Nursing analysis, assessment, planning, implement, and eval

Which anatomic location should the nurse select to safely administer an intramuscular injection in the vastus lateralis muscle of an adult client? Refer to figure.

B

When a client currently prescribed furosemide and digoxin reports both anorexia and nausea, which action should the nurse take?

Check the result of the potassium level drawn 3 hours ago.

The nurse caring for a client after right radical mastectomy includes which intervention in the nursing plan of care for this client?

Checks the right posterior axilla area when assessing the surgical dressing

The nurse is evaluating a hypertensive client's understanding of dietary modifications to control the disease process. The nurse determines that the client's understanding is satisfactory if the client made which meal selections?

Turkey, baked potato, salad with oil and vinegar

The well-baby clinic nurse is preparing to administer an immunization when the infant's mother reports that the child has had a fever and has just started taking antibiotics. The nurse takes the child's temperature rectally and notes that it is 101.5° F (38.6° C). Which nursing action is appropriate?

Delay the immunization.

The nurse who has been closely monitoring a child who has been exhibiting decorticate (flexor) posturing notes that the child suddenly exhibits decerebrate (extensor) posturing. The nurse interprets that this change in the child's posturing indicates what?

Deteriorating neurological function

A client is receiving phenobarbital orally for the treatment of a seizure disorder. The nurse should assess the client for which common side effect of this medication?

Drowsiness

An older adult client in a long-term care facility has a stable gait but demonstrates signs and symptoms of confusion. Which is the most appropriate method of restraint (safety device) to minimize the client's risk for injury?

Electronic bracelet

A client on mechanical ventilation is being weaned on the following settings: Fio2 40%, continuous positive airway pressure (CPAP) of 5, and pressure support (PS) of 5. Which finding should indicate to the nurse that the client is not tolerating the weaning process?

Heart rate increases from 82 to 135 beats per minute.

A client has been prescribed isoniazid in the treatment of tuberculosis (TB). Because the client will be receiving this medication, what should the nurse plan to monitor?

Hepatic enzymes

The nurse caring for a client diagnosed with diabetes insipidus should identify which assessment findings as being specifically related to this disorder?

Hypotension, decreased pulse pressure, and tachycardia

A newborn male infant is diagnosed with an undescended testicle (cryptorchidism), and these findings are shared with the parents. The parents ask questions about the condition. The nurse should respond to the parents that which condition can occur and have a psychosocial impact if the undescended testicle is not corrected?

Infertility

A client diagnosed with polycythemia vera asks the nurse about the disorder. Which information should the nurse provide to correctly respond to the client?

Is classified as a myeloproliferative disorder

The nurse observes slight facial jaundice in a 2-day-old, full-term newborn infant during a postpartum home visit. Which assessment guideline should the nurse use to interpret this finding?

Jaundice is first noticed in the head of the newborn infant, especially the sclera and mucous membranes.

A client diagnosed with leukemia is receiving chemotherapy. The nurse reviews the laboratory results and notes that the neutrophil count is low and the client is placed on neutropenic precautions. What should the nurse include as a necessary component of the plan of care?

Monitoring oral temperature every 4 hours

The nurse notes that an older client's current apical pulse is 82 beats per minute, strong but irregular. The nurse notes that prior baseline data indicated that the client's apical pulse ranged from 60 to 90 beats per minute and was strong and regular. On further assessment, the client reports "feeling tired lately." Based on this data, what intervention should the nurse implement?

Notify the client's primary health care provider.

A client in the second trimester of pregnancy is being assessed at the primary health care clinic. The nurse notes that the fetal heart rate (FHR) is 100 beats/min. Which nursing action would be appropriate initially?

Notify the primary health care provider of the finding.

The nurse working in the long-term care facility is administering tamsulosin to an assigned client. What is the most appropriate time to schedule the administration of this medication?

One half hour after lunch every day

The nurse is reviewing the history and physical of a client diagnosed with acute poststreptococcal glomerulonephritis (APSGN). Which manifestations of the disorder would the nurse expect to note? Select all that apply.

Proteinuria. Rusty colored urine. Generalized body edema

A client with a diagnosis of acquired immunodeficiency syndrome and cytomegalovirus retinitis is receiving ganciclovir. Which action should the nurse plan to take while the client is taking this medication?

