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A female client with acute respiratory distress syndrome (ARDS) is chemically paralyzed and sedated while she is on as assist-control ventilator using 50% FIO2. Which assessment finding warrants immediate intervention by the nurse?
Diminished left lower lobe sounds
Client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. which laboratory test should the nruse monitor?
Hemoglobin naproxen can cause gastric bleeding, so the nurse should monitor the client's hemoglobin to assess for possible bleeding. Other options are not likelyto be affected by the used of naproxen and are not related to the client's current symptoms.
An adult man reports that he recently experienced breathlessness when he was jogging in the neighborhood. He expresses concern because both of his deceased parents had heart disease and his father was a diabetic. He lives with his male partner, is a vegetarian, and takes atenolol which maintains his blood pressure at 138/74. Which risk factors should the nurse explore further with the client? Select all that apply
History of hypertension. Family health history.
Tumor Lysis Syndrome
Hyperkalemia, hyperurecemia
Priority adolescent mental health patient to assess
yelling
Recommended low fiber food for ulcerative colitis UC
turkey and vegetables
Naproxen (NSAID)
watch for bleeding
An elderly male client is admitted to the mental health unit wit ha sudden onset of global disorientation and is continuously conversing with his mother.....
Delirium
A male client is admitted for he removal of an internal fixation that was inserted for teh fracture ankle. During the admission history, he tells the nruse he recently received vancomycin (vancomycin_ for a methicillin-resistant Staph aureus (MRSA) wound infeciton. Which action should the nruse take? SATA
-Collect multiple site screening cultures for MRSA -Place the client on contact transmission precautions -Continue to monitor for client signs of infection.
A neonate with a congenital heart defect (CHD) is demonstrating symptoms of heart failure (HF). Which intervention should the nurse include in the infant's plan of care?
-Give O2 at 6 L.nasal cannula for 3 repeated oximetry screens below 90% -Evaulate heart rate for effectiveness of cardiotonic medications -Use high energy formula 30 calories/ounce at Q3 hours feeding via soft nipples -Ensure interrupted and frequent rest perids between procedures.
Two days after admission a male client remembers that he is allergi c to eggs, and informs the nruse of the allergy. Which acitons should the nruse implment? SATA
-Notify the food services department of the allergy -Enter teh allergy information in the clietn's record. -Add egg alergy to the clietn's allergy arm band
Tumor Lysis Syndrome
. Nursing priorities are directed toward 1) monitoring fluid and electrolytes, 2) providing comfort and emotional support, 3) maintaining surveillance for complications, and 4) initiating patient education.
An infant is receiving penicillin G procaine 220,000 units IM. The drug is supplied as 600,000 units/mL. Ho many mL should the nruse administer?
0.4
The HCP prescribes methotrexate 7.5 mg PO weekly, in 3 divided doses for a child with rheumatoid arthritis whose body surface area (BSA) is 0.6 m2. The therapeutic dosage of methotrexate PO is 5 to 15 mg/m2/week. How many mg should the nruse administer in each of the htree doses given weekly?
1.5
The charge nurse is planning for the shift and has a registered nurse and a practical nurse (PN) on the team. Which client should the charge nurse assign to the RN? A 64 year old client who had a total hip replacement the previous day.A 75 year old client with renal calculi who requires urine straining.An adolescent with multiple contusions due to a fall that occurred 2 days ago. A 30 year old depressed client who admits to suicide ideation. with supervision by the registered nurse.
A 30 year old depressed client who admits to suicide ideation. RATIONALE: A client who is suicidal requires psychological assessment, therapeutic communication and knowledge beyond the educational level of a practical nurse (PN). Other clients could be cared for by the PN or the UAP, with supervision by the registered nurse.
An older client is admitted for repair of a broken hip. To reduce the risk of infection in the postoperative period, which nursing care interventions should the nurse include in the client's care plan?
A. Teach client to use incentive spirometer every2 hours while awake. B. Remove urinary catheter as soon as possible and encourage voiding.
