Final Adult Health

The nurse is performing an assessment on an older client who is having difficulty sleeping at night Which statement by the client indicated the need for further teaching regarding measures to improve sleep?

"I drink hot chocolate before bed"

A client receiving 20 units of Humulin N insulinsubcutaneously at 8. At what time should the nurse plan to assess the client for a hypoglycemic reaction?

1700

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment findings would indicate that the client is developing meningitis as a complication of surgery?

A positive brudzinski sign

The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer?

A rigid, broad like abdomen

The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardio tamponade. Which observation would indicate that the procedure was effective?

A rise in blood pressure

Nurses performing a neurological assessment on a client and notes a positive Romberg's test period the nurse makes this determination based on which observation?

A significant sway when the client stands erect with feet together, arms at the side, in the eyes closed.

The client with myasthenia gravis has become increasingly weaker. The primary health care provider prepares to identify whether the client is reacting to an overdose of the medication or an increasing severity of the disease. An injection of edrophonium is administered. Which finding would indicate the client is in cholinergic crisis?

A temporary worsening of the condition

What is an advantage over an ET tube for long-term management of an upper Airway obstruction?

A tracheostomy tube allows for more comfortable and Mobility

The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees identify which client as most typically a victim of abuse?

A women who has advanced Parkinson's disease

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instruction should the nurse include on the list? Select all that apply

Activity should be resumed gradually A sputum culture is needed every two to four weeks once medication therapy is initiated Respiratory isolation is not necessary, because family members already have been exposed Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags

The client has had cardiac surgery 24 hours ago has had a urine output average 20 ml an hour for 2 hours. The client receives a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 ml. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg / DL in the serum creatinine level is 2.2. On the basis of these findings, the nurse would anticipate that the client is at risk for which problem?

Acute kidney injury

A client with hyperthyroidism has been given methimazole. Which nursing considerations are associated with this medication? Select all that apply

Administer methimazole with food Assess the client for unexpected bruising or bleeding Instruct the client to report side and adverse effects such as sore throat, fever, or headaches

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles. The nurse immediately asked another nurse to contact the primary health care provider and prepares to implement which priority intervention? Select all that apply

Administer oxygen Inserting a Foley catheter Administering Furosemide Administering morphine sulfate intravenously

A client develops an anaphylactic reaction after receiving morphine. The nurse should plan to Institute which action? Select all that apply

Administer oxygen Quickly assess the client's respiratory status Document the event, interventions, and clients response

A client with chronic kidney disease being hemodialyzed suddenly become short of breath and complains of chest pain. the client is tachycardic, pale, and anxious, and the nurse suspect air embolism. What are the priority nursing actions? Select all that apply

Administer oxygen to the client Notify the primary health care provider in rapid response team Stop dialysis, and turn the client on the left side with head lower than feet

Nurse management of the patient with acute pancreatitis includes? Select all that apply

Administering pain medication Monitoring for infection, particularly respiratory tract infection Checking for signs of hypocalcemia

The nurse is caring for a client hospitalized for heart failure exacerbation and suspects the client may be entering a State of Shock. The nurse knows that which intervention is the priority for this client?

Administration of digoxin

What group should the nurse Target when planning Community Education on preventing spinal cord injuries?

Adolescent and young adult men

The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority?

Airway patency

Which medication should the nurse anticipate being used first in the emergency department for relief of severe respiratory distress related to asthma?

Albuterol inhaler

The nurse is caring for an older client in a long-term care facility. Which action contributes to encouraging autonomy in the client?

Allowing the client to choose social activities.

The patient is admitted with angina, syncope, and dyspnea on exertion. In the assessment, the nurse notes a systolic murmur with a prominent S4. What will the nurse suspect is occurring with this patient?

Aortic valve stenosis

A patient with acute pancreatitis has hypovolemic shock. Which order will the nurse Implement first?

Apply high-flow oxygen with non-rebreather mask

A patient has ICP monitoring with an intraventricular catheter. What is the priority nursing intervention for the patient?

Aseptic technique to prevent infection

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. I should the nurse assess for its presence?

Ask the client to extend arms

The cardiovascular nurse is caring for a client who has had a cardiac stent placed one day ago. Which medication should the nurse expect to be ordered to prevent occlusion?

Aspirin clopidogrel (Plavix)

The nurse is caring for a client diagnosed with coronary artery disease the client has no known drug allergies. Which medication should the nurse expect to be prescribed for this client?

Aspirin 81 mg

When caring for a patient with an acute observation of a peptic ulcer, the nurse finds the patient double-dip in bed with shallow, granting respirations. Which action should the nurse take first?

Assess a patient's abdomen and vital signs

A client is brought to the emergency department with partial thickness Burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should Implement which nursing actions for this client? Select all that apply

Assess for Airway patency Administer oxygen as prescribed Elevate extremities if not fractures are present

The nurse is assessing a client abdomen and detects pulsation. Which action should the nurse perform next?

Assess pedal pulses in avoid further palpitation

The nurse is receiving an older client with a history of abdominal aortic aneurysm in the emergency department. The client presents with severe back pain and absent pedal pulses. Which action should the nurse take first?

Assess the client's blood pressure

A nurse had admitted a client with a history of chronic heart failure to the emergency department with severe dyspnea and a dry, hacking cough. Which action should the nurse take first?

Assess the client's breath sounds

A client presents to the emergency department with upper GI bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client?

Assessment of vital signs

The nurse is caring for a patient with COPD. Which intervention could be delegated to UAP?

Assisted patient to get out of bed

In instituting a bowel training program for a patient with fecal incontinence, what should the nurse plan to do first?

Assisted patient to the bathroom at the time of the patient's normal defecation

Caring for a client who has pericarditis and reports feeling an irregular heart rate and shortness of breath. The nurse should suspect which complication?

Atrial fibrillation

The nurses were watching the cardiac Monitor, and a client's Rhythm suddenly changes. There are no p waves instead, there are fibrillary waves before each QRS complex. How should the nurse interpret the clients heart rhythm?

Atrial fibrillation

A patient's tracheostomy tube begins dislodged with vigorous coughing. What should the nurse first action?

Attempt to replace the tube

A client is being treated with procainamide for a cardiac dysrhythmia. Following intravenous administration of the medication, the client complains of dizziness. What intervention should the nurse take first?

Auscultate the client apical pulse and blood pressure

The nurse is caring for a client after the insertion of a central intravenous catheter in the right Subclavian. The client complains of sudden onset chest pain and dyspnea. Which action should the nurse take first?

Auscultate the clients breath sounds

The nurse is caring for a client who has had an acute myocardial infarction two days ago. The client complains of stabbing chest pains that increases with deep breathing. Which action should the nurse take first?

Auscultate the heart sounds

The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and long congestion. Which should the nurse include for this type of assessment? Select all that apply

Auscultating lung sounds b. Obtained the client's temp c. obtaining information about the client's respirations

The nurse teaching young adults about behaviors that put them at risk for oral cancer include

Avoiding uses smokeless tobacco

The nurse is admitting a client with Guillain-Barre syndrome to the nursing unit. The client has complaints of inability to move both legs and reports a tingling sensation about the waistline. Knowing the complications of the disorder the nurse should bring which most essential items to the clients room?

Electrocardiographic monitoring electrodes and intubation tray

The nurse is reviewing a client's record and notes that the primary health care provider has documented that the client has chronic kidney disease. On reviewing the lab results the nurse most likely would expect to note which finding?

Elevated creatinine level

Which patient manifestations confirm the development of MODS?

Elevated serum bilirubin, serum creatinine of 3.8 mg/dL and platelet count 15,000 microliters

The nurse is caring for a client who is on strict bed rest and create a plan of care with goals related to the prevention of deep vein thrombosis and Pulmonary embolism. Which nursing action is most helpful in preventing these disorders from developing?

Encouraging active range of motion exercises

What Actually describes the pathophysiology of cad?

Endothelial change may be caused by chemical irritation, such as a lymphedema or by tobacco use

The nurse is giving report to an assistive personnel who will be caring for a client in hand restraints (safety devices). How frequently should the nurse instruct the AP to check the tightness of the restrained hands?

Every 30 minutes

A Nurse is providing discharge teaching to a client who has new diagnosis of heart failure. Which instruction should the nurse include in the teaching?

Exercise at least three times per week

A client recovering from head injury is participating in care. The nurse determines that the client understands measures to prevent elevation and intracranial pressure if the nurse observes the client doing which activity?

Exhaling during repositioning

Which patient is most likely to be diagnosed with short bowel syndrome?

Extensive resection of the ileum

The nurse is reviewing the lab results for a client receiving tacrolimus. Which Lab result would indicate to the nurse that the client is experiencing an adverse effect of the medication?

Fasting blood glucose of 200

The acronym FACES is used to treat patients to identify early signs of heart failure. What does the acronym mean?

Fatigue, limitation of activity, chest congestion/cough, edema, shortness of breath

When obtaining a health history from a patient suspected of having early TV, the nurse should ask the patient about what manifestations?

Fatigue, low grade fever, and night sweats

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations supports this diagnosis? Select all that apply

Fever Complaints of indigestion Pain in the upper right quadrant after a fatty meal

What are the key manifestations of bacterial meningitis?

Fever, Nuchal rigidity, and severe headaches

The nurse is assessing a client with epididymitis. The nurse anticipates which findings on physical examination?

Fever, nausea, vomiting, and painful scrotal edema

The nurse is caring for a client with severe dyspnea admitted to the medical surgical unit. Which laboratory data confirms the diagnosis of congestive heart failure?

BNP

Which diagnostic test is most useful differentiating dyspnea related to pulmonary effects of heart failure from dyspnea related to pulmonary disease?

BNP level

Which esophageal disorder is described as a pre-cancerous lesion and is associated with GERD?

Barrett's esophagus

What is the priority nursing responsibility in the prevention of shock?

Being aware if the potential for shock in all patients at risk

A patient is diagnosed with Bell's Palsy. What information should the nurse teach the patient about Bell's Palsy? Select all that apply

Bell's Palsy affects the motor branches of the facial nerves Herpes simplex virus one is strongly associated with the development of Bell's palsy Heat, gentle massage, electrical nerve, stimulation, and exercise are used to treat Bell's palsy An inability to close the eyelid, with an upward movement of the eyeball when closure is attempted, is evidence

Which components can change to adopt the small increases in intracranial pressure? Select all that apply

Blood Brain tissue Cerebrospinal fluid

The nurse assesses a newly admitted client with chronic heart failure who accidentally took too many prescribed medication and seems confused the client reports blacking out prior to admission. Which assessment should the nurse complete first?

