Hurst Physiological Adaptation
What signs/symptoms of worsening distress would the nurse expect to assess if the condition of the child with RSV deteriorates?
-retractions -tachypnea -periods of apnea -poor oral intake
What signs or symptoms should the nurse assess for when monitoring a client who has a brain injury?
-rhinorrhea -BP 150/60 -papilledema -projectile vomiting
What signs of cannula displacement should the nurse monitor for at an arterial line insertion site?
-swelling -fluid leaking -blanching -poor arterial waveform
The nurse should assess for what signs of toxicity in a child who is admitted with salicylate overdose?
-vomiting -tinnitus -diaphoresis -dehydration
A client with a history of intolerance to fatty foods is admitted to the hospital with a sudden onset of severe right upper quadrant pain radiating to the right shoulder. What should be included in the nurse's initial focused assessment of this client?
-"please describe your bowel habits and stool"
Which signs/symptoms would lead a nurse to suspect Fifth disease in a child brought into a pediatric clinic?
-Erythema on the cheeks -joint pain -swollen knees -pruritic rash on soles of feet
A client with type II diabetes reports normal blood glucose levels at bedtime and high blood glucose levels in the morning for the past week. What instruction would the nurse give the client?
-monitor blood sugar around 2am
A client is admitted to the hospital due to alcohol toxicity. Which interventions should the nurse initiate?
-Pad side rails -Attach client to pulse oximeter -Place in recovery position -Monitor fluids and electrolytes
A client with a diagnosis of embolic stroke is admitted to the medical unit. After 2 hours on the unit the client presents with agitation. Which nursing intervention would the nurse initially implement?
-Place the client's neck in the midline position
A client admitted to ICU has a prescription for an arterial line insertion to the right radial artery. What assessment findings by the nurse would be of concern?
-Right sided mastectomy -Negative Allen's test -Presence of A-V shunt to right forearm
A nurse is receiving morning report on the cardiovascular unit. What client should be the nurse's priority assessment?
-a client two days past abdominal aortic aneurysm repair with decreased pedal pulses
What signs/symptoms would the nurse expect to assess in a client diagnosed with tabes dorsalis neurosyphilis due to untreated syphilis?
-abnormal gait -blindness
An elderly client is admitted to the outpatient unit with anemia and is receiving a blood transfusion. What is the nurse's priority assessment?
-assess breath sounds
A nurse is planning to educate diabetic clients on how to decrease their risk for developing renal failure. What educational points should the nurse include?
-avoid daily use of non-steroidal anti-inflammatory medications -aggressive blood pressure management is necessary -aim to keep glycosylated hemoglobin less than 7%
A nurse is in the mall when a shopper who suddenly becomes non-responsive. Obtaining an available AED, the nurse would initiate what emergency interventions?
-clear everyone before shock -turn on the machine -place pads on clients chest
What signs/symptoms would the nurse expect to find in a client diagnosed with osteoarthritis (OA) in the knee?
-clicking sound when knee bends -pain that is worse after activity
A client is admitted from the emergency department to a medical unit. What acid base imbalance do the lab values indicate? pH: 7.44 PaCO2: 30 HCO3: 20
-compensated respiratory alkalosis
A client receiving torsemide 20 mg every day reports an onset of cramping in the lower extremities. Based on this report, what current lab finding would the nurse expect?
Potassium level of 3.1 mEq/L (3.1 mmol/L)
The client diagnosed with a hemorrhagic stroke has been admitted to the intensive care unit. Which nursing intervention would the nurse initiated to minimize the factors that contribute to increased intracranial cerebral pressure (ICP)?
-maintain a calming environment -Administer stool softener as prescribed - Instruct family to not wake the client if sleeping
The nurse is observing a new RN explain phototherapy to the mother of a newborn with a bilirubin of 12 mg/dL one day after birth. The nurse determines the new RN understands the phototherapy process when what statements are made to the mother?
- the infants eyes must be covered throughout the light session -body temperature must be checked frequently to monitor for fever -we check bilirubin levels several times daily to be sure its decreasing
Which comment by the client indicates understanding of possible complications of long term hypertension?
-"i would like to have my serum creatinine checked at this visit"
The nurse is caring for a client who has been receiving treatment for systolic heart failure. What assessment findings would indicate to the nurse that further treatment is necessary?
-3+ pedal edema -Purse-lip breathing -Pale nail beds
A client has been admitted to the unit with recurrent nephrotic syndrome. Which signs and symptoms does the nurse expect to find when examining the client?
-Anasarca -Foamy urine -Periorbital edema -Proteinuria
A client had a tracheostomy placed 2 days ago and requires suctioning as needed. Which action by the nurse requires intervention?
-Applying suction no longer than 10 seconds while advancing the catheter.
