Med surg exam 1
After exposure to lye, a client flushes both arms and hands with copious amounts of water prior to seeking medical attention. Which assessment finding suggests to the nurse that the chemical burn process is continuing?1.Bright red, firm tissue.2.Eschar.3.Liquefaction necrosis.4.Intact blisters.
1) Bright red, firm tissue is a result of a thermal injury.2) Acid or heat exposure causes this thick, leathery coating.3) CORRECT— An alkali such as lye causes liquefaction necrosis and indicates that the burning process is continuing.4) Intact blisters indicate a partial-thickness thermal injury.
The nurse cares for a client who is 5'7 tall, weighs 300 pounds, and is recuperating from exploratory laparotomy. The client cooperates with coughing and deep breathing exercises and ambulates a distance of 25 feet in the hallway. For which postoperative complication should the nurse most vigilantly assess the client? 1. Pneumonia 2. Fat emboli 3. Pulmonary emboli 4. Wound dehiscence
4. Wound dehiscence
The nurse asks a nursing assistive personnel (NAP) for the temperature obtained on a client prior to hanging a blood product. Which right of delegation does the nurse follow in this situation? A.Right task. B.Right circumstance. C.Right communication. D.Right evaluation.
A) Right task is ensuring the nurse is assigning an appropriate task to the NAP. B) Right circumstance is ensuring the client is stable for the NAP to complete the assigned task. C) Right communication is ensuring the nurse has provided adequate direction to the NAP. D) CORRECT - The nurse is following up with the NAP to ensure the NAP completed the task. The scenario indicates the nurse was providing right supervision/evaluation.
The nurse observes a student nurse conducting an assessment on a client with suspected hypocalcemia. The student nurse observes for a carpopedal response by inflating the blood pressure cuff above the systolic blood pressure. The nurse recognizes that the student nurse is using which assessment technique? A. Chvostek assessment. B. Babinski assessment. C. Trousseau assessment. D. Braden assessment.
A) The Chvostek assessment does indicate hypocalcemia, but a positive sign is twitching of the eye, lip and the side of face that is tested. B) The Babinski assessment is used to test reflexes in the newborn. The test is elicited by stroking the lateral sole of the newborn's foot from the heel toward and across the ball of the foot. The toes fan out. A diminished response indicates a neurological problem. C) CORRECT— The technique described is the Trousseau assessment, a technique to evaluate for hypocalcemia. A positive sign is a carpopedal spasm when the blood pressure cuff is inflated above the systolic blood pressure. D) The Braden assessment is used to predict a client's risk for developing pressure ulcers.
The nurse discovers a client's urine culture indicates at least 100,000 colonies of bacteria per milliliter. The nurse should intervene if the client makes which statement? A. "I am taking phenazopyridine to get rid of the bacteria." B. "I am drinking 10 to 12 glasses of water a day whether or not I am thirsty." C. "When my urine turned bright orange, I knew that this was expected." D. "When my skin turned yellowish, I stopped taking the medication."
A. "I am taking phenazopyridine to get rid of the bacteria."
The nurse is reviewing information about the chronic form of immune thrombocytopenia purpura (ITP). A person in which age group is most likely to develop chronic ITP? A. A young child B. 15 to 20 years old C. 20 to 50 years old D. Over age 65
A. A young child
The nurse provides care for a client recovering from surgery to repair retinal detachment. Which nursing intervention is important for this client? A. Maintain eye shield or patch. B. Encourage deep breathing. C. Monitor for hemorrhage. D. Assist with activities of daily living. E. Teach symptoms of retinal detachment.
A. CORRECT - An eye patch or shield is applied to protect the eye and prevent any further detachment. B. Following surgery for retinal detachment, the client should avoid activities that increase intraocular pressure such as coughing. C. CORRECT - Hemorrhage is a risk post-operatively. D. CORRECT - Positioning, activity restrictions, and eye patches hinder the client in the performance of activities of daily living. The client needs the nurse's assistance with these activities. E. CORRECT - Educating the client regarding symptoms is necessary because the client is at risk for subsequent retinal detachment.
The nurse provides care for a client diagnosed with diabetic ketoacidosis. Which nursing diagnosis will the nurse include in the plan of care for this client? Select all that apply A. Anxiety related to loss of control and inability to manage diabetes. B. Risk for fluid volume excess related to anuria. C. Deficient knowledge related to diabetes management. D. Risk for electrolyte imbalance related to fluid shifts. E. Risk for falls related to mental status changes.