Blood pressure

A client is having frequent premature ventricular contractions. The nurse should Place priority on assessment of which item?

Blood pressure and oxygen saturation

The ICU nurse is caring for a client receiving nitroprusside IV for acute decompensated heart failure. Which method is the best for monitoring this client blood pressure?

Blood pressure monitoring via atrial line

The nurse should report which assessment finding to the primary care provider before initiating thrombolytic therapy in a client with pulmonary embolism?

Blood pressure of 198 / 110

A client is admitted to the hospital with a diagnosis of benign prostatic hyperplasia, and a transurethral resection of the prostate is performed. 4 hours after surgery, the nurse takes the client's vital signs and empties the urine drainage bag, which assessment findings indicate the need to notify the primary health care provider?

Blood pressure, 100 / 50 pulse 130 per minute

Following kidney transplantation, cyclosporine is prescribed for a client. Which laboratory result would indicate an adverse effect from the use of this medication?

Blood urea nitrogen level of 25

A client is returning to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperative, what type of drainage should the nurse expect?

Bloody

The nurse is administering bethanechol chloride, is monitoring for cholinergic overdose associated with the medication. The nurse should check the client for which signs of overdose?

Bradycardia

A patient with a gunshot wound to the abdomen is being treated for hypovolemic and septic shock. To monitor the patient for early organ damage associated with MODS, what is most important for the nurse to assess?

Breath sounds

A cromolyn sodium inhaler is prescribed for a client with allergic asthma. The nurse provides instructions regarding the adverse effects of this medication and should tell the client that which undesirable effect is associated with the medication?

Bronchospasm

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding is noted in the client, should be reported immediately to the primary health care provider?

Bronchospasm

a cromolyn sodium inhaler is prescribed for a client with allergic asthma. The nurse provides instructions regarding the adverse effects of this medication and tell the client that which undesirable effects is associated with his medication?

Bronchospasm

The nurse is caring for a client scheduled for a transsphenoidal hypophysectomy. The pre-operative teaching instruction should include which statement?

Brushing your teeth needs to be avoided for at least 2 weeks after surgery

What statement accurately describes mitral valve prolapse?

Buckling of the valve into left atrium during ventricular systole

What physical problem Can precipitate hypovolemic shock?

Burns Ascites Hemorrhage Ruptured spleen

Since mechanical tissue trauma can trigger SIRS, the nurse will include assessing for SIRS as part of the plan of care for patients with which types of problems? Select all that apply

Burns Crush injuries Surgical procedures

What could the nurse emphasize when teaching women about the risk and incident of CAD?

CAD is the leading cause of death in women, with a high mortality rate after Mi then men

When using intraventricular ICP monitoring, what should the nurse be aware to prevent an accurate reading?

CSF is leaking around the monitoring device

The mother calls a neighbor who is a nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. The nurse would direct the mother to take which immediate action?

Call the poison control center

The patient has used sublingual nitroglycerin and various long-acting nitrates but now has an ejection fracture of 38% and is considered at high risk for cardiac event. Which medication would best be added for vasodilation and to reduce ventricular remodeling?

Captopril

The emergency nurse is caring for a client with new onset chest pain. Cardiac biomarkers are positive and the 12 lead ECG shows 2 mm elevation in three leads. The nurse should prepare the client for which intervention?

Cardiac catheterization

A client is admitted to the emergency department with chest pain that is consistent with myocardial infarction based on elevated troponin levels. Heart sounds are normal. The nurse should alert the primary health care provider because the Vital sign changes in client assessment are most consistent with which complication?

Cardiogenic shock

A client has been started on long-term therapy with rifampin. The nurse should provide which information to the client about medication?

Cause orange discoloration sweat, tears, urine, feces

A client has been started on long-term therapy with rifampin. The nurse should provide which information to the client about this medication?

Causes orange discoloration of sweat, tears, urine and feces

What Hemodynamic monitor parameter indicates to the nurse that administering large amounts of crystalloid fluids to a patient in septic shock has been effective?

Central Venous Pressure of 15 mm Hg

A patient returns to surgical unit with a nasogastric tube to low intermittent suction, IV fluid and a Jackson Pratt drain at the surgical site following an exploratory laparotomy and repair of a bowel perforation. 4 hours after Administration, the patient experiences nausea and vomiting. What is the priority nursing intervention for the patient?

Check the characteristic of gastric drainage and the patency of the NG Tube

A client is wearing a continuous cardiac monitor, which begins to sound it's alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing intervention?

Check the client status

The nurse is monitoring a client receiving peritoneal dialysis notes that the client outflow is less than the inflow. Which action should the nurse take? Select all that apply

Check the level of the drainage bag Reposition the client to her or his side place the client in good body alignment Check the peritoneal dialysis system for kinks

The nurse is assigned to care for a client in traction. The nurse creates a plan of care for the client and should include which action in the plan?

Check the weights to ensure that they are off of the floor

The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place the primary healthcare provider has now prescribed that the nasogastric tube be removed. What is the priority nursing assessment prior to removing the two?

Checking for the present of bowel sounds in all four quadrants

A fire with Crohn's disease is scheduled to receive an infusion of infliximab. What interventions by the nurse will determine the effectiveness of treatment?

Checking the frequency and consistency of bowel movements

A client is experienced pulmonary embolism. The nurse should assess for which symptoms, which is most commonly reported?

Chest pain that occurs suddenly

The emergency nurse is caring for a client who presents to the emergency department with complaints of chest pain that radiates to the left shoulder and left arm. Which diagnostic study should the nurse expect to be ordered?

Chest x-ray ECG Cardiac troponin

A client begins therapy with Theophylline. The nurse plan to teach the client to limit the intake of which items while taking this medication?

Coffee, Cola, and chocolate

A client with bowel Thriller heart disease who has a clot in the right atrium is receiving a Heparin sodium infusion at 1000 units / hour and Warfarin sodium 7.5 mg at 5 p.m. daily. The Morning laboratory results are as following: activated partial thromboplastin time 32 seconds; International normalized ratio, 1.3. The nurse should take which action based on the client's laboratory results?

Collaborate with the phcp to obtain a prescription to increase the Heparin infusion and continue the warfarin sodium as prescribed

The nurse is assessing to defibrillate a client in ventricular fibrillation. After placing the pads on the client's chest in before discharging the device, which intervention is the priority?

Confirm that the rhythm is ventricular fibrillation

The older client recently has been taking cimetidine. The nurse monitors the client for which most frequent central nervous system side effect of his medication?

Confusion

The nurse is assessing the adaptation of a client to changes in functional status after a stroke. Which observation indicates to the nurse that the client is adapting most successfully?

Consistently use adaptive equipment in your dressing self

The nurse is preparing to initiate an IV containing a high dose of potassium chloride using an IV infusion pump. While preparing to plug the pump cord into the wall, the nurse finds that no receptacle is available in the wall socket. The nurse should take which action?

Contact the electrical maintenance department for assistance.

The nurse receives a call from a client concerned about eliminating brown colored urine after taking nitrofurantoin for urinary tract infection. The nurse should take which appropriate response?

Continue taking the medication to not go in the brown urine occurs and is not harmful

A patient is hospitalized after a successful resuscitation of an episode of sudden cardiac death. During the care of the patient, What nursing intervention is most important?

Continuous ecg monitoring

A client with diabetes demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. What is the appropriate intervention to decrease the client's anxiety?

Convey empathy, trust, and respect toward the client.

A client with myocardial infarction Suddenly becomes tachycardic, show signs of air hunger, and begins coughing frothy pink tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds?

Crackles

The nurse is performing an assessment on an older adult client. Which assessment data would indicate a potential complication associated with the skin?

Crusting

The long-term care nurse is performing assessments on several of the residents. Which are normal age-related physiological changes the nurse should expect to note? Select all that apply.

Decline in visual acuity Increased susceptibility to urinary tract infections Increased incidence of awakening after sleep onset

A client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign prostatic hyperplasia, the nurse determines that the client should be questioned about the use of which medication?

Decongestants

The healthcare provider prescribes spironolactone for the patient with chronic HF. What diet modification related to the use of this drug should the nurse include in the patient's teaching?

Decrease both sodium and potassium intake

Progressive tissue hypoxia leads to anaerobic metabolism and metabolic acidosis is characteristic of the progressive stage of shock. What changes in the heart contributes to this increasing tissue hypoxia?

Decrease perfusion occurs, leading to dysrhythmias, decreased Co, and decrease oxygen delivery to cells

The nurse is collecting data from a client. Which symptom described by the client is characteristic of an early symptom of benign prostatic hyperplasia?

Decreased force in the Stream of urine

An early sign of increased ICP that the nurse should assess for is?

Decreased level of consciousness

What is the key factor in describing any type of shock?

Decreased tissue perfusion

What should the nurse assess the patient for during administration of IV norepinephrine?

Decreased tissue perfusion

The nurse is preparing a discontinued a client nasogastric tube. The client is positioned properly, the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse should make which statement to the client?

Deep breath when I tell you, and hold it while I remove the tube

The nurse is caring for a client experiencing acute lower gastrointestinal bleeding. In developing the plan of care, which priority Problem should the nurse assigned to this client?

Deficient fluid volume related to acute blood loss

The nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. The nurse is planning to use a tracheostomy plug and plan to insert it into the opening in the outer cannula. Which nursing action is required before plugging the two?

Deflate the cuff on the tube

Packed red blood cells have been prescribed for a female client with anemia who has a hemoglobin level of 7.6 and a hematocrit level of 30%. The nurse takes the clients temperature before hanging the blood transfusion and records 100.6 orally. Which action should the nurse take?

Delay hanging the blood and notify the primary health care provider

The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking Which intervention should the nurse take first?

Determine whether there are medication duplications.

The nurse is monitoring a client with hypertension who is taking Propranolol. Which assessment finding indicates a potential adverse complication associated with this medication?

Development of expiratory wheezing

Terbutaline is prescribed for a client with bronchitis. Which disorder in the client's medical history requires caution by the nurse?

Diabetes

The nurse is monitoring a client with heart failure he was taking Digoxin. Which findings are characterized digoxin toxicity? Select all that apply

Diarrhea Blurred vision Nausea and vomiting

The nurse has given a client taking ethambutol information about the medication. The nurse determines that the client understands the instructions if the client states that they will immediately report which findings?

