PNU 133 Honan PrepU Managing / Coordinating Care

The nurse is preparing the client for computed tomography. Which information should be given by the nurse?

"You must remain very still during the procedure."

The nurse is administering lispro insulin. Based on the onset of action, how long before breakfast should the nurse administer the injection?

10 to 15 minutes

A client has lung cancer and underwent chemotherapy and radiation treatment. The tumors continue to grow and have metastasized. The nurse assesses the client is in the dying phase of the Trajectory Model of Chronic Illness. The nurse

Assists with arranging hospice care for the client

A client is receiving insulin lispro at 7:30 AM. The nurse ensures that the client has breakfast by which time?

7:45 AM

The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement?

A urinary output of 30 mL/hr

A client with Hodgkin disease had a bone marrow biopsy yesterday and reports aching at the biopsy site, rated a 5 (on a 1-10 scale). After assessing the biopsy site, which nursing intervention is most appropriate?

Administer acetaminophen 500 mg po, as ordered

A client in end-stage renal disease is prescribed epoetin alfa and oral iron supplements. Before administering the next dose of epoetin alfa and oral iron supplement, what is the priority action taken by the nurse?

Assesses the hemoglobin level

The nurse is working with a client with a chronic condition. The nurse includes which elements in the plan of care? Select all that apply.

Assessment for identity changes Interventions to manage symptoms Interventions to prevent complications

The nurse is teaching a client after a medication allergic reaction has occurred. What is the most important action for the nurse to teach the client to take to prevent anaphylaxis?

Avoid potential allergens.

The nurse is providing care to a client who has had a renal biopsy. The nurse would need to be alert for signs and symptoms of which of the following?

Bleeding

When caring for the patient with acute glomerulonephritis, which of the following assessment findings should the nurse anticipate?

Cola-colored urine

The nurse is providing preoperative care for a client with gastric cancer who is having a resection. What is the nursing management priority for this client?

Correcting nutritional deficits

Which disorder is characterized by a group of symptoms produced by an excess of free circulating cortisol from the adrenal cortex?

Cushing syndrome

The nurse is caring for a 72-year-old client who has been admitted to the unit for a fluid volume imbalance. The nurse knows which of the following is the most common fluid imbalance in older adults?

Dehydration

A nurse evaluates a client with a temporary pacemaker. The client's ECG tracing shows each P wave followed by the pacing spike. What is the nurse's best response?

Document the findings and continue to monitor the client

The nurse and the client are discussing some strategies for ingesting iron to combat the client's iron-deficiency anemia. Which is among the nurse's strategies?

Drink liquid iron preparations with a straw.

A client diagnosed with a terminal illness appoints her oldest son as the authorized individual to make medical decisions on her behalf when she is no longer able to speak for herself. Which proxy directive is the patient using?

Durable power of attorney for health care

The family members of a dying patient are finding it difficult to verbalize feelings and show tenderness for the dying person. Which of the following nursing interventions should a nurse perform in such situations?

Encourage the family members to express their feelings and listen to them in their frank communication.

The nurse is making a referral to physical therapy for a client who has had a hip replacement and is going to be discharged in 2 days. The nurse understands that physical therapy as part of the client's plan of care includes the client in what discipline?

Inclusion in the collaborative healthcare team

The nurse is preparing to perform a Wood's light examination. Which of the following would be most important for the nurse to do?

Make sure that the room is darkened.

The nurse cares for a client with clubbing of the fingers and toes. The nurse should complete which action given these findings?

Obtain an oxygen saturation level.

The nurse is assisting with the development of a program to administer flu shots to a group of senior citizens. What type of prevention does this program reflect?

Primary prevention

Which action by the nurse demonstrates an effective method to assess the client and the client's family's ability to cope with end-of-life interventions?

Remaining silent, allowing the client and family to respond after asking a question related to end-of-life care

The nurse is caring for a client immediately following a spinal cord injury (SCI). Which is an acute complication of SCI?

Spinal shock

Which tool is often used by case managers?

Standards of care

A nurse is reviewing the laboratory order for a client suspected of having an endocrine disorder. The lab slip includes obtaining cortisol levels. What is being tested?

adrenal function

A client with a minor burn would be triaged as

minimal.

A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?

pH, 7.25; PaCO2 50 mm Hg

The nurse is caring for a client reporting chest discomfort. The client's diagnosis at admission is left lower lobe pneumonia. Which strategy will the nurse instruct the client to use to help alleviate the discomfort?

Assume a left side-lying position while in bed

Which precaution should the nurse take when a client is at risk of injury secondary to vertigo and probable imbalance?

Have the client wait for help before moving

Which of the following is the most effective treatment for trichomoniasis?

Metronidazole (Flagyl)

During a disaster, the nurse sees a victim with a green triage tag. The nurse knows that the person has which type of injury?

Minor; treatment can be delayed hours to days

A nurse is providing care to a client with primary hyperparathyroidism. Which interventions would be included in the client's care plan? Select all that apply.

Monitor gait, balance, and fatigue level with ambulation. Monitor for fluid overload.

A client who is HIV+ has been diagnosed with Pneumocystis pneumonia caused by P. jiroveci. What medication will the client take for the treatment of this infection?

trimethoprim-sulfamethoxazole

The nurse is caring for a client with herpes zoster. The nurse documents the lesions as

vesicles.

Which are risk factors for spinal cord injury (SCI)? Select all that apply.

Young age Alcohol use Drug abuse

The nurse is revising a client's plan of care. What is an example of an expected client outcome?

The client will have the ability to climb a flight of stairs without experiencing difficulty in breathing.

The nurse is assisting in the transport of a client with an indwelling catheter to the diagnostic studies unit. Which action made by the nursing assistant would require instruction?

The nursing assistant places the drainage bag on the client's abdomen for transport.

A client presents to the ED with serious health problems that are not immediately life threatening. The nurse will correctly triage the client into which category?

Urgent

A nurse caring for a patient with a pulmonary embolism understands that a high ventilation-perfusion ratio may exist. What does this mean for the patient?

Ventilation exceeds perfusion.

The physician orders a transfusion with packed red blood cells (RBCs) for a client hospitalized with severe iron deficiency anemia. When blood is administered, what is the most important action the nurse can take to prevent a transfusion reaction?

Verify the client's identity according to hospital policy

A client admitted to the telemetry unit has a serum potassium level of 6.6 mEq/L. Which electrocardiographic (ECG) characteristic is commonly associated with this laboratory finding?

Peaked T waves

Which diagnostic produces images of the body by detecting the radiation emitted from radioactive substances?

Positron emission tomography (PET)

The student nurse is working with a nurse manager at a hospital when a disaster drill is announced over the hospital P.A. system. The nurse manager asks the nursing student what color triage tag is used for clients who have life threatening, but survivable conditions, if rapid medical attention is provided. What color is the triage tag for these clients?

Red