PrepU chapter 69

The nurse plans nonpharmacologic interventions for a client who is approaching discharge after a left knee arthroplasty to address the client's pain.

-application of heat or cold- Physical Modality -relaxation breathing- Cognitive and Behavioral Method -yoga- Movement Therapy -aquatic therapy- Physical Modality -distraction- Cognitive and Behavioral Method -Thai Chi- Movement Therapy -proper body alignment- Physical Modality -imagery- Cognitive and Behavioral Method

The nurse plans care for a client who is diagnosed with atopic dermatitis.

-Use an emollient containing glycerol on the skin after bathing- Both -Take short showers using a mild soap for cleansing- Skin Hydration -Wear cotton fabric- Itchy Skin -Wash clothes using a mild detergent- Itchy Skin -Take an antihistamine before bed- Itchy Skin

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.

*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.

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.

-46-year-old male client who presents with suspected broken leg as a result of motor vehicle crash (MVC)- Now -22-year-old female client who presents with left quadrant abdominal pain and moderate vaginal bleeding with clots- Now -25-year-old male client who presents with a small laceration on the left upper arm- Later -52-year-old female client who presents with severe back pain of recent onset- Now

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.

-Administer nonopioid analgesics as needed- Both -Administer prescribed antibiotic- Both -Complete pin care per prescribed guidelines-External Fixation Device -Provide assistance with physical therapy- Both -Encourage isometric and muscle-setting exercises- Both -Encourage performance of activities of daily living- Both -Bear weight as determined by the surgeon- Internal Fixation Device

The community health nurse is preparing a teaching plan for a middle-aged client with hypertension, hypercholesterolemia, and obesity.

-Exercise for 45 minutes at least three times per week- Health Promotion Activities -Take medications as prescribed- Health Maintenance Activities -Avoid cigarette smoking and alcohol use- Health Promotion Activities -Practice stress reduction techniques such as yoga or meditation- Health Promotion Activities -Adhere to scheduled laboratory tests such as lipid profile, basic metabolic panel, and glucose tests- Health Maintenance Activities

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.

-I will take the antibiotics until the secretions clear up- Teach -I should get the PPSV23 this year because I got the PCV13 last year- Understand -I will drink 1 liter of fluid each day- Teach -Sleeping with a humidifier can help loosen secretions- Understand -I will seek medical attention if my cough worsens- Understand -I will rest and avoid overexertion- Understand -A persistent or recurring fever is normal after starting antibiotics- Teach -I will perform deep-breathing exercises once per day- Teach

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.

-Increase the rate of enteral fluids- Not Indicated -Administer fluids at room temperature- Fluid Balance, Gastrointestinal -Administer bolus feeding- Not Indicated -Maintain semi-Fowler position during and following feeding for at least 1 hour- Fluid Balance, Gastrointestinal -Monitor water intake used to flush tubing- Fluid Balance, Gastrointestinal -Monitor bowel sounds- Gastrointestinal -Monitor daily weights- Fluid Balance

For each nursing action, click to specify if the intervention is appropriate to increase the arterial blood supply to the client's extremities or to promote vasodilation and prevent vascular compression.

-Keep legs in a dependent position- Increase Arterial Blood Supply to the Extremities -Increase in physical activity each day- Increase Arterial Blood Supply to the Extremities -Wear warm clothing in the winter- Promote Vasodilation and Prevent Vascular Compression -Do not use of bicotine products- Promote Vasodilation and Prevent Vascular Compression -Avoid crossing the legs- Promote Vasodilation and Prevent Vascular Compression

The nurse plans care for a client who is newly diagnosed with peripheral artery disease (PAD).

-Keep legs in a dependent position- Increase Arterial Blood Supply to the Extremities -Increase in physical activity each day- Increase Arterial Blood Supply to the Extremities -Wear warm clothing in the winter- Promote Vasodilation and Prevent Vascular Compression -Do not use of bicotine products- Promote Vasodilation and Prevent Vascular Compression -Avoid crossing the legs- Promote Vasodilation and Prevent Vascular Compression

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.

