Clinical Judgement PNC
The nurse is selecting a dressing for a vascular wound that has a dry wound surface. The most appropriate dressing for this wound is one that:
adds moisture to wound bed.
A nurse is caring for a client 1 hour post-laparotomy who reports abdominal pain rating 5/10. What will the nurse prioritize when administering the ordered morphine?
administer the medication before the pain becomes severe
For which client would the use of standard precautions alone be appropriate?
an incontinent client in a nursing home who has diarrhea
intuition
the ability to understand something immediately, without the need for conscious reasoning.
salient cue
the leading, most noticeable, or most important information about a patient's health status
critical thinking
thinking that does not blindly accept arguments and conclusions. Rather, it examines assumptions, discerns hidden values, evaluates evidence, and assesses conclusions.
Which question by a depressed, inpatient, psychiatric-mental health client should the nurse interpret as a potential suicide clue?
"Are clients allowed to keep drugstore medications at their bedside?"
A nurse in a diabetes clinic receives phone calls from four clients with type 1 diabetes. The nurse returns the call of the client reporting what symptoms as highest priority?
"I noticed that my urine has a foul odor, and I have a fever."
The nurse is explaining hemodialysis to a student nurse. What statement leads the nurse to determine that additional teaching is needed?
"It will extract the client's red blood cells."
A client undergoing mastoid surgery asks the nurse about the pain following the surgery. Which response by the nurse is appropriate?
"Usually the incisional pain is mild and controlled by the prescribed medication for the first 24 hours."
An older female client calls and reports, "Another cyst in my private area. I had this years ago, but after 15 years it has returned. What should I do?" Which advice should the health care provider give to this client?
"You should call and make an appointment. I would like to evaluate this further."
The nurse is caring for a client receiving a nitroglycerin infusion for a myocardial infarction. When titrating this infusion, for which adverse effect should the nurse monitor?
Hypotension
inquiry
a request for information
As part of the process of checking the placement of a nasogastric tube, the nurse checks the pH of the aspirate. Which pH finding would indicate to the nurse that the tube is in the stomach?
4
Which client has the highest risk of ovarian cancer?
45-year-old woman who has never been pregnant
After receiving change-of-shift report about the following four clients, which client should the nurse assess first?
70-year-old returning from PACU following partial thyroidectomy who is extremely agitated, has an irregular pulse rate of 134, and an elevated temperature of 103.2°F (39.6°C)
The nurse is preparing to administer fentanyl 25 mcg I.V. The available dose is 100 mcg/2 ml vial. How much medication will the nurse ask another nurse to witness as a waste?
1.5 mL
A nurse is reviewing a patient's laboratory test results. Which serum albumin level would lead the nurse to suspect that the patient is at risk for pressure ulcers?
2.5 g/mL
A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned?
27%
A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body?
27%
Which client has an absolute neutrophil count (ANC) that is critically low and the standard of care would recommend placement on neutropenic precautions?
37-year-old client with leukemia being treated with chemotherapy with ANC of 400 (0.40 x 109/L).
A nurse on the telemetry unit is faced with various monitor rhythms. Which rhythm takes priority?
A client's cardiac rhythm suddenly changes from normal sinus rhythm to uncontrolled atrial fibrillation.
A 32-year-old construction worker is admitted to the emergency department after suffering a heat stroke. Which of the following IV solutions would the nurse expect the physician would order?
A solution of normal saline
inductive reasoning
A type of logic in which generalizations are based on a large number of specific observations.
A nurse is assessing a client with schizophrenia. Which assessment data would be priority for the nurse to follow up on?
After checking the blood pressure, the client's arm stays in the air.
The nurse is evaluating the laboratory values of a client whose nursing diagnosis is "risk for impaired skin integrity." Which of the following values places the client at greatest risk?
Albumin, 1.5 g/dL
A client refuses to remove her wedding band when preparing for surgery. What is the best action for the nurse to take?
Allow the client to wear the ring and cover it with tape.
Which is an appropriately stated nursing intervention?
Ambulate 30 ft (9 m) twice a day with the assistance of a walker.
The advanced practice psychiatric mental health registered nurse is leading a support group for adolescents who have recently experienced disruptions in their life. What participant most warrants further assessment for posttraumatic stress disorder?