Difficulty in discriminating the color red from green

The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client?

Diminished breath sounds

A client with trigeminal neuralgia tells the nurse that acetaminophen is taken daily for the relief of generalized discomfort. Which lab value would indicate toxicity associated with this medication?

Direct bilirubin level of 2

The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the t-tube has drained 750ml of green brown drainage since the surgery. Which nursing intervention is most appropriate?

Document the findings

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the Water Seal chamber. Which is the most appropriate nursing action?

Document the findings

A patient with asthma has the following ABB result early an acute asthma attack: pH 7.4 8, partial pressure of carbon dioxide in a True Blood 30, partial pressure of oxygen in atrial blood 78. What is the most appropriate action by the nurse?

Document the findings and monitor the abg's for Trends acidosis

The nurse is assessing the function of a chest tube drainage system in a client with a chest injury who has just returned from the recovery room following a thoracotomy resection. Which are the expected assessment findings? Select all that apply

Drainage system maintain below the clients chest 50 mL of drainage in the drainage collection chamber Occlusive dressing in place over the chest tube insertion site Fluctuation of water in the tube In The Water Seal chamber during inhalation and exhalation

The nurse provides discharge instructions to a client receiving trimethoprim-sulfamethoxazole. Which instruction should be included in the list?

Drink eight to 10 glasses of water per day

A client with AIDS has histoplasmosis. The nurse should assess the client for which expected findings?

Dyspnea

The community health nurse is conducting an educational session with community members regarding the signs and symptoms associated with tuberculosis. The nurse informs the participants that tuberculosis is considered as a diagnosis if which signs and symptoms are present? Select all that apply

Dyspnea Night sweats A bloody, productive cough A cough with the expectoration of mucoid sputum

a male client has a tentative diagnosis of urethritis The nurse should assess the client for which manifestations of the disorder?

Dysuria and penile discharge

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that Spinal shock persist?

Flaccid paralysis

A client has had surgery to create an ileostomy. The nurse assesses the client in the immediate post-operative period for which most frequent complication of this type of surgery?

Fluid and electrolyte imbalance

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present?

Fluid separate into concentric rings and test positive for glucose

The client admitted to the hospital with her suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply

Gray blue color at the flank Abdominal guarding and tenderness Left upper quadrant pain with radiation to the back

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific primary health care provider prescription, the nurse should safely place the client in which position? Select all that apply

Head midline Neck in neutral position Head of bed elevated 30 to 45 degrees

The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse should assess the client during dialysis for which Associated manifestation?

Headache, deteriorating level of Consciousness, and twitching

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder?

Headache, restlessness, and confusion

A patient is admitted to the emergency department with SCI at the level of T2. Which assessment finding would most concern the nurse?

Heart rate of 42

A client has been taking omeprazole for four weeks. The ambulatory care nurse evaluates that the client is receiving the optimal intended effect of the medication if the client reports the absence of which symptom?

Heartburn

A client with chronic kidney disease is receiving epoetin alpha. Which lab result would indicate a therapeutic effect of this medication?

Hemoatcrit of 33%

The nurse discusses plans for future treatment options with a client with symptomatic polycystic kidney disease. Which treatment should be included in the discussion? Select all that apply

Hemodialysis Kidney transplant Bilateral nephrectomy

The primary health care provider has determined that a client has contracted hepatitis A based on flu-like symptoms and jaundice. Which statement made by the client supports the medical diagnosis?

I ate shellfish about 2 weeks ago at a local restaurant

A sexually active young adult client has developed viral hepatitis. Which client statement indicates the need for further teaching?

I can go back to work right away

The nurse teaches a client newly diagnosed with type 1 diabetes about storing humulin N insulin. Which statement indicates to the nurse that the client understood the discharge teaching?

I can store the open insulin bottle in the kitchen cabinet for one month

The nurse is teaching the client about his prescribed Prednisone. Which statement, if made by the client, indicates that further teaching is necessary?

I can take aspirin or my antihistamine if I need it

The nurse is instructing a client with Parkinson's disease about preventing Falls. Which client Statement reflects a need for further teaching?

I don't need to use my Walker to get to the bathroom

The nurse is caring for a client receiving an albuterol/ipratropium nebulized breathing treatment. Which report from the clients should the nurse note as an expected side effect of this combination medication?

I feel like my heart is racing

The nurse is teaching a client who is beginning antiviral therapy for influenza. Which statement by the client indicates an understanding of the instructions?

I must take the medication exactly as prescribed

The nurse is providing discharge teaching for a client newly diagnosed with type 2 diabetes who has been prescribed metformin. Which client statement indicates the need for further teaching?

I need to constantly watch for signs of low blood sugar

When the nurse provides instructions to a client about measures to treat inflammatory bowel syndrome. Which statement by the client indicates a need for further teaching?

I need to limit my intake of dietary fiber

The home health nurse visits a client with a diagnosis of type one diabetes. The client reports a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching?

I need to stop my insulin

The nurse is teaching a client with hyperparathyroidism how to manage the condition at home. Which response by the client indicates the need for additional teaching?

I should consume less than one liter of fluid per day

The nurses teach the client who's newly diagnosed with diabetes insipidus about the prescribed intranasal desmopressin. Which statement by the client indicates understanding? Select all that apply

I should decrease my oral fluids when I start this medication I should report headaches and drowsiness to my doctor since these symptoms could be related to my desmopressin.

The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instructions?

I should increase the fiber in my diet

The nurse has conducted discharge teaching with a client diagnosed with tuberculosis who has been receiving medication for 2 weeks. The nurse determines that the client has understood the information if the client makes which statements?

I should not be contagious after two to three weeks of medication therapy

The client with hyperparathyroidism is taking alendronate. Which statements by the client indicate an understanding of the proper way to take this medication? Select all that apply

I should sit up for at least 30 minutes after taking this medication I should take this medication first thing in the morning on an empty stomach

The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines the client needs further teaching if the client makes which statements

I tried to eat my food either very warm or very cold

A staff nurse is precepting a new graduate nurse and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management?

I will be sure to queue in to any indicators that the client may be exaggerating their pain.

A client with terminal cancer arrives at the emergency department Dead on Arrival. After an autopsy is prescribed, the client's family requests that no autopsy be performed. Which response to the family is most appropriate?

I will contact the medical examiner regarding your request

The nurse has completed discharge instructions for client with application of a Halo device who sustained a cervical spinal cord injury. Which statement indicates that the client needs further classification of the instructions?

I will drive only during the daytime

The nurse teaches skin care for a client receiving external radiation therapy. Which client statement indicates the need for further instruction?

I will limit sun exposure to 1 hour daily

The nurse provides instructions to a client newly diagnosed with type one diabetes. The nurse recognizes accurate understanding of measures to prevent DKA when the client makes which statement?

I will notify my primary care provider if my blood glucose level is higher than 250

The nurse is planning to discharge a client with chronic stable angina. The nurse is teaching the client how to use the prescribed short-acting and long-acting nitrates. Which client statement indicates that the teaching has been effective?

I will stop what I am doing in sit down before I put the nitroglycerin under my tongue

The nurse provides discharge instructions to a client with atrial fibrillation who is taking Warfarin sodium. Which statement, by the client, reflects the need for further teaching?

I will take coated aspirin for my headaches because it will code my stomach

The nurse determines the client needs further instruction on cimetidine if which statement were made? Select all that apply

I will take the cimetidine with my meals I'll know the medication is working if my diarrhea stops Taking the cimetidine with an antacid will increase its effectiveness

The nurse teaches a client about the effects of diphenhydramine, which has been prescribed as a cough suppressant. The nurse determines that the client needs further instructions if the client makes which statement?

I will take the medication on an empty stomach

The home health care nurse is visiting a client with coronary artery disease with elevated triglyceride levels in a serum cholesterol level of 398. The client is taking cholestyramine, and the nurse teaches the client about the medication. Which statement by the client indicates the need for further teaching?

I'll continue my nicotinic acid from the health food store

The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatiophy Procedure. The nurse determines that the client needs further information if the client makes which statement?

I'm glad I don't have to lie steal for this procedure

A patient with Addison's disease comes to the e d with reports of nausea, vomiting, diarrhea, and fever. What interprofessional care what the nurse expect?

IV administration of hydrocortisone

A client is admitted to the hospital with a diagnosis of DKA. The initial blood glucose level is 950. a continued IV infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decrease to 240. The nurse should next prepare to administer which medication?

IV fluids containing dextrose

The client is admitted to a hospital with a diagnosis of DKA. The initial blood glucose level is 950. A continuous IV infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240. The nurse would next prepare to administer which medications?

IV fluids containing dextrose

The nurse is preparing to administer dopamine to a client with acute decompensated heart failure. Which route of administration should the nurse use to administer the medication?

IV infusion via infusion pump

When the patient who is diagnosed with an MI is not relieved of chest pain with IV NTG, which medication will the nurse expect to be used?

IV morphine sulfate

The nurse provides instruction to a client about Nicotinic acid prescribed for hyperlipidemia. Which statement by the client indicates an understanding of the instructions?

Ibuprofen taken 30 minutes before the Nicotinic acid may decrease the Flushing

The nurse is providing medication instructions to an older client who is taking digoxin daily. The nurse explains to the client that decreased lean body mass and decreased glomerular filtration rate, which are age-related body changes, could place the client at risk for which complications with medication therapy?

Increased risk for digoxin toxicity.

The nurse is caring for a client with increase intracranial pressure as a result of a head injury. The nurse would know which Trend in vital signs if the intracranial pressure is rising?

Increasing temperature, decrease pulse, decreasing respirations, increased blood pressure.

What causes an initial incomplete SCI to result in complete Cord damage?

Infarction and necrosis of the cord caused by a demon, a hemorrhage, and metabolites

The nurse plans long-term goals for the patient who has had heart transplant with the knowledge that what is the most common cause of death in heart transplant patients during the first year?

Infection

A client with a urinary tract infection is receiving ciprofloxacin by intravenous route. The nurse appropriately administers the medication by performing which action?

Infusing slowly over 60 minutes

The community health nurse is providing a teaching session about anthrax to members of the community and asks the participants about the methods of transmission. Which answer by the participants would indicate that teaching was effective? Select all that apply.

Inhalation of bacterial spores Through a cut or abrasion in the skin Ingestion of contaminated undercooked meat

The nurse is admitting a client who is diagnosed with SIADH and has a serum Sodium of 118. Which Primary Health care provider prescriptions should the nurse anticipate receiving? Select all that apply

Initiate an infusion of 3% in NaCl Restrict fluids to 800ml over 24 hour Administer a vasopressin antagonist as prescribed.

