Prep U Ch 69: NGN
A client is receiving enteral therapy following gastric surgery. To maintain fluid balance and minimize any gastrointestinal symptoms such as cramping, diarrhea, and/or nausea, the nurse should follow appropriate enteral therapy protocols. For each intervention, click to specify if the action should be included in the plan of care to improve outcomes for fluid balance or improvement of gastrointestinal symptoms.
Fluid Balance - Monitor daily weights. Gastrointestinal - Monitor bowel sounds. Not Indicated - Increase the rate of enteral fluids. - Administer bolus feeding. Fluid Balance & Gastrointestinal - Administer fluids at room temperature. - Monitor water intake used to flush tubing. - Maintain semi-Fowler position during and following feeding for at least 1 hour.
The nurse is collaborating with the health care provider on a plan of care for a 54-year-old male client with osteomyelitis of the left femur secondary to uncontrolled type 1 diabetes. Click to highlight the prescriptions for care that the nurse should anticipate for this client.
HIGHLIGHT THE FOLLOWING - Perform neurovascular checks of lower extremities every 8 hours. - Administer IV antibiotic based on culture and sensitivity report. - Administer ibuprofen 400 mg orally three times daily, as needed for pain. - Make referral to dietitian to discuss nutrition for healing and blood glucose control. - Provide education on self-blood glucose monitoring and insulin administration.
A nurse is reviewing the history of a client who has been admitted for a pressure injury. Click to highlight the findings that are risk factors associated with pressure injuries. A 74-year-old female client is admitted from the emergency department. The client arrived by ambulance. The client's adult son, the primary caregiver, accompanied the client. The client is bedridden due to a right-sided stroke sustained 6 months ago. The client lives with the adult son and the son's spouse. The family has 24-hour home care . The client is incontinent of urine and feces . Care is provided by home health assistants , who bath, feed, and provide companionship when the family is not available. The client is alert but confused with time and place . The client refuses to eat most meals but will drink a high-calorie milkshake daily. The reason for the ambulance is that the client attempted to get out of bed and fell.
HIGHLIGHT THE FOLLOWING - bedridden due to a right-sided stroke, - incontinent of urine and feces, - confused with time and place,
The nurse plans care for a client who was admitted for the treatment of a gastrointestinal (GI) bleed due to cirrhosis of the liver. Complete the table of nursing concerns by choosing from the list of options.
Injury Risk - Monitor the client for symptoms of anxiety. Altered Skin Integrity - Perform range-of-motion exercises every 4 hours Acute Confusion - Keep the environment warm and draft free.
A nurse is caring for a team of clients, each with an orthopedic injury. Click to indicate which interventions are included in a plan of care between the different orthopedic repairs.For each intervention, click to specify if the action is taken for clients with an internal fixaction device and/or with an external fixation device. Each intervention may support more than 1 type of device.
(Internal Fixation Device) - Bear weight as determined by the surgeon. (External Fixation Device) - Complete pin care per prescribed guidelines. (Internal & External Fixation Device) - Encourage performance of activities of daily living. - Administer nonopioid analgesics as needed. - Administer prescribed antibiotic. - Provide assistance with physical therapy. - Encourage isometric and muscle-setting exercises.
The nurse is providing education to a 65-year-old female client with pneumococcal pneumonia being discharged from the health clinic on oral antibiotics. The client is a nonsmoker, takes levothyroxine for Hashimoto disease, and is otherwise in good health. For each client statement, click to specify if the finding indicates understanding or the need for reinforcement of the teaching.
(Understanding) -"I should get the PPSV23 this year because I got the PCV13 last year. -"Sleeping with a humidifier can help loosen secretions -"I will seek medical attention if my cough worsens." -"I will rest and avoid overexertion." (Requires Reinforcement of Teaching) -"I will take the antibiotics until the secretions clear up." -"I will drink 1 liter of fluid each day." -"A persistent or recurring fever is normal after starting antibiotics." -"I will perform deep-breathing exercises once per day."
The nurse is preparing to administer medication to a client who has been diagnosed with glaucoma. Which information should the nurse include related to client teaching for each of the identified medications? Complete the following table by choosing from the list of options.
Pilocarpine - Use safety measures in dim lighting Timolol maleate - It can cause hypotension Acetazolamide - Have your electrolyte levels monitored.
The nurse assesses a client who has a nasogastric tube for long-term nutritional needs for complications associated with the medical device. Complete the following sentence by choosing from the lists of options. The nurse monitors the client for
Purulent nasal drainage, rhino sinusitis
The emergency nurse is preparing to triage a group of four clients who have presented to the emergency department (ED) and arrived at the same time. For each client, determine based on the system of triage if the client requires immediate intervention or can wait to be seen.
Requires Immediate Intervention - 46-year-old male client who presents with suspected broken leg as a result of motor vehicle crash (MVC) - 22-year-old female client who presents with left quadrant abdominal pain and moderate vaginal bleeding with clots - 52-year-old female client who presents with severe back pain of recent onset Can Wait to Be Seen - 25-year-old male client who presents with a small laceration on the left upper arm
The community health nurse is assessing the risk factors for osteoporosis in a female client at a health fair. For each assessment finding, click to specify if the finding is a risk factor for osteoporosis or is not a risk factor for osteoporosis.