An adolescent who has committed uncharacteristic acts of violence since the death of the adolescent's mother
The nurse observes a hematoma over the site of the generator placement on a client with a permanent pacemaker. Which action would be most appropriate based upon this finding?
Apply a cool compress to the site.
Which of the following procedures involves a surgical fusion of the joint?
Arthrodesis
A nurse is caring for a client scheduled to have angiography of the right eye in 1 hour. What is the highest priority nursing intervention?
Assess blood urea nitrogen (BUN) and creatinine levels.
A client prescribed pain medication around the clock experiences pain 1 hour before the next dose of the pain medication is due. Which is the most appropriate action by the nurse?
Assess for medication prescription for breakthrough pain.
The nurse is caring for a client with a brain tumor when the client begins to vomit. Which intervention should the nurse do first?
Assess for other signs/symptoms of increased intracranial pressure.
The nurse gives a client 0.25 mg of digoxin instead of the prescribed dose of 0.125 mg. What action should the nurse take after realizing the mistake?
Assess the client and notify the physician.q
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
A female client is diagnosed with breast abscess. She would like to continue to breast-feed her newborn. Which of the following would be most appropriate in this situation?
Assist the client to pump the breasts to remove breast milk.
A client presents to the emergency department via ambulance with a heart rate of 210 beats/minute and a sawtooth waveform pattern per cardiac monitor. The nurse is most correct to alert the medical team of the presence of a client with which disorder?
Atrial flutter
A mother brings her daughter to the clinic for an evaluation because the child is complaining of ear pain. Which of the following would lead the nurse to suspect that the child is experiencing otitis externa and not otitis media?
Aural tenderness
A patient is to have an angiography done using fluorescein as a contrast agent to determine if the patient has macular edema. What laboratory work should the nurse monitor prior to the angiography?
BUN and creatinine
The nurse is caring for four clients who have come to the clinic for eye exams. The nurse would know that which client is visually impaired?
Client B - eyes test at 20/100 and 20/200
The nurse is helping a client who experiences frequent constipation select meal choices for the day. Which food should the nurse encourage the client to order?
Bran cereal
A 46-year-old client with a high body-mass index and a sedentary lifestyle has been diagnosed with hypertension after serial blood pressure readings. The clinician has opted to begin the client on captopril (Capoten). The nurse should recognize that the therapeutic effect of this drug is achieved in what way?
By inhibiting the transformation of angiotensin I to angiotensin II
A client comes to the clinic for evaluation because of complaints of dizziness and difficulty walking. Further assessment reveals a staggering gait, marked muscle incoordination, and nystagmus. A brain tumor is suspected. Based on the client's assessment findings, the nurse would suspect that the tumor is located in which area of the brain?
Cerebellum
What assessment findings would lead the nurse to suspect that the client has an addiction to a pain medication?
Client compulsively uses the pain medication. Client continues use of pain medication despite of risk of harm. Client loses control of use of pain medication.
A client has been prescribed furosemide 80 mg twice daily. The asymptomatic client begins to have rare premature ventricular contractions followed by runs of bigeminy with stable signs. What action will the nurse perform next?
Check the client's potassium level.
A client with calculi in the gallbladder is said to have
Cholelithiasis
The nurse is evaluating the plan of care for a client with an allergic disorder who has a nursing diagnosis of deficient knowledge related to measures for allergy control. What client statement will indicate to the nurse that the outcome has been met?
Client identifies methods for reducing exposure risk to allergens.
A nurse assesses that a patient is at increased risk for depression based on which of the following?
Co-existing medical problems
The client is admitted to the hospital with a diagnosis of acute glomerulonephritis. Which clinical manifestation would the nurse expect to find?
Cola-colored urine
The nurse working on a cancer treatment floor assesses her assigned clients. It is most important for the nurse to report which assessment finding?
Coolness and mottling of a newly constructed breast site Chapter 52: Assessment and Management of Patients with Breast Disorders - Page 1725-1726 (med surg)
The client is admitted to the hospital with a diagnosis of acute pyelonephritis. Which clinical manifestations would the nurse expect to find?
Costovertebral angle tenderness
Which of the following medications needs to be withheld for 5 to 7 days prior to cataract surgery?
Coumadin
The nurse is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation?
Crackles at lung bases
A patient with end-stage kidney disease (ESKD) has developed anemia. What laboratory finding does the nurse understand to be significant in this stage of anemia?