A client with severe back pain and hematuria is found to have hydronephrosis due to urolithiasis. The nurse anticipates which treatment will be done to relieve the obstruction? Select all that apply

Insertion of a nephrostomy tube Placement of a uterine stent with ureteroscopy

The nurse is monitoring a client receiving levothyroxine sodium for hypothyroidism. Which findings indicate the presence of side effects associated with this medication? Select all that apply

Insomnia Weight loss Mild heat intolerance

The nurse should include which interventions in the plan of care for a client with hypothyroidism? Select all that apply

Instruct the client about thyroid replacement therapy Encourage the client to consume fluids and high fiber foods in the diet Instruct the client to contact the primary health care provider if episodes of chest pain occur

A client is brought to the emergency department in an unresponsive state, and a diagnosis of HHS is made. The nurse would immediately prepare to initiate which anticipated Primary health care provider's prescription?

Intravenous infusion of normal saline

The nurse should evaluate that defibrillation of a client was most successful if which observation was made?

Irascible, sinus rhythm, blood pressure 116/72

The nurse suspect stable angina rather than Mi pain in the patient who reports that his chest pain

Is released by NTG

The nurse working in the emergency department is assessing a client who recently returned from Nigeria and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action should the nurse take next?

Isolate the client in a private room.

An external insulin pump is prescribed for a client with diabetes. When the client asks the nurse about the functioning of the pump, the nurse faces the response on which information about the pump?

It administers a small continuous dose of short-duration insulin subcutaneously. The client can self-administer an additional bolus dose from the pump before each meal.

A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be most concerned about with this dysrhythmia?

It can develop into ventricular fibrillation at any time

The patient had a blood transfusion reaction what is the best explanation the nurse can give the patient as to why hemolytic jaundice that has occurred?

It is caused by increased breakdown of red blood cells that increase serum unconjugated bilirubin

A client newly diagnosed with diabetes is instructed by the primary health care provider to obtain Glucagon for emergency home use. The client Ask a home-care Nurse about the purpose of the medication. What is the nurses best response to the clients question?

It is for the time when your blood glucose is too low from too much insulin

To treat a cirrhotic patient with hepatic encephalopathy, lactulose, rifaximin, and a protein pump inhibitor are ordered. The patient's family wants to know why the laxative is ordered. What is the best explanation the nurse can give to the patient's family?

It's traps ammonia and eliminates it in the feces

A patient with hepatitis A is in the acute phase. The nurse plans care for the patient based on knowledge that

Itching is common problem with jaundice in this phase

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply

Keeping the Linens wrinkle free under the client Preventing unnecessary pressure on the lower limbs Turning and repositioning the client at least every 2 hours

What causes the pain that occurs with MI?

Lactic acid accumulation during anaerobic metabolism

A client is receiving a continuous IV infusion of heparin sodium to treat DVT. The client activated partial thromboplastin time is 65 seconds. The nurse anticipates which action is needed?

Leave the rate of heparin infusion as is normal is 30 to 40 what happened to prevent DVT range is 45 to 100

The nurse is monitoring a client diagnosed with acromegaly who was treated with transsphenoidal hypophysectomy and is recovering in the ICU. Which findings should alert the nurse to the presence of possible postoperative complications? Select all that apply

Leukocytosis Urinary output of 800 milliliters an hour Clear drainage on nasal drip pad

The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which lab result should the nurse expect to know if the client does have appendicitis?

Leukocytosis with shift to the left

The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measures to assist in preventing dumping syndrome?

Limit the fluids taken with meals

The nurse is reviewing the whole medication list of a client with chronic stable angina, and ejection fracture of 35%, and hypertension. Which medication should the nurse expect to be on the list?

Lisinopril

A client with tuberculosis is starting anti-tuberculosis therapy with isoniazid. Before giving the client the first dose, the nurse should ensure that which Baseline study has been completed?

Liver enzyme levels

Zafirlukast is prescribed for a client with bronchial asthma. Which Laboratory test does the nurse expect to be prescribed before the administration of this medication?

Liver function tests

The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicate effective coping? Select all that apply

Looking at old snapshots of family Participating in a senior citizens program Visiting the spouse's grave once a month Decorating a wall with the spouse's pictures and awards received.

The nurse is caring for a client who begins to experience seizure activity while in bed. Which action should the nurse take? Select all that apply

Loosening a restrictive clothing Removing the pillow and raising padded side rails Positioning the client to the side, if possible, with the head Flex forward

A patient with a lung Mass found on chest x-ray is undergoing further testing. The nurse explains that a definitive diagnosis of lung cancer can confirm using which diagnostic test?

Lung biopsy

The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply

Maintain NPO status Encourage coughing and deep breathing Hydromorphone intravenously as prescribed for pain

What should the nurse teach the patient with diverticulosis to do?

Maintain a high fiber diet and encourage fluid intake of at least two liters daily

Client is admitted to the emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially?

Maintain a patent airway

What should the nurse do when providing care for a patient with an acute attack of trigeminal neuralgia

Maintain a quiet, comfortable dress free environment

During the treatment of the patient was bleeding esophageal varices, what is the most important thing the nurse should do?

Maintain the patient's Airway and prevent it aspiration of blood

When administering any vasoactive drug during the treatment of shock, what should the nurse recognize as the goal of the therpay?

Maintaining a MAP >65

The nurse is providing care to a Puerto Rico American client who is terminally ill. Numerous family members are present most of the time, and many of the family members are very emotional. What is the most appropriate nursing action for this client?

Make the necessary arrangements to the family members can visit

Which drug treatment helps decrease ICP by expanding plasma and the osmotic effect to remove fluid?

Mannitol

A patient with severe trauma has been treated for hypovolemic shock. What assessment finding is consistent with the refractory stage of shock?

Marked hypertension and refractory hypoxemia

A patient is admitted to the emergency department with an acute asthma attack. Which patient assessment is at greatest concern to the nurse?

Markedly decreased breath sounds with no wheezing

The nurse is taking the history of a client with occupational lung disease (silicosis). The nurse should assess whether the client wears which item during periods of exposure to silica particles?

Mask

The nurse is caring for a client with chronic kidney disease on continuous replacement renal therapy without the use of hemodialysis machine. The nurse determines that which parameter is most important in ensuring success of the treatment?

Mean arterial pressure

A client with a history of type 2 diabetes is admitted to the hospital with chest pain. The client is scheduled for a cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure in for 48 hours after the procedure?

Metformin

The nurse is caring for a client with chronic back pain. Codeine has been prescribed for the client. Specific to this medication, which intervention should the nurse include in the plan of care while the client is taking this medication?

Monitor bowel activity

Which characteristics describe the anticoagulant Warfarin? Select all that apply

Monitor dosing using INR Vitamin K is the antidote

The nurse is caring for a client with surgical repair of abdominal aortic aneurysm. Which nursing action should be included in the plan of care?

Monitor fluid intake and urine output

The client is receiving an electrocardiogram Rhythm strip. The p waves and QRS complexes are regular. The PR interval is 0.16 seconds, in QRS complex measures 0.06 seconds. The overall heart rate is 64 beats per minute. Which action should the nurse take?

Monitor for any rhythm changes

A client is diagnosed with a stemi and is receiving a tissue plasminogen activator, alteplase. Which action is a priority nursing intervention?

Monitor for signs of bleeding

Vigorous control a fever in the patient with meningitis is needed to prevent complications of increased cerebral edema, seizures frequency, neurological damage, and fluid loss. What nursing care should be included?

Monitor loc related to increase brain metabolism

A client has had a radical neck dissection and begins to Hemorrhage at the incision site. The nurse should take which actions in this situation? Select all that apply

Monitor vital signs Monitor the client's Airway Apply manual pressure over the site Call the primary health care provider immediately

A patient with Guillain-Barre syndrome asked whether he is going to die as the paralysis spreads towards his chest. To be able to best answer this question, what should the nurse now?

Most patients with Guillain Barre syndrome do not die, but recover

The nurse has just administer the first dose of omalizumab to a client. Which statement by the client alerts the nurse of a life-threatening effect?

My lips and tongue are swollen

A client with variant angina is scheduled to receive an oral calcium channel blocker twice-daily. Which statement by the client indicates the need for further teaching?

My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning

The nurse is assessing the motor and sensory function of an unconscious client who sustained a head injury. The nurse should use which technique to test the client peripheral response to pain?

Nailbed pressure

The nurse notes that a client ABG results reveal a pH of 7.50 and a Paco2 of 30. The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply.

Nausea Confusion Tachycardia Lightheadedness

A client has an as-needed prescription for ondansetron. For which condition should the nurse administer this medication?

Nausea and vomiting

Which characteristics describe unstable angina? Select all that apply

New onset angina with minimal exertion Characterized by increased duration of severity

The nurse is caring for a client with chronic stable angina. Which medication should the nurse expect to be ordered to reduce the frequency of angina attacks?

Nitropaste

The nurse is conducting an interview of an older client and is concerned about the possibility of benign prostatic hyperplasia. Which are characteristics of this disorder? select all that apply

Nocturia Incontinence Enlarged prostate

The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis the client complains of a headache and nausea and is extremely Restless. Which is the priority nursing action?

Notify primary health care provider

The client is admitted to the emergency department following a fall from a horse, the primary health care provider prescribes insertion of urinary catheter. While preparing for the procedure, the nurse notes blood at the urinary meatus. The nurse should take which action?

Notify the phcp before performing the catheterization

A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the clients temperature is 101.2. Which nursing action is most appropriate?

Notify the primary health care provider

The nurse is caring for a client immediately after repair of an abdominal aortic aneurysm. Upon assessment, the nurse notes absent popliteal, the posterior tibial and dorsal pedis pulse. The legs are cool and molted. Which action should the nurse take first?

Notify the surgeon and anesthesiologist

When shock occurs in the patient with pulmonary embolism or abdominal compartment syndrome, what type of shock would that be?

Obstructive shock

The nurse is preparing a list of home care instructions regarding stoma and laryngectomy care for a client with laryngeal cancer who had laryngectomy. Which instruction should be included in the list? So it's all that apply

Obtain a Medic Alert bracelet Prevent debris from entering the stoma Avoid exposure to people with infections Avoid swimming and use care when showering

Potassium chloride intravenously is prescribed for a client with heart failure experiencing hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply.

