NEURO/GI READINESS
A nurse is providing nutritional teaching to a client who has dumping syndrome following a hemi-colectomy. Which of the following foods should the nurse instruct the client to avoid? A. Rice B. Poached eggs C. Fresh apples D. White bread
C. Fresh apples Rationale: Clients with dumping syndrome following a hemi-colectomy should avoid fresh fruits and choose canned or well-cooked fruits instead.
A nursing is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following is an appropriate response by the nurse? A. "Incorporate nonverbal cues in the conversation." B. "Ask multiple choice questions as part of the conversation." C."Use a higher-pitched tone of voice when speaking." D. "Use simple child-like statements when speaking."
A. "Incorporate nonverbal cues in the conversation." Nonverbal cues enhance the client's ability to comprehend and use language.
A nurse is caring for a client who has cancer and is receiving total parenteral nutrition (TPN). Which of the following lab values indicates the treatment is effective? A. Hct 43% B. WBC 8,000 C. Albumin 4.2 D. Calcium 9.4
C. Albumin 4.2 Rationale: Clients who have cancer can receive TPN to provide needed proteins and glucose they are otherwise unable to obtain. An albumin level of 4.2 g/dL is within the expected reference range and indicates the client is receiving adequate amounts of protein.
A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm/Hg. Which assessment should the nurse recognize as a late sign of ICP? (Select all that apply. A. Tachypnea B. Hyperthermia C. Bradycardia D. Nonreactive dilated pupils E. Widened pulse pressure.
C. Bradycardia D. Nonreactive dilated pupils E. Widened pulse pressure.
A nurse is monitoring a client who is at risk for increased intracranial pressure. While assessing the client's cranial nerves, the nurse should check the function of cranial nerve III by: A. testing visual acuity. B. Observing for facial symmetry C. eliciting ga reflex D. checking the pupillary response
D. checking the pupillary response
A nurse is caring for a client who has diverticular disease. When palpating the client's abdomen where should the nurse anticipate abdominal pain? A. LLQ B. LUQ C. RLQ D. RUQ
A. LLQ
A nurse is caring for a child with a suspected diagnosis of bacterial meningitis. Which of the following is the priority action by the nurse? A. Administer abx when available B. Reduce environmental stimuli. C. Document intake and output. D. Maintain seizure precautions
A. Administer abx when available The priority nursing action is to administer antibiotics when available. Bacterial meningitis is an acute inflammation of the meninges and the CNS, and antibiotic therapy has a marked effect on the course and prognosis of the illness.
A nurse is planning care for a client who has a GI bleed. Which of the following actions should the nurse take first? A. Assess orthostatic blood pressure. B. Explain the procedure for an upper GI series. C. Administer pain medication. D. Test the emesis for blood.
A. Assess orthostatic blood pressure. The first action the nurse should take using the nursing process is to assess the client; therefore, assessing the orthostatic blood pressure is the first priority to determine if the client is hypovolemic.
A client has increased intracranial pressure following a closed-head injury. The nurse should recognize which of the following interventions as contraindicated for this client? A. Cough and deep breathe B. Elevate the HOB C. Avoid neck x hip flexion D. Log roll when reposition
A. Cough and deep breathe
A nurse is caring for a client who is 6 days postoperative following a craniotomy for removal of an intracerebral aneurysm. The client has been transferred from the ICU to the PACU. The nurse should assess the client for early signs of increased intracranial pressure (ICP) when the client states? A. Could you get me a bowl? I feel nauseated. B. I'm so bored in here. I want to go home. C. Can you assist me to the bathroom? I need to urinate. D. I think I'm constipated. I haven't had a stool since before surgery.
A. Could you get me a bowl? I feel nauseated.
A nurse is caring for a client at a rehabilitation center 3 weeks after a cerebrovascular accident (CVA). Because the client's CVA affected the left side of the brain, which of the following goals should the nurse anticipate including in the client's rehabilitation program? A. Establish the ability to communicate effectively. B. Have a regular, formed stool at least every other day. C. Learn to control impulsive behavior. D. Improve left-side motor function.