Creatinine level of 6 mg/100 mL
A male client takes cholesterol absorption inhibitors as a monotherapy without statins. He develops mild hepatic insufficiency. What would the nurse expect the health care provider to do?
Decrease the dosage of his medication
A patient with chronic renal failure is examined by the health care provider for anemia. Which laboratory results will the nurse monitor?
Decreased level of erythropoietin
A 70-year-old client is admitted with acute pancreatitis. The nurse understands that the mortality rate associated with acute pancreatitis increases with advanced age and attributes this to which gerontologic consideration associated with the pancreas?
Decreases in the physiologic function of major organs
A nurse notes that a client's I.V. insertion site is red, swollen, and warm to the touch. Which action should the nurse take first?
Discontinue the I.V. infusion.
When auscultating the heart sounds of a client who's 34 weeks pregnant, the nurse detects a systolic ejection murmur. Which action should the nurse take?
Document the finding, which is normal during pregnancy.
The nurse is caring for a client 1 day after having a colectomy. The client is lethargic and difficult to arouse; the temperature is 101.5°F (38.6°C), blood pressure is 92/36 mm Hg (MAP 55 mm Hg), and heart rate is 114 bpm with SpO2 of 88% on oxygen at 2 L/min per nasal cannula (previously 94%). A saline lock has been established and is patent. Which prescription should the nurse implement first?
Draw blood cultures.
After multiple treatment plans, a client with cancer has been told that the tumors continue to grow and have metastasized. The nurse is assisting with arranging hospice care for the client. The nurse assesses the client is in which phase of the Trajectory Model of Chronic Illness?
Dying
A client who sustained a complete C6 spinal cord injury 6 months ago has been admitted to the hospital for pneumonia. The nurse observes the client with diaphoresis above the level of C6 and the blood pressure is 260/140 mm Hg. What is the first intervention the nurse should provide?
Elevate the head of the bed.
A client is prescribed an intravenous dose of iron dextran. What is the nurse's best action?
Ensures that epinephrine is available
The nurse is caring for a client diagnosed with Legionnaires disease. What medication would the nurse expect the health care provider to prescribe?
Erythromycin
Which source of information helps the nurse formulate nursing diagnoses for a specific client?
Essential assessment data
A patient is undergoing platelet pheresis at the outpatient clinic. What does the nurse know is the most likely clinical disorder the patient is being treated for?
Essential thrombocythemia Chapter 28: Assessment of Hematologic Function and Treatment Modalities - Page 896
A client with an enlarged abdominal aorta admitted to the emergency department has severe back pain, nausea, blood pressure of 90/40 mm hg, heart rate 128 bpm, and respirations 28/min. In which order from first to last should the nurse implement these prescriptions?
Establish an intravenous infusion. Insert a nasogastric tube. Administer pain medication. Monitor intake and output.
A client who was involved in an automobile accident experienced major trauma and sustained a fractured femur. The nurse notices the following changes 4 hours after admission to the critical care unit: Disorientation Dyspnea Tachycardia Low-grade temperature Diaphoresis Substernal chest pain The nurse suspects:
Fat embolism syndrome (FES)
The nurse is assessing an acutely ill patient. When prioritizing the patient's care, the nurse should recognize that the patient is at risk for hypovolemic shock when:
Fluid circulating in the blood vessels decreases.
intellect
ability to think
When the nurse is caring for a patient with acute pancreatitis, what intervention can be provided in order to prevent atelectasis and prevent pooling of respiratory secretions?
Frequent changes of positions
Which assessment finding is most important in determining nursing care for a client with diabetes mellitus?
Fruity breath
The nurse is completing an initial assessment on an elderly client with impaired mobility. When asked about urinary patterns, the client states, "I can never get to the bathroom in time." The nurse documents this as which type of incontinence?
Functional incontinence
Which feature(s) indicates a carpopedal spasm in a client with hypoparathyroidism?
Hand flexing inward
The nurse knows that a client is at high risk for developing drug tolerance because the client will be taking which drug for a long period of time?
Hydromorphone (Dilaudid) for pain Chapter 2: Drugs and the Body - Page 29 (pharm)
An elderly client diagnosed with diarrhea is taking digoxin. Which electrolyte imbalance should the nurse be alert to?
