PN Adult Medical Surgical Online Practice 2023 A
A nurse is reinforcing teaching with a client who has coronary artery disease. Which of the following instructions should the nurse include in the teaching?
"Add oily fish to your diet twice weekly."
A nurse is reinforcing discharge teaching with a client who has cirrhosis. Which of the following instructions should the nurse include?
"Consume foods that are low in sodium."
The nurse is evaluating the client's understanding of the discharge instructions. Click to highlight the client statements that indicate an understanding of the teaching. To deselect a statement, click on the statement again.
"Foods that contain tyramine might trigger my headaches." "I will keep a food and headache diary." "I will place a cool cloth on my forehead when I experience a migraine."
A nurse in a health clinic is reinforcing teaching with a client about tuberculosis (TB). Which of the following client statements indicates an understanding of the teaching?
"I can develop TB by breathing in the infection."
A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. Which of the following statements indicates that the client is adhering to the nurse's instructions?
"I don't cross my legs anymore."
A nurse is reinforcing teaching with a client who has asthma. Which of the following client statements indicates an understanding of the use of budesonide and albuterol inhalers? (Select all that apply.)
"I never forget to rinse my mouth after using my budesonide inhaler." "Between office visits, I keep a record of how many times I use my albuterol inhaler." "I use my albuterol inhaler before I go swimming." "I should use my budesonide inhaler before using my albuterol inhaler."
A nurse is reinforcing teaching with a client who has mitral valve disease. Which of the following statements by the client indicates an understanding of the disease process?
"I should call my doctor if my ankles swell."
A nurse is reinforcing teaching about gastroesophageal reflux disease (GERD) with a client. Which of the following statements by the client indicates an understanding of the teaching?
"I should wait at least 2 hours after eating before going to bed."
A nurse is reinforcing teaching with a client prior to the removal of a leg cast. Which of the following statements should indicate to the nurse that the client understands the teaching?
"I will feel vibrations on my leg from the cast cutter."
A nurse is reinforcing teaching about glycosylated hemoglobin (HbA1c) testing with a client who has diabetes mellitus. Which of the following statements indicates that the client understands the teaching?
"I will have my HbA1c checked twice per year."
A nurse is reinforcing teaching with a client about preventing osteoporosis. Which of the following client statements indicates an understanding of the teaching?
"I will limit my coffee intake."
A nurse is reinforcing teaching with a client who has chronic kidney disease about disease management. Which of the following statements by the client indicates an understanding of the teaching?
"I will limit my daily intake of protein."
A nurse is reinforcing discharge teaching with a client who has Crohn's disease. Which of the following statements should the nurse include in the teaching?
"Maintain a low-residue diet."
A nurse is collecting data from an older adult client who has several concerns. Which of the following concerns should the nurse recognize as an expected change associated with aging?
"My food tastes bland even after I add seasoning."
A nurse is providing information regarding transmission-based precautions for a client who has Clostridium difficile to an assistive personnel (AP). Which of the following instructions should the nurse include? (Select all that apply.)
"Provide the client with disposable utensils and dishes for meals." "Leave blood pressure equipment in the client's room." "Clean contaminated surfaces with a bleach solution."
A nurse is reinforcing teaching about pursed-lip breathing with a client who has a new diagnosis of COPD. The nurse should identify that which of the following client statements indicates an understanding of the teaching?
"Pursed-lip breathing works best for activities like walking up stairs."
.A nurse is assisting with the care of a client who has prostate cancer. The client asks the nurse why they are having difficulty with urination. Which of the following responses should the nurse make?
"The tumor causes obstruction of urine from the urethra."
A nurse is reinforcing teaching with a client who has a new diagnosis of genital herpes. Which of the following information should the nurse include?
"The virus can be transmitted without lesions being present."
A nurse is collecting data from a client and notices several skin lesions. Which of the following findings should the nurse report as possible melanoma?
Irregular borders
A nurse is reinforcing teaching regarding the use of a continuous passive motion (CPM) machine with a client who is scheduled for a total knee arthroplasty. Which of the following information should the nurse include in the teaching? (Select all that apply.)
"Your knee is flexed and extended as prescribed by your provider." "The machine is padded with sheep skin."
A nurse is reinforcing dietary teaching with a client about increasing the intake of foods containing vitamin C to enhance absorption of oral iron supplements. Which of the following food choices should the nurse include in the teaching?