Risk factor for osteoporosis - Takes fluticasone inhaler for asthma - asian heritage - 66 years of age - postmenopausal status Not a risk factor for osteoporosis - Walks 2 miles, 3 days/week - Nonsmoker - large frame - alcohol intake of 3 drinks/week,
The nurse plans care for a client who is diagnosed with atopic dermatitis. For each teaching point, click to specify if the instruction addresses skin hydration or itchy skin. Each teaching point may address more than 1 condition
Skin Hydration - Take short showers using mild soap for cleansing. Itchy Skin - Wear cotton fabric. - Wash clothes using a mild detergent. - Take an antihistamine before bed. Skin Hydration & Itchy Skin - Use an emollient containing glycerol on the skin after bathing.
The nurse provides care for a client who is diagnosed with shock and who is at risk for multiple organ dysfunction syndrome (MODS).Complete the following sentence by choosing from the lists of options.
acute lung injury (ALI), shortness of breath
A 47-year-old male client presented to the medical unit and the health care team suspects tuberculosis (TB). The nurse is admitting the client to a reverse isolation room. QuantiFERON testing and chest x-ray are pending. Urinalysis results are negative. No other testing was performed prior to admission to isolation. The client denies any chest pain, shortness of breath (SOB), or respiratory difficulty. The client presents with productive yellow sputum. Complete the following sentence by choosing from the lists of options.
airborne precautions, sputum
A 47-year-old male client presented to the medical unit and the health care team suspects tuberculosis (TB). The nurse is admitting the client to a reverse isolation room. QuantiFERON testing and chest x-ray are pending. Urinalysis results are negative. No other testing was performed prior to admission to isolation. The client denies any chest pain, shortness of breath (SOB), or respiratory difficulty. The client presents with productive yellow sputum. Complete the following sentence by choosing from the lists of options. Based on the provided assessment status, the nurse should utilize
airborne precautions, sputum
A client will undergo abdominal surgery. The nurse provides preoperative education regarding the importance of diaphragmatic breathing exercises to prevent postoperative complications. Drag words from the choices below to fill in each blank in the following sentence.
atelectasis, pneumonia, bronchospasm
A nurse is caring for a client. After review of the laboratory assessment, the nurse identifies that the potassium level is 6.2 mEq/l (6.2 mmol/l). Select the mechanism of action from each of the following medications.
calcium gluconate - antagonizes the potassium in the heart sodium bicarbonate - alkalizes the plasma IV regular insulin and hypertonic dextrose - shifts potassium into the cells renal replacement therapy - removal of potassium out of the body
The nurse provides care for a client, with a history of atherosclerosis, who is hospitalized for the initiation of pharmacotherapy for the treatment of hypothyroidism.
cardiac dysfunction, angina
The office nurse is reviewing an 80-year-old female client's reports related to the onset of a severe headache, rated at 9 out of 10 on the pain scale, with recent onset. The client denies any visual changes. During a prior visit to the office a few months ago, the client had reported a ground-level fall as a result of falling off a chair and hitting the back of their head. The client had been taken to the emergency department, where imaging was performed with negative results. Complete the following sentence by choosing from the lists of options
chronic subdural hematoma, computed tomography ( CT ) imaging of the brain
The nurse should determine the adult client's learning readiness by assessing
cultural identification, personal values, physical status, emotions
The nurse assesses a client who is diagnosed with human immunodeficiency virus (HIV) for adverse reactions associated with the prescribed medication, abacavir. Drag words from the choices below to fill in each blank in the following sentence. The nurse provides emergency intervention when the client exhibits the following symptoms
dyspnea, sore throat, and cough
A nurse is assessing a client who is experiencing significant stress due to septicemia. Drag words from the choices below to fill in each blank in the following sentence. The nurse should
Obtain the lactate level, monitor temperature, administer oxygen therapy
The nurse on a telemetry unit is caring for a 54-year-old male client, admitted with chest pain, who has an arteriovenous (AV) fistula in the left arm for hemodialysis secondary to chronic kidney disease. For each intervention, click to specify if the intervention is indicated or contraindicated for this client.
Contraindicated - Take blood pressure readings in the left arm. - Use AV fistula site to draw blood. - Wrap the AV fistula site in the left arm with a compression dressing Indicated - Palpate for a thrill over the AV fistula every 8 hours. - Auscultate for a bruit over AV fistula every 8 hours - Assess for redness, swelling, and drainage at AV fistula site.