Hypokalemia
The nurse is caring for a patient at risk of shock. What physiologic response would the nurse know to look for while assessing for shock?
Hypoperfusion of tissues
A parent calls the health care provider reporting the child has red sores on the face, especially around the nose and mouth that have pus/fluid inside and when the sores burst, they develop a honey-colored crust. The parent is asking whether to make an appointment. Which contagious skin lesion does the provider think the child has developed?
Impetigo pustule
The nurse is performing a Weber test on a client. During this test, where should the nurse place the tuning fork?
In the midline of the client's skull or in the center of the forehead
A client comes to the walk-in clinic reporting feeling a "bug in my ear." What action should be taken when there is an insect in the ear?
Instillation of mineral oil
A client reports urinary frequency, urgency, and dysuria. Which of the following would the nurse most likely suspect?
Infection
A nurse reports to the physician that a client receiving a blood transfusion has a temperature that is 1° C greater than the baseline and reports of a headache. The physician says to continue the blood infusion. What is the most appropriate action by the nurse to ensure the safety of the client?
Inform the physician of hospital policy for managing transfusion reactions.
A client has been diagnosed with a frontal lobe brain abscess. Which nursing intervention is appropriate?
Initiate seizure precautions.
A client is receiving enoxaparin and warfarin therapy for a venous thromboembolism (VTE). Which laboratory value indicates that anticoagulation is adequate and enoxaparin can be discontinued?
International normalized ratio (INR) is 2.5.
A client taking furosemide and digoxin for exacerbation of heart failure reports weakness and heart fluttering. What would be the priority action by the nurse?
Investigate the symptoms further with the client and suggest contacting the physician.
A child with attention deficit hyperactivity disorder has been receiving methylphenidate for several years. The prescriber has explained a plan to temporarily discontinue the drug. What rationale for this action should the nurse explain?
It needs to be determined if the child still has symptoms that require treatment.
A nurse is assessing a client with congestive heart failure for jugular vein distension (JVD). Which observation is important to report to the physician?
JVD is noted 4 cm above the sternal angle.
A client has experienced hypovolemic shock and is being treated with 2 liters of lactated Ringer's solution. It is now most important for the nurse to assess
Lung sounds Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome - Page 282 (med-surg)
A client comes to the eye clinic for an examination. The client tells the nurse that his vision is like a target with the bull's eye area of the image missing. What would the nurse suspect?
Macular degeneration
A client with a traumatic brain injury is showing early signs of increasing intracranial pressure (ICP). While planning care for this client, what would be the priority expected outcome?
Maintains a patent airway
Assessment of visual acuity reveals that the client has blurred vision when looking at distant objects but no difficulty seeing near objects. The nurse documents this as which of the following?
Myopia
A school-age child had a colostomy performed 4 weeks ago. The parents report to the nurse that for the past 3 weeks the child's stoma passed adequate amounts of formed stool, but in the past 2 days only thin, ribbon-like stool is passing. What action will the nurse take?
Notify the healthcare provider for stool softener prescription.
A nurse receives a report that a client has had an overdose of heparin. Which action by the nurse is most important in managing the overdose?
Obtain an order to give protamine sulfate.
A client presents to the emergency room with abdominal pain and upper gastrointestinal bleeding. The client is sweating and appears to be in moderate distress. Which nursing action would be a priority at this time?
Obtain vital signs.
The nurse is caring for a client with intussusception of the bowel. What does the nurse understand occurs with this disorder?
One part of the intestine telescopes into another portion of the intestine.
A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment:
Oxygen at 2 L/min by nasal cannula
A 45-year-old female client tells the nurse she has a dimpling of the right breast that has occurred in the past 2 weeks. What action will the nurse take next?
Perform an examination of both of the client's breasts.
The nurse notes several very small, round, red and purple macules on a patient's skin. The patient has a history of anticoagulant use. The nurse records this finding as which of the following?
Petechiae
A client with acquired immune deficiency syndrome (AIDS) is exhibiting shortness of breath, cough, and fever. What type of infection will the nurse most likely suspect?
Pneumocystis jiroveci
The nurse enters the client's room in the acute care unit immediately after the client experiences a generalized tonic-clonic type seizure in bed. What is the first action the nurse should take?
Position the client in a side-lying position.
Which treatment should take place immediately in a client experiencing autonomic dysreflexia?