1 cup of boiled broccoli
A nurse is assisting in the care of a client who is receiving a continuous tube feeding of 60 mL/hr at 1.2 cal/mL. How many calories will the client receive in 12 hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
864 cal
A nurse is contributing to the plan of care for a client who has Ménière's disease. Which of the following interventions should the nurse include in the plan of care?
Administer an antiemetic to the client.
A nurse is planning care for a group of clients after receiving change-of-shift report. Which of the following clients should the nurse plan to see first?
A client who is dehydrated, has mental confusion, and has tried to get out of bed several times during the night
Exhibit 1 Nurses' Notes 0730 Vital signs Temperature 38° C (100.4° F)Heart rate 72/min and regularRespiratory rate 16/minBlood pressure 128/78 mm HgPain rating 6/10 Exhibit 2 History and Physical History of type 2 diabetes mellitus and hypertension Allergies: 1) Penicillin reaction severe2) Aspirin3) Heparin Exhibit 3 Diagnostic Results Capillary blood glucose 102 mg/dL
A nurse is preparing to administer scheduled medications to a client. Which of the following prescriptions should the nurse verify with the provider? Ceftriaxone
A nurse is assisting with the care of a client who has a migraine. Which of the following interventions should the nurse anticipate? Select all that apply.
Administer sumatriptan. Dim the lights in the client's room.
A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis. Which of the following interventions should the nurse include when contributing to the plan of care?
Apply a mask to the client if transport is needed.
A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. Which of the following information should the nurse include in the teaching?
Apply cold packs to the inflamed joints.
A nurse is contributing to the plan of care for a client who has just transferred to the medical-surgical unit from the PACU following a right total knee arthroplasty. Which of the following interventions should the nurse include in the plan?
Assist the client to change positions at least every 2 hr.
A nurse is collecting data from a client who has hypothyroidism. Which of the following manifestations should the nurse anticipate?
Bradycardia
A nurse is reinforcing teaching with the caregiver of a client who has a cervical injury and has a halo vest in place. Which of the following safety precautions should the nurse include in the teaching?
Change the sheepskin liner weekly.
A nurse is assisting with the care of a client who is receiving 0.9% sodium chloride by continuous IV infusion. The client reports pain and swelling at the IV site. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Check iv site Stop infusion Withdraw the iv catheter Elevate the affected arm Notify the charge nurse
A nurse is assisting with the care for a client who is 2 hr postoperative following the amputation of a foot. Which of the following actions should the nurse take first?
Check the incisional dressing.
A nurse is assisting with the care for a client who is suspected of having a myocardial infarction. Which of the following actions should the nurse take to prepare the client for an ECG?
Cleanse the client's skin prior to electrode placement.
The nurse is assisting with the care of the client 1 hr following chest tube insertion. Click to highlight the findings that indicate the client's condition is improving. To deselect a finding, click on the finding again.
Client reports pain as a 3 on a scale of 0 to 10. Client reports shortness of breath has decreased. Wound dressing is dry and intact. Respiratory rate 24/min Blood pressure 108/74 mm Hg Oxygen saturation 95% on oxygen 2 L/min via nasal cannula
A nurse is assisting with the care for a client who has a history of breast cancer. The client asks the nurse about birth control. Which of the following methods of birth control is contraindicated for this client?
Combination oral contraceptives
A nurse is assisting with the care of a client. Exhibit 1 Diagnostic Results Aspartate aminotransferase (AST) 45 units/L (0 to 35 units/L)Alanine aminotransferase (ALT) 39 international units/L (4 to 36 international units/L)Total lactic dehydrogenase (LDH) 200 units/L (100 to 190 units/L)WBC count 12,000/mm3 (5,000 to 10,000/mm3) Exhibit 2 Vital Signs Blood pressure 132/86 mm HgHeart rate 101/minRespiratory rate 18/minTemperature 37.2° C (99° F)Oxygen saturation 97% on room air Exhibit 3 Physical Examination Client presents to the ED with upper abdominal pain that radiates to the right shoulder. Pain is rated as a 7 on a scale of 0 to 10. Client also reports nausea, vomiting, and dyspepsia.Client awake, alert, and oriented to person, place, and time. Lung sounds are clear bilaterally. S1 and S2 heart tones noted. All pulses are palpable. Bowel sounds are active in all four quadrants.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Administer morphine IV. (action) Ensure the client is NPO. (action) Cholecystitis (condition) Jaundice (monitor) Increasing temperature (monitor)
A nurse is assisting with the care for a client who is postoperative and has a portable wound bulb suction device. Which of the following actions should the nurse take?
Compress the bulb reservoir and then close the drainage valve.