In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider? A. Watery diarrhea B. Yellow-tinged sputum C. Increased fatigue D. Nausea and headache
A. Watery diarrhea
After several hours of non-productive coughing, a client presents to the 129.emergency room complaining of chest tightness and shortness of breath. History includes end stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. While completing the pulmonary assessment, the nurse hears wheezing and poor air movement bilaterally. Which actions should the nurse implement? (Select all that apply.) 130.
Administer PRN nebulizer treatment. Obtain 12 lead electrocardiogram. Monitor continuous oxygen saturation.
A nurse receives a shift report about a male client with OCD. The nruse does morning rounds and reaches the client while he is repeatedly washing the top of the same table. What intervention shuld the nurse implment?
Allow time for the behavior and then redirect the client to other activities.
In making client care assignment, which client is best to assing to the practical nurse (PN_ working on the unit with the nruse?
An immediate client receiving low molecular weight heparin q12h. A describe the most stable client. The other ones are at risk for bleeding problems and require assessment skills.
Based on the principles of asepsis, the nruse should consider which circumstances to be sterile?
An open sterile foley catheter kit set up on a table at the nurse waist level
A male client notifies the nurse that he feels short of breath and has chest pressure radiating down his left arm. A STAT 12 lead electrocardiogram (ECG) is obtained and shows ST segment elevation in leads II, II, aVF and v4R. The nurse collects blood samples and gives a normal saline bolus. What action is most important for the nurse to implement?
Asses for contraindications for thrombolytic therapy aPTT or APTT, Activated partial thromboplastin time; INR, international normalized ratio; PE, pulmonary embolism.
A preoperative client states he is not allergic to any medications. What is the most important nursing action for the nurse to implement first?
Assess client's knowledge of an allergic response.
Which nrusing intervention has the highest priority for a multigravida who delivered
Assess fundal tone and lochia flow
A male client with rheumatoid arthritis is scheduled for a procedure in the morning. The unable to complete the procedure because of early mornign stiffness. WHich intervention..implment?
Assign a UAP to assit the client with a warm shower early in the morning.
A client with gestational diabetes, at 39 weeks of gestation, is in the second stage of labor. After delivering of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first?
Assist the client to sharply flexing her thighs up against the abdomen. Rationale: Flexing the client's thighs the abdomen (McRobert's maneuver) changes the angle of the pelvis and increases the pelvic diameter, making more room for the shoulders to emerge. ABD are implemented after C.
The nurse assesses a female client with obstructive sleep apnea syndrome who is 5 feet tall and weights 155 pounds, the client's 24 hour diet history includes no breakfast, cheeseburger and fries for lunch, lasagna, chocolate ice cream and a cola drink for dinner and 2 glasses of wine in the evening before going to bed for a total caloric intake of 3500 caloires. What instructions should the nurse provide?
Avoid use of alcohol as a sleep aide at bedtime start a weight loss program.
The nruse is collecting a sterile sample for culture and sensitivity form a disposable three chamber water-seal drainage system connected toa pleural chest tube. The nrsue should obtain the sample form which site on the drainage system?
B. Plastic tubing located at the chest insertion site.
A client is admitted to a mental health unit after attempting suicide by taking a handful of medications. In developing a plan of care for this client, which goal has the highest priority? B. Signs a no-self-harm contract. B. Sleep at least 6 hours nightly. C. Attends group therapy every day D. Verbalizes a positive self-image
B. Signs a no-self-harm contract.
For shock
Bolus of 50% dextrose
Which statement is accurate regarding the pathological changes in the pulmonary system associated with acute (adult) respiratory distress syndrome (ARDS)?
Capillary hydrostatic pressure exceeds colloid osmotic pressure, producing interstitial edema.
When assessing a multigravia the first postpartum day, the nurse find a moderate amount of lochia rubra, with the uterus firm, and three finger-breadths above the umbilicus. What action should the nurse implement first?
Check for a distended bladder
Duchenne Muscular Dystrophy
Continue swimming
The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first?
Convey to the client that birth is imminent.