Position the client in upright position, and correct the initiating stimulus.
The nurse is preparing to administer furosemide to a client with severe heart failure. What lab study should be of most concern for this client while taking furosemide?
Potassium level of 3.1
A client is diagnosed with oppositional defiant disorder (ODD). Which assessment finding would indicate that the client needs medications?
Presence of comorbid psychiatric disorders
clinical decision making
Problem-solving approach that nurses use to define patient problems and select appropriate treatment.
A client is admitted to the hospital with systolic left-sided heart failure. The nurse knows to look for which assessment finding for this client?
Pulmonary congestion
The nurse is caring for a client whose respiratory status has declined since shift report. The client has tachypnea, is restless, and displays cyanosis. Which diagnostic test should the nurse perform first?
Pulse oximetry
Which of the following would least suggest emotional health?
Realistic sense of hopelessness
A client comes into the emergency department with severe back pain radiating to the left lower groin. The healthcare provider prescribes morphine sulfate 5-10 mg IV every 2 hours. One hour after receiving 10 mg of morphine, the client is restless and distressed, reporting the pain is still at 8 of 10. What action will the nurse take?
Reassess the client's pain and associated symptoms, and report findings to the healthcare provider to advocate for better pain control.
A nurse is evaluating a fetal monitor strip and finds the fetal heart rate accelerated 20 beats per minute for 15 seconds. What is the nurse's best action?
Reassure the client that all is well with the fetus.
The nurse is assessing a client taking an anticoagulant. What nursing intervention is most appropriate for a client at risk for injury related to side effects of medication enoxaparin?
Report any incident of bloody urine, stools, or both.
The nurse is caring for a client exposed to a blistering agent. While the nurse is quickly decontaminating the client by showering and bagging all client clothing, what is the nurse simultaneously assessing for?
Respiratory compromise
A client is admitted to the ICU with a diagnosis of heart failure. The client is exhibiting symptoms of weakness, ascites, weight gain, and jugular vein distention. The nurse would know that the client is exhibiting signs of what kind of heart failure?
Right-sided heart failure
When working with a client with diffuse scleroderma who is exhibiting a 'stone face' expression, the nurse should consider which of these to be a priority nursing diagnosis for this client?
Risk for aspiration related to swallowing impairments.
The nurse is reading the previous shift's documentation of an open area on the client's sacrum. The wound is documented as a partial-thickness wound whose etiology is pressure. The nurse anticipates the assessment of the client's sacrum will reveal a pressure ulcer in which stage?
Stage II
A client is being sent home with subcutaneous heparin after a total hip replacement. The nurse understands what symptom would indicate a serious drug reaction?
Tarry stools
Specific disease processes and ingestion of certain foods and medications may change the appearance of the stool. If blood is shed in sufficient quantities into the upper gastrointestinal (GI) tract, it produces which change in the stool appearance?
Tarry-black
A client is suspected of sepsis from a postsurgical incision infection. What characteristic of sepsis would the nurse recognize?
Temperature of 102F Heart rate of 120 beats/minute Respiratory rate of 24 breaths/minute
A client is suspected of sepsis from a postsurgical incision infection. What characteristic of sepsis would the nurse recognize
Temperature of 102F Respiratory rate of 24 breaths/minute Heart rate of 120 beats/minute
A client has undergone a renal transplant and returns to the health care agency for a follow-up evaluation. Which finding would lead to the suspicion that the client is experiencing rejection?
Tenderness over transplant site
A client's BUN test results are significantly elevated. When reviewing the client's history, which finding is consistent with BUN elevation other than renal compromise?
The client is dehydrated.
During preparation for bowel surgery, a client receives an antibiotic to reduce intestinal bacteria. The nurse knows that hypoprothrombinemia may occur as a result of antibiotic therapy interfering with synthesis of which vitamin?
Vitamin K
A client tells the nurse, "I am not having normal bowel movements." When differentiating between what are normal and abnormal bowel habits, what indicators are the most important?
The consistency of stool and comfort when passing stool
A client is scheduled to undergo an open reduction internal fixation of the right femur. The night before surgery, the nurse administers zolpidem as ordered. Which statement about zolpidem is correct?
The nurse should administer the drug immediately before bedtime.