A nurse is assisting in the care of a client who has AIDS-related pneumonia. The client is receiving antibiotic therapy and albuterol nebulizer treatments daily. Which of the following findings should indicate to the nurse that the client's therapeutic regimen is effective?
Decrease in exertional dyspnea
A nurse is preparing to administer furosemide to a client who has heart failure. Which of the following findings should the nurse report before administering the medication?
Decreased potassium
A nurse is collecting data from a client who has heart failure and is taking digoxin. Which of the following outcomes from the medication should the nurse expect?
Decreased shortness of breath
A nurse is assisting with the care for a client who has age-related macular degeneration. Which of the following findings should the nurse expect?
Distorted central vision of the eyes
A nurse is assisting with the care of a client who was admitted from the emergency department with a burn injury. Exhibit 1 Nurses' Notes 1800: Client has full thickness burns over both forearms; partial thickness burns are present on the client's neck.Sinus tachycardia noted. Pulses to extremities are palpable. 1+ edema to upper extremities noted.Respirations are even and labored with scattered rhonchi.Hypoactive bowel sounds are present.16 French indwelling urinary catheter was inserted with return of 250 mL of yellow urine.Lactated Ringer's is infusing to the right antecubital.1830: Client's voice is becoming hoarse, and client reports difficulty swallowing. Wheezes are present in upper lobes bilaterally. Charge nurse was notified. Client is positioned upright, and oxygen 40% is being delivered via face tent. Blood collected for ABGs. Exhibit 2 Vital Signs 1800: Temperature 37.2° C (99° F)Heart rate 112/minRespiratory rate 24/minBlood pressure 136/84 mm HgOxygen saturation 95% on oxygen 40% via face tent1815: Temperature 36.6° C (97.8° F)Heart rate 120/minRespiratory rate 28/minBlood pressure 116/78 mm HgOxygen saturation 93% on oxygen 40% via face tent1830: Temperature 36.1° C (97° F
During the emergent phase of burn care, the client is at risk for developing hypovolemia and respiratory failure
A nurse is assisting with the care for a client who is postoperative and has an epidural infusion. Which of the following findings should the nurse recognize as the priority?
Dyspnea
A nurse is assisting with the care for a client who is receiving chemotherapy. The client mentions that they have a loss of appetite because of sores in their mouth and that food no longer tastes good. Which of the following suggestions to the client should the nurse make?
Eat several small-portioned meals daily.
A nurse is reviewing the medical record of a client who has acute pancreatitis. Which of the following findings should the nurse anticipate?
Elevated serum amylase level
A nurse is reviewing the laboratory reports of a client who reports chest pain. Which of the following laboratory results indicates the client is experiencing a myocardial infarction?
Elevated troponin
A nurse is contributing to the plan of care for a client who has COPD and is dyspneic. Which of the following interventions should the nurse include in the plan?
Encourage abdominal breathing.
A nurse is assisting with the care for a client who has dementia due to Alzheimer's disease. Which of the following actions should the nurse take to reduce the client's confusion?
Encourage reminiscence of past experiences.
The nurse is assisting with the care of the client following the placement of a chest tube for a hemothorax. Which of the following actions should the nurse take? Select all that apply.
Ensure that all chest tube connections are securely attached. Palpate the chest tube insertion site for subcutaneous emphysema. Place two rubber-tipped hemostats in the client's room. Place the client in high-Fowler's position.
For each finding below, click to specify if the finding is consistent with migraine, stroke, or meningitis. Each finding may support more than 1 disease process.