Provide the client with a soft toothbrush and an electric razor.

In preparation to administer an intermittent tube feeding, the nurse aspirates 40 mL of undigested formula from the client's nasogastric tube. Which intervention should the nurse implement as a result of this finding?

Reinstill the aspirate through the nasogastric tube via gravity and syringe.

Intravenous (IV) human albumin is prescribed for a client with second- and third-degree burns of the anterior chest and both legs. Before administering the albumin, the nurse reads the documented client history to identify the presence of any existing conditions that would be a contraindication in its use. Which condition, if noted in the client's medical record, would be a contraindication?

Renal insufficiency

The home care nurse visits a client with a diagnosis of cirrhosis and ascites. Which action should the nurse encourage the client to take when providing dietary instructions?

Restrict sodium intake.

The nurse notes bilateral 2+ edema in the lower extremities of a client diagnosed with coronary artery disease who was admitted 2 days ago. Based on this finding, which action should the nurse implement?

Review the intake and output records since admission.

The nurse is preparing to provide discharge instructions to a client diagnosed with Raynaud's disease. When considering self-management, what should the nurse stress as a priority?

Stop smoking because it causes cutaneous vasospasm.

A client is 3 hours postoperative after a right upper lobectomy done to treat a lung tumor. The collection chamber of the closed pleural drainage system contains 400 mL of bloody drainage. The client's vital signs are blood pressure, 100/50 mm Hg; heart rate, 100 beats per minute; and respiratory rate, 26 breaths per minute. There is intermittent bubbling in the water seal chamber. One hour after the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant and the client appears dyspneic. What should the nurse assess first?

The chest tube connections

A client with a tracheostomy is being considered for long-term home ventilator therapy. The nurse determines that the client is not yet ready for discharge when which observations are noted?

The family is cardiopulmonary resuscitation (CPR) certified through a course designed for lay people in the community.

The nurse is teaching a pregnant client about prenatal nutritional needs. The nurse should include which information in the client's teaching plan?

The nutritional status of the mother significantly influences fetal growth and development.

A client had thoracic surgery 2 days ago and has a chest tube in place connected to a Pleur-Evac drainage system. The nurse notes that there is continuous bubbling in the water seal chamber. How does the nurse interpret this finding?

There is a leak in the system that requires immediate investigation and correction.

The nurse is collecting a sputum specimen for culture and sensitivity testing from a client who has a productive cough. Which intervention should the nurse implement to obtain the specimen?

Use a sterile plastic container for obtaining the specimen.

The nurse is preparing to administer an intramuscular injection to a 11-month-old child. Which location should the nurse select to administer the medication?

Vastus lateralis muscle

The nurse is caring for a victim of a burn injury during the emergent/resuscitative phase. On assessment of the client, the nurse notes that the urine output has decreased and the blood pressure is dropping. Which action should the nurse immediately take?

Notify the primary health care provider.

A client diagnosed with nephrolithiasis arrives at a clinic for a follow-up visit. The laboratory analysis of the stone that the client passed 1 week ago indicates that the stone is composed of calcium oxalate. The nurse should encourage the client to avoid consuming which food item?

Strawberries

The nurse is orienting a new RN in the care for a client diagnosed with an immunodeficiency condition. Which statement by the new RN indicates that teaching has been effective?

"The client has an absence of immune bodies."

The nurse provides medication instructions to a client prescribed fluoxetine hydrochloride. Which statements by the client indicate a need for further teaching? Select all that apply.

"The sexual dysfunction should be a passing symptom." "I know that there are no side effects with this medication." "I have been on this medication for 3 days and already feel better."

Which problems should the nurse counsel adoptive parents about encountering? Select all that apply.

1.Setting unrealistically high standard for themselves 2.Lacking basic knowledge about the child's biological health history 3.Having difficulty assimilating if the child is adopted from another country 4.Having difficulty deciding when and how to tell the child about being adopted 6.Dealing with feelings of loss and grief in the child regarding family social history and traditions

The nurse is preparing a chemotherapy infusion to be administered to a client with a diagnosis of Hodgkin's disease. Which precaution should the nurse take during the preparation of this intravenous (IV) infusion? Select all that apply.