Obtain and IV infusion pump Monitor urine output during administration Monitor the IV site for signs of infiltration or phlebitis Ensure that the medication is diluted in the appropriate volume or fluid. ensure that the bag is labeled so that it reads the volume of potassium in the solution.

The emergency nurse has admitted a client with chest pain. The client EKGs reveals ST depression >2 in three leads. Vital signs are BP 190 / 98, heart rate 110, respiratory rate 26, and O2 saturation 85% on room air. Which action are the nurses priority? Select all that apply

Obtain blood for cardiac enzyme studies as ordered Administer nitroglycerin sublingual as described Administer oxygen at 2L by nasal cannula

The nurse provides instruction to a client who is taking levothyroxine. The nurse should tell the client to take the medication in which way?

On an empty stomach

A client with a gastric ulcer has a prescription for sucralfate 1 gram by mouth four times daily. The nurse should schedule the medication for which times?

One hour before meals and at bedtime

The teaching plan for the patient being discharged after an acute episode of upper GI bleeding includes information about the importance of? Select all that apply

Only taking drugs prescribed by the healthcare provider Avoiding taking aspirin and drugs containing aspirin

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measure should the nurse include in planning for the client's safety? Select all that apply

Padding the side rails of the bed Placing an airway at the bedside Placing oxygen and suction equipment at the bedside Flushing the intravenous catheter to ensure that the site is patent

The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which manifestations of duodenal ulcers?

Pain relieved by food intake

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding?

Pain, especially with inspiration

What clinical manifestation would the nurse observe when a patient is in the compensatory stage of shock? Select all that apply

Pale and cool Tachypnea and tachycardia

The nurse is assessing the patency of the clients left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent?

Palpitation Of A Thrill over the fistula

A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of a flail chest?

Paradoxical chest movement

The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which items when performing this care?

Particulate respirator, gown, and gloves

The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85. Which dietary selection does the nurse suggested a client?

Pasta with sauce

A patient is admitted to the emergency department with profuse bright red hematemesis. During the initial care of the patient, what is the nurses first priority?

Perform a focus nursing assessment of the patient status

A client has been taking isoniazid for 2 months. The client complains to the nurse about numbness, paresthesia, and tingling in the extremities. The nurse interprets that the client is experiencing which problem?

Peripheral neuritis

The nurse is caring for an older adult who has been placed in Buck's extension traction after a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. What is the best nursing action based on this information?

Place a clock and calendar in the clients room

A client with acute kidney injury has a serum potassium level of 7. The nurse should plan which action as a priority? Select all that apply

Place the client on a cardiac monitor Notify the primary health care provider Review the clients medication to determine whether any contain or retain potassium

The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention, if noted in the plan, indicates the need for revision of the plan?

Placing the client in semiprivate room at the end of the hallway.

The nurse is monitoring a client newly diagnosed with diabetes for signs of complications. Which sign or symptom, if frequently exhibited in the client, indicates that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed?

Polyuria

During the cute exclamation of mild COPD, the patient is severely short of breath. The nurse identifies a nursing diagnosis of impaired breathing, Etiology, alveolar hyperventilation and anxiety. What is the best nursing action?

Position the patient up right with the elbows resting on the over the bed table

A client who is HIV-positive has had a tuberculin skin test. The nurse notes a 7 mm area of induration at the side of the skin test in interprets the results as which finding?

Positive

The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Paco2 of 30. The nurse has determined that the client is experiencing respiratory alkalosis. Which lab value would most likely be noted in this condition?

Potassium level of 3

A client with diabetes visits a healthcare clinic. The client's diabetes previously had been well controlled with glyburide daily, but recently the fasting blood glucose level has been 180 to 200. Which medication, if added to the client's regimen, may have contributed to the hyperglycemia?

Prednisone

A client in sinus bradycardia, with a heart rate of 45 beats per minute and blood pressure of 82/64 reports dizziness. Which intervention should the nurse anticipate will be prescribed?

Prepare for a transcutaneous pacing

A client with diabetes has A1C level of 8%. On the basis of this results, the nurse plans to teach the client about the need for which measure?

Preventing and recognizing hyperglycemia

The nurse is caring for a client who had resection of an abdominal aortic aneurysm yesterday. The client has an intravenous infusion at a rate of 150 ml/hour, uncharged for the last ten hours. The clients urine output for the last 3 hours has been 90, 50, and 28 ml. The clients blood urea nitrogen level is 35 mg / DL, and the serum creatinine level is 1.8, measured this morning. Which nursing action is the priority?

Primary health care provider

The nurse is caring for a client with meningitis and implements which transmission-based precaution for this client?

Private room or cohort client

The nurse is caring for a client with Crohn's disease who has a calcium level of eight. Which patterns would the nurse watch for on the ECG?

Prolonged UTI intervals Prolonged St segments

What is the most important role of the nurse in preventing rheumatic fever?

Promote the early diagnosis and immediate treatment of group a streptococcal pharyngitis

The nurse is teaching the patient and family that peptic ulcers are

Promoted by a combination of factors that cause erosion of the gastric mucosa, including certain drugs and H pylori

Important nursing intervention when caring for a patient with Cushing syndrome include? Select all that apply

Protecting the patient from exposure to infection Monitoring blood glucose levels

An important nursing intervention for a patient with a small intestinal obstruction who has an NG tube is to?

Provide mouth care frequently

A client with Guillain-Barre syndrome has ascending paralyzes and intubated and receiving mechanical ventilation. Which strategy would the nurse incorporate in the plan of care to help a client cope with this illness?

Providing information, giving positive feedback, and encouraging relaxation

When the V/Q lung scan results show a mismatch ratio that >1, which condition should be suspected?

Pulmonary embolus

The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the primary health care provider?

Purple discoloration of the stoma

When patient reports chest pain, why must unstable angina be identified in rapidly treated?

Rapture of unstable plaque may cause complete thrombosis of the vessel lumen

The client has begun medication therapy with pancrelipase. The nurse evaluates that the medication is having the optimal intended benefit if which effect is observed?

Reduction of steatorrhea

The home care nurse visits a client recently diagnosed with diabetes who is taking Humulin NHP insulin daily. The client asked the nurse how to store the unopened vials of insulin. The nurse should tell the client to take which actions?

Refrigerate the insulin

A client here uses NSAIDs has been taking misoprostol. The nurse determines that the misoprostol is having the intended therapeutic effect if which finding is noted?

Relief of epigastric pain

The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for a client which is the priority nursing action?

Removing the client from any immediate Danger

The client is to begin a 6-month course of therapy with isoniazid. The nurse should plan to teach the client to take which action?

Report yellow eyes or skin immediately

The clinic nurse is assessing a client who is taking furosemide for the treatment of heart failure and now complains of generalized weakness. Which action by the nurse is correct?

Request an order for a basic metabolic panel

The nurse is caring for a client with DKA in documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe?

Respirations that are increase in rate respirations that are abnormally deep this is caused by compensatory reactions

The nurse reviews the ABG results of a client with emphysema and notes that the lab report indicates a pH of 7.30, paco2 of 58, PA02 80, and hco3 of 27. The nurse interpret that the client has which acid-base disturbance?

Respiratory acidosis

The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid base imbalance?

Respiratory acidosis from inadequate ventilation

The client who is unresponsive has ABG drawn and the results indicate the following: PH is 7.12, Paco2 is 90, and HCO3- is 22. The nurse interprets the results as indicating which condition?

Respiratory acidosis without compensation

The nurse reviews the ABG results of a client and notes the following: pH 7.45, Paco2 of 30 and HCO3- of 20. The nurse analyzes these results as indicating which condition?

Respiratory alkalosis, compensated normal pH is 7.35 to 7.45. The pH is on the higher side with the PCO 2 is low this shows compensation from the kidneys.

The nurse is preparing to administer morphine sulfate to a client with acute decompensated heart failure. Which nursing assessment is the priority for the client?

Respiratory assessment

The patient was in traffic collision and has loss of function below C4. Which affect most influences how the nurse prioritize care?

Respiratory diaphragmatic breathing

Define is admitted to the hospital with a diagnosis of Guillain-Barr syndrome. Which past medical history finding makes the client most at risk for this disease?

Respiratory or gastrointestinal infection during the previous month

Oxybutynin chloride is prescribed for a client with urge incontinence. Which sign would indicate a possible Toxic effect related to this medication

Restlessness

Which assessment findings would lead the nurse to suspect the early onset of hypoxemia?

Restlessness

The nurse is preparing to administer a dose of naloxone intravenously to a client with an opioid overdose. Which supportive medical equipment should the nurse plan to have at the client's bedside?

Resuscitation equipment

The nurse notes documentation that a client is exhibiting cheyne Stokes respiration. On assessment of the client, the nurse should expect to note which findings?

Rhythmic respirations with periods of apnea

Medical surgical nurse is caring for a client admitted with acute exacerbation of chronic heart failure two days ago. The client began diuretic therapy with spironolactone upon admission. Which lab study should the nurse monitor?

Serum potassium levels Creatinine BUN

In the patient with chest pain, which result can distinguish unstable angina from an MI?

Serum troponin level increased four to six hours after infarct

The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's house. Which interventions are appropriate? Select all that apply

Set the room temperature at a comfortable level Remove distracting objects from the interviewing area Ensure comfortable seating at eye-level for the client and nurse

The nurse is providing discharge teaching to a client who is recovering from an acute MI. The client as the nurse when sexual intercourse can be resumed. Which response by the nurse is correct?

Sexual activity, like other forms of activities, should be gradually resumed after a mi. Sexual activity uses about as much energy as climb two flights of stairs.

The nurse provides discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client indicates to report which early signs of exacerbation?

Shortness of breath

A client is about to undergo a lumbar puncture. The nurse describe to the client that which position will be used during the procedure?

Sidelines with the legs pulled up in the head bent down onto the chest

rifabutin is prescribed for a client with active mycobacterium avium complex disease in tuberculosis. The nurse should monitor for which side and adverse effects of rifabutin?

Signs of hepatitis Flu like syndrome Low neutrophil count Ocular pain or blurred vision

The nurse is creating a plan of care for a client and skin traction. The nurse should monitor for which priority findings in the client?

Signs of skin breakdown

A client's electrocardiogram strip shows atrial and ventricular rate of 110 beats per minute the PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, in the pp end r r intervals are regular. How should the nurse interpret this rhythm?