The nurse is assing the emitional status of a client with Parkinson's disease. Which lcient finding is most helpful in planning gaols to meet hte clietn's emtional needs?
Cries frequently during the interview
A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nruse to note before administering the initial dose?
Current diagnosis of hepatitis B. Prophylactic treatment of TB with isoniazid is contraindicated for persons with liver disease because it may cause liver damage. The nurse should withhold the prescribed dose and contact the healthcare provider.
For an infant with respirations under 60
Do Not Feed
A client being discharged with a prescription for warfarin (Coumadin_. What instruction should the nurse provide this client regarding diet?
Eat approximately the same aount of leafy green vegetables daily so the amount of vitamin K consumed is consistent.
A male client with cancer, who is receiving antineoplastic drugs, is admitted to the ....what findings is most often manifest this condition?
Ecchymosis and hematemesis
Which of the leukocyte is involved with allergic reponses and the destrucition of parasitic worms?
Eosinophils: Eosinophils are involved in allergic responses and destruciton of parasitic worms.
A client admitted to the psychiatric unit diagnosed with major depression wants to 144.sleep during the day, refuses to take a bath, and refuses to eat. Which nursingintervention should the nurse implement first?
Establish a structured routine for the client to follow.
A client with rapid respirations and audible rhonchi is admitted to the intensive care unit because of a pulmonary embolism (PE). Low-flow oxygen by nasal cannula and weight-based heparin protocol is initiated. Which intervention is most important for the nurse to include in this client's plan of care?
Evaluate daily blood clotting factors.
What determines what is getting better?
Everything is effective except 1 Refused to ride in the car
Sucicide
Follow unit protocol, and keep detailed records in the patient's chart.
Pyloric stenosis
IV fluids
The nruse is develping the plan of care for a client with pneumonia and includes the nrusing diagnosis of "ineffective airway clearnace related to thick pulmonary secretions. Which intervention is most important for the nruse to include in the client's plan of care?
Increase fluid intake to 3000 ml.daily
What action shoud the school nurse implment ot provide secondarypreventio nto a school-age children?
Initiate a hearing and vision screening progrma for first graders.
A mother brings her 3 week old son to the clinic because he is vomiting "all the time" in performing a physical assessment the nruse notes that the infant has poor skin turgor, has lost 20% of his brith weight, and have small palpable oveal shaped mass in his abdomen. What intervention should the nruse implment first?
Initiate a prescribed IV for parental fluid.
A client is receiving lactulose (Portalac) for signs of hepatic encephalopathy. To evaluate the clietn's therapeutic repsonse to this medicaiton, which assessment should the nurse obtain?
Level of consciousness
A male client who had a small bowel reseciton acquired methicillin-resistant Staphylococcus aureus (MRSA) while hospitalized. he was treated and realsed, but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implment which intervention?
Maintain contact transmission precautions.
The nruse is assessing a first day postpartum client. WHich finding is most indicative of a postpartum infeciton?
Moderate amount of foul-smelling lochia.
After receiving lactulose, a client with hepatic encephalopathy has several loose stools. What action should the nruse implmement?
Monitor mental status Colonic bacteria digest lactulose to create a drug-induces acidic and hyperosmotic environment that draws water and blood ammonia into the colon and coverts ammonia to ammonium, which is trapped in the intestines and cannot be reabsorbed into the systemic circulation. This therapeutic action of lactulose is to reduce serum ammonia levels, which improves the client's level of consciousness and metal status.
An older client is admitted to the intesnive care unit with severe abdominal pain, abdominal distention, and absent bowel sound. The client has a history of smoking 2 packs of cigarettes daily for 50 years and is currently restless and confused. Vital signs are temperature 96 F, haert rate 122 betas/minute, respiratory rate 36 breaths/minute, mean arterial pressure (MAP_ 64 mm Hg and central venou pressure (CVP) 7 mm Hg. Serum laboratory findings include hemoglobin 6.5 g/dl, platelets 60,000, and white blood cells count 3,000/mm3. Based on these findings this client is at greatest risk for which pathophysiological condition?