1.Wear a mask. 2.Wear a gown. 3.Wear double gloves. 5.Wear eye protectors.

A client who is serving a life sentence without parole has been transferred from maximum security to the infirmary and is being assessed by the prison nurse. In preparing a treatment plan for this client, which should the nurse give priority to?

Assessment for suicidal risk

The nurse is admitting a client with a diagnosis of Ménière's disease. Which assessment question elicits information specific to the signs/symptoms that occur with this disorder?

"Do you have a feeling of fullness in your ear?"

A client with a diagnosis of trigeminal neuralgia is started on a regimen of carbamazepine. The nurse provides instructions to the client about the medication. What statement by the client indicates that the client understands the instructions?

"I will report a fever or sore throat to my doctor."

A 10-day postpartum breast-feeding client telephones the postpartum unit reporting a reddened, painful breast and elevated temperature. Based on assessment of the client's complaints, which action should the nurse tell the client to do?

"Notify your health care provider because you may need medication."

The director of a level 1 trauma center is planning for the required hospital-wide disaster drills. The director begins instructing some of the nurse managers on the requirements of the drill. Which statements by the managers indicate that the teaching has been effective? Select all that apply.

"One of the drills needs to use community-wide resources." "To maintain ongoing disaster preparedness, we must participate in drills and emergency training at least twice a year."

A client is being discharged to home after spinal fusion with insertion of a spinal rod. The nurse should consult with the continuing care nurse regarding the required need for follow-up with modification of the home environment when the client makes which statement?

"The bedroom and bath are on the second floor of the home."

The nurse is checking a baseline serum creatinine level on an adult client who will be receiving an intravenous antibiotic that is nephrotoxic. The nurse determines that it is safe to administer the medication, based on which serum creatinine level?

1.2 mg/dL (106 mcmol/L)

The nurse creates a postprocedure care plan for a client scheduled for a colonoscopy. Which should be included in the immediate postprocedure plan? Select all that apply.

1.Assess for rectal bleeding and clots. 2.Take vital signs every 15 to 30 minutes. 3.Maintain a nothing by mouth (NPO) status. 4.Monitor for manifestations of bowel perforation.

The nurse is performing an assessment of a client who is a full-time student and reporting sleep deprivation due to college workload. Which assessment data should the nurse collect on this client? Select all that apply.

1.Irritability 2.Decreased motivation 3.Cardiac dysrhythmias 4.Increased sensitivity to pain

The nurse is caring for a client prescribed digoxin. Which manifestations correlate with a digoxin level of 2.3 ng/dL (2.93 nmol/L)? Select all that apply.

1.Nausea 2.Drowsiness 3.Photophobia 6.Seeing halos around bright objects

A client diagnosed with osteoporosis is at risk for falls. What action should the nurse advise the client to take in order to maintain safety in the home? Select all that apply.

1.Placing a mat in the tub 2.Obtaining a shower chair 3.Placing a night-light in the hall 4.Making sure that railings are secure

The nurse is developing a care plan for a client experiencing urge urinary incontinence. Which interventions would be helpful for this type of incontinence? Select all that apply.

2.Bladder retraining 3.Scheduled toileting 4.Dietary modifications 5.Pelvic muscle exercises

The nurse is preparing to carry out a primary health care provider's prescription to deliver a bolus of lidocaine, 1 mg/kg intravenously, to a client with a ventricular dysrhythmia. The client weighs 110 lb. How many milligrams of lidocaine should the nurse plan to administer? Fill in the blank.

50 mg

Propofol is prescribed to induce sedation for a client who is intubated and is being mechanically ventilated. The nurse prepares the medication and selects which solution to dilute the medication?

5% Dextrose

A client diagnosed with heart failure has been receiving furosemide 40 mg orally daily. The nurse determines that the medication is effective when which findings are noted? Select all that apply.

5.Clear sounds to bilateral lungs 6.Weight loss of 3 pounds over 24 hours

The nurse is assessing a client with gestational hypertension who was admitted to the hospital 48 hours ago. Which current assessment data would indicate that the condition has not yet resolved?

Client complaints of blurred vision

The registered nurse (RN) planning the assignments for the day is leading a team composed of a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP). Based on licensure, which client is most appropriate to assign to the LPN?