Sinus tachycardia

The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs a client that which positions alleviate dyspnea?Select all that apply

Sitting up and leaning on a table Standing in leaning against a wall Sitting up with elbows resting on knees

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic period. Which position should the nurse instruct the client to assume?

Sitting up and leaning on an overbed table

Before surgical stabilization of a cervical SCI, what method of patient and mobilization should the nurse expect to be used?

Skeletal traction with skull tongs

A client is taking the prescribed dose of Phenytoin to control seizures. Result of a phenytoin blood level study reveals a level of 35. Which finding would be expected as a result of this lab result?

Slurred speech

trimethoprim-sulfamethoxazole is prescribed for a client. The nurse should instruct the client to report which symptoms if it develops during the course of this medication therapy?

Sore throat

A male patient has COPD and is a smoker. The nurse notes respiratory distress and no breath sounds over the left chest. Which type of Pneumothorax should the nurse suspect is occurring?

Spontaneous pneumothorax

The nurse performs an administration assessment on a client with a diagnosis of tuberculosis. The nurse should check the results of which diagnostic test that will confirm the diagnosis?

Sputum culture

A client at risk for shock secondary to pneumonia develops restlessness and is agitated and Confused. Urinary output has decreased and the blood pressure is 92/68. The nurse minimally is aspects which stage of shock based on this data?

Stage 2

A client complains of fever perineal pain, and urinary urgency; frequencies, and dysuria. To assess whether the clients problem is related to bacterial prostatitis, the nurse reviews the results of the prostate Examination for which characteristic of this disorder?

Tender, indurated prostate gland that is warm to the touch

The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action?

Test the drainage for glucose

Which condition is transmitted through one contamination, causes painful tonic spasms or seizures, and can be prevented by Immunization?

Tetanus

The nurse is assessing a clients expected of having meningitis from meningeal irritation and elicits of positive Brudzinski's sign. Which finding did the nurse observe?

The client passively flexes the hip and knees in response to neck flexion and reports pain in the vertebral column.

A client trigeminal neuralgia is being treated with carbamazepine, 400 mg orally daily. Which value indicates that the client is experiencing an adverse effect to this medication?

White blood cell count, 3,000

The Primary Health care provider prescribes exenatide for a client with type one diabetes who takes insulin. The nurse should plan to take which most appropriate intervention?

Withhold the medication and call the PCP, questioning the prescription for the client.

The patient has been diagnosed with a cerebral concussion. What should the nurse expect to see in the station?

Your day, with your grade Amnesia, and Transient reduction in Loc

While performing a cardiac assessment on a client with an incompetent heart valve the nurse auscultates a murmur. The nurse documents the findings and describes the sound as which?

a blowing or swishing noise

The nurses assigned to here for a group of clients. On review of the clients medical records, the nurse determines that which client is most likely at risk for fluid volume deficit?

a client with an ileostomy

The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder?

a heart rate that is 90 beats per minute and irregular

A client diagnosed with conductive hearing loss asked the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that his condition is caused by which problem?

a physical obstruction to the transmission of sound waves.

Which obstructive pulmonary disease would a 30 year old white female patient with a parent with the disease be most likely to be diagnosed with?

a-Antitrypsin deficiency

A client arrives at the emergency department with complaints of low abdominal pain and hematuria. The client is afebrile. The nurse assesses the client to determine a history of which condition?

Trauma to the bladder or abdomen

What is a primary treatment go for cor pulmonar?

Treating the underlying pulmonary condition

The nurse should tell the client who's taking levothyroxine to notify the Primary Health care provider if which problem occurs?

Tremors

meperidine has been prescribed for a client to treat pain. Which side and adverse effects should the nurse monitor for? Select all that apply

Tremors Drowsiness Hypotension

The nurse reviews a clients electrolyte laboratory report and notes that the potassium level is 2.5. Which pattern should the nurse watch for on the ECG as a result of the laboratory values?

U wave inverted T waves depressed St segment

What are characteristics of PAD? Select all that apply

Ulcers over bony prominence on toes and feet Second, brittle nails

What are manifestations of acute coronary syndrome? Select all that apply.

Unstable angina Stemi Nstemi

Phenazopyridine is prescribed for a client with urinary tract infection. The nurse evaluates the medication is effective base on which observation?

Urination is not painful

The nurse administers intravenous bumetanide to a client being treated for heart failure. Which outcome indicates that the medication has achieved the expected effects?

Urine output increases from 10 mL / hour to greater than 50 ml hourly

Be quiet with myocardial infarction is developing cardiogenic shock. What condition should the nurse carefully assess the client for?

Ventricular dysrhythmias

The nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The clients Rhythm suddenly changes to one with no p waves, no defensible QRS complexes, and coarse wavy lines of varying amplitudes. How should the nurse interpret this Rhythm?

Ventricular fibrillation

The nurse is watching the cardiac Monitor and notices that a client's Rhythm suddenly changes. There are no p waves, the QRS complexes are wide, in The ventricle rate is regular but more than 140 beats per minute. The nurse determines that the client is experiencing which dysrhythmias?

Ventricular tachycardia

A client has a new prescription for metoclopramide. On review of the chart, the nurse identifies that this medication can be safely administered with which condition?

Vomiting following cancer chemotherapy

After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse should expect to note which finding?

Waves of the loud gurgling auscultation in all four quadrants

The nurse has instructed the family of a client with stroke it has homonymous hemianopsia about measures to help the client overcome the defect. Which statement suggests that the family understands the measures to use when caring for a client?

We need to remind him to turn his head to scan the Lost visual field

A patient was diagnosed with nonalcoholic fatty liver disease. What treatment measures should the nurse plan to teach the patient about? select all that apply

Weight loss Dietary management of hyperlipidemia Diabetes management

The nurse caring for a client who has been receiving IV diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment findings would the nurse note in a client with this condition?

Weight loss and poor skin turgor

The nurse is caring for a client who has experienced an MI a few days ago. The client states I just had a little chest pain. As soon as I get out of here, I'm going for my vacation as planned. Which reply would be most appropriate for the nurse to make?

What do you think caused your chest pain?

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client?

Wheezing

Which statement describes janeway's lesions as manifestations of infective endocarditis?

Where, red, painless spots on the palm of the hands and soles of the feet

The nurse is caring for a client with chronic heart failure. Which first-line medication should the nurse expect to be prescribed by the license provider?

captopril

The nurse is planning to teach the client with GERD about substance to avoid. Which item should the nurse include on this list? Select all that apply

coffee Chocolate Peppermint Fried chicken

A client with a diagnosis of DKA is being treated in the emergency department. Which findings support this diagnosis? Select all that apply

comatose state Deep, rapid breathing Elevated blood glucose levels

The home health nurse is visiting a client who was recently diagnosed with type 2 diabetes. The client is prescribed repaglinide and metformin. The nurse should provide which instructions to the client? Select all that apply

diarrhea may occur secondary to the metformin The repaglinide Is not taken if a meal is skipped The repaglinide it's taken 30 minutes before eating A simple sugar food item is carried and used to treat mild hypoglycemia episodes

A client brought to the emergency department states that he has accidentally been taking two times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action?

draw samples for prothrombin times and international normalized ratio

A daily dose of Prednisone is prescribed for a client. The nurse provides instructions to the client regarding administration of the medication and should instruct the client that which time is best to take this medication?

early morning

The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? select all that apply

feeling cold Loss of body hair persistent lethargy puffiness of the face

The client has been diagnosed with hyperthyroidism. The nurse monitors for which signs and symptoms indicate a complication of this disorder? Select all that apply

fever Nausea Tremors Confusion

The client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a PT of 35 seconds. On the basis of these lab values, the nurse anticipates which prescription?

holding the next dose of warfarin a PT greater than 25 seconds puts clients at risk for bleeding.

The nurse is caring for a client with heart failure who is receiving high doses of diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weaknesses, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to know in a client with hypornatremia?

hyperactive bowel sounds

A client with diabetes is taking Humulin NPH in regular insulin every morning. The nurse should provide which instructions to the client? Select all that apply

hypoglycemia may be experienced before dinner time the insulin should be administered at room temperature

A client with a diagnosis of Addisonian crisis is being admitted to the ICU. Which findings will the interprofessional healthcare team focus on? Select all that apply

hypotension Hyperkalaemia

A client with a three day history of nausea and vomiting presents to emergency department. The client is hypoventilating it has a respiratory rate of 10 breaths per minute. The ECG monitor displaced tachycardia, with a heart rate of 120 beats per minute. ABG's are drawn in the nurse reviews the results, expecting two note which findings?

in increased pH in an increase HCO3-

The nurse is preparing the plan of care for a client with diabetes who has hyperglycemia. The nurse places priority on which client's problem?

inadequate fluid volume

My client is diagnosed with viral hepatitis complaining of no appetite and losing my taste for food. What instructions should the nurse give the client to provide adequate nutrition?

increase intake of fluids, including juices

The nurse is reading a primary healthcare provider's progress notes in the client's record and reads that the provider has documented insensible fluid loss of approximately 800 milliliters daily the nurse makes a notation that insensible fluid loss occurs through which type of excretion?

integumentary output insensible loss - we're also fluid without the person being aware of it. This is through the skin in the lungs. Sensible loss - where the person realizes fluid has been lost. This can happen through urinary output, wound drainage, and GI tract.

An adult female client has a hemoglobin level of 10.8. The nurse interprets that this result is most likely caused by which condition noted in the client's history?

iron deficiency anemia Normal for adult females is 12 to 16

A patient with head injury develops SIADH manifestations the nurse should expect to find include

low urine output and hyponatremia

A client with hiatal hernia chronically experiences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contradicted with a hiatal hernia?

lying recumbent following meals

The client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment findings?

malaise

The nurse reviews a client's laboratory report and notes that the client's serum phosphates level is 1.8. Which condition most likely caused the serum phosphorus level?

malnutrition normal phosphorus level is 3 to 4.5

The nurse is caring for a client with an NG tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for?

metabolic alkalosis

The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in two hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended in bowel sounds are diminished. Which is the most appropriate nursing intervention?

notify the Primary Health provider

The nurse refused the blood gas result of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings?

pH 7.25, Paco2 50

A Spanish speaking client arrives at the triage desk in the emergency department and states to the nurse that the interpreter is needed which is the best action for the nurse to take?

page an interpreter from the hospitals interpreter services

A hemodialysis client with a left-arm fistula is at risk for atrial steal syndrome. The nurse should assess for which manifestations of this complication?

pallor, diminished pulse, and pain in the left hand

A client with a history of upper GI bleeding has a platelet count of 300,000. The nurse should take which action after seeing the lab results?

place the normal report in the client's medical record.

