select all that apply

a client newly diagnosed with diabetes mellitus suddenly becomes confused and weak. Which intervention should the nurse implement? - give the client 4 ounces of orange juice - obtain blood pressure and pulse rate - provide the client with 1/2 cup diet carbonated soda - administer a PRN dose of regular insulin - check the client's current finger stick blood glucose

- Give the client 4 ounces of orange juice - obtain blood pressure and pulse rate - check the client's current finger stick blood glucose

A client who is newly diagnosed with type 2 diabetes (DM) receives a prescription for metformin (glucocphage) 500 mg PO twice daily. what information should the nurse include in the client's teaching plan? - recognize signs and symptoms of hypoglycemia - report persist polyuria to the HCP - Use sliding scale insulin for finger stick glucose elevation - Take Glucophage with the morning and evening meal

- Recognize signs and symptoms of hypoglycemia - Report persist polyuria to the HCP - Take Glucophage with the morning and evening meal

a client is admitted with an exacerbation of heart failure secondary to COPD. which observations by the nurse require immediate intervention to reduce the likelihood of harm to this client? - a bedside commode is positioned near the bed - a full pitcher of water is on the bedside table - a low sodium diet tray was brought to the room - the client is lying in a supine position in bed - a saline lock is present in the right forearm

- a full pitcher of water is on the bedside table - the client is lying in a supine position in bed

which conditions are most likely to respond to treatment with antihistamine? - bronchitis - allergic rhinitis - otitis media - contact dermatitis - myocarditis

- allergic rhinitis -contact dermatitis

an older client's daughter calls the home health nurse and reports that her mother has become forgetful and is very confused at night. the daughter states that her mother's behavior changed suddenly a few days ago and is now getting worse. which actions should the nurse take? - ask if mother is experiencing any pain with urination - encourage increased intake of high protein foods -instruct the daughter to check her mothers temperature - review the clients current food and medication allergies - determine if the mother has recently experienced a fall

- ask if the mother is experiencing any pain with urination - instruct the daughter to check her mothers temperature -determine if the mother has recently experienced a fall

the nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. which behaviors indicate the client understands how to maintain balance safely? - lean forward to pull a pan from a high shelf - bends from the waist to pick trash off the floor - locks knees while preparing food on the counter - brings a heavy can close to body before lifting - widens stance while working near the sink

- bends from the waist to pick trash off the floor - brings a heavy can close to body before lifting

the nurse is teaching a primigravida about preeclampsia. which findings are indicators of preeclampsia and should be reported to HCP? - blurred vision - headache - lack of appetite - urinary frequency - chills and fever - swollen hands

- blurred vision - headache - swollen hands

when caring for a client with full thickness burns to both lower extremities, which assessment findings warrant immediate intervention by the nurse? - weeping serosanguineous fluid from wounds - sloughing tissue around wound edges - change in the quality of the peripheral pulses - loss of sensation to the left lower extremity - complaint of increased pain and pressure

- change in the quality of the peripheral pulses - loss of sensation to the left lower extremity - complaint of increased pain and pressure

the nurse request a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. which menu items should the nurse request for this client? - chicken broth - apply juice -hot chocolate -black coffee - orange juice

- chicken broth - apple juice

the home health care nurse provided self care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. which instruction should the nurse include in the client's discharge teaching plan? - cross legs at knee but not at ankle - maintain bed flat while sleeping - continue wearing compression stockings - avoid prolonged standing or sitting - use recliner for long periods of sitting

- continue wearing compression stockings - avoid prolonged standing or sitting - use recliner for long periods of sitting

an older adult client is admitted to the stroke unit after recovery from the acute phase of ischemic cerebral vascular accident. which interventions should the nurse include in the plan of care during convalescene and rehabilitation? - encourage family to participate in the client's care - play classical music in room while client is awake - suction oral cavity every 4 hours - place a bedside commode next to bed - measure neurologic vital signs every 4 hours

- encourage family to participate in the client's care - measure neurological vital signs every 4 hours

the nurse is interacting with a female client who is diagnostic with postpartum depression. which findings should the nurse document as an objective signs of depression?