Findings Nausea - migraine, meningitis Visual changes - migraine, stroke, meningitis Pain - migraine, stroke, meningitis Family history - migraine, stroke
A nurse is assisting with the care of a client. Exhibit 1 Nurses' Notes 1200:Client was admitted to the unit with shortness of breath, a nonproductive cough, chest discomfort, and myalgia. Prefers orthopneic position. Client reports that manifestations began about 2 days ago.1215:Oxygen applied at 2 L/min via nasal cannula. Wheezes noted bilaterally. Use of accessory muscles noted. Client speaks in short phrases, with increased shortness of breath. Oral mucosa is pink; capillary refill is 4 seconds. Exhibit 2 Vital Signs 1200:Temperature 38.7° C (101.6° F)Blood pressure 104/64 mm HgHeart rate 100/minRespiratory rate 26/minOxygen saturation 88% on room air1215:Temperature 38.7° C (101.6° F)Blood pressure 106/64 mm HgHeart rate 104/minRespiratory rate 24/minOxygen saturation 93% on oxygen 2 L/min via nasal cannula
For each finding, click to specify if the finding is consistent with emphysema, asthma, or pneumonia. Each finding may support more than 1 disease process. Findings: Temperature - pneumonia Breath sounds - emphysema, asthma, pneumonia Respiratory rate - emphysema, asthma, pneumonia Cough - emphysema, asthma, pneumonia
A nurse is assisting with monitoring a client who is receiving dialysis treatment. Exhibit 1 Nurses' Notes 0530:Client is awake and alert. Arteriovenous fistula (AVF) to right forearm with thrill palpated and auscultated for bruit. Breath sounds are clear upon auscultation; client denies shortness of breath. No peripheral edema noted; capillary refill is less than 3 seconds; +2 bilateral pedal and radial pulses.AVF access prepared and cannulated twice with no difficulty. Lines are taped and secured; treatment is initiated.0600:Client is reading a book. Access is visible, and lines are secure. Client reports no discomfort or pain.0630:Client reports feeling warm, nauseated, and lightheaded; appears restless and slightly confused. Exhibit 2 Vital Signs 0530:Current weight 88 kg (194 lb)Temperature 37° C (98.6° F)Blood pressure• Lying - 152/92 mm Hg• Sitting - 148/90 mm Hg• Standing - 144/88 mm HgHeart rate 90/minRespiratory rate 20/minOxygen saturation 98% on room air0600:Temperature 36.9° C (98.4° F)Blood pressure 120/80 mm HgHeart rate 96/minRespiratory rate 20/minOxygen saturation 97% on room air0630:Temperature 36.2° C (97.1° F)Blood pressure 88/50 mm HgHeart rate 110/minRespiratory ra
For each potential nursing intervention, click to specify if the intervention is indicated or not indicated. Nursing Intervention Request a chest x-ray - not indicated Place the client in reverse Trendelenburg position - indicated Assist with administering a 0.9% sodium chloride 200 mL IV bolus - indicated Apply oxygen at 2 L/min via nasal cannula - indicated Notify the charge nurse immediately - indicated Obtain the client's blood glucose level - not indicated
A nurse is assisting with the care for a client who has difficulty swallowing. Which of the following actions should the nurse implement to prevent aspiration?
Give the client liquids with increased viscosity.
A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus about glycosylated hemoglobin (HbA1c) testing. Which of the following information should the nurse include in the teaching?
HbA1c results measure glucose control for the prior 3 months.
A nurse is collecting data from a 55-year-old female client who reports vaginal dryness and hot flashes. The client is interested in trying hormone replacement therapy (HRT). Which of the following should the nurse recognize as a contraindication to HRT?
History of treatment for blood clots
A nurse is reinforcing teaching with a client who has a new diagnosis of tuberculosis (TB) and a prescription for isoniazid and rifampin. Which of the following information should the nurse include in the teaching?
Household family members should be tested for TB.
A nurse is reinforcing teaching with a client who is on a low-sodium diet and asks about how to improve the taste of bland food. Which of the following foods should the nurse recommend?
Lemon juice
A nurse is assisting with the care for a client who has neutropenia. Which of the following nursing interventions should the nurse implement?
Limit visitors to healthy adults.
A nurse is assisting with the care for a client who begins to have a seizure while ambulating in the hall. Identify the sequence of actions the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Lower client to the floor. Place a pad beneath the client's head. Loosen the clothing around the client's neck. Time the length of the client's seizure. Reorient and reassure the client.
A nurse is assisting in the care of a client who is experiencing withdrawal from heroin. Which of the following medications should the nurse expect the provider to prescribe?
Methadone
A nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a client who has skin cancer. Which of the following information should the nurse include in the teaching?
Mohs surgery is a horizontal shaving of thin layers of the tumor.
A nurse is assisting with the care for a client who is undergoing testing for multiple sclerosis. Which of the following findings should the nurse expect?
Muscle spasticity
A nurse is assisting with the discharge planning for a client who is postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the discharge plan?
Obtain a raised toilet seat.
A nurse is preparing to assist a client out of bed 4 hr following a laparoscopic cholecystectomy. Which of the following actions should the nurse take first?
Obtain the client's blood pressure.
A nurse is reinforcing teaching with a client who has asthma and a new prescription for a corticosteroid. Which of the following findings should the nurse include as an adverse effect of the medication?
Orthostatic hypotension
A nurse is preparing to remove a client's NG tube. Which of the following interventions should the nurse take to decrease the risk for aspiration?