A. Establish the ability to communicate effectively. A CVA is an interruption of the blood supply to any part of the brain, resulting in damaged brain tissue. The left hemisphere is usually dominant for language. Because this client had a left-side CVA, the nurse should anticipate the client will have some degree of aphasia and will require speech therapy to establish communication
A nurse is assessing a client who has obstruction of the common bile duct due to cholelithiasis. Which of the following is an expected finding? A. Fatty stools B. Straw-colored urine C. Tenderness in the LUQ D. Ecchymosis of extremities
A. Fatty stools Rationale: An expected client finding is fatty stools due to biliary obstruction causing a lack of bile for the absorption of fats in the intestines
A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate in the client's history? A. Gallstones B. Hypolipidemia C. COPD D. Diabetes Mellitus
A. Gallstones The client's history may reveal biliary obstruction from a gallstone causing bile to inflame the pancreas.
A nurse is caring for a client following surgical treatment for a brain tumor near the hypothalamus. For which of the following is the client at risk? A. Inability to regulate body temperature. B. Bradycardia C. Visual disturbances D. Inability to perceive sound.
A. Inability to regulate body temperature.
A nurse is caring for a client in liver failure with ascites who is receiving spironolactone (Aldactone). Which of the following outcomes should the nurse expect from this client's medication therapy? A. Increased sodium excretion. B. Decreased urinary output C. Increased potassium excretion D. Decreased sodium excretion
A. Increased sodium excretion. The primary action of spironolactone is to increase sodium excretion in the urines. Spironolactone is a potassium SPARING diuretic so it would be decreased potassium secretion.
A nurse is reviewing medications for a client who has a diagnosis of a small bowel obstruction. The nurse should withhold senna (Senoket) prescribed orally based on understanding of which of the following? A. Laxatives are contraindicated in clients who have a small bowel obstruction. B. Only bulk-forming laxatives such as psyllium (Metamucil) should be prescribed C. Medication should be administered via NG tube rather than the oral route cautiously. D. Opioid analgesics, rather than laxatives, should be prescribed to alleviate discomfort.
A. Laxatives are contraindicated in clients who have a small bowel obstruction.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a peripherally inserted central catheter (PICC) line. When assessing the client, the nurse notes that the client's arm seems swollen above the PICC insertion site. Which of the following actions should the nurse take first? A. Measure the circumference of both upper arms. B. Notify the provider who inserted the PICC line. C. Remove the PICC line D. Apply a cold pack to the clients upper arm.
A. Measure the circumference of both upper arms. The first action to take if the client's arm appears to be swollen is to measure the arm and compare it to the circumference of the other arm. If the arm is swollen, it is appropriate to notify the provider who inserted the PICC line. Swelling could indicate formation of a clot above the site.
A nurse is caring for a client receiving total parenteral nutrition (TPN). Which of the following should the nurse recognize as a complication of this therapy? A. Polyuria B. Aspiration C. Diarrhea D. Stomatitis
A. Polyuria TPN is prescribed when extensive nutritional support for prolonged periods of time is required. It is delivered through a central venous access device, usually via the internal jugular or subclavian vein. TPN contains a high concentration of dextrose, which can result in hyperglycemia. Clinical manifestations of hyperglycemia include polydipsia, polyphagia, and polyuria. Frequent glucose monitoring should be implemented in clients receiving TPN. Administering regular insulin according to a sliding scale will help control glucose levels
A nurse creates a plan of care for a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is within normal limits? A. Pushes away painful stimuli B. Extends the body part toward the stimuli C. Shows no reaction to painful stimuli D. Flexes the upper and extends the lower extremities
A. Pushes away painful stimuli
A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following statements indicates the nurse understands the rationale for using this solution? A. Reduce edema of the brain B. Provide fluid hydration C. Increase cell size in brain D. Expand extracellular fluid volume
A. Reduce edema of the brain
A client is recovering from a cerebrovascular accident (CVA). Which of the following information should the nurse include when teaching family members about repositioning? (Select all that apply.) A. Remove pillows prior to repositioning B. Elevate the bed to waist height C. Position the client towards the edge of bed with a foam wedge. D. Stand with the feet wide apart E. Face the direction of movement when positioning the client.
