Med Surg Final review
A pt who has begun to awaken after 30 min in the PACU is restless and shouting at the nurse. The pt oxygen sat in 96% and recent labs results are all normal. what action is most appropriate by the nurse?
Assess for bladder distention
A pt with a tracheostomy has a new order for a fenestrated trach tub. Which action should the nurse include in the plan of care in collaboration with the speech therapist?
Assess the ability to swallow before using the fenestrated tube
A client hospitalized for one week with subacute infective endocarditis is afebrile and has no signs of heart damage. Discharge with outpatient antibiotic therapy is planned. During discharge planning with the client which is most important for the nurse to do?
Assess the client's home environment in terms of family assistance in hospital access
A newly admitted pt is diagnosed with hyponatremia. When making room assignments the charge nurse should take what action?
Assign the patient to a room by the nurses' station
The nurse is caring for a 65-year-old client with an exacerbation of COPD who is in respiratory distress which intervention should the nurse implement first?
Assist the client into a sitting position at 90 degrees
the nurse is caring for a client who has an open repair of an abdominal aortic aneurysm two days ago. Which intervention is appropriate for the nurse to delegate to the unlicensed assistive personnel?
Assist the client to use a pillow to splint with coughing
The NG tube is removed on the second post op day and the pt is placed on a clear liquid diet. Four hours later, the pt complains of sharp, cramping gas pains. what action is most appropriate by the nurse?
Assist the pt to ambulate
Surgical unit has pt who has a history of smoking what action is most important
Auscultate for adventitious breath sounds
two days after an acute myocardial infarction, client complains of stabbing chest pain that increases with a deep breath. Which action will the nurse take first?
Auscultate heart sounds
Sinus brady complains of syncope and weakness and has BP of 90/50 what collaborative treatment should be implemented
Prepare pt for insertion of pacemaker
A nurse is caring for a client who has herpes zoster. Which of the following actions should the nurse take?
Prepare to administer acyclovir
What action will the nurse take immediately after surgery for a pt who received Ketamine as an anesthetic agent
Provide a quiet environment in post anesthesia care unit
A nurse is caring for a client who has pruritus following treatment for scabies. Which of the following actions should the nurse take?
Provide mittens for the client to wear at night
What action best describes the role of the CRNA on the surgical care team
Release or discharge pt from post an care
A nurse is caring for a client who has contact dermatitis of the neck and upper chest. Which of the following is an expected finding?
Report of exposure to a skin irritant
A pt who was involved in a crash has a tracheostomy placed to allow for continued mechanical vent. How should the nurse interpret the following arterial blood gas results. pH 7.48, paO2 85 PaCO2 32 and HCO3 25
Respiratory alkalosis
The nurse is caring for a client with COPD. Which health information is most important for the nurse to obtain?
Risk factors for complications
The nurse plans discharge teaching for a client with chronic heart failure who has prescriptions for digoxin and hydrochlorothiazide. Appropriate instructions for the client would be
Skip the digoxin if the pulse is below 60 beats per minute
the nurse is caring for a 50 year old client who weighs 210 pounds has a 70 pack smoking history, hypertension, high sodium intake, and sedentary lifestyle. Which is the most important factor for peripheral artery disease to address in the nursing plan of care?
Smoking cessation
after teaching the client with newly diagnosed Raynaud's phenomenon about how to manage the condition which action by the client demonstrates that the teaching has been effective?
The client exercises indoors during the winter months
the nurse is caring for a client diagnosed with arterial occlusive disease. what assessment finding would warrant immediate intervention by the nurse?
The client has numbness and tingling
A nurse at an outpatient surgery center is providing discharge teaching to a client and his spouse following surgical removal of a cataract. Which of the following should the nurse include in the teaching?
The client should wear dark glasses while outdoors
Which diagnostic test will be most useful to the nurse in determining whether a client admitted with acute shortness of breath had heart failure?
12-lead electrocardiogram
The nurse is calculating the total intake for a client diagnosed with hypertensive crisis. The client has received 880 milliliters of D5 W AVPB and 100 milliliters normal Saline 8 ounces of water 4 ounces of milk and six ounces of chicken broth. The client's urinary output is 1480 milliliters what is the total intake for the client?