The client is returning from the operating room following a bronchoscopy. Which action, performed by the nursing assistant, would the nurse stop if began prior to nursing assessment?
The nursing assistant is pouring a glass of water to wet the client's mouth.
The patient has just received a central venous catheter placed by the physician. Which of the following should the nurse anticipate next?
The patient will have an X-ray to confirm placement of the device.
A client is receiving support through an intra-aortic balloon counterpulsation. The catheter for the balloon is inserted in the right femoral artery. The nurse evaluates the following as a complication of the therapy:
The right foot is cooler than the left foot.
The nurse is conducting a morning assessment of an 80-year-old female patient who has a longstanding diagnosis of heart failure (HF). The nurse notes an elevation in jugular venous pressure (JVP) greater than 4 cm above the woman's sternal angle, a finding that did not exist the day before. What conclusion should the nurse draw from this assessment finding?
The woman may be experiencing an exacerbation of right-sided HF.
A client with GERD develops esophagitis. Which diagnostic test would the nurse expect the physician to order to confirm the diagnosis?
Upper endoscopy with biopsy
A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs, the nurse notes edema, brown pigmentation in the gaiter area, pedal pulses, and a few irregularly shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with peripheral circulation. Which of the following does the nurse suspect?
Venous insufficiency
clinical reasoning
a specific term usually referring to ways of thinking about patient care issues (determining, preventing, and managing patient problems); for reasoning about other clinical issues (e.g., teamwork, collaboration, and streamlining work flow); nurses usually use critical thinking
A female HIV-positive patient with a high CD4 count has been taking nevirapine (Viramune) for 9 weeks. What clinical manifestations indicate to the nurse that the patient is having complications from this medication?
Yellow sclera and hepatomegaly
Laboratory testing is ordered for a male client during a clinic visit for routine follow-up assessment of hypertension. When interpreting lab values, the nurse knows:
a normal value represents the test results that fall within the bell curve.
A 70-year-old man has been living with a diagnosis of heart failure (HF) for several years and has been vigilant about monitoring the trajectory of disease and adhering to his prescribed treatment regimen. The man has scheduled an appointment with his primary care provider because he has noted a weight gain of 6 pounds over the past week. The nurse should anticipate that this patient may benefit from which of the following treatment measures?
an increase in the dose of his prescribed diuretic
clinical judgement
an interpretation or conclusion about a patient's needs, concerns, or health problems, and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient's response
Which allergic reaction is potentially life threatening?
angioedema
situations that put patients at risk
bias misinterpret S/S
Which is the earliest and the most common symptom of endometrial cancer?
bleeding
The nurse assesses a 6-month-old infant who is lethargic and suspected to be severely dehydrated. Which additional information is a priority for the nurse to determine?
blood pressure and capillary refill time
The nurse knows that acetaminophen should not be used in older adults with which condition?
cirrhosis.
A woman with cardiac disease has come to the office for prenatal counseling. Assessment supports the decision to caution the woman against pregnancy. The woman most likely fits the criteria for which functional risk classification?
class IV
What is the term for the ability of the cardiac muscle to shorten in response to an electrical impulse?
contractility
Medical management of arthropod-borne virus (arboviral) encephalitis is aimed at
controlling seizures and increased intracranial pressure.
A client with acute renal failure has the following laboratory results. Based on these findings, which of the following should the nurse administer? hemoglobin 9.2 g/dL blood urea nitrogen 22 mg/dL creatinine 0.7 mg/dL potassium 4.8 mEq/L
erythropoietin
A nurse is caring for a client with diabetes mellitus. The client takes insulin 2 times per day. The nurse makes sure the client's meals arrive in coordination with the insulin's effect. The knowledge used by the nurse is:
integrated.
What would the nurse expect to prioritize in the assessment of a newborn who has a positive Coombs test?
jaundice development
Each chamber of the heart has a particular role in maintaining cellular oxygenation. Which chamber is responsible for pumping blood to all the cells and tissues of the body?
left ventricle
A client is prescribed digitalis medication. Which condition should the nurse closely monitor when caring for the client?
nausea and vomiting
The client presents to the emergency department with reports of dark urine and swelling in the face, bilateral hands, and feet. The client is subsequently admitted with the diagnosis of glomerulonephritis and is receiving trimethoprim-sulfa. Which data will the nurse examine to indicate the medication is effective?
negative urine culture after treatment negative urine leukocyte esterase
A physician orders supplemental oxygen for a client with a respiratory problem. Which oxygen delivery device should the nurse use to provide the highest possible oxygen concentration?
nonrebreather mask
The school nurse has several children with hemophilia A. After recess, one hemophilia student comes to the school nurse complaining of pain in the knee from falling on the playground. The nurse notes there is swelling in the knee and pain on palpation. The nurse should:
notify parents to pick up the child and possibly administer Factor VIII.