A. CORRECT - Anxiety related to loss of control and inability to manage diabetes would be appropriate for the client diagnosed with diabetic ketoacidosis. B. The client diagnosed with diabetic ketoacidosis is at risk for deficient fluid volume related to polyuria and dehydration. C. CORRECT - The client diagnosed with diabetic ketoacidosis may have deficient knowledge related to diabetes management that led to the complication. D. CORRECT - The client with diabetic ketoacidosis is a risk for electrolyte imbalance related to fluid loss and shifts. E. CORRECT - A client with diabetic ketoacidosis is at risk for falls secondary to mental status changes that may occur.
The nurse observes a client using a four-point cane. The client had a cerebral vascular accident affecting the left side of the body. The nurse knows the client needs additional teaching after observing which behavior? A. The client holds the cane in the left hand during ambulation. B. The client moves the left leg and cane forward together. C. The client moves the cane one average step forward each time. D. The client advances the right leg first when ascending stairs
A. CORRECT— The client's left hand and leg are weaker. The cane should be held on the properly functioning side. The nurse needs to correct this action. B. The client is using proper technique by bringing the affected leg and the cane forward at the same time. C. Moving the cane one step at a time, rather than larger or smaller steps, is a correct action. D. The rule of thumb for stairs is "up with the good" and "down with the bad," meaning the unaffected lower extremity is used to ascend stairs.
The nurse assesses a client with Guillain-Barre syndrome. Which finding indicates to the nurse that the client is developing complications? Select all that apply. A. Diaphoresis B. Bilateral leg pain C. Absent bowel sounds in the 4 quadrants D. Malodorous urine output E. Respiratory rate 10 breaths/min
A. Diaphoresis B. Bilateral leg pain C. Absent bowel sounds in the 4 quadrants D. Malodorous urine output E. Respiratory rate 10 breaths/min
The nurse cares for the client being evaluated for aortic stenosis. which assessment data does the nurse expect to find? A. Dyspnea B. Hypertension C. Cyanosis D. Respiratory acidosis
A. Dyspnea
The nurse provides care for a client following a transphenodial hypophysectomy for pituitary tumor. Which signs indicate to the nurse that the client has developed ADH insufficiency? A. Extreme thirst and large amounts of diluted urinary output B. Minimal urinary output and edema C. Serum hypo-osmolality and hyponatremia D. Elevated serum and urine glucose levels
A. Extreme thirst and large amounts of diluted urinary output
The nurse provides care for a client who is prescribed a transfusion of packed red blood cells. Which information is required to be checked by two registered nurses before beginning the transfusion? (Select all that apply.) A. Health care provider's prescription. B. Baseline vital signs. C. Client's identity. D. Hospital ID band name and number. E. Blood component tag name and number.
A. Health care provider's prescription. C. Client's identity. D. Hospital ID band name and number. E. Blood component tag name and number.
The nurse provides care to a client with liver failure. Which medication route will the nurse use to avoid the first-pass effect with this client? Select all that apply A. Inhaler B. Oral C. Intramuscular D. Sublingual E. Transdermal
A. Inhaler C. Intramuscular D. Sublingual E. Transdermal
The nurse provides discharge teaching for a client diagnosed with a thoracic spinal cord injury. Which activity does the nurse teach the caretakers to do to prevent contractures from occurring? A. Perform range of motion exercises. B. Turn the client in bed every four to six hours. C. Initiate flexor muscle spasms regularly. D. Massage the client's calves and thighs.
A. Perform range of motion exercises.
The nurse provides care for a client who becomes restless and confused every morning. the client tries frequently to get out of bed. which strategy does the nurse implement to prevent client injury? Select all that apply A. Play soft, calming music B. Ask a family member to stay in the room during the periods of restlessness C. Assist the client to the bathroom every 2 to 3 hours D. Have family bring familiar objects to the client's room E. Check on the client every 2 to 3 hours
A. Play soft, calming music B. Ask a family member to stay in the room during the periods of restlessness C. Assist the client to the bathroom every 2 to 3 hours D. Have family bring familiar objects to the client's room E. Check on the client every 2 to 3 hours
A nurse cares for a client diagnosed with second degree atrioventricular block, mobitz type II. while assessing the client the nurse notes a hear rate of 34, the client reports dizziness, and passes out. the nurse places the client on a cardiac monitor. which is the next nursing action?
