NUR 113 Coordinating & Managing Care Prep-U
A client with Hodgkin disease had a bone marrow biopsy yesterday and reports aching at the biopsy site, rated a 5 (on a 1-10 scale). After assessing the biopsy site, which nursing intervention is most appropriate? Reposition the client to a high Fowler position and continue to monitor the pain Administer acetaminophen 500 mg po, as ordered Administer aspirin (ASA) 325 mg po, as ordered Notify the physician
Administer acetaminophen 500 mg po, as ordered
A client undergoing coronary artery bypass surgery is subjected to intentional hypothermia. The client is ready for rewarming procedures. Which action by the nurse is appropriate? Administer IV fluids warmed to room temperature. Temporarily set the OR temperature to 30°C. Apply a warm air blanket, gradually increasing body temperature. Place warm damp drapes on the client, replacing them every 5 minutes.
Apply a warm air blanket, gradually increasing body temperature
The nurse is providing care to a client who has had a renal biopsy. The nurse would need to be alert for signs and symptoms of which of the following? Dehydration Allergic reaction Bleeding Infection
Bleeding
A nurse is assigned to care for a patient with increased parathormone secretion. Which of the following serum levels should the nurse monitor for this patient? Calcium Glucose Sodium Potassium
Calcium
When caring for the patient with acute glomerulonephritis, which of the following assessment findings should the nurse anticipate? Pyuria Left upper quadrant pain Cola-colored urine Low blood pressure
Cola-colored urine
The fifth step of the nursing process is evaluation. As part of this step, the nurse does which of the following? carries out the written plan of care and monitors the client's status observes and documents the client's health status sets priorities and defines expected outcomes compares actual client outcomes to the expected outcomes
Compares actual client outcomes to the expected outcomes
Effective, individualized care that shows respect for the dignity, personal rights, preferences, beliefs, and practices of people receiving care while acknowledging the bias of the caregiver and preventing that bias from interfering with care. This is a definition of? The School of Nursing's mission statement A nursing pledge written by Florence Nightingale The Patient's Bill of Rights Culturally competent nursing care
Culturally competent nursing care
Which disorder is characterized by a group of symptoms produced by an excess of free circulating cortisol from the adrenal cortex? Addison disease Hashimoto disease Graves disease Cushing syndrome
Cushing syndrome
During the integumentary assessment of an adult female client, the nurse observes that the client has dry, dull, brittle hair and dry, flaky skin with poor turgor. When planning this client's nursing care, the nurse should prioritize interventions that address what problem? Exposure to environmental toxins Deficient nutritional status Inadequate physical activity Ineffective personal hygiene
Deficient nutritional status
The family members of a dying patient are finding it difficult to verbalize feelings and show tenderness for the dying person. Which of the following nursing interventions should a nurse perform in such situations? Encourage conversations on the impending death of the patient. Be a silent observer and allow the patient to communicate with the family members. Encourage the family members to express their feelings and listen to them in their frank communication. Encourage the patient's family members to spend time with the patient.
Encourage the family members to express their feelings and listen to them in their frank communication
Which activity should be avoided in clients with increased intracranial pressure (ICP)? Position changes Enemas Minimal environmental stimuli Suctioning
Enemas
When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? Hyperoxemia, hypocapnia, and hyperventilation Hypercapnia, hypoventilation, and hypoxemia Hypotension, hyperoxemia, and hypercapnia Hyperventilation, hypertension, and hypocapnia
Hypercapnia, Hypoventilation, Hypoxemia
After chemotherapy for AML, what interventions will best help to prevent renal complications? Select all that apply. Administer rasburicase. Encourage exercise. Administer potassium therapy. Increase hydration. Administer allopurinol.
Increase hydration, Administer allopurinol, and Administer rasburicase
The nurse cares for a client with a right-arm arteriovenous fistula (AVF) for hemodialysis treatments. Which nursing action is contraindicated? Obtaining blood samples from the left arm Palpating the fistula for a "thrill" Obtaining a blood pressure reading from the right arm Placing the client's watch on the left wrist
Obtaining a blood pressure reading from the right arm
A nurse is performing passive range of motion to a client's upper extremities. The nurse touches the client's thumb to each fingertip on the same hand. The nurse is performing which of the following? Opposition Pronation Adduction Dorsiflexion
Opposition
During a family assessment, the mother states, "When I was a child, we always had a special dinner on Christmas Eve, that my mother had when she was a child. Now our family follows the same tradition." The nurse interprets this statement as indicating which family function? Socialization Education Management Boundary setting
Socialization
The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority? Ability to deep breathe Medication allergies Swallow reflex Presence of carotid pulse
Swallow reflex
The nurse observes that a client's medical report indicates that the client has Cushing syndrome. During inspection, the nurse notes that the client's BMI is 31, waist circ is 40 in, and localized fat pads exist around the neck/upper part of the back. Which of the following must the nurse keep in mind while planning the client's care? The nurse recognizes that the client's obesity may be specifically related to the endocrine disorder. The nurse performs a nutritional assessment. The nurse knows that a waist circ of 40 places the client at risk. The nurse instructs the client to remember all food consumed over the next 24-hr period. Knowing that the client is obese, the nurse plans to provide dietary ed to reduce the daily caloric intake using the U.S. Dept of Ag's MyPlate pyramid. A BMI of 31 indicates obesity, and the nurse instructs the patient to keep a record of food actually consumed over the next 3 to 7 d
The nurse recognizes that the client's obesity may be specifically related to the endocrine disorder. The nurse performs a nutritional assessment.
A client diagnosed with Huntington disease is on a disease-modifying drug regimen and has a urinary catheter in place. Which potential complication is the highest priority for the nurse while monitoring the client? Urinary tract infection Severe depression Choreiform movements Emotional apathy
Urinary tract infection
A nurse caring for a patient with a pulmonary embolism understands that a high ventilation-perfusion ratio may exist. What does this mean for the patient? There is an absence of perfusion and ventilation. Perfusion exceeds ventilation. Ventilation exceeds perfusion. Ventilation matches perfusion.
Ventilation exceeds perfusion