1520 milliliters
A nurse is admitting a client who has sustained severe burn injuries in a grease fire. The nurse shades in a diagram including the burned surface areas. Using the Rule of Nines, the nurse should estimate that the client has burned what percentage of the body surface area? (round to the nearest tenth.)
31.5 (but who really knows) head: 9%, torso: 36%(front 18% back 18%), Arm: 9% each, leg: 18% each
a nurse is caring for a client who is to receive liquid medication via a gastrostomy tube the client is prescribed phenytoin 250 milligrams. The amount available is phenytoin oral solution 25 milligrams per 5 milliliters. How many milliliters should the nurse administer per dose?
50 milliliters
after receiving report, which client admitted to the emergency department should the nurse assess first?
60 year old who is complaining of sudden "sharp" and "worse than ever upper back pain"
what instructions should the nurse include when providing discharge instructions to a client diagnose with the peripheral artery disease? Select all that apply
you should wear comfortable shoes with rounded toes you will need to modify your diet to a low sodium low fat diet you should contact a smoking cessation program you want to inspect your feet and legs daily
While in the holding area, pt is telling the nurse his father's high temp after surgery. What should the nurse do?
Alert the CNRA of the family members reaction
Pt with MI with HR=126bpm, if not treated what could it cause
An increase in infarct size
Dietary teaching that includes dietary sources of potassium is indicated for the hypertensive client taking which drug
Hydrochlorothiazide
No RR and HR, tachycardic - 132
Start CPR
The nurse educator facilitates student clinical experiences in the surgical suite. Which action what require intervention by the nurse
Student wears surgical scrubs in semi restricted area
The HCP provider writed an order for bacteriologic testing for a pt who has a positive TB skin test. what action is most appropriate by the nurse?
Teach ab the need to get sputum specimens d=for 2/3 consecutive days
A pt scheduled for an elective hysterectomy tells the nurse "I am afraid I will die in surgery like my mother did" what response is most appropriate by the nurse?
Tell me more about what happened to your mother
A client with asthma has been prescribed an inhaled corticosteroid. What information should the nurse teach regarding this medication?
You should immediately rinse your mouth after taking this medication
Pt w no prior surgeries who is allergic to avocados and bananas
Alert surgery center of latex allergy
Post-op client at risk for VTE
Ambulate quickly, elevating feet, flexing ankles - safe Massaging leg - unsafe
The health care provider prescribes an angiotensin converting enzyme inhibitor for a client diagnosed with primary hypertension. Which statement is the most appropriate rationale for administering this medication?
Ace inhibitors prevent vasoconstriction and sodium and water retention
A nurse assists a patient of the first post op to ambulate, cough, deep breath, and turn. what action is most appropriate by the nurse?
Admin the ordered analgesic med before these activities
A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first?
Administer IV fluids
A patient seen in the asthma clinic has recorded daily peak flows that are 75% of the baseline. Which action will the nurse plan to take next?
Administer a bronchodilator and recheck the peak flow
Clint in cardiac arrest - CPR then getting amiodarone what to tell pt
Anti-dysrhythmic, will slow sinus rate and increase PR and QT interval decreases peripheral vascular resistance Decreases rate in which heart fires
Dilated cardiomyopathy has a new onset of Afib and is unresponsive to drug therapy - top teaching priority
Anticoagulant therapy
the nurse is caring for a client who recently had a valve replacement period which drugs would the nurse expect to be prescribed for the client with a mechanical valve replacement?
Anticoagulants
the nurse is caring for 23 year old client that reports experiencing cold numb fingers when running during the winter an Raynaud's phenomenon is suspected. The nurse will anticipate teaching client about test for which of the following?
Autoimmune disorders
A nurse is caring for a client who has poison ivy and is prescribed diphenhydramine. Which of the following instructions should the nurse give regarding the adverse effects of dry mouth associated with diphenhydramine?
Chew on sugarless gum or suck on hard, sour candies
A nurse is providing discharge teaching to a client following an excisional biopsy of a skin lesion. Which of the following information should the nurse include in the teaching?
Clean the incisional site daily after the dressing is removed
a nurse is caring for a client who has valvular heart disease and is at risk for developing left sided heart failure. Which of the following manifestations should alert the nurse that the client is developing this condition?
Breathlessness
When teaching the client with newly diagnosed heart failure about a 2000 milligrams sodium diet the nurse explains that foods to be restricted include?