Following a hemorrhagic stroke, a client had a craniotomy with insertion of a ventriculostomy. Upon arrival in the ICU, the nurse's initial readings indicate an increase in intracranial pressure (ICP). What is the nurse's priority action?
-Hyperventilate client with a bag valve mask
What interventions should the nurse initiate while caring for a client who has a cooling blanket in place?
-Perform comparison check with another thermometer periodically -Assess client skin condition hourly -Observe for signs of chilling
A post-operative client becomes anxious and reports acute onset of chest pain when taking a deep breath and shortness of breath. Initial vital signs obtained by the nurse reveals tachycardia, hemoptysis, and a pulse oximeter reading of 90%. What intervention should the nurse initiate first?
-Raise head of bed to 90 degrees.
A client, who arrives at the emergency department, reports flashes of light. What problem does the nurse suspect?
-Retinal detachment
A client is admitted for management of ulcerative colitis. What sign/symptom would be of immediate concern to the nurse?
-abdominal guarding
The nurse is caring for a client with cirrhosis of the liver and suspects that the client may be developing hepatic encephalopathy. Which assessments by the nurse suggest that the client is developing this complication?
-asterixis -lethargy -amnesia -behavioral changes
The nurse recognizes which manifestations as signs of community-acquired pneumonia?
-cough -fever -myalgia -pleuritic chest pain
The parents of a child admitted with rheumatic fever (RF) ask why the child has been placed on bedrest. The nurse explains that bedrest serves what primary purpose for the client?
-decreases workload on the heart
The nurse should teach the client with chronic pancreatitis how to monitor for which problem that can occur as a result of the disease?
-diabetes
Which signs/symptoms should the nurse assess for in the client admitted with a diagnosis of myasthenia gravis?
-difficulty holding head erect -limited facial expression -ptosis
What signs and symptoms does the nurse expect a client diagnosed with bacterial pneumonia to exhibit?
-dyspnea -tachypnea -pleuritic chest discomfort -increased tactile fremitus
A nurse notes that a client with end-stage chronic renal failure has dry, itchy skin, white crystals on the skin, and uremic halitosis. Which nursing interventions would be appropriate for this client?
-encourage use of cotton gloves during sleep -apply emollients to the skin -cut fingernails short -provide mouth care prior to meals
A 9 month old client is admitted to the hospital with a diagnosis of pertussis. Which interventions should the nurse initiate?
-initiate droplet precaution -administer erythromycin 10mg/kg/dose 4 times daily for 7 days -use client dedicated and disposable equipment
A client is transported to the emergency department following a 20 foot fall from a ski lift. The nurse records initial assessment findings on the chart. Based on that data, what actions should the nurse implement immediately?
-initiate large gauge IV line -preparre for chest tube placement -administer high flow oxygen
The clinic nurse is reviewing pre-op teaching with a client diagnosed with uterine prolapse who is scheduled for vaginal hysterectomy. The client asks the nurse if having three pregnancies caused the prolapse. The nurse correctly identifies which factors increase the risk for uterine prolapse?
-obesity -vaginal deliveries -menopause
A client requires external radiation therapy. The nurse knows external radiation may cause which problems?
-pancytopenia -erythema -fatigue
A new nurse asks the charge nurse for assistance in interpreting arterial blood gases (ABGs) for a client. What acid/base imbalance should the charge nurse tell the new nurse these ABGs indicate in the client? pH: 7.5 PaO2: 94% PaCO2: 58 HCO3: 35
-partially compensated metabolic alkalosis
A client with a history of congestive heart failure (CHF) has been admitted with digoxin toxicity. After reviewing the initial laboratory results, the nurse knows what abnormal findings most likely contributed to the digoxin toxicity?
-potassium -magnesium
The nurse is caring for a client admitted with a diagnosis of pheochromocytoma. What sign/symptom does the nurse expect during an acute episode?
-profuse sweating -hypertension -tachycardia -palpitations
A client presents in the emergency department with acute onset of fever, headache, stiff neck, nausea/vomiting, and mental status changes. What interventions should the nurse initiate?
-provide a quiet environment -pad side rails -place on droplet precautions -maintain head in midline position
A client returns to the unit after having extracorporal lithotripsy. Which assessment finding by the nurse would be the best indicator that the treatment has been effective?
-tiny fragments noted in strainer after voiding
A client diagnosed with a hemorrhagic stroke is being transferred to the medical unit from the intensive care unit. Which nursing intervention should the nurse initially implement?
-maintain the head of the bed at 30 degrees
What independent nursing interventions should the nurse include when planning care for a client who is in a fluid volume excess (FVE)?
-monitor for orthopnea -raise head of bed to 45 degree -elevate edematous extremities