A 1-day postoperative mastectomy client

Which newborn has the highest risk for developing physiological jaundice?

A preterm newborn

The nurse is admitting a client with a diagnosis of Guillain-Barré syndrome. During the history taking, the nurse should ask if the client has recently experienced which physical problem?

A respiratory or gastrointestinal (GI) infection

A client diagnosed with urolithiasis is being evaluated to determine the type of calculi that are present. The nurse should plan to keep which item available in the client's room to assist in this process?

A urine strainer

A client reports experiencing severe mouth and throat pain 10 days after receiving chemotherapy. Which client problem is appropriate based on this assessment data?

Acute pain

The client is scheduled for an endoscopic retrograde cholangiopancreatography (ERCP). Which intervention should the nurse include in the plan of care for the client?

After the procedure, keep client NPO until the gag reflex returns.

An infant has been diagnosed with acute chalasia. During the nursing history, the mother tells the nurse, "I am concerned that I am somehow causing my infant to vomit after feeding her." Considering this statement, which concern should the nurse identify for the mother?

An unrealistic expectation of herself

The nurse is bathing a neonate and notices small dark tufts of fine hair on the neonate's lower back. Based on this observation, the nurse should take which action?

Arrange to notify the primary health care provider of this physical finding.

The clinic nurse notes that a client reports taking a natural supplement, called butcher's broom (Ruscus aculeatus). The nurse further questions the client, knowing that this supplement most likely has been used to treat which disorder?

Arthritis

An acutely ill client reports, "The worst pain I've ever felt in my belly. I can't get comfortable," and with each movement the client cries out in pain. The nurse suspects that the client has peritonitis. In order to validate that suspicion, what should the nurse initially plan to do? Select all that apply.

Assess for hiccups. Assess for tachycardia. Inspect the abdomen for rigidity. Inspect the client's mucous membranes.

An emergency department nurse is performing an assessment on a client who has sustained circumferential burns of both legs. Which assessment should be the priority in caring for this client?

Assessing peripheral pulses

The nurse has finished suctioning the tracheostomy of a client. Which parameter should the nurse monitor to determine the effectiveness of the procedure?

Breath sounds

The nurse is assessing a client diagnosed with Addison's disease for signs of hyperkalemia. Which sign/symptom should the nurse observe with this electrolyte imbalance?

Cardiac dysrhythmias

The nurse reads the radiology report of the initial chest X-ray taken on an infant with respiratory distress syndrome (RDS) who has received surfactant replacement therapy. The report states that both lung fields have a "ground glass" appearance. How should the nurse interpret this report?

Characteristic of clinical findings in neonatal RDS

The nurse is preparing to insert a peripheral intravenous (IV) line and administer prescribed 0.45% normal saline at 75 mL/hr. Which is the order of priority that the nurse should take to prepare for the IV insertion? Arrange the actions in the order of priority that they should be performed. All options must be used.

Check health care provider prescriptions. Explain the procedure to the client and assess the client's previous experience with IV therapy. Assess the client for risk factors. Perform hand hygiene. Prepare the infusion set.

The nurse reviews the health care record of a client who never received a varicella vaccine and now presents with a rash and very painful headache. Which finding should the nurse expect to note as characteristic of this client's suspected disorder?

Clustered and grouped skin vesicles

A client diagnosed with Raynaud's disease tells the nurse that he has a stressful job and does not handle stressful situations well. Which life change should the nurse teach the client to consider to help alleviate his stress?

Consider a stress management program.

The nurse is caring for a hospitalized child diagnosed with rubella (German measles). Which priority precaution should the nurse implement while caring for this child?

Contact isolation

An anxious client enters the emergency department seeking treatment for a laceration of the finger. The client's vital signs are pulse 106 beats per minute, blood pressure (BP) 158/88 mm Hg, and respirations 28 breaths per minute. After cleansing the injury and reassuring the client, the nurse rechecks the vital signs and notes a pulse of 82 beats per minute, BP 130/80 mm Hg, and respirations 20 breaths per minute. Which factor likely accounts for the change in vital signs?

Decline in sympathetic nervous system discharge

A client is prescribed glipizide once daily. What intended effect of this medication should the nurse observe for?