Canned and frozen foods
A nurse is preparing to start an IV infusion of lactated ringer's for a client who sustained a burn injury. The client is prescribed 5,200 mL of fluid over the first 24 hr. How many mL/hr should the nurse set the pump to infuse for the first 8 hr? (round to the nearest whole number)
325 mL/hr Half is infused in the first 8 hours = 2,600mL 2600mL/ 8 hr = 325
The nurse monitors a pt after chest tube placement for a hemopneumothorax. The nurse is most concerned if what is observed
400 mL of blood in the collection chamber
Warfarin lab values to monitor
Monitor prothrombin time
Pt has a large percentage of burned body surface area. What is the priority nursing intervention?
Monitor the pulmonary artery pressure
a registered nurse is working with the license practical nurse and caring for a group of clients on a cardiac telemetry unit. Which nursing activity could be delegated to the LPN?
Monitor vital signs and oxygen saturations before during and after ambulation
A client who has chronic heart failure tells the nurse I was fine when I went to bed but I woke up in the middle of the night feeling like I was suffocating. The nurse will document this assessment finding as
Orthopnea
A client is admitted to the ED. What signs and symptoms would make the nurse suspect the client is experiencing an MI? SATA
Diaphoresis and cool, clammy skin Midepigastric pain and pyrosis Dependent edema and jugular vein distension Crushing chest pain
The nurse is completing an admission assessment on a 20-year-old client diagnosed with an acute asthma exacerbation. Which signs and symptoms would the nurse back to find?
Dyspnea and wheezing
The nurse if providing teaching to a pt on treatment for whooping cough. What statement is made by the pt indicated the need for additional teaching
I will need to take a cough suppressant
A nurse is providing teaching to a client who has a prescription for heat therapy for treatment of cellulitis of the right lower leg. Which of the following client statements indicates an understanding of the teaching?
I will wrap a warm, wet towel around my right calf every 4 hours (Moist heat then dry heat treats cellulitis)
The home health nurse cares for a alert and oriented older adult patient with a history of dehydration. What instructions should the nurse give to this patient related to fluid intake
Increase fluids when mouth is dry
The nurse is caring for a client with COPD. Which breathing technique to promote exhalation should the nurse teach?
Pursed lip breathing
Following a laryngectomy, a patient coughs violently during suctioning and dislodges the trach tube what action should the nurse take first?
Put it back in
A pt who is taking Rifampin for TB calls the clinic and says their pee is orange
Reassure the pt that this is normal
An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. What action by the nurse will be most helpful in reducing the incidence of lung disease?
Require use of protective equipment
A nurse is assessing a client who is brought to the emergency room with burn injuries. Which of the following findings should the nurse identify as a deep partial-thickness burns?
The burned area is red in color with eschar present Pink with blisters: superficial partial-thickness Black in color with no pain: deep full-thickness
Which information given by a client with chronic stable angina will help the nurse confirm this diagnosis?
The client states that the pain goes away with one sublingual nitroglycerin tablet
A nurse in a community health clinic is caring for a client who has a new diagnosis of plantar warts. The nurse should include which of the following in the teaching plan for this client?
They may be painful with ambulation
Nurse is caring for a pt diagnosed with pertussis. What order should the nurse question?
Azithromycin
A client with hypertension who is taking chlorothiazide and lisinopril has prazosin added to the medication regimen . What is most important for the nurse to teach the client to do?
Change position slowly and avoid prolong standing
A nurse is providing discharge teaching to a client who has an implantable cardioverter/deliberator, what of the follow information should the nurse include?
Client should hold cellphone on the opposite side of ICD
After receiving change of shift report on a heart failure unit, which client should the nurse assess fist?
Client taking carvedilol and heart rate of 58
On admin of a pt the PACU, the BP is 122/72 and 30 min later its 114/62 with a pulse of 74. What action of the nurse is most appropriate?
Continue to take vital signs every 15 minutes
The nurse is caring for a female client with a blood pressure of 145/90, an HDL cholesterol of 40, fasting triglycerides 155, fasting blood glucose of 125, and waist measurement of 38 inches. The nurse understands that the client has most likely which of the following conditions?