Pinch the NG tube.
A nurse is contributing to the plan of care for a client who has tuberculosis (TB). Which of the following interventions should the nurse include?
Place the client in a negative-pressure airflow room.
A nurse is assisting with the care for a client following a gastrectomy. Which of the following actions should the nurse take to decrease episodes of dumping syndrome?
Place the client in the supine position after meals.
A nurse is reviewing the chart of a client who is experiencing an adrenal crisis, which was precipitated by the client not taking their medication for several days. The nurse should identify that withdrawal from which of the following medications potentiated the adrenal crisis?
Prednisone
A nurse is contributing to the plan of care for a client who has a new prescription for nystatin suspension for oral candidiasis. Which of the following interventions should the nurse include in the plan?
Remind the client to swish the medication in their mouth.
A nurse is reinforcing discharge teaching about wound care with the caregiver of a client who is postoperative. Which of the following instructions should the nurse include in the teaching?
Report purulent drainage to the provider.
A nurse on a medical-surgical unit is assisting with the care of a newly admitted client. Exhibit 1 Progress ReportDay 1 2330:Report received from emergency department:Client has a penetrating wound to the anterior upper right chest. Client is alert and oriented with a Glasgow Coma Scale (GCS) score of 15. Wound dressing has moderate serosanguineous drainage. Client reports pain as a 6 on a scale of 0 to 10. Shortness of breath noted. Exhibit 2 Graphic RecordDay 1 2330:Vital signs from the emergency department:Heart rate 125/minRespiratory rate 28/minTemperature 36° C (96.8° F)Blood pressure 145/90 mm HgOxygen saturation 90% on oxygen 2 L/min via nasal cannula
Select the 3 findings that require follow-up by the nurse. Oxygen saturation Pain level Wound dressing
Exhibit 1 Nurses' Notes1000:Client reports visual disturbances, including flashing lights in their vision, especially on the right side.Client is alert and oriented to person, place, and time; client appears anxious. No facial drooping noted. Hand grasps are equal and strong bilaterally.Client reports throbbing pain behind the left eye, photophobia, and nausea. The client rates the pain as a 7 on a scale of 0 to 10. Exhibit 2 Graphic Record1000:Temperature 36.9° C (98.4° F)Heart rate 112/minRespiratory rate 22/minBlood pressure 138/80 mm HgOxygen saturation 98% on room air Exhibit 3 History and PhysicalHistory of high cholesterol, diet controlledFamily history of coronary artery disease, epilepsy, and migraines
Select the 3 findings that require follow-up by the nurse. Visual disturbances Headache Nausea
A nurse in an orthopedic clinic is reinforcing teaching with a client who has osteoarthritis. Which of the following instructions should the nurse include to promote comfort?
Sleep on a firm mattress.
A nurse is contributing to the plan of care for a client who had a stroke. For which of the following interprofessional team members should the nurse recommend a referral prior to initiating oral intake for the client?
Speech-language pathologist
A nurse is assisting with the care of client. Exhibit 1 Nurses' Notes 1000:Client is alert and oriented and reports not feeling well for a few days.Client is on continuous ambulatory peritoneal dialysis (CAPD) and reports that dialysate appeared cloudy this morning.Client reports abdominal pain as a 4 on a scale of 0 to 10. Bowel sounds are active in all quadrants.Peritoneal dialysis access site is red and warm to the touch, with a small amount of purulent drainage noted on the dressing.1300:Client is lying in bed with their knees flexed, guarding their abdomen. Abdomen is slightly distended; hypoactive bowel sounds are present. Client reports nausea and pain as a 6 on a scale of 0 to 10. Provider notified and updated with client condition and diagnostic results. Exhibit 2 Vital Signs 1000:Blood pressure 142/90 mm HgRespiratory rate 18/minTemperature 38.3° C (101° F)Heart rate 90/minOxygen saturation 96% on room air Exhibit 3 Diagnostic Results 1300:WBC count 17,000/mm3 (5,000 to 10,000/mm3)Potassium 4.8 mEq/L (3.5 to 5 mEq/L)Free T4 1.4 ng/dL (0.8 to 2.8 ng/dL)Thyroid stimulating hormone (TSH) 4.5 μU/mL (0.3 to 5 μU/mL)Platelets 220,000/mm3 (150,000 to 400,000/mm3)Abdominal x-ray resu
The client is experiencing manifestations of peritonitis due to the client's abdominal x-ray results
