Prepu | Chapter 69: Next Generation | NGN
A client is receiving enteral therapy following gastric surgery. To maintain fluid balance and minimize any gastrointestinal symptoms such as cramping, diarrhea, and/or nausea, the nurse should follow appropriate enteral therapy protocols. For each intervention, click to specify if the action should be included in the plan of care to improve outcomes for fluid balance or improvement of gastrointestinal symptoms. If the action should not be included in the plan of care for either outcome, note as not indicated. Each intervention may be included for more than 1 outcome.
Not Indicated) Increase the rate of enteral fluids Not Indicated) Administer bolus feeding.
The nurse monitors the laboratory data for several clients who are diagnosed with hypoproliferative anemias. For each laboratory data, click to specify if the finding indicates microcytic anemia or megaloblastic anemia.
Microcytic Anemia decreased mean corpuscular volume (MCV) Microcytic Anemia decreased reticulocytes Microcytic Anemia increased total iron-binding capacity (TIBC)
A nurse is assessing a client who is experiencing significant stress due to septicemia. Drag words from the choices below to fill in each blank in the following sentence. The nurse should
Obtain the lactate level, monitor temperature, administer oxygen therapy
The nurse provides care for a client who is critically ill due to a diagnosis of pneumonia and is at risk for developing shock. Assessment data reveals a white blood cell (WBC) count of 15 × 103 cells/mm3 (15 × 109/l) (normal: 4.5 to 10.5 × 103 cells/mm3 (4.5 to 10.5 × 109/l), a temperature of 102.2°F (39°C), and warm, flushed skin.
septic shock____septic shock
A nurse is caring for a client who was admitted for an asthma exacerbation. In the past year, the client has been admitted for three asthma events. What will the nurse include in the client teaching about preventing repeat hospitalizations? Complete the following sentence(s) by choosing from the lists of options.
triggers to avoid_____medication knowledge
The nurse provides care for a client who is prescribed bladder retraining following urinary catheterization. Complete the following sentence by choosing from the lists of options.
urinate__bladder scan
The nurse provides care for a 28-year-old female client experiencing an initial outbreak of herpes simplex virus 2 (HSV-2). Drag words from the choices below to fill in each blank in the following sentence.
an increased risk for sterility___ neonatal transmission___aseptic meningitis
A client will undergo abdominal surgery. The nurse provides preoperative education regarding the importance of diaphragmatic breathing exercises to prevent postoperative complications. Drag words from the choices below to fill in each blank in the following sentence.
atelectasis__pneumonia__bronchospasm
The nurse monitors a client for side effects associated with furosemide, which is newly prescribed for the treatment of heart failure. Complete the following sentence by choosing from the lists of options.
hypokalemia____ventricular arrhythmia
The nurse plans care for a client who is newly diagnosed with peripheral artery disease (PAD). For each nursing action, click to specify if the intervention is appropriate to increase the arterial blood supply to the client's extremities or to promote vasodilation and prevent vascular compression.
(Increase Arterial Blood Supply to the Extremities) Keep legs in a dependent position. (Increase Arterial Blood Supply to the Extremities) Increase in physical activity each day. (Promote Vasodilation and Prevent Vascular Compression) Wear warm clothing in the winter. Promote Vasodilation and Prevent Vascular Compression) Do not use of bicotine products. (Promote Vasodilation and Prevent Vascular Compression) Avoid crossing the legs.
The nurse provides care for a client who is critically ill due to a diagnosis of pneumonia and is at risk for developing shock. Assessment data reveals a white blood cell (WBC) count of 15 × 103 cells/mm3 (15 × 109/l) (normal: 4.5 to 10.5 × 103 cells/mm3 (4.5 to 10.5 × 109/l), a temperature of 102.2°F (39°C), and warm, flushed skin. Complete the following sentence by choosing from the lists of options.
-septic shock_______altered mentation
A nurse is assessing an older adult client who has returned for a follow-up visit after receiving medications related to the diagnosis of hypertension. The nurse prepares to evaluate the client's blood pressure. Drag words from the choices below to fill in each blank in the following sentence.