- express suicidal thoughts - avoid eye contact - has a disheveled appearance - interacts with felt effect

An adult male reports that he recently experienced an episode of chest pressure and breathlessness when he was jogging. the client expresses concern because both of his deceased parents had heart disease and his father had diabetes. he lives with his male partner, is a vegetarian, and takes atenolol which maintains his blood pressure at 130/74 mmHg. which risk factor should the nurse explore further with the client? - family health history - homosexual lifestyle - history of hypertension -vegetarian diet - excessive aerobic exercise

- family health history - history of hypertension

an older client is admitted in respiratory distress secondary to HF, CAD, HTN and atrial fibrillation. which nursing problems should the nurse include in this client's plan of care? - fluid volume excess - decreased cardiac output - altered peripheral tissue perfusion - fluid volume deficit - fatigue

- fluid volume excess - decreased cardiac output - altered peripheral tissue perfusion - fatigue

when conducting diet teaching for a client who was diagnosed with hypertension, which food should the nurse encourage the client to eat? - fruits without sauce - canned soup - fresh or frozen vegetables without sauce - cottage cheese - pickled olives

- fruits without sauce - fresh or frozen vegetables without sauce

A client with Addison's crisis is admitted for treatment with adrenal cortical supplementation. Based on the client's admitting diagnosis, which findings require immediate action by the nurse? - headache and tremors - irregular heart rate - skin hyperpigmentation - postural hypotension - pallor and diaphoresis

- headache and tremors - irregular heart rate - pallor and diaphoresis

an adult woman who was recently diagnosed with type 2 diabetes is seen in the clinic for laboratory tests. the clients height is 5 feet 2 inches and weight is 165 pounds. her recent laboratory findings are described above. in planning nutrition teaching for this client, what diet modifications should the nurse recommend? - reduce daily fat intake to 10% of total calories - increase dietary fiber such as whole grains - decrease processed carbohydrate in diet - eliminate alcohol intake except for special occasions - restrict protein to 10% of total calories in diet

- increase dietary fiber such as whole grains - decrease processed carbohydrate in diet - eliminate alcohol intake except for special occasions

a client who is hospitalized and recently diagnosed with Addison's disease is now confused and lethargic. which actions should the nurse implement? - measure capillary blood glucose level - monitor cardiac telementry pattern - reduce rate of intravenous fluid infusion - withhold next dose of corticosteriod - initiate fall risk precautions

- measure capillary blood glucose level - monitor cardiac telemetry pattern - initiate fall risk precautions

an older adult is admitted to the stroke unit after recovery from the acute phase of an ischemic cerebral vascular accident. which intervention should the nurse include in the plan of care during convalescene and rehabilitation? - measure neurologic vital signs every 4 hours - place a bed side commode next to bed - encourage family participate in client's care - play classical music in the room while client is awake

- measure neurologic vital signs every 4 hours - encourage family participate in the client's care - play classical music in room while client is awake

a male client with a history of mitral valve prolapse is admitted because of fever and dyspnea on exerton, and is diagnosed with acute infective endocarditis. during the admission assessment, the nurse observes multiple areas of petechiae on the client's skin. which interventions should the nurse include in the client's plan of care? - monitor cardiac rhythm via telemetry - report changes in pre-exisiting murmors - schedule rest periods between activities - maintain record of fluid intake and output - initiate contact transmission precautions

- monitor cardiac rhythm via telemetry - report changes in preexisitng murmurs - initiate contact transmission precautions

A nurse is administering diazepam, a benzodiazepine, 10 mg IV push PRN, as prescribed to a client with alcohol withdrawal symptoms. Which actions should the nurse implement when administering the medication? - Protect medication from exposure to light - Monitor for changes in level of consciousness - Observe for onset of generalized bruising or bleeding - perform ongoing assessment of respiratory status - administer slowly over at least two minutes

- monitor for changes in level of consciousness - perform ongoing assessment of respiratory status - administer slowly over at least two minutes

during discharge teaching, an overweight client with HF is asked to make a grocry list for the nurse to review. which food choices included on the client's list should the nurse encourage? - natural whole almonds - cheddar cheese cubes - lightly salted potato chips - plain, air-popped popcorn - canned fruit in heavy syrup

