates to the nurse that the child is experiencing an expected side effect of this medication?

Weight loss of 5 pounds in 1 month

The nurse is teaching a group of women about osteoporosis and exercises. The nurse should emphasize the need for which type of regular activity?

Weight-bearing exercises

On admission to the Emergency Department, a female client who was diagnosed with bipolar disorder 3 years ago reports that this morning she took a handful of medications and left a suicide note for her family. Which information is most important for the nurse to obtain?

What drugs the client used for the suicide attempt

In assessing a client with type 1 diabetes mellitus, the nurse notes that the client's respirations have changed from 16 breaths per minute with normal depth to 32 breaths per minute and deep, and the client has become lethargic. Which assessment data should the nurse obtain next?

blood glucose

A client with postpartum depression, who is admitted to the behavioral health unit, refuses to leave her room or eat meals. In addition to maintaining physical safety, which short-term goal should th enurse include in the plan of care?

consumes 3 meals and 1500mL of fluid per day

A client is admitted with rectal bleeding and melena. Which action should the nurse take to assess the client for blood loss?

observe the rectal area for bleeding hemorrhoids

A low-risk primigravida at 28 weeks gestation arrives for her regular antepartum clinic visit. Which assessment finding should the nurse consider within normal limits for this client?

pulse increase of 10 beats/minute

A teenager presents to the emergency department with palpitations after vaping at a party. The client is anxious, fearful and hyperventilating. The nurse anticipates the client developing which acid imbalance?

respiratory alkalosis

Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain?

upper body muscle strength

A client with type 1 diabetes mellitus is experiencing a hypoglycemic episode. The healthcare provider prescribes glucagon 1 mg IM STAT before an IV site is established. The medication is available in 1mg vial. The instructions for reconstitution state "add 1mL of sterile water for injection. How many mL should the nurse administer?

1 mL

A Client who is admitted for primary hypothyroidism has early signs of myxedema coma. In assessing the client, in which sequence should the nurse complete these actions?

1. Measure body temperature 2. Assess blood pressure 3. Observe breathing patterns. 4. Palpate for pedal edema

A heaparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80units/kg, the nurse calculates the infusion rate for the heparin solution at 18 units/kg/hour. The available solution is heparin sodium 25,000 units in 5% Dextros injection 250ml. The nurse should program the infusion pump to deliver how many mL/hour?

18mL/hour 220/2.2=100 18(100)(60) = 108000/25000=4.32(250mL)=1080/60=18mL/hr

The healthcare provider prescribes caphalexin 125mg/5ml oral suspension for a client who weighs 77 pounds. The recommended safe dose 25mg/kg/24 hours in 4 divided doses. Based on the client's weight, how many mL should the nurse administer?

2.8ml

A client arrives to the emergency department with scald burns on the front and back of the right arm and across the front of the torso. Using the rule of nines, which percentage should the nurse use to describe the total body surface area of this burn?

27% The front and back of the head and neck equal 9% of the body's surface area. The front and back of each arm and hand equal 9% of the body's surface area. The chest equals 9% and the stomach equals 9% of the body's surface area. The upper back equals 9% and the lower back equals 9% of the body's surface area.

The nurse is assessing a client who reports falling 2 days ago and has a history of gouty arthritis that is controlled with allopurinol. The client states that left knee is swollen and extremely painful to touch. What instruction should the nurse include in the discharge teaching?

Decrease consumption of red meat and most seafood.

Which pathophysiological finding is most likely to occur in a client with cor pulmonaie?

Decrease pulmonary resistance (?) Cor pumonale is an enlargement of the right ventricle caused by a respiratory disorder. The right ventricle has to push against higher pressure in your pulmonary artery, where blood pressure is normally low.