Several lab tests are prescribed for a client, and the nurse reviews the results of the test. Which lab test results should the nurse report? Select all that apply

platelets 35,000 Sodium 150 Segmented neutrophils 40%

The nurse is completing an assessment on a client who is being admitted for a diagnostic work up for primary hyperparathyroidism. Which client complaints would be characteristic of this disorder? Select all that apply

polyuria Bone pain

Intravenous Heparin therapy is prescribed for a client with atrial fibrillation. Which implementing this prescription, the nurse ensures that which medication is available on the nursing unit?

protamine sulfate

Glimepiride is prescribed for a client with diabetes. The nurse instructs the client that which food items are most acceptable to consume while taking this medication? Select all that apply

red meats Whole grain cereals carbonated beverages

The nurse reviews a client's record in determines that the client is at risk for developing a potassium defect if which situation is documented?

requires nasogastric suction Potassium levels: 3.5 to 5

The nurse has a prescription to give a client salmeterol, two Puffs, and beclomethasone dipropionate, 2 puffs, by metered dose inhaler. The nurse should administer the medication using which procedure?

salmeterol First and then the beclomethasone

The nurse teaches a client with diabetes about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptoms develop? Select all that apply

shakiness Palpitations Lightheadedness

A client had 1000 ml bag of 5% dextrose and 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous bag has 400 ml remaining. The nurse should take which action first?

slow the IV infusion

Tracrolimus is prescribed for a client who underwent a kidney transplant. Which instruction should the nurse include when teaching a client about this medication?

take oral medication every 12 hours at the same time everyday

The nurse is providing instruction to the client newly diagnosed with diabetes who has been prescribed pramlintide. Which instruction should the nurse include in the discharge teaching?

take your prescribed pills one hour before or two hours after the injection

The nurse is explaining the appropriate methods for measuring an accurate temperature to end assistive personnel. Which method, is noted by the UAP as being inappropriate method, indicates the need for further teaching?

taking an oral temperature for a client with a cough and nasal congestion

The nurse reviews the electrolyte results of a client with chronic kidney disease and notes that the potassium level is 5.7. Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory values?

tall peaked T waves Widen QRS complexes

The nurse is testing the extraocular movements in a client to assess for muscle weaknesses in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eyes?

test the six cardinal positions of gazes

70 year old patient is admitted after falling from his roof. He has SCI at the level of C7. What assessment findings would indicate the presence of spinal shock?

tetraplagia With total sensory loss

Which client is at risk for development of potassium level of 5.5?

the client who has sustained a traumatic burn cellular shifting of potassium in the early stages massive cell destruction

Which client is at risk for the development of a sodium level at 130?

the client who is taking diuretics sodium level: 135 to 145

On review of clients medical records, the nurse determines that which client is at risk for fluid volume excess?

the client with kidney disease and a 12 year history of diabetes mellitus.

The nurse is monitoring a client who was diagnosed with type one diabetes is being treated with NPH and regular insulin. Which manifestations would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply

tremors irritability nervousness

The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?

twitching calcium levels are 9 to 10.5. People with lactose intolerance disorder is at risk because food products that contain calcium also contain lactose.

The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history and determines it is necessary to contact the Primary Health care provider if the client is also taking which medication? Select all that apply

warfarin Glimepiride Amlodipine

The nurse is teaching a client with diabetes how to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the client, indicates the need for further teaching?

withdrawals that NPH insulin first

What accurately describes the PR interval? Select all that apply

0.12 to 0.20 seconds Measures from beginning of P wave to beginning of QRS complex

The client has been admitted to the hospital for gastroenteritis and dehydration. The nurse determines that the client has received adequate volume replacement if the BUN level drops to which value?

15 normal BUN levels is 10 to 20 > 20 the patient is dehydrated < 10 the patient is overloaded

Which statement describing systemic inflammatory response syndrome and/or multiple organ dysfunction syndrome is accurate?

A common initial mediator that causes endothelial damage leading to SIRS and MODS is endotoxin

A client who is receiving digoxin daily has a serum potassium level of three in reports anorexia. The healthcare provider prescribes a serum digoxin level to be done. The nurse checks the results in should recognize which level that is outside of the therapeutic range?

2.2

The patient was an increase ICP is being monitored with a brain tissue oxygenation catheter. What range should for the pressure of oxygen in brain tissue will maintains cerebral oxygen supply and demand?

20 - 40

The nurse is caring for a client with a diagnosis of breast cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the clients white blood cell count was which value?

2000

Emergency nurse is preparing a client for a cardiac catheterization due to an st-elevation acute myocardial infarction. The client presented to the ED at 1:15 am. The nurse should ensure the client is in the cath lab by which time?

2:45 a.m.

A client with tuberculosis whose status is being monitored in at the Ambulatory Care Clinic ask the nurse when it is permissible to return to work. What factor should the nurse include when responding to the client?

3 sputum cultures are negative

A client with a history of heart failure is due for a morning dose of furosemide. Which serum Potassium level, if noted in the client's lab report, should be reported before administrating the dose of furosemide?

3.2

A client in ventricular fibrillation is about to be defibrillated. To convert this or them effectively, the monophasic defibrillator machine should be set at which energy level for the first delivery?

360j

Levothyroxine is prescribed for a client diagnosed with hypothyroidism. Upon review of the clients records, the nurse notes that the client is taking Warfarin. Which modification to the plan of care should the nurse review with the client's primary care provider?

A decreased dose of Warfarin sodium

The nurse is caring for a client hospitalized with acute exacerbation of COPD. Which findings would the nurse expect to know on assessment of this client? Select all that apply

A hyper-inflated chest noted on the chest x-ray Decreased oxygen saturation with mild exercise

A patient with irregular heart rate has four QRS complexes between every 3 seconds marker on the ECG paper. Calculate the patient's heart rate

80 beats per minute

The nurse is admitting a client to the emergency department. Which of these clients should the nurse see first?

50 year old who is complaining of tearing chest pain that radiates to the scapular area

Which patient is at high risk of having gastric ulcers?

55 year old female smoker with nausea and vomiting

The nurse has assumed care for a group of clients. Which clients should the nurse assess first?

A 50 year old smoker who's complaining, this pain in my chest feels like a knife into the middle of my shoulders

The nurse has received change of shift report on the cardiovascular unit. Which clients should the nurse that says first?

A client who is cool and clammy, with new onset confusion and restlessness

As the body continues to try to compensate for hypovolemic shock, there is increased Angiotensin II from the activation of the renin angiotensin aldosterone system. What physiological change occurs related to the increase Angiotensin II?

Antidiuretic hormone

A patient with an obstruction of the common bile duct that has clay-colored fatty stool among other manifestations. What is the pathophysiological change that causes this manifestation?

Absence of bilirubin and bile salts in the small intestine prevent conversion to urobilinogen and fat emulasion in digestion prevents conversion to urobili

What would best indicate successful achievement of outcomes for the patient with cranial surgery

Absence of signs and symptoms of increased ICP

The nurse is caring for a client in the emergency department who has been diagnosed with Bell's Palsy. The client has been taking acetaminophen, and acetaminophen overdose is suspected. Which antidote should the nurse prepared to administer if prescribed?

Acetylcysteine

A client arrives at the clinic complaining of fatigue, lack of energy, constipation, and depression. Hypothyroidism is diagnosed, and levothyroxine is prescribed. What is an expected outcome of the medication?

Achieve normal thyroid hormone levels

The emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse should take which initial action?

Activate the emergency response plan specific to the facility.

The enters a client's room and finds that the wastebasket is on fire. The nurse immediately assisted the client out of the room. What is the next nursing action?

Activate the fire alarm

A client with atrial fibrillation is receiving a continuous Heparin infusion at 1000 units /hour. The nurse determines that the client is receiving the therapeutic effect based on which result?

Activated partial thromboplastin time of 60 Seconds

The nurse is caring for a client who has just had Implantation of an automatic internal cardioverter-defibrillator. The nurse should assess which item based on priority?

Activation status in settings of the device

A client has an as-needed prescription for loperamide hydrochloride. For which condition should the nurse administer this medication?

An episode of diarrhea

A client with diabetes mellitus is told that iAmputation of the leg is necessary to sustain life. The client is very upset and tells the nurse this is all my primary Health Care Providers fault. I have done everything I've been asked to do! Which nursing interpretation is best for the situation?

An expected coping mechanism

Which method is preferred for immediate treatment of an acute episode of constipation?

Anemia

A client in shock develops a central venous pressure of 2 and a mean arterial pressure of 60. Which prescribed intervention should the nurse Implement first?

Increase the rate of intravenous fluids

The most appropriate therapy for a patient with acute diarrhea caused by viral infection is to

Increase the word intake

The nurse expects the color of the drainage from a nasogastric tube on a post-operative client approximately twenty-four hours after gastric surgery. Which finding indicates the need to notify the primary health care provider?

Dark red drainage

A patient is admitted to the emergency department with adhf. Which IV medication would the nurse expect to administer first?

Furosemide

In the patient with HF, which medication of treatments requires careful monitoring of the patient's serum potassium level to prevent further cardiac dysfunction? Select all that apply

Furosemide Spironolactone

Metformin is prescribed for a client with type 2 diabetes. What is the most common side effect that the nurse should include in the client's teaching plan?

GI disturbances

Contact precautions are initiated for a client with a healthcare-associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure?

Gloves, gown, goggles, and a mask or face shield.

The nurse has given medication instructions to a client receiving phenytoin. Which statement indicates that the client has an adequate understanding of the instructions?

Good oral hygiene is needed, including brushing and flossing

What is the most important measure in treatment of venous leg ulcers?

Graduated compression stocking

The nurse is providing dietary instructions to a client who has been prescribed cyclosporine. Which food item should the nurse instruct the client to exclude from the diet?

Grapefruit juice

What is a initial antibiotic treatment for pneumonia based on?

History and physical examination and characteristic chest x-ray findings

The nurse is instructing a client with diabetes about peritoneal dialysis. The nurse tells the client that it is important to maintain prescribed dwell time for dialysis because of the risk of which complication?

Hyperglycemia

The nurse is planning an education program for a group of clients at risk for developing coronary artery disease. Which modifiable risk factors could be included in the teaching?