Multiple organ dysfunction syndrome (MODS)
A client with uticaria due to an environmental allergy is taking diphenhydramine...which complaint should the nurse identify to the client as a side effect of the OTC medication?
Nausea and indigestion
A client with a postoperative wound that eviscerated yesterday has an elevated temperature most important for the nurse to implment?
Obtain a wound swab for culture and sensitivity.
A client who has a suspected brain tumor is scheduled for a computed scan. When preparing the client for the CT scan, which intervention should the nurse implement?
Obtain the client's food allergy history
Secondary diagnosis
PTSD due to traumatic life event
In early septic shock states, what is the primary cause of hypotension?
Peripheral vasodilation
A health care provider continuously dismisses the nrusing care suggestion made by staff nruses. As a result...dealing with the healthcare provider. What action should the nruse manager implement?
Plan an interdisciplinary staff meeting to develop strategies to enhance client care.
A female client who was mechanically ventilated for 7 days is extubated. Two hours later...productive cough, and her respirations are rapids and shallow. Which intervention is most important?
Prepare the client for intubation.
The nurse is preparing a 50 ml dose of 50% dextrose IV for a client with insulin...medication?
Push the undiluted Dextrose slowly through the currently infusion IV
prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client's teaching plan? (Select all that apply.)
Recognize signs and symptoms of hypoglycemia. Report persist polyuria to the healthcare provider. Take Glucophage with the morning and evening meal.
An older adult male is admitted with complications related to chronic obstructive pulmonary disease (COPD). He reports progressive dyspnea that worsens on exertionand his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide?
Restrict daily fluid intake.
A client whose wrists are sutured from a recent suicide attempt is being transferred form a medical unit. which nrusing diagnosis is of the highest priority?
Risk for self-directed violence related to impulsive actions
Case study Suicidal woman who's father survived is seeking help for depression. "I don't want to kill myself but I wish I died in the crash."
Risk for suicidal ideation due to thoughts of death
The nurse is assessing a client's laboratory values following administration of chemotherapy. Which lab value leads the nurse to suspect that the client is experiencing tumor lysis syndrome (TLS)?A. Serum PTT of 10 secondsB. Serum calcium of 5 mg/dlC. Oxygen saturation of 90%D. Hemoglobin of 10 g/dl
Serum calcium of 5 mg/dlC
A young adult client is admitted to the emergency room following a motor vehicle collision. The client's head hit the dashboard. Admission asessment include: Blood pressure 85/45 mm Hg, temperature 98.6 pulse 124 beat/min and respirations 22 breath/min. Based on these data, the nruse formulates thefirst portion of nursing diagnosis as risk of injury. What term best expressses the related to portion of nursing diagnosis.
Shock
The client recovering from a PE is receiving a continuous infusion of heparin IV. When the nurse comes to take vital signs, the client has blood on his pajama jacket and pillow. He is pinching his nose to control a nosebleed. What is the nurse's best first action?
Slow the IV, assess the bleeding
A mother bbrings her 4 month old son to the clinic with a quarter taped over his umbilicus, and tells the nruse the quarter is supposed to fix her child's hernia. Which explainations should the nurse provide?
This hernia is a normal variation that resolves without treatment.
The nruse administers an antibiotic to a client with respiratory tract infection. To evaluate the medication's effectiveness, which laboratory values should the nurse monitor? SATA
Whtie blood cells Sputum culture and sensitivity
Ideal infant serum glucose level
above 45
She adds that her husband left her because he says he can't take her behavior any more since all she does is care for their son. What intervention should the nurse implement?
acknowledge the client's stres and suggest that she consider respite care
A client diagnosed with calcium kidney stones has a history of gout. A new prescirption for aluminum hydroxide (Amphogel) is cheduled to begin at 0730. Which client medicaiton should the nruse bring to the healthcare provider's attention?
