funds final
A nurse is teaching a client who has a new prescription for ibuprofen to treat hip pain. Which of the following instructions should the nurse include in the teaching?
Take the medication with food
A nurse is caring for a client who has been diagnosed with end-stage liver cancer. Which of the following responses is an indication the client is in the denial phase of the grief process?
"The doctor says I only have a few months to live, but I know he is exaggerating to get me to take my medication."
A nurse is caring for an older adult client who has had surgery for an intestinal obstruction and has an NG tube to wall suction. Which of the following interventions should the nurse include in the client's postoperative plan of care? (Select all that apply.)
-discontinue suction when assessing for peristalsis -irrigate NG tube with 0.9% NaCl solution -place sequential devices on the bilateral lower extremities -reposition client from side to side every 2 hours
A nurse is providing postmortem care for a client. Identify the sequence of steps the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
1. make sure the provider has certified the client's death 2. verify the client's organ and tissue donation status. 3. remove medical equipment from the client. 4. cleanse the body while adhering to body-fluid precautions. 5. attach identification tags to the body
A nurse is assessing a client who is 2 days postoperative and auscultates bilateral breath sounds, but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications?
Atelectasis
A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate?
Before the examination your provider will give you a sedative that will make you sleepy
A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time?
Check the client's chart for the provider's order
A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8º C (98.2º F). Which of the following actions should the nurse perform?
Complete a neurological check
A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?
Determine if the client uses hearing aids.
A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?
Encourage the use of an incentive spirometer
A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. To focus on affective learning with this client, which of the following interventions should the nurse use?
Explore the client's feelings about dietary modifications
A nurse in the PACU is assessing a client who has an endotracheal tube (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?
Movement of the ET tube into the right main bronchus
A nurse is assessing a client who is 3 days postoperative following abdominal surgery and notes the absence of bowel sounds, abdominal distention, and the client passing no flatus. Which of the following conditions should the nurse suspect?
Paralytic ileus
A nurse is working with an assistive personnel (AP) while caring for a surgical client who is 1 day postoperative. Which task should the nurse take responsibility for completing?
Removing the abdominal dressing
A nurse is changing the dressing of a client who is 1 week postoperative following abdominal surgery and notes the presence of serosanguineous drainage. The nurse should recognize that this is an indication of which of the following circumstances?
Serosanguineous drainage at this time is a manifestation of possible dehiscence.
A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client's pan?
The client's self-report of pain severity
A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
Yellow-green drainage on the surgical incision
A nurse is planning care for a client who is postoperative and at risk for paralytic ileus. Which of the following interventions should the nurse plan to take to promote peristalsis?
increase ambulation
A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse the client's peristalsis is returning?
passage of flatus
A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements by the client should the nurse report to the provider?
"I don't eat shellfish because it gives me hives."
A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse's responsibilities?
explain the operative procedure, risks, and benefits
A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?
pain
A nurse is caring for client who just returned from the PACU with an IV fluid infusion and an NG tube in place following abdominal surgery. Which of the following data is the priority for the nurse to assess?
the surgical dressing
A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect?
fatigue
A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. When he arrives for his first dialysis treatment, he tells the nurse, "I decided to come today, but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again." The nurse should identify that this client is demonstrating which of the following Kübler-Ross stages of grieving?
denial
A nurse is planning care for a client who is postoperative. Which of the following statements about pain management should the nurse consider when implementing client care? (Select all that apply.)
-Each client's expression of pain may be different and individualized -Patient-controlled analgesia (PCA) offers a constant level of opioids within therapeutic range -Pain level and pain tolerance can be assessed using a scale from 0 to 10.
A hospice nurse is reviewing the prescriptions for a client who is receiving palliative care. Which of the following prescriptions should the nurse expect? (Select all that apply.)
-Provide skin care with a moisture barrier cream. -Administer artificial tears PRN hr. -Perform mouth care every hour. -Administer oxygen 2 L/min via nasal cannula.
A nurse provides a back massage as a palliative care measure to a client who is unconscious, grimacing, and restless. Which of the following findings should the nurse identify as indicating a therapeutic response? (Select all that apply.)
-Shoulders droop -Facial muscles relax -Pulse is within expected range
A nurse is assessing a client who is postoperative and finds the client's abdominal incision has eviscerated. Which of the following actions should the nurse take?
Cover the wound with a sterile-saline dressing.
A nurse is caring for a client who has metastatic bone cancer. The client states, "I want to go home to die." The family is concerned about meeting the client's care needs at home. Which of the following actions should the nurse take?
Discuss initiating hospice care with the client and family.
A nurse manager is discussing the differences between normal and maladaptive grief with nursing staff. Which of the following findings should the nurse manager identify as being a unique component of the maladaptive grieving process?
low self-esteem
A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help, Which of the following actions should the nurse take first?
Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation.
A nurse is assessing a client 1 day postoperative following abdominal surgery. Suddenly the client reports a pulling sensation and pain in his surgical incision. Which of the following actions should the nurse take?
Cover the area with saline-soaked sterile dressings.
A nurse is caring for a client who has cancer and is receiving palliative care. Which of the following statements by the client indicates they understand this type of treatment?
"I am hoping this will limit my discomfort."
A nurse is caring for a client who has a new diagnosis of chronic kidney disease. Which of the following statements should the nurse identify as an indication of anticipatory grieving?
"I just can't believe that my whole life is going to be ruined by dialysis."
A nurse is calculating the output of a client at the end of the shift. The nurse notes the following: client voided 400 mL at 1100 and 350 mL at 1430. The closed chest drainage system was previously marked at 155 mL and is now at 175 mL. The NG tube has 575 mL in drainage container, and 25 mL is emptied out of the Jackson-Pratt drainage tube. How many mL should the nurse record in the medical record as the client's output?
1370 mL
A nurse is assessing the respiratory pattern of an older adult client who is receiving end-of-life care. Which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations?
Breathing ranging from very deep to very shallow with periods of apnea
A nurse is planning preoperative care for a client who will undergo surgery. Which of the following is the priority action by the nurse?
Determine what the client knows about the surgery.
A nurse is providing teaching to an assistive personnel (AP) about caring for clients with restraints. Which of the following statements by the AP indicates an understanding of the teaching?
I will tie a restraint to the portion of the bed that moves when the head of the bed is moved
A nurse is preparing to teach a client who has a low literacy level. Which of the following methods should the nurse plan to include?
have 2 to 3 information sessions