Coronary artery disease
A nurse is caring for a client who has questions concerning the various treatment options for his new diagnosis of basal cell carcinoma (BCC). Which of the following treatments should the nurse include in the discussion? (SATA)
Cryosurgery Electrosurgery Radiation therapy Micrographic surgery
A pt is admitted for hypovolemia with multiple draining wounds. Which assessment would be the most accurate way for the nurse to evaluate fluid balance?
Daily weight
A client diagnosed with primary hypertension asked the nurse I don't know why the doctor is worried about my blood pressure I just feel great. Which statement by the nurse would be the most appropriate response?
Damage can be occurring to your eyes heart and kidney even if you feel great
Pt on a diuretics and k= 3.0. what action is most appropriate by the nurse?
Digoxin
An older pt is bring discharges from the ambulatory surgical until following left eye surgery the pt tells the nurse "I do not know if I can take care of myself with a patch over my eye" what action is most appropriate by the nurse?
Discuss the specific concerns regarding self-care
The nurse is administering eyedrops to a client. Which guidelines should the nurse adhere to when instilling the drop into the eye? (SATA)
Do not touch the tip of the medication container to the eye Gently pull the lower lid down and instill drops into the conjunctiva Gently pat the skin to absorb excess eyedrops on the cheek
The nurse is caring for a pt who complained of dyspnea, chest pain, and hemolysis. The nurse suspects a PE. What if the following is a priority action for the nurse SATA
Elevate head of bed Maintains pt clients iv live No using a razor
A nurse is developing a plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse include in the plan?
Elevate the affected leg on two pillows
In the PACU the pts vital signs are 116/72, HR - 74. Rr 12 and pulse ox 91% the pt is sleepy but awakens easily. What should the nurse do?
Encourage deep breathing
A client in the ICU with acute decompensated heart failure complains of severe dyspnea and in anxious, tachypneic, and tachycardic. All the following medications have been ordered for the client. The nurse's priority action will be to
Give IV diazepam (Valium) 2.5 mg
A client with cystic fibrosis reports increased sweating and weakness during the summer months. Which action by the nurse would be most appropriate?
Have the client add dietary salts to meals
A client is diagnosed with rule out myocardial infarction experiences chest pain while walking to the bathroom. What action should the nurse implement first?
Have the client sit down immediately
the nurse is admitting a client with possible rheumatic fever. Which question on the admission history will be most pertinent to ask?
Have you had a recent sore throat?
Which nursing intervention will be the most effective when assisting the client with coronary artery disease to make appropriate dietary changes?
Help the client modify favorite high fat recipes by using monosaturated oils when possible
What data identified during the perioperative assessment alert the nurse that special protection techniques should be implemented during surgery
History of spinal and hip arthritis
A nurse obtains a health history from a pt who has a 35-pack year smoking history. The pt complains of hoarseness and tightness in the throat and difficulty swallowing. Which question is most important for the nurse to ask?
How much alcohol do you drink a week?
The nurse discusses management of upper respiratory infection with a patient who has acute sinusitis. What statement by the patient indicated that additional teaching is needed?
I can use my nasal decongestant spray until the congestion is all gone
A client is diagnosed with essential hypertension is taking furosemide. Which assessment data would require a media intervention by the nurse?
I client has a 3-kilogram weight gain within one to two days
A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider?
I need something for the pain in my eye. I can't stand it
The nurses started discharge teaching for a client who is to continue warfarin following hospitalization for venous thromboembolism. The nurse determines that additional teaching is needed when the client says which of the following?
I should reduce the amount of green leafy vegetables that I eat ????????
After the nurse has finished teaching a client about the use of sublingual nitrogen which client statement indicates the teaching has been effective?
I will call an ambulance if I still have pain after taking three nitroglycerin tablets 5 minutes apart
the nurse teaches a pt about discharge instructions after a rhinoplasty. Which statement if made by the pt indicates that the teaching was successful
I will keep my head elevated for 48 hours to minimize swelling and pain
The nurse plans to teach a patient how to manage allergic rhinits. What info should the nurse include in the teaching plan
Identify and avoid environmental triggers
The nurse completes discharge instructions for a pt with a total laryngectomy. What statement by the pt indicated that additional instruction is needed?
Keeping the dressing over the stoma
A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hr following a burn injury?