A. Remove pillows prior to repositioning B. Elevate the bed to waist height D. Stand with the feet wide apart E. Face the direction of movement when positioning the client.
A nurse is assessing an adult who has meningococcal meningitis. Which of the following is an appropriate finding by the nurse? A. Severe HA B. Bradycardia C. Increased muscle tone D. Oriented to time and place.
A. Severe HA Rationale: The nurse should find as a sign of meningococcal meningitis severe headache due to meningeal inflammation.
A nurse is caring for a client who has an acute respiratory illness. The nurse should monitor the client for which of the following manifestations of impending airway obstruction. (Select all that apply.) A. Tachycardia B. Nausea C. Retractions D. Muscle tremors E. Restlessness
A. Tachycardia C. Retractions E. Restlessness Tachycardia is correct. Increases in pulse and respiratory rates are indications of impending airway obstruction. Nausea is incorrect. Gastrointestinal upset is not an indication of impending airway obstruction. Retractions is correct. Substernal, suprasternal, and intercostal retractions and flaring nares are indications of impending airway obstruction. Muscle tremors is incorrect. Muscle tremors are not an indication of impending airway obstruction. Restlessness is correct. Restlessness is an indication of impending airway obstruction.
A nurse monitors for increased intracranial pressure (ICP) on a client who has a leaking cerebral aneurysm. If the client manifests increased intracranial pressure, which of the following findings should the nurse expect? (Select all that apply) A. Violent headache B. Neck pain and stiffness C. Slurred speech D. Projectile vomiting E. Rapid loss of consciousness
A. Violent headache C. Slurred speech D. Projectile vomiting E. Rapid loss of consciousness RATIONALE: Violent headache is correct. The client who manifests ICP should display a violent headache Neck pain and stiffness is incorrect. The client who manifests ICP should not display neck pain and stiffness Slurred speech is correct. The client who manifests ICP may display slurred speech. Projectile vomiting is correct. The client who manifests ICP may display sudden onset of projectile vomiting. Rapid loss of consciousness is correct. The client who manifests ICP may display a sudden rapid loss of consciousness
A nurse is providing discharge teaching for a client who has chronic pancreatitis. Which of the following statements by the nurse is appropriate? A. "You should decrease your caloric intake when abdominal pain is present." B. "You should increase your daily intake of protein." C. "You should increase fat intake when experiencing loose stools." D. "You should limit alcohol intake to 2-3 drinks per week."
B. "You should increase your daily intake of protein." Rationale: Clients who have chronic pancreatitis should consume a diet that is high in protein
A nurse is planning possible interventions in the care for a client who may need for total parenteral nutrition (TPN). Which of the following clients should benefit from TPN? A. A client who has acute gastritis B. A client who has a complete bowel obstruction C. A client who has been vomiting for the past 4 hour D. A client who has undergone a cholecystectomy
B. A client who has a complete bowel obstruction
A nurse is caring for a conscious client who has an airway obstruction. Which of the following is an appropriate intervention? A. Tilt the head and lift the chin B. Begin the Heimlich maneuver C. Turn the client to the side D. Perform a blind finger sweep
B. Begin the Heimlich maneuver
A nurse is collaborating on care for a client following a cerebrovascular accident (CVA). Which of the following should be addressed by an occupational therapist? A. Using assistive devices B. Completing self-care C. Thickening clear liquids D. Transferring from chair to bed.
B. Completing self-care
A client comes to the emergency department reporting severe abdominal pain in the left lower quadrant. The provider suspects a ruptured ectopic pregnancy. Which of the following signs indicates to the nurse that the client has blood in the peritoneum? A. Chvostek's sign B. Cullen's sign C. Chadwick's sign D. Goodell's sign
B. Cullen's sign Cullen's sign is a blue discoloration similar to ecchymosis around the umbilicus. It indicates hematoperitoneum, a common clinical manifestation of a ruptured ectopic pregnancy.