A. Prepare for transcutaneous pacemaker
The nurse prepares a client for placement of internal radiation. The nurse understands the client will receive an indwelling Foley catheter and a tap water enema for which of the following reasons? A. Prevent displacement of the implant. B. Make the patient more comfortable during the treatment C. Maintain an uncontaminated work area. D. Avoid excessive bladder and bowel irradiation.
A. Prevent displacement of the implant.
The 3-day old infant is born with a myelomeningocele. the nurse caring for the neonate should place the infant in which position? A. Prone B. Fowler's C. Trendelenburg D. Side-lying
A. Prone
The nurse understands that in a psychiatric inpatient setting, which description is the best for milieu therapy? A. Providing a therapeutic physical and social environment B. Manipulating the environment in a way that makes the client feel at home C. Establishing therapeutic communication with numerous staff members D. Setting limits on behaviors
A. Providing a therapeutic physical and social environment
The nurse receives information on four clients. Which client does the nurse assess first? A. Client with diabetes insipidus (DI) who has urine specific gravity that has increased from 1.009 g/mL to 1.010 g/mL B. Client with Type 1 DM who has a hemoglobin (Hgb) A1C of 7.1% C. Client recovering from a thyroidectomy w/an oral temperature of 102.3ºF (39.1ºC) D. Client with hypothyroidism who reports cold intolerance, consultation and feelings of depression
A. The client with DI who has an increased urine specific gravity is improving. The specific gravity in DI is very dilute, often less than 1.005 g/ml. The normal range for specific gravity is 1.010 to 1.030. B. The client with type I diabetes mellitus who has an Hgb A1C of 7.1% is above the goal of 6.5% but does not need immediate assessment. Hgb A1C measures the amount of glycosylated Hgb as a percentage of total Hgb. An A1C of 7.1% means 7.1% of the total Hgb has glucose attached to it. The A1C test measures glycemic control over the past 2 to 3 months, with increases in the A1C reflecting elevated blood glucose levels. The goal is an A1C less than 6.5%. C. CORRECT— The client recovering from a thyroidectomy who now has a temperature of 102.3°F (39.1°C) may be having a thyroid crisis, which usually occurs within the first 12 hours postoperatively. All the signs and symptoms of hyperthyroidism are exaggerated. Also, the client may develop nausea, vomiting, severe tachycardia, severe hypertension, and hyperthermia up to 106°F (41°C). This client needs to be assessed first. D. The client who has hypothyroidism and reports cold intolerance, constipation, and feelings of depression is experiencing expected findings.
The nurse provides care for a client admitted to the postanesthesia care unit (PACU) after a thoracotomy that required prolonged anesthesia. The client develops noisy, irregular respirations and the oxygen saturation level drops. Which action does the nurse implement first? A. Deliver breaths with a handheld resuscitation bag and mask. B. Auscultate the client's breath sounds. C. Tilt the client's head back and push forward on lower jaw. D. Increase the supplemental oxygen, as prescribed.
A. The client's airway should be opened before delivering breaths with a handheld resuscitation bag. B. Auscultating breath sounds at this point will not provide additional useful information. C. CORRECT— Clients undergoing prolonged anesthesia are typically unconscious when entering the PACU. Due to their relaxed state, the client's lower jaw and tongue fall back and obstruct the airway, causing hypopharyngeal obstruction. The nurse opens the client's airway by tilting the client's head back and pushing the lower jaw forward. D. The client's airway should be opened before increasing supplemental oxygen.
The nurse provides care for a client with a body mass index of 17.0 kg/m. Which is the best description of the clients body weight? A. Underweight B. Normal weight C. Overweight D. Obese
A. Underweight
The nurse assesses an older client for substance abuse. Which medications does the nurse specifically ask if the client uses? A.Sedatives hypnotics B. Stimulants C. Opioids D. Over-the-counter medications
A. Unless by prescription, the use of sedatives-hypnotics is usually minimal in older clients. B. The use of central nervous system (CNS) stimulants is usually minimal in older clients. C. Unless by prescription, the use of opioids is usually minimal in older clients. D. CORRECT — Older adults specifically have the highest use of over-the-counter medications.