Decreased blood glucose

As the nurse approaches a client with paranoid schizophrenia who was recently admitted to the inpatient unit of a psychiatric hospital, the client says, "Quit following me. You're with the FBI; I can tell by the way you are walking." This is an example of which alteration in thinking?

Delusion

What action should a unit manager take when after overhearing a staff nurse making a negative comment about his or her leadership style?

Encourage the staff nurse to discuss the comments.

A client diagnosed with both a wound infection and osteomyelitis is to receive hyperbaric oxygen therapy. During the therapy, which priority intervention should the nurse implement?

Ensuring that oxygen is being delivered

The nurse is preparing to assess the fetal heart rate (FHR) of a pregnant woman who is at 20 weeks' gestation. Which piece of equipment will the nurse use to assess the FHR?

Fetoscope

A client diagnosed 3 months ago with hypothyroidism is at the clinic for a checkup. The nurse performs an assessment using which type of database?

Follow-up database

A client is admitted to the emergency department after a burn injury sustained in a house fire. How should the nurse interpret that this client's burn should be documented? Refer to Figure.

Full thickness

The nurse assists a client diagnosed with a renal disorder in collecting a 24-hour urine specimen. Which intervention does the nurse implement to ensure proper collection of the 24-hour urine specimen?

Have the client void at the start time and discard the specimen.

A child is hospitalized with a diagnosis of atrial septal defect. The nurse plans care knowing that what are the characteristics of this type of defect? Select all that apply.

It is a left-to-right heart shunt.. Oxygenated and unoxygenated blood mix. Left side of the heart is experiencing higher pressure than the right side.

The nurse caring for a client with an acute head injury should carefully assess which function as the primary indicator of neurological status?

Level of consciousness

An older client has been diagnosed with functional incontinence. Which strategies are most appropriate to implement for this type of incontinence? Select all that apply.

Modify clothing for easy removal. Assess environment for obstacles. Schedule a toileting routine every 2 hours. Set up schedule of cues such as mealtimes, awakening, and bedtime.

The nurse is caring for a postoperative client who had a nephrostomy tube inserted. What are some specific areas the nurse needs to monitor this client for? Select all that apply.

Monitor intake and output for the first several hours. Check the site of the tube for leaking urine or blood. Assess for infection, such as fever or change in urine character.

When giving an intramuscular injection to a 4-year-old child, which technique is best for the nurse to use?

Obtain assistance to administer the injection.

The nurse monitoring a client who has been prescribed heparin infusion therapy should suspect that the client is experiencing a complication of the therapy if which finding is noted?

Oozing from venipuncture site

A dehydrated toddler asks the nurse for something to drink. Which beverage is appropriate for the nurse to offer this child?

Pedialyte

The nurse is monitoring a client with a diagnosis of chronic kidney disease (CKD). Which assessment finding should the nurse report to the primary health care provider?

Petechiae

A client previously well controlled with glyburide has recently begun reporting fasting blood glucose to be 180 to 200 mg/dL (10.28 to 11.42 mmol/L). Which medication, noted in the client's record, may be contributing to the elevated blood glucose level?

Prednisone

A client is admitted to the hospital for an emergency cesarean delivery. Contractions are occurring every 15 minutes. The client has a temperature of 100° F (37.8° C), ate 2 hours ago, and indicates that she has had no preparation for the cesarean delivery. Which action should the nurse plan to take first?

Report the time of the last food intake to the obstetrician.

A 9-year-old child is newly diagnosed with type 1 diabetes mellitus. The nurse is planning for home care with the child and the family and determines that which is an age-appropriate activity for health maintenance?

Self-administering insulin with adult supervision

A client's blood pressure is 100/78 mm Hg; the client has tachycardia and is cool and pale. Which position should the nurse assist the client into to promote tissue oxygenation?

Semi-Fowler's

A client recovering from myocardial infarction is anxious about the condition and being alone. What action should the nurse take to give the client some control over the condition and to help alleviate the fear?

Show the client how to use the call button and keep it within the client's reach at all times.

A client with an intravenous (IV) catheter has a prescription for an IV solution to be changed to 1000 mL 0.9% sodium chloride to infuse at 100 mL/hour. When determining the rationale for the change in fluid, the nurse interprets that the client probably needs this type of solution for which reason?