A nurse is admitting a client who is at 10 weeks of gestation and reports abdominal pain and moderate vaginal bleeding. The tentative diagnosis is inevitable abortion. Which of the following actions should the nurse include in the client's plan of care? A. Prepare to administer O2 B. Determine the amt and type of bleeding C. Instruct the client in appropriate birth control methods D. Keep the client on bed rest
B. Determine the amt and type of bleeding
A nurse is planning care for a client who has a decreased level of consciousness from bacterial meningitis. The client is receiving continuous nourishment via gastrostomy tube (G-tube) feedings due to an inability to swallow. Which of the following is the priority action by the nurse? A. Turn and reposition every 2 hours/ B. Elevate the head of the client's bed 30 - 45 degrees C. Change the client's g-tube D. Place SCD's on the client while in bed
B. Elevate the head of the client's bed 30 - 45 degrees
A nurse is caring for a client receiving total parenteral nutrition (TPN) therapy via an infusion pump. When assessing the client receiving this therapy, which of the following observations by the nurse is of least importance? A. IV site B. Height of IV pole C. Date on tubing D. Contents of solution bag.
B. Height of IV pole
A client comes to the emergency department reporting nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see if the client has acute pancreatitis? A. Decreased WBC B. Increased serum amylase C. Decreased serum lipase D. Increased serum calcium
B. Increased serum amylase With acute pancreatitis, serum amylase rises within 24 hr of the start of the client's symptoms. WBC's are elevated. Serum lipase is elevated. Hypocalcemia is common.
A nurse is caring for a school-age child who sustained a closed head injury. Which of the following findings is an early indicator of increased intracranial pressure? A. Pupils 4mm and reactive B. Irritability C. Bradycardia and HTN D. GCS of 14
B. Irritability
A nurse is reviewing the client's laboratory values who is receiving total parenteral nutrition (TPN) has the following lab values: glucose = 72 mg/dL, chloride = 98 mEq/L, sodium = 138 mEq/L, and potassium = 3.0 mEq/L. Which of the following may the nurse expect to implement? A. Discontinue the TPN infusion. B. Plan to infuse a potassium replacement C. Administer 50% dextrose immediately. D. Monitor weekly weights.
B. Plan to infuse a potassium replacement
A nurse is caring for a client following a CVA and observes the client experiencing severe dysphagia. The nurse notifies the provider. Which of the following nutritional therapies will likely be prescribed? A. NPO until dysphagia subsides B. Supplement via NG tube C. Initiation of TPN D. Soft residue diet.
B. Supplement via NG tube Rationale: Supplements via nasogastric tube provide enteral nutrition for clients who are at risk for aspiration caused by a diminished gag reflex or difficulty swallowing. This nutritional therapy will likely be prescribed.