The nurse plans care for the client with a history of substance abuse. It is most important for the nurse to select which approach? A. a structured but permissive setting B. an environment that increases reality testing C. a structured non permissive setting D. an environment that decreases stimuli and redirects behavior
A. a structured but permissive setting
The nurse provides care to a client scheduled for surgery. Which information is accurate about the informed consent? A. The RN explains the surgical procedure to the client B. A client who is not of legal age can sign the consent form if a parent is not available C. A client who is confused about the surgical procedure can be encouraged to sign the consent D. A written consent protects the client from unsanctioned surgery
A.Because the nurse does not perform the surgery, providing information about the procedure and obtaining a client's informed consent does not fall within the nurse's scope of practice. The nurse may witness a client's signature on a consent form, but the health care provider who is doing the surgery explains the procedure and obtains the consent form. B. Parents are the legal guardians of pediatric clients. Therefore, one of them signs the consent form for treatment. C. If the nurse suspects that the client does not understand the procedure, the nurse notifies the health care provider and the nursing supervisor. D. CORRECT—The signed informed consent document gives legal authorization for the surgical procedure. It helps to protect the client from having unauthorized procedures performed. It protects the health care team and hospital from claims by the client that an unauthorized procedure was performed.
The nurse provides care for a client who exhibits a sacral pressure injury. The foam dressing was changed 13 hours ago. No drainage is noted on the dressing. Which action should the nurse take next? A.Document that the dressing is intact. B.Clean the wound and apply a new dressing. C.Place a consult with the wound care team. D.Remove the dressing to assess the wound.
A.Document that the dressing is intact.
The nurse must position an immobile, 450-pound client up in bed. Mechanical lift equipment is not available. Which technique must the nurse include in this intervention? A.Position staff to distribute client weight equally. B.Obtain the assistance of one additional staff member. C.Lift by shifting weight from the left arm to the right arm. D.Extend draw sheet from client's mid-back to thighs.
A.Position staff to distribute client weight equally.
The nurse interviews an adolescent client. Which statement causes the nurse concern if made by the adolescent during the health history interview? A. "Sometimes I feel really tired" B. "I don't perspire like other kids" C. "I can be a real klutz sometimes" D. "I have two pimples on my forehead"
B. "I don't perspire like other kids"
The nurse cares for the client diagnosed with a spinal cord injury. the nurse enters the client's room to hang an IV antibiotic. the nurse notes the client has diarrhea, and the client reports experiencing pain. which action should the nurse take first? A. Hang the IV antibiotic B. Administer the prescribed pain medication C. Perform perineal care for the client D. Log-roll and reposition the client
B. Administer the prescribed pain medication
Client diagnosed with gastroenteritis and dehydration is receiving fluid volume replacement with NS infusing at 100mL/hr. Four hours after the infusion is started, the nurse assesses the client and notes the BP 84/50, HR 110, and urine output is 15mL/hr and dark yellow. Which action does the nurse take initially ? A. increase IV fluids to 150mL/hr B. Assess the IV access C. place in Trendelenburg position D. notify HCP
B. Assess the IV access
After 2 weeks of chemotherapy treatments, a client's white blood cell count is 2,000 mm. The nurse knows this finding is most likely due to which factor? A. Infection B. Bone marrow depression C. Weight loss D. Polycythemia
B. Bone marrow depression
The nurse teaches nursing students about the relationship of psychological risk factors in persons with coronary heart disease. Which risk factor does the nurse identify? A. Schizophrenia B. Depression C. Sleep disturbance D. Phobias
B. Depression
The nurse cares for the client admitted 3 days ago with a gunshot wound to the abdomen. The client has developed DIC. Which symptom would the nurse expect to see in the client? A. Bradycardia B. Ecchymosis C. Polyuria D. Bradypnea
B. Ecchymosis
The nurse prepares to leave the room after irrigating the infected wound of a client in contact transmission-based precautions. Which PPE item does the nurse remove next after taking off the contaminated gloves? A. Mask B. Gown C. Eye goggles D. Foot covering
B. Gown
The nurse provides care for a client prescribed warfarin sodium to manage atrial fibrillation. The nurse determines teaching is effective if the client identifies which menu selection as containing little or no vitamin K? A. Spinach B. Oranges C. Broccoli D. Beef
B. Oranges
A 67-year-old client receives treatment for an acute attack of gout. which finding would the nurse expect? A. Pale B. Red C. Mottled D. Cyanotic
B. Red
The nurse cares for the client diagnosed with an intracranial bleed. The nurse notes pupils are not equal (2 mm and 5 mm), the larger pupil is non-reactive to light, and the client only responds to pain. Which explanation does the nurse determine based on this assessment? A. These findings are normal for the client B. The client has s/s of ICP C. These are side effects from the narcotic the client is receiving D. These findings are abnormal but not significant
B. The client has s/s of ICP
A client who is on active military duty is dying and arrives from oversees for end-of-life care. The client's adult child is concerned because the client is not receiving any food or fluids. Which response is the most appropriate for the nurse to make? A."Your other parent made the decision to withdraw food and fluids." B."At the end of life, a person loses interest in eating and drinking. I will show you how to moisten your parent's mouth for comfort if you want." C."Food or fluids would not help your parent. It is the disease that is killing your parent, not me." D."The health care provider will come around in the morning. You need to ask the health care provider about the lack of fluids and food."