Sodium chloride is isotonic with the plasma and other body fluids.

The nurse is assigned to care for a client being admitted with a diagnosis of cirrhosis and ascites. Which dietary measure should the nurse expect to be prescribed for the client?

Sodium restriction

Which psychosocial factor obtained during an assessment of an older client places the client most at risk for abuse?

The client is completely dependent on family members for both food and medicine.

The nurse is preparing a client for elective cardioversion. The nurse determines that a need for further preparation for the procedure is necessary if which condition is present?

The client is wearing a nasal cannula delivering oxygen at 2 L per minute.

A client with the diagnosis of acute pyelonephritis who is very shy and modest is scheduled for a voiding cystourethrogram. Why should the nurse determine that this client would benefit from increased support and teaching about the procedure?

The client must void while the voiding process is filmed.

An unconscious client brought to the emergency department requires immediate emergency treatment. From the viewpoint of informed consent, what principle governs the initiation of treatment for this client?

The emergency doctrine allows for treatment to be provided in emergency situations.

In which situation is the nurse manager utilizing an autocratic leadership style?

The nurse manager provides the solution for a unit problem.

A client newly prescribed clonazepam reports increasing clumsiness and unsteadiness since starting the medication. The client is visibly upset by these manifestations and asks the nurse what to do. The nurse's response is based on which understanding of these symptoms?

The symptoms are severe during initial therapy and decrease or disappear with long-term use.

A primary health care provider has written a prescription for a client diagnosed with diabetic gastroparesis to receive metoclopramide four times a day. The nurse schedules this medication to be given at which times?

Thirty minutes before meals and at bedtime

An adolescent is hospitalized for evaluation and treatment of Tourette's disorder. The nurse reviews the client's record and notes that the client is exhibiting motor tics. What should the nurse most expect to note on assessment of the client?

Tongue protrusion

The emergency department nurse is assessing a client who abruptly discontinued benzodiazepine therapy and is experiencing withdrawal. Which manifestations of withdrawal should the nurse expect to note? Select all that apply.

Tremors. Sweating. Agitation. Nervousness

A client with a history of prostatic hypertrophy has been prescribed propantheline bromide for the treatment of peptic ulcer disease. The nurse determines that the client understands the medication instructions if the client states that she or he should report which possible side effect?

Urinary hesitancy or retention

The nurse inspects a client's right lower extremity and finds an open area 3 by 4 cm in size that has a deep reddish base. The surrounding skin is edematous, with a brownish tinge to it. Pedal pulses are palpable in the right leg. The nurse interprets that the ulcerated area is a result of which predisposing condition?

Venous insufficiency

A client who is newly diagnosed with chronic kidney disease is scheduled for hemodialysis this morning and asks the nurse why the daily dose of enalapril has not been given. The nurse tells the client that this medication will be given at which point?

When dialysis is completed

When a primary health care provider prescribes a chemotherapy drug dosage that the nurse believes is in error, which immediate action should the nurse take?

Call the primary health care provider who prescribed the medication.

The nurse is providing endotracheal suctioning to a client who is being mechanically ventilated. During the procedure the client becomes restless and tachycardic. What is the priority nursing action in this situation?

Check the vital signs and discontinue attempts at suctioning until the client is stabilized.

The nurse preparing to administer medications to an assigned client notes that the prescription for furosemide is higher than the recommended dosage. When the nurse calls the primary health care provider to express the concern about the dosage, the primary health care provider refuses to change the prescription and instructs the nurse to administer the dose as prescribed. Which action should the nurse take next?

Contact the nursing supervisor.

Which statement by the client indicates an understanding of the signs of hypoglycemia?

"I may feel weak and shaky."

The nurse teaches a client at risk for coronary artery disease about lifestyle changes needed to reduce his risks. The nurse determines that the client understands these necessary lifestyle changes if the client makes which statements? Select all that apply.

"I will be sure to include some exercise such as walking in my daily activities." "I will work at losing some weight so that my weight is at normal range for my age." "I will limit my sodium intake every day and avoid eating high-sodium foods such as hot dogs." "I will schedule regular doctor appointments for physical examinations and monitoring my blood pressure."