- natural whole almonds - plain, air-popped popcorn

a client is receiving ophthalmic drops preoperatively for a cataract extraction and asks the nurse why the healthcare provider has prescribed all these medications. which information should the nurse include when responding to this client? - one of the medication is used to anesthesize the corneal surface - pupillary dilation is necessary to access the eye chamber for lens removal - the iris must be paralyzed during surgery to prevent it from reacting to light - a medication is used to induce sleep during the procedure - these medications assist in obstructing client's vision during the surgey

- one of the medication is used to anesthesize the corneal surface - pupillary dilation is necessary to access the eye chamber for lens removal - the iris must be paralyzed during surgery to prevent it from reacting to light

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? - take out dentures and place in a labeled cup - apply a body shroud - place a small pillow under the head - remove resuscitation equipment from the room - gently close the eyes

- place a small pillow under the head - remove resuscitation equipment from the room - gently close the eyes

after an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. the family wish to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? - take out dentures and place in a labeled cup - apply a body shroud - place a pillow under the head - remove resuscitation equipment from the room - gently close the eyes

- place a small pillow under the head - remove resuscitation equipment from the room - gently close the eyes

to reduce the symptoms of exacerbation for a client with multiple sclerosis, which instructions should the nurse include in the client's discharge plan? - practice relaxation exercises - limit fluids to avoid bladder distention - space activities to allow for rest periods - avoid persons with infections - take warm baths before starting exercise

- practice relaxation exercises - space activities to allow for rest periods - avoid persons with infections

while assessing a client's chest tube, the nurse discovers bubbling in the water seal chamber of the chest tube collection device. the client's vital signs are: blood pressure 80/40 mmHg, heart rate 120 BPM, respiratory rate 32 BPM, oxygen sat 88%, which interventions should the nurse implement? - provide supplemental oxygen - ausculate bilateral lung fields - administer a nebulizer treatment - reinforce a occlusive CT dressing - Give PRN dose of pain medication

- provide supplemental oxygen - ausculate bilateral lung fields - reinforce occlusive CT dressing

a client with cirrhosis of the liver is admitted with complications related to end stage liver disease. which interventions should the nurse implement? - report serum albumin and globulin levels - provide diet low in phosphorus - increase fluid intake to 1500 mL daily - note signs of swelling and edema -monitor abdominal girth

- report serum albumin and globulin levels - note signs of swelling and edema -monitor abdominal girth

An older client is admitted for surgical repair of a broken hip. to reduce the risk for infection in the postoperative period, which nursing care interventions should the nurse include in the client's plan of care? - teach the client to use incentive spirometer q2 hours while awake - remove urinary catheter as soon as possible and encourage voiding - maintain sequential compression devices while in bed - administer low molecular weight heparin as prescribed - assess pain level and medicate PRN as prescribed

- teach the client to use the incentive spirometer q2 hours while awake - remove urinary catheter as soon as possible and encourage voiding

the school nurse is preparing a presentation for elementry school teachers to inform them about when a child should be referred to the school clinic for further follow up. the teachers should be instructed to report which situations to the school nurse? - thirst and frequent requests for bathroom breaks - shaking that changes the child's handwriting legibility - bruises on both knees after the weekend - refuses to complete written homework assignments - sunburn with blisters on the face, arms and hands

- thirst and frequent requests for bathroom breaks - shaking that changes the child's handwriting legibility - sunburn with blisters on the face, arms and hands

the nurse is preparing a client who had a below the knee amputation for discharge to home. which recommendations should the nurse provide this client? - avoid range of motion exercises - use a residual limb shrinker - wash the stump with soap and water - inspect skin for redness - apply alcohol to the stump after bathing

- use a residual limb shrinker - wash the stump with soap and water - inspect skin for redness

the nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. which behaviors indicate the client understands how to maintain balance safely? - brings a heavy can close to body before lifting - locks knees while preparing food on the counter - widens stance while working near the sink - bends from the waist to pick trash off the floor - leans forward to pull a pan from a high shelf

brings a heavy van close to body before lifting - locks knees while preparing food on the counter