B."At the end of life, a person loses interest in eating and drinking. I will show you how to moisten your parent's mouth for comfort if you want."
The nurse does discharge teaching for a client after a right mastectomy. The nurse determines the teaching is effective if the client makes which statement? A. "I should eat a full liquid diet for 3-4 days" B. "I can take a shower as soon as I get home" C. "I should empty the drain reservoir twice a day" D. "I should eat with my left hand until the stitches are removed"
C. "I should empty the drain reservoir twice a day" Measure and record the amount of drainage Change dressing as needed
At discharge, the nurse advises a client about a calorie-restricted diet. Which is an ideal rate of weight loss? A. 1/2 pound per day B. 1/2 pound per week C. 1 lb per week D. 1 lb per day
C. 1 lb per week
The nurse identifies which sign or symptom as an early indication of fluid volume excess? A. Cyanosis B. Diarrhea C. Edema D. Shock
C. Edema
Which of the following nursing measures is MOST effective for preventing thrombophlebitis for a patient while on bed rest? A. Elevate the foot of the bed with the knee patch and pillow B. Apply Ace bandages from ankle to thigh C. Instruct the pt to flex and point his toes every two hours D. Massage the pt's legs, except for the calf area, several times a day
C. Instruct the pt to flex and point his toes every two hours
The nurse provides care to a newborn in the delivery room. Which intervention does the nurse implement to prevent the newborn from experiencing radiant heat loss? A. Drying the newborn's skin immediately after birth B. Putting the unclothed newborn against the mother's skin C. Keeping the incubator away from windows and outside walls D. Placing the newborn under a radiant warmer
C. Keeping the incubator away from windows and outside walls
The client reports nausea, vomiting and abdominal pain that becomes more intense approximately one to two hours after eating. Which action should the nurse take to correctly assess for the presence and character of bowel sounds? A. Palpate the abdomen for tenderness before auscultating for bowel sounds. B. Use the bell fo the stethoscope to auscultate for the presence of bowel sounds C. Listen for bowel sounds for three to five minute before charting "absent bowel sounds" D. Assess for a positive fluid wave before listening for bowel sounds
C. Listen for bowel sounds for three to five minute before charting "absent bowel sounds"
A client has a left modified radical mastectomy. upon transfer from the recovery room to the surgical unit, the nurse notices the hemovac drain is half filled with blood. which action should the nurse take first? A. Contact the HCP B. Increase the rate of the IV fluids C. Look at the recovery room record D. Measure the client's hemovac output
C. Look at the recovery room record
The client diagnosed with Hodgkin's disease previously had treatment with radiation therapy. Now, the client is diagnosed with hypothyroidism. the nurse identifies which is the MOST likely reason for the hypothyroidism? A. Abnormal cells have engulfed the thyroid gland B. TSH production in the pituitary gland is inadequate d/t the Hodgkin disease C. Radiation therapy has destroyed the thyroid gland D. Autoimmune processes have gradually destroyed the thyroid gland
C. Radiation therapy has destroyed the thyroid gland Destruction of the thyroid gland by radiation is one latrogenic cause of hypothyroidism; it is hyposecretion of thyroid hormone it slows physical and mental functions; indicates include decreased activity level, sensitivity to cold, etc.
The nurse provides care for a newly admitted client with chest pain. Which task will the nurse complete instead of delegating to nursing assistive personnel (NAP)? A. Set up the client's meal tray. B. Obtain a urine specimen and send it to the laboratory. C. Remove the client's oxygen if chest pain is rated as zero. D. Place the client on the cardiac monitor.
C. Remove the client's oxygen if chest pain is rated as zero.
The nurse cares for the client who had a modified radical mastectomy yesterday. The client has portable wound suction in place. How should the nurse empty the suction apparatus? A. Disconnect the tubes from the suction device, empty the container, and reconnect the tubes. B. Turn off the suction machine, empty the bottle into a measuring container, and reconnect after washing the bottle with soapy water. C. Remove the plug from the opening while keeping it sterile, empty the contents, compress the container, and replace the plug into the opening. D. Remove the dressing, advance the drainage tube, and redress the wound.