A client is hospitalized during an acute period of mania. The client is restless and pacing in the hallway, and slaps another client who is walking to a group meeting. Which therapeutic statements to the client by the nurse would be most appropriate? Select all that apply.

"If you are having difficulty controlling yourself right now, I will help you." "I understand that you are not feeling well, but you may not hurt others." "You may not hit other people. Come with me to your room now."

The home care nurse visits a client with a diagnosis of diabetes mellitus at home. The nurse notes that the client has cut the blood glucose monitoring strips in half lengthwise, and the client tells the nurse that he did this to save money. Based on the client's action, which would be the most appropriate statement by the nurse?

"The glucose value can be underestimated with such a small area to read."

The nurse is caring for a client scheduled for a bilateral adrenalectomy for treatment of an adrenal tumor. What information should the nurse give the client about the postsurgical needs?

"You will need to take daily hormone replacements beginning after the surgery."

The nurse discontinues a unit of packed red blood cells (RBCs) because the client is experiencing a transfusion reaction. After discontinuing the transfusion, what action should the nurse take next?

Contact the primary health care provider.

The nurse is caring for a client who received local cervical ablation for a stage I cervical tumor. What procedures do cervical ablation include? Select all that apply.

Cryosurgery. Laser therapy. Electrosurgical excision

The nurse has prepared a client for an intravenous pyelogram (IVP). The nurse determines that the client understands the procedure if the client states the need to report which sensation immediately, if it occurs during the procedure?

Difficulty breathing

A client diagnosed with a personality disorder will begin recreational therapy as a component of the treatment plan. The nurse provides information to the client regarding the therapy, knowing that this modality is helpful for clients who demonstrate which behavior?

Difficulty socializing

The nurse is planning care for a client admitted with suicidal ideations. To best assure client safety the nurse will implement additional precautions during which time period?

During the unit shift change

A client is to receive heparin sodium 6000 units subcutaneously. The medication label on the medication bottle states heparin 10,000 units per 1 mL. The nurse should prepare how many mL for administration? Fill in the blank.

0.6 mL

Quinupristin-dalfopristin is prescribed for a client diagnosed with a skin infection. The nurse, preparing to administer the medication by intermittent intravenous (IV) infusion, should plan to administer the medication over which time frame?

1 hour

A client has developed atrial fibrillation resulting in a ventricular rate of 150 beats per minute. The nurse should assess the client for which effects of this cardiac occurrence? Select all that apply.

Dyspnea. Chest pain or discomfort. Hypotension and dizziness

The nurse is assisting in preparing a pregnant client for Leopold's maneuvers. Which should be included in the preprocedure plan of care?

Asking the client to empty her bladder

A client has implemented dietary and other lifestyle changes to manage hypertension. The nurse determines that the client has been most successful when the client has which follow-up blood pressure reading?

128/84 mm Hg

A client is prescribed oral lorazepam 4 mg daily to help manage manic behavior. The medication label reads 2 mg/mL. To receive the correct dose, how many mL per dose should the nurse administer? Fill in the blank.

2 mL

A client is receiving continuous bladder irrigations. Three thousand milliliters of normal saline irrigant has been infused over the last 8 hours. The Foley catheter bag has been emptied 3 times during the 8 hours for the following amounts: 1150 mL, 1225 mL, and 840 mL. Calculate the client's true urine output for the 8 hours. Fill in the blank.

215 mL

An intravenous dose of labetalol 20 mg is prescribed. The medication label reads: 5 mg/mL. The nurse should prepare how many mL of labetalol for administration? Fill in the blank.

4 mL

A client is brought to the emergency department after having seriously lacerated both wrists. The initial action that the nurse should take is which step?

Assess and treat the wound sites.

A client reports to the clinic for follow-up after a 1-month treatment with acebutolol. The clinic nurse determines that a therapeutic effect of the medication has occurred if which is noted?

A blood pressure of 120/78 mm Hg

A client with dry skin is in need of a moisturizing agent. Which product should the nurse choose in order to be most effective?

A petrolatum-based ointment

The nurse is assigned to provide primary care to a client in labor and will care for the client throughout labor and into the postpartum period. When creating a plan of care for a client in the fourth stage of labor, what should the nurse determine is the initial priority nursing assessment?