-Take blood pressure readings in the left arm- No -Auscultate for a bruit over AV fistula every 8 hours- Yes -Assess for redness, swelling, and drainage at AV fistula site- Yes -Use AV fistula site to draw blood- No -Palpate for a thrill over the AV fistula every 8 hours- Yes -Wrap the AV fistula site in the left arm with a compression dressing- No

The nurse is assessing a 78-year-old female client admitted with a stroke of recent onset within 2 hours of admission. Vital signs: blood pressure, 150/90 mm Hg; pulse rate, 112 beats/min; respiratory rate, 20 breaths/min; temperature, 100.4°F (38.0°C); pulse oximetry reading, 96% on room air. Audible murmur heard upon auscultation. Client is awake but somewhat lethargic and cannot respond to questions. Exhibiting neurologic deficits and impaired mobility of the left side of the body. The client is being evaluated for tissue plasminogen activator (t-PA) therapy.

-blood pressure reading- t-PA Therapy Indicated -computed tomograph confirmation of ischemic stroke- t-PA Therapy Indicated -international normalized ratio (INR) result of 2.0- t-PA Therapy Not Indicated -NIH Stroke Scale/Score (NIHSS) result of 17- t-PA Therapy Indicated -heart murmur- t-PA Therapy Not Indicated

The nurse monitors the laboratory data for several clients who are diagnosed with hypoproliferative anemias.

-decreased mean corpuscular volume (MCV)- Microcytic Anemia -decreased reticulocytes- Microcytic Anemia -increased mean corpuscular volume (MCV)- Megaloblastic Anemia -increased total iron-binding capacity (TIBC)- Microcytic Anemia -decreased vitamin B12- Megaloblastic Anemia -decreased folate- Megaloblastic Anemia

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.

Based on the nursing assessment, the priority action the nurse should take is to notify the orthopedic health care provider immediately and prepare the client for bivalving of the cast.

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.

Based on the provided assessment status, the nurse should utilize airborne precautions to prevent exposure and sputum to collect specimens for additional testing.

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.

Client symptoms indicative of this complication that the nurse monitors for following a TURP include dysuria, straining, and a weak urinary stream.

The nurse collects data related to cultural beliefs as part of the comprehensive assessment process for a client admitted for the treatment of newly diagnosed type 2 diabetes mellitus (DM). The nurse is asking about cultural beliefs.

Communication- How do you usually respond when asked a question? Space- How close do you stand to a family member when asking a question? Social Organization- What is your role in your family?

The nurse provides care for a 28-year-old female client experiencing an initial outbreak of herpes simplex virus 2 (HSV-2).

Complications associated with HSV-2 applicable to the client's teaching plan developed by the nurse include severe emotional stress, aseptic meningitis, and neonatal transmission.

The nurse monitors a client for side effects associated with furosemide, which is newly prescribed for the treatment of heart failure.

Due to the client's high risk for developing hypokalemia as a result of the prescribed medication, the nurse focuses on monitoring the client for ventricular arrhythmia.

The nurse assesses a client who is diagnosed with bulimia nervosa and at risk for alterations in both fluid and electrolyte balance.

During the assessment, the nurse focuses on monitoring the client for hypokalemia as evidenced by cardiac arrhythmia.

The nurse plans care for a client who was admitted for the treatment of a gastrointestinal (GI) bleed due to cirrhosis of the liver.

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.

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?

Pilocarpine- Use safety measures in dim lighting Timolol maleate- It can cause hypotension Acetazolamide- Have your electrolyte levels monitored

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.

The client is at highest risk for developing cardiac dysfunction as evidenced by angina.

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.

The client is at the highest risk for developing septic shock as evidenced by altered mentation.

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.

The nurse anticipates that the client has developed chronic subdural hematoma stroke and that computed tomography (CT) imaging of the brain will be ordered.

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.

The nurse anticipates that the client has developed hemorrhage and that the laboratory results will reveal thrombocytopenia.

The nurse provides care for a client who is prescribed bladder retraining following urinary catheterization.

The nurse should first ask the client to urinate then perform the prescribed bladder scan

A nurse is assessing a client who is experiencing significant stress due to septicemia.

The nurse should monitor temperature, administer oxygen therapy, and obtain the lactate level.

A nurse is reviewing the history of a client who has been admitted for a pressure injury.

bedridden due to a right-sided stroke incontinent of urine and feces confused with time and place

The nurse should determine the adult client's learning readiness by assessing

cultural identification personal values physical status emotions