Lactated ringer
A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse ask the nurse what the procedure entails. Which of the following nursing statements is appropriate?
Large incisions will be made in the eschar to improve circulation
The nurse is caring for a client diagnosed with glaucoma. Which symptom would the nurse expect the client to report?
Loss of peripheral vision
A nurse is assessing a client who reports a nevus that has increased in size and an irregularly shapes lesion that varies in color. These findings are consistent with which of the following medical diagnoses?
Malignant melanoma
Which action should the nurse include in the plan of care when caring for a client admitted with acute decompensated heart failure who is receiving Nesiritide?
Monitor blood pressure frequently
The client is diagnosed with acute pericarditis which signs and symptoms warrant immediate attention by the nurse?
Muffled heart sounds
The nurse teaches a pt about the transmission about pulmonary TB. What statement if made by the patient indicated that teaching was effective
My husband will sleep in the other room
What statement by the patient indicated that the teaching has been effective for a patient scheduled for radiation on therapy for larynx?
Need to carry a water bottle with you
What action should the nurse take first when a pt develops a nosebleed
Pinch the lower portion of nose for 10 minutes
A nurse is caring for the client who has Meniere's disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make?
Please ring for assistance when you wish to get out of bed
Multifocal PVCs and couplets BP 118/78 and irregular pulse of 86- priority nursing action
Prepare to admin antidysrhythmic
The nurse is caring for a client who developed reflex tachycardia after being prescribed isosorbide mononitrate to treat chronic stable angina. Which of the following medications should the nurse anticipate the provider to prescribe?
Ranolazine
when obtaining a nursing history for a client who has myocarditis which should the nurse specifically question the client about?
Recent symptoms of a viral illness such as fever and malaise
The nurse is caring for a patient who is receiving IV furosemide and morphine for the treatment of acute decompensated heart failure with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective?
Reduce dyspnea with the head of the bed at 30 degrees
The nurse is at a local park and witnesses an individual who has fallen to the ground and has a stick lodged in the right eye. Which intervention should the nurse implement at the scene?
Stabilize the stick as best as possible
A client is scheduled for a pulmonary function test. Which action should the nurse take to prepare the client for this procedure?
Withhold bronchodilators for 6 to 12 hours before the examination
A 38-year-old male client is treated for hypertension with triamterene and hydrchlorohiazide and metoprolol. Four months after his last clinical visit his blood pressure returns to pretreatment levels and he admits to not taking his medication regularly. What is the nurse's best response to the client?
You are taking drugs that can cause sexual dysfunction in many clients. Are you experiencing any of these problems?
Instructing a client with Reynard's disease prevent onset of symptoms -- additional teaching
"I will take my meds at first onset of an attack" - not correct Correct - wearing gloves, avoid stress, smoking cessation
Strip shows normal HR and rhythms, but p wave is 0.26 seconds
Admin atropine per protocol
e nurse is caring for a patient with a massive burn injury and possible hypovolemia. What assessment data will be of most concern to the nurse?
BP is 90/40
the nurse is caring for a client diagnosed with an acute Emma. Which cardiac enzyme would the nurse expect to be elevated first?
Creatinine kinase
an 80 year old client with a history of an abdominal aortic aneurysm arrives at the emergency Department with severe back pain, pale and weak, tachycardia and diaphoretic. Which action should the nurse take first?
obtain the blood pressure
A nurse is assessing a client who has basal cell carcinoma on her nose. The nurse should expect which of the following findings?
A small, translucent papule with rolled borders
A young adult client with no history of smoking is seen in the clinic with a new diagnosis of COPD. It is most appropriate for the nurse to teach the client about
A1 anti trypsin testing
A pt with newly diagnosed lung cancer tells the nurse "I don't think I'm going to live to see my next birthday"
Can you tell me what it is that makes you think you will die so soon?
What action should the peri-op nurse take to best protect the pt from burn injury during surgery
Ensure correct placement the grounding pad
A 66-year-old client visited a community health fair that performed blood pressure checks. The client's blood pressure is 168/98. What is the most appropriate action for the nurse to take?
Instruct the client to see a health care provider as soon as possible
What I said the clinic nurse is obtaining a history from a new client complaining of pain in both legs when walking but is relieved after a few minutes of rest period which medical term with the nurse used to document client's complaints?