C. Remove the plug from the opening while keeping it sterile, empty the contents, compress the container, and replace the plug into the opening.
The nurse prepares a school-age client diagnosed with a fractured humerus to be discharged home with the parents. Which observation requires the nurse to make a referral to home health? A. The child does not play with toys during the hospital stay. B. One parent is working the night shift. C. The mother has bruises around the wrists. D. The father is anxious to leave the hospital.
C. The mother has bruises around the wrists.
The nurse provides care for a client receiving peritoneal dialysis. which action is a priority for the nurse during PD exchanges? A. Re-positioning the client regularly from side to side B. Warming the dialysate to approximately 98.6ºF (37ºC) C. Using a surgical mask when connecting dialysate bags D. Maintaining negative balance in client's fluid status
C. Using a surgical mask when connecting dialysate bags
The nurse teaches the client diagnosed with glaucoma about medications that are contraindicated. Which client statement alerts the nurse that the client needs further teaching? A. "Pupil-dilating drugs are contraindicated." B. "If I need surgery, I must tell them I have a glaucoma." C. "I have to avoid some drugs used to treat ulcers" D. "I have to stop taking my diuretic until I have finished my eye drops."
D. "I have to stop taking my diuretic until I have finished my eye drops."
The nurse cares for a client diagnosed with a fractured right hip. The client's lab values are: Hgb 15 g/dL, Hct 46%, sodium 140 mEq/L, potassium 6.2 mEq/L, and chloride 100 mEq/L. The nurse is most concerned if which finding is observed? A. A weight gain of 4 lbs in 1 day B. An increase in nausea C. An increase in muscle irritability D. An episode of ventricular fibrillation
D. An episode of ventricular fibrillation
The nurse cares for the client admitted from the operating room after coronary artery bypass graph (CABG) surgery. which is the first action the nurse should take because the client is mechanically ventilated? A. Monitor for s/s of increased cardiac output B. Drains liquid condensed in the ventilator hoses back into the humidifier C. Auscultates the client's chest to detect s/s of pneumonia D. Assesses the client's LOC
D. Assesses the client's LOC
The nurse receives report on a client who was confused overnight and is scheduled for surgery later in the morning. The nurse asks the off-going nurse if the preoperative checklist and informed consent are complete. The off-going nurse replies, "I did the checklist. Since he doesn't have any family, the client 'made a mark' on the signature line of the consent". Which action does the nurse take first? A.Continue to prepare the client for surgery. B.Contact the health care provider (HCP). C.Ask the client if the purpose of the surgery is understood. D. Contact the nurse manager.
D. Contact the nurse manager
The client diagnosed with burns on the face and upper arms prepares for discharge. The nurse wants to help ease the client's adjustment back into the community. Which of the nurse's actions would be most helpful? A. Discuss the use of make-up to minimize the scars B. Encourage the client to be along until comfortable with the physical changes C. Persuade the client to view the face and arms in the mirror D. Encourage the client to walk in the hall with family members
D. Encourage the client to walk in the hall with family members
A client is diagnosed with hypoparathyroidism. Which action does the nurse take to ensure the safety of the client? A. Encourages exercise to strengthen muscles B. Maintains a stimulating environment C. Checks on the client every two hours D. Institutes seizure precautions
D. Institutes seizure precautions
The client reports sleepiness, nausea, and vomiting. The nurse notes the client is confused and respirations are deep and labored with a respiratory rate of 32 breaths per minute. The arterial blood gas values are PaCO2 30 mmHg, pH 7.30, and HCO3 20 mEq/L. Which action does the nurse take? A. Starts an infusion of 5% dextrose and water as per standing orders and contacts the health care provider B. Places a paper bag over the client's nose and mouth to re-breathe expired air C. Gives morphine intravenously to relieve the client's pain D. Places the client in Fowler's position and encourages measures to support hyperventilation
D. Places the client in Fowler's position and encourages measures to support hyperventilation
The home care nurse evaluates the client's ability to use aseptic technique when changing the dressing on the abdominal wound. Which client action demonstrates an understanding of correct technique? A. the client does not wear gloves to change the dressing. B. the client utilizes tap water to cleanse the wound. C. the client applies the anti-biotic ointment to the wound w/ the fingers. D. the client washes the hands before beginning the dressing change.
D. the client washes the hands before beginning the dressing change.
The nurse reviews informed consent with a group of nursing students. which conditions must the informed consent meet to be valid?
There is adequate disclosure the informed consent is given voluntarily the client has sufficient comprehension