Final

D5NS with 20 mEq potassium

A client with metabolic alkalosis has arrives on the unit. The nurse anticipates that the physician will order which of the following IV fluids?

Pain Assessment

A hospice nurse caring for a terminally ill client should adjust the dose of morphine administered to the client based on which assessment?

Rapid, deep respirations

The nurse is caring for a 77 year old client with an acid-base imbalance. For which of the following symptoms of metabolic acidosis would the nurse plan interventions?

metabolic alkalosis

The nurse is caring for a client who has had a nasogastric tube connected to low intermittent suction for the last three days. The nurse should monitor the client for which acid-base disorder?

Respect the clients wishes and withhold the pain medications

A client nearing death requests that no medication be given that would cause loss of consciousness, including pain medication. What would the nurse do to provide the best end-of-life care for the client?

"The facial injuries are affecting your sense of taste and flavor"

A client recovering from surgery to repair fractured bones in the face tells the nurse that dinner "tastes horrible." Which response is most appropriate?

Living will

A client tells the nurse that the client wants "everything" done if something goes wrong in the hospital. The nurse checks the clients chart for which of the following?

Metabolic acidosis

A client has been admitted for dehydration after fasting for 5 days. For which of the following acid-base imbalances would the nurse anticipate that this client is at risk?

Further assess pain to determine the best intervention.

A client indicates an intensity of 8 on the 0-10 pain scale. The best action for the nurse to take is which of the following?

Symptoms of tetany

A client is admitted to the hospital with a diagnosis of respiratory acidosis secondary to overdose of barbiturates. Which of the following assessments would the nurse make?

Coolness of extremities

A hospice nurse is working with the family of a dying client and tells the family that death is imminent. The family asks how the nurse knows this. The nurse tells the family that which of the following is a sign of imminent death?

Coughing

A nurse is caring for a client who reports problems with urinary stress incontinence. The nurse would expect the client to state that the incidence of stress incontinence occurs during which activity?

Eat small, frequent meals

A nurse is caring for a client with GERD. Which information should the nurse include in the clients discharge instructions?

Use relaxation skills such as imagery during bedtime

A nurse is counseling a client who is experiencing insomnia. Which intervention should the nurse include in the plan of care?

'Open-angle glaucoma occurs more frequently in Latinos and African-Americans"

A nurse is educating a client with glaucoma about the different types of the disease. Which statement is appropriate for the nurse to include in the teaching session?

Bloodborne

A nurse is providing community health education on hepatitis B. Which information about hepatitis B transmission is accurate?

Sleep Deprivation related to change in sleep-wake patterns.

A nurse who works days fills in for a week for a nurse who works nights. After returning to the regular shift, the nurse feels tired all the time and finds it difficult to fall asleep at night. Which nursing diagnosis is the most appropriate for the client.

Helping him to a chair or bringing a flower into the room, sitting down, speaking, touching and listening to his feelings and perceptions.

A patient has been on contact isolation for 4 days bc of a gastrointestinal infection. He has had a few visitors and few opportunities to leave his room. His ambulation is also still limited.Nursing measures to reduce sensory deprivation include:

Loud noises can cause immediate, permanent loss of hearing

An older adult client, reporting a significant loss of hearing after being involves in an explosion asks when hearing will return. Which response by the nurse is most appropriate?

pH 7.32, PaCO2 46 mmHg, HCO3 24

An older client comes to the emergency department experiencing chest pain and shortness of breath. An arterial blood gas is ordered. Which of the following ABG results indicate respiratory acidosis.

the cause of acidosis

Arterial blood gases results indicate a pH of 7.33 and a PaC02 of 38 following arrest and subsequent rescuscitation of 3-year-old child. Which nursing intervention should be employed to attempt to correct this metabolic disorder?

Motivation

In teaching a client about heart disease, the client may need to know the effects of smoking before recognizing the need to stop smoking. In this situation, what factor can best facilitate client learning?

Inform clients of reputable internet sites for health care information

One of the nurses responsibilities in client education is to:

Assist the client to a nearby chair.

The client is ambulating for the first time postoperatively and tells the nurse,"I feel faint" -The best action by the nurse includes which of the following?