The nurse has documented an assessment on a 45-year-old male client on the third postoperative day following an open abdominal appendectomy. Click to highlight the assessment findings that will require follow up. Client has 3 in (7.6 cm) right lower abdominal incision. Proximal 2 in (5 cm) of incision edges are red and well-approximated. Distal portion of incision has separated and has yellow drainage on dressing. Bulb drain has serosanguinous drainage and clumps of yellow pus. Oxygen saturation on room air 97%. Blood pressure, 112/60 mm Hg; heart rate, 102 beats/min; respiratory rate, 22 breaths/min; temperature, 101.2°F (38.4°C) orally. Denies chills. Bowel sounds hypoactive in all 4 quadrants. . Client reports passing flatus, no Abdomen firm and slightly distended bowel movement. Lungs clear to auscultation bilaterally. Client reports incisional pain level of 3/10 red blood cell count 4.2 million/mcl (4.2 x 1012/l) thirty (30) minutes following oxycodone 5 mg orally. Reports an increased, but tolerable, level of pain while performing cough and deep-breathing exercises while splinting incision. Reports minimal pain on abdominal palpation. White blood count 12.9 x 103 cells/mm3 (12.9 x 109 /l) , , hemoglobin 14 g/dl (140 g/l) , blood glucose level 130 mg/dl (7.21 mmol/l).
HIGHLIGHT THE FOLLOWING - has separated and has yellow drainage on dressing - clumps of yellow pus - 102 beats/min; respiratory rate, 22 breaths/min; temperature, 101.2°F (38.4°C) orally. - White blood count 12.9 x 103 cells/mm3 (12.9 x 109 /l) - blood glucose level 130 mg/dl (7.21 mmol/l).
The community health nurse is preparing a teaching plan for a middle-aged client with hypertension, hypercholesterolemia, and obesity. For each of the health teachings provided by the nurse, click to specify whether the information is focused on health promotion or health maintenance.
Health Promotion Activities - Exercise for 45 minutes at least three times per week - Avoid cigarette smoking and alcohol use - Practice stress reduction techniques such as yoga or meditation. Health Maintenance Activities - Adhere to scheduled laboratory tests such as lipid profile, basic metabolic panel, and glucose tests. - Take medications as prescribed.
The nurse assesses a client who is diagnosed with bulimia nervosa and at risk for alterations in both fluid and electrolyte balance. Complete the following sentence by choosing from the lists of options. During the assessment, the nurse focuses on monitoring the client for
Hypokalemia, cardia arrythmia
The nurse monitors the laboratory data for several clients who are diagnosed with hypoproliferative anemias. For each laboratory data, click to specify if the finding indicates microcytic anemia or megaloblastic anemia.
Microcytic Anemia - decreased mean corpuscular volume (MCV) - decreased reticulocytes - increased total iron-binding capacity (TIBC) Megaloblastic Anemia - increased mean corpuscular volume (MCV) - decreased folate - decreased vitamin b12
The nurse plans nonpharmacologic interventions for a client who is approaching discharge after a left knee arthroplasty to address the client's pain. For each intervention, click to specify if the therapy indicates a physical modality, cognitive and behavioral method, or movement therapy for the treatment of pain.
Movement Therapy - Thai chi - yoga Cognitive and Behavioral Method - Imagery - relaxation breathing - distraction Physical modality - Aquatic therapy - proper body alignment - application of heat or cold
The nurse is caring for a 24-year-old female client with a right tibial fracture treated with a cast 2 hours ago. The client now reports unrelenting pain, rated as 7/10, despite taking oxycodone, and decreased sensation in the right foot. A nursing assessment reveals the right foot is cooler and paler than the left foot, with delayed capillary refill and a weak pulse. Complete the following sentence by choosing from the lists of options.
Notify the orthopedic health care provider immediately, bivalving of the cast
The nurse in the oncology clinic is caring for a 42-year-old female client receiving chemotherapy with fludarabine for acute myeloid leukemia who has developed petechiae, epistaxis, and ecchymosis.
hemorrhage, thrombocytopenia
The nurse monitors a client for side effects associated with furosemide, which is newly prescribed for the treatment of heart failure. Complete the following sentence by choosing from the lists of options.
hypokalemia, ventricular arrhythmia
The nurse provides care for a client who is critically ill due to a diagnosis of pneumonia and is at risk for developing shock. Assessment data reveals a white blood cell (WBC) count of 15 × 103 cells/mm3 (15 × 109/l) (normal: 4.5 to 10.5 × 103 cells/mm3 (4.5 to 10.5 × 109/l), a temperature of 102.2°F (39°C), and warm, flushed skin. Complete the following sentence by choosing from the lists of options. The client is at the highest risk for developing
septic shock, altered mentation
The nurse monitors a male client for symptoms of urethral strictures following a transurethral resection of the prostate (TURP) for the treatment of prostate cancer. Drag words from the choices below to fill in each blank in the following sentence. Client symptoms indicative of this complication that the nurse monitors for following a TURP include
straining, a weak urine stream, dysuria
A nurse is caring for a client who was admitted for an asthma exacerbation. In the past year, the client has been admitted for three asthma events. What will the nurse include in the client teaching about preventing repeat hospitalizations? The nurse should teach about
triggers to avoid, medication knowledge
The nurse provides care for a client who is prescribed bladder retraining following urinary catheterization. Complete the following sentence by choosing from the lists of options.
urinate, bladder scan