Intermittent claudication
A pt received inhalation anesthesia during surgery, postop the nurse should monitor the pt for which complication
Laryngospasm
38 year old pt who is about have an elective surgical procedure. What pre-op assessment data is most important to report to the ACP?
Last menstrual period was 8 weeks ago
a nurse is assessing a milk heart who has advanced peripheral artery disease. Which of the following findings should the nurse expect?
Leg pain at rest
Mandatory EKG before soccer
Let the kid play
Pt having emergency appendectomy has been taking St. John's Wort what to expect after surgery
Longer time to recover for anesthesia
A client diagnosed with primary hypertension asked the nurse why do I have high blood pressure? Which of the following responses by the nurse would be most appropriate?
There is no specific cause for hypertension but there are many risk factors
The nurse is admitting client with complaints of severe chest pain which is worse with inspiration and dyspnea. The nurse interprets the client's complaints as being most consistent with
acute pericarditis
a client with acute pericarditis has pain from pericardial inflammation. Which of the following are the best nursing interventions for the client? Select all that apply
administer in NSAIDs as ordered position the client on the right side with the head of the bed elevated to 15 degrees
While caring for a 23 year old client with a mitral valve prolapse without valvular regurgitation the nurse determined that discharge teaching has been effective when the client states that it will be necessary to
avoid the use of over-the-counter medications that contain stimulant drugs
The nurse is teaching a client recently diagnosed with primary hypertension. Which instruction should the nurse provide when discussing heart healthy exercises?
Walking 30 minutes a day most days of the week
a nurse is providing discharge teaching to a client who has peripheral artery disease. Which of the following instructions should the nurse include in the teaching?
Adjust the thermostat so that the environment is warm
The nurse is caring for a client diagnosed with a MI who is experiencing chest pain. Which interventions should the nurse implement? SATA
Admin 325 mg chewable aspirin tablet Admin nitroglycerin subcutaneously Apply oxygen via cannula
The nurses working on the heart failure unit know that teaching an older female client with newly diagnosed heart failure is effective when the client states that?
An additional pillow can help her sleep if she is feeling short of breath at night
During a routine physical examination, a nurse observes a 1-cm (0.4) lesion on a client's chest. The lesion is raised and flesh-colored with pearly white boarders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer?
Basal cell carcinoma
a charge nurse is teaching a group of nurses about clients who report use of garlic, ginger, and ginkgo biloba. The charge nurse should identify which of the following is an adverse effect of these supplements?
Increased effects of oral anticoagulants
IV KCl 60 mEq is prescribed for treatment of a patients with severe hypokalemia. what action is most appropriate by the nurse?
Infuse the KCl at a rate of 10 mEq/hr
The nurse is caring for a client with moderate persistent asthma. Which daily use medications should the nurse discuss with the client? SATA
Inhaled fluticasone/Salmetrol Daily use of albuterol
The nurse is providing education on risk factors of primary hypertension. What of the following should the nurse include as modifiable risk factors? SATA
Obesity Diet
what should the nurse teach the client who has endocarditis about preventing recurrence of infection?
Obtain prophylactic antibiotic therapy before certain invasive medical or dental procedures
5 min after receiving the ordered preop midazolam by IV the pt asks to get up to pee what action is appropriate by the nurse
Offer a urinal or bedpan and position the patient in bed to promote voiding
the nurse is caring for a client with peripheral artery disease who is taking clopidogrel. Which of the following medication order should the nurse question?
Omeprazole
A pt experienced a chest wall contusion as a result being struck in the chest with a baseball bat. The ED would be most concerned if which finding is observed during the initial assessment?
Paradoxical chest movement
What information should the nurse include in the teaching plan for a young adult recently diagnosed with cystic fibrosis? SATA
Perform chest physiotherapy Modify activities to accommodate daily physiotherapy Recognize signs and symptoms od infection Avoid anyone suspected of having upper respiratory infections
New nurse in PACU what action is appropriate by the new nurse
The new nurse turns pt to the side upon arrival to PACU
When discussing risk factor modification with the 63 year old client who has a 4 CM abdominal aortic aneurysm and a history of hypertension the nurse will focus discharge on which client risk factor?
Uncontrolled hypertension
A nurse in a clinic is caring for a female client who has a new diagnosis of acne vulgaris on her cheeks. Which of the following should the nurse include in the teaching plan for this client?