A nurse is caring for a client who has hemianopsia following a cerebrovascular accident (CVA). The nurse should document an improvement in this condition when the nurse observes that the client: A. walks independently with a cane. B. eats items from both sides of her lunch tray C. has infrequent episodes of crying D. maintains communication with others
B. eats items from both sides of her lunch tray
A nurse is caring for a client whose total parenteral nutrition (TPN) was stopped for an hour by mistake. After restarting the infusion pump, the nurse should watch the client carefully for the development of: A. excessive thirst and urination B. shakiness and diaphoresis C. fever and chills D. HTN and crackles
B. shakiness and diaphoresis
A nurse is assessing a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying? A. Kernig's sign B. Nuchal rigidity C. Brudzinski sign D. Bradykinesia
C. Brudzinski sign The client was manifesting Brudzinski sign, flexes hips and knees when neck is flexed, a common sign of meningitis
A nurse is caring for a client who is one day post-operative from an appendectomy and is HIV positive. Which of the following actions requires the nurse to wear a gown as personal protection equipment? A. Talking to the client at the bedside. B. Administering an IV piggyback medication C. Completing a dressing change D. Administering an IM injection
C. Completing a dressing change
A nurse is caring for a client who has a long history of peptic ulcers and is admitted for treatment of pyloric obstruction. The nurse is preparing to insert a nasogastric tube. Which of the following options is the rationale for the use of the nasogastric tube? A. Determine the pH of the gastric secretions. B. Supply nutrients via tube feedings C. Decompress the stomach D. Administer medications
C. Decompress the stomach Rationale: Due to a pyloric obstruction, removal of gastric secretions and gas from the stomach is needed. This is the purpose of the nasogastric tube.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The pharmacy is delayed insupplying the client's next container of TPN. Which of the following fluids should the nurse infuse until the next container arrives? Rationale: A. Dextrose 5% in water B. 0.9% Sodium Chloride C. Dextrose 10% in water D. Lactated Ringer's Solution
C. Dextrose 10% in water TPN contains high concentrations of dextrose and proteins. To avoid hypoglycemia, the nurse should infuse dextrose 10% or 20% in water until the next container of TPN solution arrives.
A nurse is caring for a client who has increased intracranial pressure. Which of the nursing interventions by the nurse is appropriate? A. Teach controlled coughing and deep breathing B. Provide a brightly lit environment C. Elevate the HOB x 30 degrees D. Encourage a minimum intake of 2000mL/day of clear fluids.
C. Elevate the HOB x 30 degrees
After receiving TPN at 84 ml/hr continuously for five days, a client, in a state of confusion, pulled out their central line. Prior to notifying the physician, the nurse should start a peripheral IV and do which of the following? A. Flush the peripheral IV line with 0.9% sodium chloride to await further instructions from the physician B. Change the tubing and filter on the TPN C. Hang an infusion 10% dextrose D. Notify the pharmacy
C. Hang an infusion 10% dextrose The sudden withdrawal from the TPN (hypertonic solution) can cause the client to experience hypoglycemia. Administering an infusion of 10% dextrose will adjust the client's blood glucose levels
After receiving TPN at 84 ml/hr continuously for five days, a client in a state of confusion pulled out their central line. Prior to notifying the provider, the nurse should start a peripheral IV and do which of the following? A. Flush the peripheral IV line with 0.9% sodium chloride to await further instructions from the physician. B. Change the tubing and filter on the TPN C. Hang an infusion 10% dextrose. D. Notify the pharmacy
C. Hang an infusion 10% dextrose. The sudden withdrawal from the TPN (hypertonic solution) can cause the client to be experiencing hypoglycemia. Administering an infusion of 10% dextrose will adjust the client's blood glucose levels.
A nurse on a pediatric unit is caring for a client who has a brain tumor. To help ensure the client's safety, which of the following actions should the nurse take? A. Do not allow the child to ambulate in his room alone. B. Limit contact with other pediatric clients. C. Initiate seizure precautions for the child. D. Have the child use a wheelchair fo all out-of-bed activities
C. Initiate seizure precautions for the child.
A nurse is anticipating the provider's orders for a client who has a paralytic ileus following an appendectomy. Which of the following are expected nursing actions? A. Administer antacids B. Provide bulk-forming agent C. Insert NG tube D. Apply a truss
C. Insert NG tube The nurse should expect to insert a nasogastric tube for the client who has no peristaltic activity to decompress the gastrointestinal system of draining fluid and flatus.