The nurse is assisting with the care of the client. Exhibit 1 Progress ReportDay 1 2330:Report received from emergency department:Client has a penetrating wound to the anterior upper right chest. Client is alert and oriented with a Glasgow Coma Scale (GCS) score of 15. Wound dressing has moderate serosanguineous drainage. Client reports pain as a 6 on a scale of 0 to 10. Shortness of breath noted. Exhibit 2 Graphic RecordDay 1 2330:Vital signs from the emergency department:Heart rate 125/minRespiratory rate 28/minTemperature 36° C (96.8° F)Blood pressure 145/90 mm HgOxygen saturation 90% on oxygen 2 L/min via nasal cannulaDay 1 2345:Heart rate 135/minRespiratory rate 34/minTemperature 35.9° C (96.6° F)Blood pressure 96/45 mm HgOxygen saturation 92% on oxygen 40% via face mask Exhibit 3 Nurses' NotesDay 1 2345:Client is alert and oriented with a CGS score of 15. Reinforced dressing over the chest wound with sanguineous drainage. No other wounds or injuries found.Bilateral radial and pedal pulses are +1. Left lung sounds are clear; right upper lung sounds are diminished.Client still reports pain as a 6 on a scale of 0 to 10 over anterior chest.Bowel sounds are present in all four quadrants
The client is most likely experiencing a hemothorax as evidenced by the client's respiratory findings
A nurse is examining a client's IV site and notes a hardened vein above their IV site. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client's manifestations indicate which of the following complications of IV therapy?
Thrombophlebitis
For each potential provider prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.
Transfuse packed RBCs - anticipated Place the client in Trendelenburg position - contraindicated Prepare the client for chest tube insertion - anticipated Cover the client with a cooling blanket - contraindicated Initiate NPO status - anticipated
A nurse is contributing to the plan of care for a client who has a head injury and is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse include in the plan?
Use a turn sheet to reposition the client.
A nurse is preparing to suction a client who has a tracheostomy. Which of the following actions should the nurse take first?
Ventilate the client with 100% oxygen.
A nurse is reviewing the medical record of a client who is postoperative. Which of the following findings should the nurse identify as a complication of surgery?
WBC count of 15,000/mm3
A nurse is assisting with the care of a client who is postoperative following abdominal surgery. Exhibit 1 Nurses' Notes 1100: Client received from PACU; initial vital signs recorded. Client is drowsy but arouses to verbal stimuli. Oriented to person, place, and time. Client is able to move all extremities. Normal sinus rhythm noted. Breath sounds are clear upon auscultation. Dressing to abdomen is intact with a small amount of serosanguinous drainage noted and marked. No bowel sounds in all four quadrants. Indwelling urinary catheter is in place and draining clear, yellow urine. Lactated Ringer's is infusing at 100 mL/hr via IV catheter in the right forearm.1200: Client reports nausea and pain as an 8 on a scale of 0 to 10. Abdominal dressing is intact with no further drainage noted. Urine output of 15 mL noted since arrival from PACU. Analgesic and antiemetic were administered as prescribed.1230: Client reports relief from nausea, and pain as a 4 on a scale of 0 to 10. Oxygen saturation is 96%. Client was repositioned for comfort and encouraged to turn, cough, and deep breathe.1300: No additional urine output noted since 1200.
Which of the following actions should the nurse take? Select all that apply. Instruct the client to splint their abdomen with a pillow when coughing. Report the client's urinary output to the charge nurse. Monitor the client's pain level.
A nurse is reinforcing teaching with a client who has diabetes mellitus and a new prescription for regular and NPH insulin. Which of the following instructions on preparing the insulins should the nurse include?
Withdraw the regular insulin before withdrawing the NPH insulin.
A nurse is assisting with the care for a client who has a prescription for digoxin 0.25 mg PO daily. While taking the client's apical pulse, the nurse notes a rate of 58/min. Which of the following actions should the nurse take?
Withhold the dose.
Complete the following sentence by using the lists of options. The nurse should identify that the client is most likely experiencing a migraine , and the nurse should address the client's pain .
a migraine pain
Complete the following sentence by using the list of options. Following the administration of sumatriptan, the nurse should monitor for chest pain due to the risk for myocardial ischemia
chest pain myocardial ischemia
A nurse is preparing to assist with the insertion of a double-lumen gastric sump tube for a client who has peptic ulcer disease and has developed gastrointestinal bleeding. Which of the following images depicts the tube that the nurse should select?
clear with blue tube
The nurse should first address the client's oxygenation , followed by the client's blood pressure
oxygenation blood pressure