Maslow's Hierarchy of Needs Theory
offers a pyramid of physiological, safety, social, esteem, and self-actualization needs base last
A client is experiencing vomiting and diarrhea for 2 days. Blood pressure is 88/56, pulse rate is 122 beats/minute, and respirations are 28 breaths/minute. The nurse starts intravenous fluids. Which of the following prescribed prn medications would the nurse administer next?
ondansetron
A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and they frequently indulge in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition?
postpartum psychosis
gate theory of pain
proposes that there is a special "gating" mechanism that can turn pain signals on or off, affecting whether or not we perceive pain - spinal cord can preferentially forward signals from other modalities (pressure, temp)
Pink, frothy sputum may be an indication of
pulmonary edema
deductive reasoning
reasoning in which a conclusion is reached by stating a general principle and then applying that principle to a specific case (The sun rises every morning; therefore, the sun will rise on Tuesday morning.)
A client is readmitted to the facility with a warm, tender, reddened area on the right calf. Which contributing factor should the nurse recognize as most important?
recent pelvic surgery
Nursing students are reviewing the pathophysiology of human immunodeficiency virus (HIV). They demonstrate understanding of the information when they state which of the following as the form of the genetic viral material?
ribonucleic acid (RNA)
A nurse is changing a client's surgical incision dressing on post-op day three. For which observation would the nurse take immediate action?
small amount of creamy yellow drainage
A client comes to the clinic for a follow-up visit. During the interview, the client states, "Sometimes when I have to urinate I can't control it, and do not reach the bathroom in time." The nurse suspects that the client is experiencing which type of incontinence?
urge
A 24-month-old child has been diagnosed with pneumococcal pneumonia. The healthcare provider has prescribed penicillin G, 300,000 units IM daily. What site should the nurse use to administer this injection?
ventrogluteal muscle
Before a transesophageal echocardiogram, a nurse gives a client an oral topical anesthetic spray. When the client returns from the procedure, the nurse observes no active gag reflex. What nursing action is a priority?
withhold food and fluids.
The nurse is assigned multiple clients with anemia. Which client may be experiencing a failure of the body to produce erythropoietin and thus may require supplemental injections of this hormone?
Client with history of chronic kidney failure
Which of the following would lead a nurse to suspect that a client has a rotator cuff tear?
Difficulty lying on affected side
The nurse has positioned the client on the right side (see figure). Which areas will the nurse assess for pressure when repositioning two hours later? Select all that apply.
ankle auricle greater trochanter clavicle
The client has come to the hospital emergency room reporting lethargy and vomiting. The healthcare provider makes a tentative diagnosis of Reye's syndrome. The client's history reveals a recent acute viral infection and the use of several medications. The nurse suspects which medication to be implicated in the development of Reye's syndrome?
aspirin
The oncology nurse understands that chemotherapeutic agents are most effective during a particular phase of the cell cycle. This means the agents are:
cell cycle-specific.
Which category of medications would the nurse expect to administer for a client with myasthenia gravis?
cholinesterase inhibitors and corticosteroids
A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has:
cirrhosis.
A physician has prescribed triamterene to a client with renal disease. The client informs the nurse that they are taking potassium supplements to address some heart problems. The nurse would be alert for which of the following?
increased risk of hyperkalemia.
The nurse cares for a client with end-stage kidney disease (ESKD). Which acid-base imbalance is associated with this disorder?
pH 7.20, PaCO2 36, HCO3 14-
Which client requires immediate nursing intervention? The client who
presents with a rigid, boardlike abdomen.
A female client with hyperglycemia who weighs 210 lb (95 kg) tells the nurse that her husband sleeps in another room because her snoring keeps him awake. The nurse notices that the client has large hands and a hoarse voice. Which disorder would the nurse suspect as a possible cause of the client's hyperglycemia?