Use a new cosmetic pad with each limited application of makeup
Client with no history of heart disease has a rhythms strip that shows an occasional distorted P wave followed by normal AV and ventricular conduction. About what should the nurse question the client
Use of ___
The nurse is assessing a client diagnosed with COPD which assessment data requires immediate intervention by the nurse
Use of accessory muscles during respiration
A nurse is teaching a client who is postoperative following the insertion of a permanent pacemaker. Which of the following instructions should the nurse include? Select all that apply
count your pulse for one minute each morning do not wear tight clothing over insertion area
The nurse obtains a health history from a 65 year old client with a prosthetic mitral valve who has no symptoms of infective endocarditis. Which question by the nurse is most appropriate
have you had any recent immunizations?
a client has a 6-cm thoracic aortic aneurysm that was discovered during a routine chest xray. When obtaining an admission history from the client will be most important for the nurse to ask about
trouble swallowing
A nurse is caring for a client who has heart failure and a prescription for D Jackson 125 micrograms by mouth daily . Available is digoxin by mouth 0.25 milligrams per tablet. How many tablets should the nurse administer per dose?
0.5 tablet
Strip after MI - no visible P waves, PR interval not measurable, ventricle rate 162, R-R regular and QRS complex wide and distorted,
;
An alcoholic and homeless pt is diagnosed with active TB. What intervention by the nurse will be most effective in ensuring adherence with treatment regimen?
Arrange for ad daily noon meal at a community center where the drug with be admin
A patient who is taking a K-wasting diuretic of hypertension complains of generalized weakness. what action is most appropriate by the nurse?
Ask the HCP about a BMP
A client with chronic heart failure who is taking a diuretic and an ACE- inhibitor and who is on a low-sodium diet tells the home health nurse about a 5-pound weight gain in the last 3 days. The nurse's priority action will be to
Ask the client about the use of the prescribed medications
The nurse is caring for a client following a cardiac catheterization that was inserted through the femoral artery. While turning the client the nurse discovers blood underneath the client on the bed which of the following complications should the nurse suspect?
Bleeding at the incisional site
A 65-year-old client is diagnosed with macular degeneration. Which statement by the client indicates the client needs more teaching?
I need to use low-watt light bulbs in my house
Which statement made by a client with cystic fibrosis who has a lung infection demonstrates understanding of the prescribed medication regimen?
I should do my bronchodilator first then my tobi, then dormase alpha
The nurse is teaching a client diagnosed with primary hypertension about the dash diet. Which statement if made by the client demonstrates understanding of the teaching?
I should drink no more than two glasses of whole milk daily
a nurse is reviewing discharge instructions with a client who has Raynaud's disease which of the following client statements indicates an understanding of the teaching?
I'm going to take a stress management class
Strip shows Afib what action should nurse to do first
Immediate CPR
What assessment data collected by the nurse who is admitting a client with chest pain suggests that the pain is caused by an acute myocardial infarction?
The pain is relieved after the client takes nitroglycerin
A pt arrives as the ambulatory surgery center for a scheduled laparoscopy procedure in outpatient surgery. What information is most concerning to the nurse
The pt is planning to drive home after surgery
A client is admitted to the telemetry unit diagnosed with an acute exacerbation of congestive heart failure. Which signs and symptoms would the nurse expect to find when assessing the client?
Thick white sputum and crackles that clear with cough
A client is admitted with a diagnosis of acute left sided infective endocarditis. What is the best test to confirm this diagnosis?
Three blood cultures from three different sites
The nurse is caring for a client with exercise induced asthma what information should the nurse include when providing education to the client
Use your bronchodilator medication immediately prior to beginning exercise
The nurse is caring for a client with cystic fibrosis. What should the nurse teach as the most effective treatment for cystic fibrosis?
Vigorous and consistent airway clearance techniques
The nurse is caring for a client with intermittent asthma. What should the nurse teach about identifying specific triggers of asthma?
Viral upper respiratory infections are a common precipitating factor in acute asthma attacks
A nurse is teaching a client who has a new diagnosis of atopic dermatitis. Which of the following statements should the nurse include in the teaching?
Your provider may recommend a daily antihistamine to help control your symptoms Commonly related to an allergic reaction