A nurse is planning care for a 6-year-old client who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client's plan of care? A. Place the client in semi fowlers position B. Admit the client to a private room C. Measure head circumference every shift D. Implement seizure precautions
C. Measure head circumference every shift
An acute care nurse receives shift report for a client with increased intracranial pressure and is told the client demonstrates decorticate posturing. Which of the following should the nurse expect to observe upon assessment of this client? A. Extension of the extremities B. Pronation of the hands C. Plantar flexion of the legs D. External rotation of the lower extremities
C. Plantar flexion of the legs
A nurse is caring for an adolescent client in the emergency department who sustained a head injury. The nurse notes the client's IV fluids are infusing at 125 mL/hour. Which of the following is an appropriate action by the nurse? A. Slow the rate to 20 mL/hr. B. Continue the rate ar 125 mL/hr C. Slow the rate to 50mL/hr D. Increase the rate to 250mL/hr
C. Slow the rate to 50mL/hr Rationale: The nurse should decrease the rate to 50 mL/hr to minimize cerebral edema and prevent increased intracranial pressure.
A client has right-sided paralysis from a cerebral vascular accident (CVA). Which of the following interventions should the nurse implement to prevent foot-drop? A. Place sandbags to maintain right plantar flexion. B. Position soft pillows against the bottom of the feet C. Support the right foot in dorsiflexion with a footboard. D. Splint the right lower extremity to maintain proper alignment
C. Support the right foot in dorsiflexion with a footboard.
A nurse is caring for an older adult client who is hospitalized for a bowel obstruction and has a nasogastric (NG) tube to wall suction. Which of the following nursing interventions should be included in the postoperative plan of care? (Select all that apply.) A. Offer small amounts of clear liquids after the client's gag reflex returns. B .Maintain the client on complete bed rest for 48 hr. C.Irrigate the nasogastric tube with saline as needed. D.Place sequential compression devices on the bilateral lower extremities. E.Reposition the client from side to side every 2 hr. F.Encourage the use of an incentive spirometer ever hour while the client is awake.
C.Irrigate the nasogastric tube with saline as needed. D.Place sequential compression devices on the bilateral lower extremities. E.Reposition the client from side to side every 2 hr. F.Encourage the use of an incentive spirometer ever hour while the client is awake.
A nurse in the antepartum unit is caring for a client who is at 36 weeks of gestation and has pregnancy- induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications? A. Placenta previa B. Prolapsed cord C. Ruptured ovarian cyst D. Abruptio placentae
D. Abruptio Placentae he cardinal signs and symptoms of abruptio placentae include a rigid board-like abdomen, severe pain, and heavy vaginal bleeding.
A nurse is caring for a client who has acute pancreatitis. While evaluating the client's admission blood chemistry report, the nurse should expect to find an elevated serum: A. Ammonia B. Bilirubin C. Lactate acid D. Amylase
D. Amylase
A nurse is caring for a client who has a history of pancreatitis. Which of the following food choices should the client avoid? A. Noodles B. Vegetable soup C. Baked fish D. Cheddar cheese
D. Cheddar cheese Clients who have pancreatitis should avoid foods high in fat. Cheddar cheese is high in fat content and the client should avoid this food choice
A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). The nurse should know that which of the following client findings supports this suspicion? A. Cyanotic fingertips B. Nuchal rigidity C. Fever D. Diplopia
D. Diplopia Rationale: Clients who have meningitis can be at risk for developing increased intracranial pressure (ICP). The classic triad of manifestations for increased ICP consists of headache, nausea/vomiting, and diplopia, or double vision. The client who has meningitis and reports diplopia must be carefully monitored for other manifestations of increased ICP.
A nurse is caring for an infant who has inadequate motility of part of the intestine resulting in a mechanical obstruction. Which of the following disorders does the infant have? A. Encopresis B. Entercolitis C. Pyloric stenosis D. Hirschsprung disease
D. Hirschsprung disease
A nurse is admitting a client who has bacterial meningitis. The nurse notes during the physical examination that the client cannot extend his leg when his hip is flexed so that his thigh rests on his abdomen. The nurse should document this as which of the following A. Brudzinski's sign B. Chvostek's sign C. Goodell's sign D. Kernig's sign
D. Kernig's sign
A nurse admits a client who has a concussion for overnight observation. Alert and oriented on admission, the client reports a headache along with neck pain and generalized muscle aches. The nurse knows that a manifestation considered an early indication of increased intracranial pressure (ICP) is: A. Bradycardia B. Ipsilateral pupil dilation C. Widening pulse pressure D. Lethargy
D. Lethargy Rationale: Increased intracranial pressure is a condition in which the pressure of the cerebrospinal fluid or brain matter within the skull exceeds the upper limits for normal. An early sign of increasing ICP is lethargy.