Assessing vital signs and the uterine fundus and lochia

The hospital nurse is admitting a client who sustained an extensive burn injury. The nurse reviews the primary health care provider's prescriptions and should question which prescription?

Administer morphine sulfate intramuscularly every 3 hours as needed for pain.

The labor room nurse is caring for a client in labor with a known history of sickle cell anemia. Which action should the nurse implement to assist in preventing a sickle cell crisis from occurring during labor?

Administer the prescribed oxygen throughout labor.

The nurse is called by the American Red Cross to assist in caring for victims and survivors of an explosion at a local industrial plant. The nurse plans to implement crisis intervention for which type of crisis that occurred?

Adventitious

A client has a cuffed tracheostomy tube that has been plugged for 3 days; the primary health care provider tells the nurse that the tube will be removed. The nurse plans to ensure that which important action is taken just before the primary health care provider removes the tube?

Airway suctioning

The nurse is preparing to comb the hair of a client who has pediculosis. The nurse should perform the actions in which priority order? Arrange the actions in the order that they should be performed. All options must be used.

Apply a disposable gown and gloves. Divide the client's hair in sections. Dip the comb in a cup of water. Look through the hair for attached lice. Remove attached lice with the comb or tweezers.

An adult calls the emergency department seeking advice on managing the pain caused by a bee sting to the arm. The client states that previous bee stings did not result in any allergic reactions. What should the nurse tell the client to do first?

Apply ice and elevate the arm.

The nurse is planning care for a client with the diagnosis of deep vein thrombosis (DVT) of the left leg. The client is experiencing severe edema and pain in the affected extremity. Which interventions should the nurse plan to implement in the care of this client? Select all that apply.

Elevate the left leg. Apply moist heat to the left leg. Administer acetaminophen as prescribed. Administer anticoagulation as prescribed.

The nurse determines that the client with atherosclerosis understands dietary modifications to lower the risk of heart disease if which food selection is made?

Fresh cantaloupe

The nurse is preparing to change the linens and gown of a client who received an unsealed radiation source earlier in the day for treatment of breast cancer. Which protective items should the nurse wear?

Gown and gloves

The nurse is caring for a client with a radial arterial line that needs to be removed. Which personal protective items should the nurse implement for best self-protection during this procedure? Select all that apply.

Gown, Face shield, Clean gloves

The nurse has provided instructions to the parents of a child diagnosed with diabetes mellitus about management of hypoglycemia. The nurse determines that the family understands the instructions if they indicate that they will take which action?

Have the child carry LifeSavers with him whenever he leaves the home.

The nurse enters a new mother's room and finds that the mother is crying and that the infant is undressed on the bed in front of the mother. The mother looks at the nurse and says, "I can't even dress this baby!" After reassuring the client, the nurse determines that which is an appropriate nursing action?

Have the mother place the infant in the bassinet and assist the mother in dressing the baby.

The nurse employed in a community hospital as a unit manager determines that authority in this situation appropriately refers to which area of responsibility?

Having power to approve and/or command an action, or to see that a decision is enforced

An adolescent client is crying and clinging to his mother after being told that he needs an intravenous (IV) catheter. The nurse has supplies at the bedside to perform the venipuncture that include a vial of lidocaine. Which intervention should the nurse implement?

Perform the venipuncture using the lidocaine.

The client prescribed phenelzine sulfate suddenly exhibits signs of hypertensive crisis. Which medication should the nurse plan to prepare?

Phentolamine

A client diagnosed with acquired immunodeficiency syndrome (AIDS) as well as cytomegalovirus (CMV) retinitis is receiving ganciclovir. Which intervention should the nurse plan to implement while the client is being prescribed this medication?

Providing the client with a soft toothbrush and an electric razor

The nurse is assisting with providing a form of psychotherapy in which the client acts out situations that are of emotional significance. Based on this assessment data, which form of therapy should the nurse expect the primary health care provider has prescribed?

Psychodrama

A registered nurse suspects that a colleague is substance impaired when observing signs of alcohol intoxication during a shift. The nurse practice act requires that the registered nurse take which action?

Report the information to a nursing supervisor.