Acromegaly
A nurse is completing a health assessment with an adult client in a healthcare provider's office. What assessment data will the nurse report to the healthcare provider as indications of fluid volume excess?
decreased blood pressure bounding pulses decreased heart rate pitting extremity edema feelings of fatigue ????
A client, who has been diagnosed with schizophrenia and is taking an antipsychotic medication, reports constant thirst, frequent urination, and feeling nauseous. The nurse knows that the client may:
have undiagnosed diabetes.
Which type of nursing diagnosis is a clinical judgment of a client's motivation and behavior to increase his or her well-being?
health promotion
When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem?
prolonged decelerations
A nurse is managing the care of a client in a critical care unit. What medication may be used to reduce stress ulcers?
proton pump inhibitors cytoprotective agents histamine receptor antagonists
A client with pancreatitis is admitted to the medical intensive care unit. Which nursing intervention is most appropriate?
reserving an antecubital site for a peripherally inserted central catheter (PICC)
A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects:
respiratory alkalosis.
After a fall at home, a client hits their head on the corner of a table. Shortly after the accident, the client arrives at the ED, unable to see out of their left eye. The client tells the nurse that symptoms began with seeing spots or moving particles in the field of vision but that there was no pain in the eye. The client is very upset that the vision will not return. What is the most likely cause of this client's symptoms?
retinal detachment
A 55-year-old female client presents at the walk-in clinic complaining of feeling like a mask is on her face. While doing the initial assessment, the nurse notes the demonstration of a pill-rolling movement in the right hand and a stooped posture. Physical examination shows bradykinesia and a shuffling gait. What would the nurse suspect is the causative factor for these symptoms?
Parkinson's disease
A client with bipolar disorder is taking lithium carbonate 300 mg t.i.d. The client's lithium level is 2.7 mEq/L. In assessing the client, the nurse finds no evidence of lithium toxicity. The first assessment question the nurse should ask before ordering another blood test is:
"When did you take your last dose of lithium?"
A large volume of intravenous fluids is being administered to an elderly client who experienced hypovolemic shock following diarrhea. The nurse is evaluating the client's response to treatment and notes the following as a sign of an adverse reaction:
Jugular venous distention
A hospitalized client who has a living will is being fed through a nasogastric (NG) tube. During a bolus feeding, the client vomits and begins choking. Which action should the nurse take?
Clear the client's airway.
The nurse is admitting a patient to the cardiac care unit with complaints of dyspnea on exertion and fatigue. The patient's electrocardiogram (ECG) shows dysrhythmias associated with left ventricular hypertrophy. What diagnostic tool would be the most helpful in diagnosing cardiomyopathy?
Echocardiogram
A client is admitted to the healthcare facility suspected of having acute pancreatitis and undergoes laboratory testing. Which of the following would the nurse expect to find?
Elevated urine amylase levels
The nurse attempts to obtain a blood specimen from an implanted port. The port does not have blood return. What should the nurse do next?
Have the client change positions.
A client is in active labor. Checking the EFM tracing, the nurse notes variables that are abnormal. What would be the nurse's first nursing intervention?
Help the woman change positions.
A client with renal impairment is in need of a diuretic. Because of the renal problem, potassium-sparing diuretics are contraindicated but may be used if there is no other option. If they are used at all, what nursing intervention would be most important for this client?
Monitoring of serum electrolytes, creatinine, and BUN
The most common cause of cholinergic crisis includes which of the following?
Overmedication
A primigravida client arrives at the labor and birth unit at 39 weeks gestation. Once completing the initial assessment, the nurse documents the note above. Which nursing action is anticipated per the healthcare provider?
Provide instructions to remain within 10 minutes of the birthing center and to ambulate.
The nurse is caring for a pediatric client post tonsillectomy. Which nursing actions are important when caring for a client postoperatively?
setting up suction keeping the client side lying
A client is being treated for increased intracranial pressure (ICP). The nurse should ensure that the client does not develop hypothermia because:
shivering in hypothermia can increase ICP.
A nurse is conducting a detailed skin assessment on an 80-year-old client. Which finding requires further investigation?
small, waxy nodule with pearly borders
A client with severe mitral valve insufficiency has been admitted to your unit. The client is in heart failure and has developed pulmonary edema. What would be the best course of treatment for this client?
surgery