An acute care nurse is caring for an adult client who is undergoing evaluation for a possible brain tumor. When performing a neurological examination, which of following is the most reliable indicator of cerebral status? A. Pupil response B. Deep tendon reflexes C. Muscle strength D. Level on consciousness
D. Level on consciousness The nurse should examine the client's level of consciousness as the most reliable indicator of cerebral status.
A nurse is caring for a client who has acute pancreatitis. After the client's pain has been addressed, which of the following is the next intervention to include in the plan of care? A. Monitor for respiratory status. B. Encourage a side-lying position with knees flexed. C. Provide frequent oral hygiene D. Maintain NPO status
D. Maintain NPO status To rest the pancreas and reduce secretion of pancreatic enzymes, oral fluids and food are withheld during the acute phase of pancreatitis. This is the next intervention to be included in the plan of care
A nurse is caring for a client who is diagnosed with a cerebrovascular accident (CVA, stroke). Which of the following actions should be implemented to prevent deep-vein thrombosis (DVT)? A. Massage lower extremities daily B. Check for positive Homans sign C. monitor LOC D. Place SCD's bilaterally
D. Place SCD's bilaterally
A nurse is developing an educational poster regarding risk factors for cerebrovascular accidents (CVA) for a group of clients. In a listing of nonmodifiable risk factors, the nurse should include A. Smoking B. Obesity C. HTN D. Race
D. Race
A nurse is caring for a client who has just had an evacuation of a subdural hematoma following a head injury. Which of the following is the nurse's highest priority assessment? A. ICP B. serum electrolytes C. Temperature D. Respiratory status
D. Respiratory status
A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F), and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications? A. Dehydration B. Seizures C. Burns D. Shivering
D. Shivering The hypothermia (cooling) blanket, if used improperly (at inappropriately low temperatures, or without skin protection), can cause the client to cool too fast, leading to shivering. To prevent heat loss from the skin, the body becomes peripherally vasoconstricted in an attempt to reduce heat loss. The body will also try to increase heat production by shivering, which can increase the metabolic rate by two to five times and in doing so greatly raise oxygen consumption
A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data? A. The client can follow simple motor commands. B. The client is unable to make vocal sound C. The client is unconscious D. The client opens his eyes when spoken to
D. The client opens his eyes when spoken to
A nurse is providing discharge teaching for a client who has acute pancreatitis and has a prescription for fat-soluble vitamin supplements. The nurse should instruct the client to take a supplement for which of the following? A. Vitamin A B. Vitamin B1 C. Vitamin C D. Vitamin B12
D. Vitamin B12 THIS IS NOT A FAT SOLUBLE VITAMIN
A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). To determine if the client is experiencing pain, the nurse should use: A. Pulse and BP findings B. behavioral indicators and affect C. facial expressions and grimaces D. a self-report pain rating scale
D. a self-report pain rating scale
A nurse is caring for a 5-month-old undergoing a lumbar puncture to rule out meningitis. The nurse who is planning to assist with the procedure should? A. utilize a papoose board to restrain limbs B. Position the infant seated on the side of table. C. have several other nurses hold the infant D. hold the infants chin to chest and knees to abdomen.
D. hold the infants chin to chest and knees to abdomen.
A nurse is providing education to a client who is being discharged home with total parenteral nutrition (TPN). Which of the following statements by the nurse is most appropriate? (Select all that apply.) a. Keep the TPN refrigerated when not in use B. Warm the TPN bag in the microwave before hanging C. Shake the TPN bag before administering D. Stop using TPN once weight gain is achieved E. Maintain TPN infusion rate when behind schedule.
a. Keep the TPN refrigerated when not in use E. Maintain TPN infusion rate when behind schedule.