NurseLogic: Nursing Concepts Advanced

A nurse is caring for a client who has an acid-base imbalance. For which of the following manifestations is metabolic alkalosis a possible complication? -Hyperkalemia -Severe diarrhea -Atelectasis -Excessive vomiting

-Excessive vomiting Metabolic alkalosis is a potential complication of excessive vomiting because of the loss of acid from the body.

a nurse working in a hospice facility is talking to a client's son who is distressed because his mother cries frequently and says she wants to die. Which of the following responses is appropriate? -I know this must be difficult, but your mother will calm down soon. -Let's discuss some strategies you can use when this happens again -individuals near death are ready to let go towards the end -have you determined why she is crying and saying she is ready to die?

-Let's discuss some strategies you can use when this happens again The use of therapeutic communication assists the nurse to develop client relationships that foster trust and respect. This response by the nurse offers to provide information, which can reduce anxiety and enhance decision-making.

A nurse has assigned four tasks to an assistive personnel (AP). Which of the following should the nurse instruct the AP to perform first? -Take an ABG specimen tot he laboratory -Transport a client to the radiology dept. for an x-ray -obtain a clean catch urine sample from a newly admitted client -pass fresh water to clients

-Take an ABG specimen tot he laboratory

A nurse is reinforcing teaching with the caregiver of a client who has aphasia. The nurse should include which of the following communication strategies in the teaching? -cue the client by providing picture cards that portray common needs. -Increase the volume of the voice when speaking to the client. -encourage the client to limit hand gestures when communicating -vary the use of phrases and terminology in discussions

-cue the client by providing picture cards that portray common needs.

A nurse is caring for a client who has a UTI and is prescibed ciproflaxin (Cipro). The client exhibits urticaria and angioedema following administration of the medication. Which is the first action the nurse should take? -administer epinephrine -elevate the lower extremities -determine respiratory status -apply O2 via non-rebreather mask

-determine respiratory status The content of this question emphasizes the concept of priority setting by determining priority nursing action for a client experiencing an allergic reaction. Priority setting is the use of nursing judgment when making decisions about the rank order in which to take nursing actions.

A nurse is caring for a client that was admitted for acute alcohol delirium withdrawal 2 days ago. Which of the following findings is associated with this diagnosis? -increased appetite -elevated temp -bradycardia -drowsiness

-elevated temp

a nurse is working in a provider's office is reinforcing teaching with a client who is 14 weeks of gestation. The nurse should instruct the client to immediately notify the provider if she experiences which of the following: -facial edema -urinary frequency -acid indigestion -breast leakage

-facial edema indication of pregnancy induced hypertension

A nurse is caring for a client who had a CVA 2 days ago. Which of the following is the first sign of increased intracranial pressure (ICP)? -pupil dilation -ataxia -lethargy -bradycardia

-lethargy

A nurse is caring for a client that is receiving parenteral nutrition through a non-tunneled central venous catheter and reports hearing gurgling sound on the side of the catheter. The nurse suspects the catheter has migrated to the jugular vein. Which of the following actions should the nurse take first? -Notify provider -chest x-ray -flush the catheter -stop the infusion

-stop the infusion

A nurse is caring for a child who is 24 hour postoperative following a supratentorial craniotomy. The nurse should maintain the child in which of the following positions? -prone with head of the bed flat -dorsal recumbent with the head of the bed elevated to 15 degrees -supine with the head of the bed elevated to 30 degrees -side-lying with the head of the bed elevated to 30 degrees

-supine with the head of the bed elevated to 30 degrees