allopurinol (zyloprim)
Pancreatitis
assess for pain
ERSD end stage renal disease
assess potassium, and calcium
Diabetic Mom
baby will have hyperbilirubinemia respiratory distress cardiomyopathy
A 7-year-old boy is brought to the clinic because of facial edema. He reports that he has been voiding small amounts of dark, cloudy, tea-colored urine. The parents state that their son had a sore throat 2 weeks earlier, but it has resolved. After assessing the child's vital signs and weight, what intervention should the nurse implement next? a. Perform an otoscopic examination b. Measure the child's abdominal girth c. Collect a urine specimen for routine urinalysis d. Obtain a blood specimen for serum electrolytes.
c. Collect a urine specimen for routine urinalysis
Following a motor vehicle collision (MCV), a male adult in severe pain is brought to the emergency department via ambulance. His injured left leg is edematous, ecchymotic around the impact of injury on the thigh, and shorter than his right leg. Based on these findings, the client is at greatest risk for which complication? a. Arterial ischemia b. Tissue necrosis c. Fat embolism d. Nerve damage
c. Fat embolism
Aspirin is prescribed for a 9-year-old child with rheumatic fever to control the inflammatory process, promote comfort, and reduce fever. What intervention is most important for the nurse to implement? a. Instruct the parents to hold the aspirin until the child has first had a tepid sponge bath. b. Administer the aspirin with at least two ounces of water or juice. c. Notify the healthcare provider if the child complains of ringing in the ears. d. Advise the parents to question the child about seeing yellow halos around objects.
c. Notify the healthcare provider if the child complains of ringing in the ears.
The home health nruse is assessing a male client who has started peritoneal dialysis 5 days ago. Which assessment finding warrants immediate intervention by the nurse?
cloudy dialystate outpout nad rebound abdominal pain.
An adult female client is admitted to the psychiatric unit because of a complex handwashing ruitual she performed dialy that takes two hours or longer to complete. She worriesabout staying clean and refuses to sit on any of the chairs in teh day area. This client's handwashing is an example of which clinical behavior?
compulsion
A client with Alzheimer's disease is receiving trazodone, a recenrlt prescribed atypical antidepressant. The caregiver tells the home health nurse that the client's mood and sleep patterns are improved, but there is no change in cognitive ability. how should the nruse respond to this information?
confirm the desired effect of the medicaiton has been achieved.
Sleep Apnea
continuou positive airway pressure--CPAP and Nasal Mask
A female client with severe renal impairment is receiving enoxaprin (lovenox) 30 mg SUB Q BID. Which laboratory value due to enoxaparin should the nruse report to the healthcare provider?
creatinine clearnace 25 ml/minute
Priority for SIRS systemic inflammatory response syndrome
culture and sensitivity
client with a kidney transplat ask, What will happein if chronic rejection devleops?
dialysis would need to be resumed if chronic rejection becomes a reality
Cataracts
eye shield at night
A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and glycosylated hemoglobin (HbA1C) of 10%. Insulin glargine 10 unis subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h are prescribed. What aciton should the nruse includei n this client's plan of care?
fingerstick glucose assessment q6h with meals. review with the client proper foot care and prevention of injury coordinate carbohydrate controlled meals at consistent times and intervals teach subcutaneous injeciton technique, site rotaiton and insulin management
SIDS
firm mattress
Stomach
has the syringe, pours fluid into tube, one medication, instruct to use plunger Ensure the student is documenting the correct volume Make sure the correct amount is aspirated
Tumor lysis syndrome
hydration is priority
Deep tendon reflexes
hypertension
Anticipated additional medications when taking morphine include:
laxatives NSAIDS naloxone
Osteomalacia
lot's of sun exposure
A client is admitted with the diagnosis of active tuberculosis (TB). Which infection control measures should the nruse implement?
negative pressure environment
With sedatives and antidepressants watch for:
orthostatic hypotension
SOB, pulmonary edema
pink sputum
Regarding the eyes, what would the nurse be on alert for in a patient taking morphine?
pinpoint pupils
Morphine sulfate is a:
pure opioid agonist
Second stage of labor
push PUSH