Hyperlipidemia Hypertension Obesity Tobacco use Physical inactivity

The nurse is encouraging a sanitary patient with major risk for CAD to perform physical exercise on a regular basis. In addition to decreasing the risk factors of physical inactivity, the nurse tells the patient that exercise will directly contribute to reducing which factors?

Hyperlipidemia and obesity

The healthcare provider prescribes levothyroxine for a patient with hypothyroidism. After teaching about this drug, the nurse determines that further instructions as needed when the patient says

Hyperthermia and severe tachycardia

What patient manifestation does the nurse recognize as an early sign of hepatic encephalopathy?

Impaired computational skills

Carbidopa levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side and adverse effects of this medication which finding indicates the client is experiencing an adverse effect to?

Impaired voluntary movements

The nurse is caring for a client with acute pancreatitis and is monitoring the client for a paralytic ileus. Which piece of assessment data should alert the nurse to this occurrence?

Inability to pass flatus

When the nurse is explaining respiratory failure to the patient's family, what is the most accurate description to use?

Inadequate gas exchange arising from problems with oxygenation or ventilation

To control the side effects of corticosteroid therapy, the nurse teaches the patient who is taking corticosteroids to

Increase calcium intake 1500 mg daily

A week after kidney transplantation, a client develops a temperature of 101, the blood pressure is elevated, and there is tenderness over the transplanted kidney. The serum creatinine is rising in urine output is decreased. The X-ray indicates that the transplanted kidney is enlarged. Based on these assessment findings, the nurse anticipates which treatment?

Increase immunosuppressant therapy

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest signs of acute respiratory distress syndrome?

Increase respiratory rate

What abnormal findings should the nurse expect to find in early compensatory shock?

Increase serum sodium

The patient is brought to the emergency department with acute coronary syndrome. What changes should the nurse expect to see on the ECG if only myocardial injury has occurred?

ST segment elevation

THe nurse obtains a prescription from a primary health care provider to restrain a client and instructs an assistive personnel (AP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required for the AP?

Safely securing the safety device straps to the side rails.

Although ARDS may result from direct lung injury or indirect lung injury from systemic inflammatory response syndrome, the nurse is aware that ARDS is most likely to occur in the patient with damage resulting from what?

Sepsis

A 70 year old patient with malnourishment and a history of type 2 diabetes is admitted from the nursing home with pneumonia and tachypnea. Which kind of shock is the patient most likely to develop?

Septic shock

Prior to administering a client's daily dose of digoxin to treat heart failure, the nurse reviews the clients lab data and notes the following results: serum calcium 9.8; serum magnesium 1; potassium 4.1; serum creatinine 0.9. Which result should alert the nurse that the client is at risk for digoxin toxicity?

Serum magnesium level

A patient with hypovolemic shock is receiving lactated Ringer's solution for fluid replacement therapy. During this therapy, what lab result is most important for the nurse to monitor

Serum pH

A client receiving from below deck therapy with A continuous infusion of alteplase suddenly becomes extremely anxious and reports itching. The nurse hear stridor in notes generalized urticaria and hypotension. Which intervention should the nurse anticipate? Select all that apply

Stop infusion Administered diphenhydramine Call for rapid response team

A nurse is caring for a client who has streptococcal pneumonia and a prescription for penicillin G by intermediate IV bolus. 10 minutes into the infusion of the third dose, the client reports that the IV site itching and that he feels dizzy and short of breath. Which of the following actions should the nurse take first?

Stop the infusion

Well the nurse is feeding a patient, the patient appears to choke on the food. Which symptoms indicate to the nurse that the patient has a partial Airway obstruction? Select all that apply

Stridor Cyanosis Wheezing

The nurse is caring for a client who is experiencing acute episode of angina. Which medication should the nurse administer first?

Sublingual nitroglycerin

The visiting nurse observes that the older male client is confined by his daughter-in-law to his room. When the nurse suggests that he walk to the den and join the family, he says, "I'm in everyone's way; my daughter-in-law needs me to stay here." Which is the most important action for the nurse to take?

Suggest appropriate resources to the client and daughter-in-law, such as respite care and a senior citizens center.

The nurse is monitoring a client for adverse effects of medications. Which findings are characterized of adverse effects of hydrochlorothiazide? Select all that apply

Sulfa allergy Hyperkalemia Hyperglycemia Hypercalcemia

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence?

Sweating and pallor

Define has developed atrial fibrillation, with a ventricular rate of 150 beats per minute. The nurse should assess the client for which Associated signs and/or symptoms? Select all that apply

Syncope Dizziness Palpitations

A client has a prescription to take guaifenesin. The nurse determines that the client understands the proper administration of this medication if the client states that she or he will perform which action?

Take this tablet with a full glass of water

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenia and cholinergic Crisis. Which client activity suggests that teaching is most effective?

Taking medications at schedule

The nurse is performing a physical assessment on a client with type 2 diabetes. Findings include a fasting blood glucose level of 70, temperature of 101, pulse of 82 beats per minute, respirations of 20 breaths per minute, and blood pressure of 118/68. Which findings would be the priority concern to the nurse?

Temperature

Which clinical findings are consistent with sepsis diagnostic criteria? Select all that apply

Temperature of 102 Heart rate of 96 beats per minute Mean arterial pressure 65

The client with type one diabetes who takes NPH daily in the morning calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an adequate understanding of the peak action of NPH insulin and exercise?

The best time for me to exercise is after breakfast

Which instructions would the nurse include in a teaching plan for a patient with mild GERD?

The best time to take an as-needed antacid is one two three hours after meals

Which statement by a patient after mechanical valve replacement indicates to the nurse that further instruction is needed?

The biggest risk I have during invasive health proceduresis bleeding because of my anticoagulants

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent ABG values are pH = 7.53, Pao2 = 72, PA CO2 = 32, and HCO3- = 28. Which conclusion about the client should the nurse make?

The client is probably hyperventilating respiratory alkalosis = hyperventilating

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke. Which characteristics are associated with this condition? Select all that apply

The client is aphasic The client has weakness on the right side of the body The client has weakness on the right side of the face and tongue

Nitrofurantoin is prescribed for a client with a urinary tract infection. The client contacts the nurse and reports a cough, chills, fever, and difficulty breathing. The nurse should make which interpretation about the clients Complaints?

The client is experiencing a pulmonary reaction requiring cessation of the medications

Two days after SCI, a patient asks continually about the expense of impairment that will result from the injury. What is the best response by the nurse?

The extent of your injury cannot be determined until the secondary injury to the cord resolves

A patient is scheduled to have CABG surgery. What should the nurse explain is involved with the procedure?

The internal mammary artery will be detached from the chest wall attached to a coronary artery distal to the obstruction

A client with a peptic ulcer is diagnosed with h. pylori infection. The nurse is teaching the client about the medications prescribed, including clarithromycin, esomeprazole, and amoxicillin. Which statement by the client indicates the best understanding of the medication regimen?

The medication will kill the bacteria and stop the acid production

Patient is admitted to the hospital with Guillain-Barre syndrome. She had weakness in her feet and ankles that has prolonged illness, what should the nurse know about to Gillian Barre syndrome?

The most important aspect of career is to monitor the patient's respiratory rate and depth and vital capacity

The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing an aortoiliac bypass graft. The affected leg is warmed, in the nurse notes redness and edema. The pedal pulse is palpable. How should the nurse interpret the client neurovascular status?

The neurovascular status is normal because of increased blood flow through the leg

54 year old man is recovering from a skull fracture with a sub-acute subdural hematoma that caused unconsciousness. He has returned to motor control in orientation but appears apathetic and reduce awareness of the environment. One planning discharge of the patient, what should the nurse explain to the patient and family?

The patient will likely have long-term and mental changes and need professional help

When should the nurse check for leaks in the chest tube and pleural drainage system?

There is continuous bubbling in the Water Seal chamber

The home health nurse visits a client who's taking phenytoin for control of seizures. During assessment, the nurse notes that the client is taking birth control pills. Which information will the nurse include in the teaching plan?

There is the potential of decrease effectiveness of birth control pills while taking phenytoin

The nurse is providing instructions to the assistive personnel regarding care of an older client with hearing loss. What should the nurse tell the AP about older clients with hearing loss?

They respond to low-pitched tones.

A client has a new colostomy created two days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse?

This is normal, expected event

The nurse has given instructions to a client who has just been prescribed cholestyramine. Which statement by the client indicates a need for further instructions?

This medication should only be taken with water

The family members of patient with hepatitis A ask if There is anything that will prevent them from developing the disease. What is the best response by the nurse?

Those who live in the household or have close contact with the patient should receive IG

Which lab test results indicate to the nurse sepsis as a cause of shock?

Thrombocytopenia

The client arrives at the emergency department complaining of back spasms. The client states, I have been taking two to three aspirin every 4 hours for the last weeks, and it hasn't helped my back. Since acetylsalicylic acid intoxication is it suspected, the nurse should assess the client for which manifestations?

Tinnitus

The nurse is caring for a client admitted to the emergency department with DKA. In the acute phase, the nurse plans for which Priority intervention?

administer short duration insulin intravenously

A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply

administers stool softeners as prescribed Encourage a high fiber diet to promote bowel movements without straining Apply cold packs to the annual rectal area over the dressing until the packing is removed

A client has a neurologist deficit Involving the limbic system. On assessment, which finding is specific to this type of deficit?

affect is flat, With periods of emotional liability

The nurse is instructing a client how to perform a testicular self exam. The nurse should explain that which is the best time to perform this exam?

after a shower or bath

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, in crackles are audible on auscultation. What additional manifestations would the nurse expect to know in this client if excessive fluid volume is present?

an increase in blood pressure and increased respirations

The emergency nurse is caring for a client suspicious for acute myocardial infarction. Which symptoms are consistent with this diagnosis? Select all that apply

ashen skin Nausea Tachycardia Vomiting Elevated blood pressure Diaphoresis

The client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the clients care plan?

assessing for the return of the gag reflex

The nurse is caring for a postoperative client who is receiving demand dose hydromorphone via a patient controlled analgesia for pain control. The nurse enters the clients room and finds the client drowsy and records the following vital signs: temp 97.2, pulse 52 beats per minute, blood pressure 101/58, respiratory rate 11 breaths per minute, and SpO2 of 93% on three liters of oxygen via nasal cannula. Which action should the nurse take next?

attempt to arouse the client

A client has just been admitted to the nursing unit following a thyroidectomy. Which assessment is the priority for this client?

audible stridor

Which conditions contribute to the formation of abdominal ascites?

blood flow through the portal system is obstructed which causes portal hypertension