Sodium bicarbonate

The clients arterial blood gases values pH 7.3, PaCO2 47, PaCO2 88, and HCO3 16.5. Which medication would the nurse anticipate being ordered?

Use of fluorescent lighting

The home care nurse is instructing a nursing assistant about interventions to facilitate location of items for patients with vision impaired vision?

Although near death, the client can probably hear the conversation.

The hospice nurse is visiting the dying client when the family sitting near by begins to talk about what to do about the client's belongings when the client dies. The nurse asks the family to discuss the subject out of the clients room for which of the following reasons?

"your child is experiencing parallel play, an appropriate action for this age."

The mother is concerned that while at childcare her toddler child plays next to other children, but does not interact while playing. What would be an appropriate response by the nurse?

"The childs temperment will determine interaction ability."

The mother of a child starting school in a few weeks is concerned how her child will interact with other children. Which response by the nurse is best to address the mothers concern?

Sleep always includes rest

The nurse explains to a client and family the relationship between rest and sleep, which includes which of the following?

Provide assistance with meals and eating

The nurse has identifies the nursing diagnosis Disturbed Sensory Perception: Visual as appropriate for a client with glaucoma. Which intervention should be added to this client's plan of care?

Identify assistive devices

The nurse identifies potential safety concerns for a client with a sensory disorder. Which intervention should the nurse include in the clients plan of care?

Risk for Injury

The nurse identifying nursing diagnoses appropriate for a client with severe symptoms of tinnitus, vertigo, sensorineural hearing deficit, nausea, and vomiting. Which diagnosis would be a priority for this client?

Risk for injury

The nurse is admitting a client with acute respiratory acidosis to the medical unit and, after assessment, selects which of the following as a priority nursing diagnosis?

Feeds self with finger foods

The nurse is assessing a toddler's psychosocial eight stages. Which behavior demonstrated by the toddler indicated a mastery of autonomy ?

Sharp, shooting pain

The nurse is aware that the A- delta fibers conduct which of the following types of pain?

Schedules care around periods of rest

The nurse is caring for a client with metabolic alkalosis. The nurse has several interventions planned for the client for the shift. The nurse delivers care to this client in which of the following ways?

Whatever the client says it is

The nurse is evaluating a client's pain. When documenting the pain, the nurse remembers the pain is

Intesity

The nurse is evaluating a clients pain. The client states that the pain is at a level 2. The client is indicating which of the following about the pain?

Fast walking is a good form of aerobic exercise

The nurse is participating in a health promotion fair. When discussing exercise, the nurse should include which of the following points?

Antioxidants and Zinc

The nurse is planning care for an older adult client diagnosed with age-related macular degeneration. What prescriptions does the nurse anticipate for this client?

Methods to self administer prescribed eye medication, Importance of attending follow-up appointments with the physician, Avoiding over-the-counter medication unless discussed with the physician

The nurse is planning instruction for a client who is newly diagnoses with glaucoma. What should be included in this teaching?

The client will experience reduced anxiety

The nurse plans care for a dying client to help the client attain which of the following priority outcomes.

Observe the clients interaction with family

The nurse suspects that a client has a hearing disorder; however, the client denies not being able to hear. Which initial action by the nurse to assess the clients hearing is appropriate?

Calcium Carbonate (Tums)

The nurse would suspect that a client who frequently uses which of the following is at risk for the development of metabolic alkalosis?

Visceral pain

When describing pain, the client states the pain is a dull, aching pain. The nurse determines that this description tends to indicate that the clients pain is most likely:

Personal motivation of the individual

Which principle should the nurse keep in mind when developing a health promotion program?

sit the client in semi fowlers

the nurse is caring for a client with pneumonia and finds the following ABG results in the clients chart. pH 7.3, PaCO2 58, HCO3 26, PaO2 72. What is the priority nursing intervention.

Community based vocational education opportunities

the nurse working in a community based clinic for developmentally delayed clients is preparing to talk with the parents of a 17-year-old boy who has developmental issues. The nurse is aware the parents are concerned about his reaching adulthood and aging out of the provided services. The nurse would prepare to talk to the parents about which topics?