Ask the client to sit quietly for 5 minutes_______obtain an accurate measurement
A nurse is caring for a team of clients, each with an orthopedic injury. Click to indicate which interventions are included in a plan of care between the different orthopedic repairs. For each intervention, click to specify if the action is taken for clients with an internal fixaction device and/or with an external fixation device. Each intervention may support more than 1 type of device.
External Fixation Device Complete pin care per prescribed guidelines Internal Fixation Device Bear weight as determined by the surgeon
The nurse plans care for a client who was admitted for the treatment of a gastrointestinal (GI) bleed due to cirrhosis of the liver. Complete the table of nursing concerns by choosing from the list of options.
Injury Risk Monitor the client for symptoms of anxiety. Altered Skin Integrity Perform range-of-motion exercises every 4 hours Acute Confusion Keep the environment warm and draft free.
The nurse plans care for a client who is diagnosed with atopic dermatitis. For each teaching point, click to specify if the instruction addresses skin hydration or itchy skin. Each teaching point may address more than 1 condition
Skin Hydration Use an emollient containing glycerol on the skin after bathing. Skin Hydration Take short showers using mild soap for cleansing.
The nurse provides care for a client, with a history of atherosclerosis, who is hospitalized for the initiation of pharmacotherapy for the treatment of hypothyroidism.
cardiac dysfunction_____angina
The nurse should determine the adult client's learning readiness by assessing
cultural identification, personal values, physical status, motions
The nurse in the oncology clinic is caring for a 42-year-old female client receiving chemotherapy with fludarabine for acute myeloid leukemia who has developed petechiae, epistaxis, and ecchymosis.
hemorrhage____thrombocytopenia
The nurse on a telemetry unit is caring for a 54-year-old male client, admitted with chest pain, who has an arteriovenous (AV) fistula in the left arm for hemodialysis secondary to chronic kidney disease. For each intervention, click to specify if the intervention is indicated or contraindicated for this client.
(Indicated) Auscultate for a bruit over AV fistula every 8 hours Indicated) Assess for redness, swelling, and drainage at AV fistula site (indicated)) Palpate for a thrill over the AV fistula every 8 hours (Contraindicated) Take blood pressure readings in the left arm. (Contraindicated) Wrap the AV fistula site in the left arm with a compression dressing.
A nurse is caring for a team of clients, each with an orthopedic injury. Click to indicate which interventions are included in a plan of care between the different orthopedic repairs. For each intervention, click to specify if the action is taken for clients with an internal fixaction device and/or with an external fixation device. Each intervention may support more than 1 type of device.
(Internal Fixation Device)-(External Fixation Device) Administer nonopioid analgesics as needed. (Internal Fixation Device)-(External Fixation Device) Administer prescribed antibiotic. (Internal Fixation Device) Complete pin care per prescribed guidelines. (Internal Fixation Device)-(External Fixation Device) Provide assistance with physical therapy. (Internal Fixation Device)-(External Fixation Device) Encourage isometric and muscle-setting exercises. (Internal Fixation Device) Bear weight as determined by the surgeon.
The nurse is preparing to administer medication to a client who has been diagnosed with glaucoma. Which information should the nurse include related to client teaching for each of the identified medications? Complete the following table by choosing from the list of options.
(Pilocarpine) Use safety measures in dim lighting (Timolol maleate) It can cause hypotension Acetazolamide Have your electrolyte levels monitored.
The nurse is providing education to a 65-year-old female client with pneumococcal pneumonia being discharged from the health clinic on oral antibiotics. The client is a nonsmoker, takes levothyroxine for Hashimoto disease, and is otherwise in good health. For each client statement, click to specify if the finding indicates understanding or the need for reinforcement of the teaching.
(Understanding) "I should get the PPSV23 this year because I got the PCV13 last year. (Understanding) "Sleeping with a humidifier can help loosen secretions (Understanding) "I will seek medical attention if my cough worsens." (Understanding) "I will rest and avoid overexertion." (Requires Reinforcement of Teaching) "I will take the antibiotics until the secretions clear up." (Requires Reinforcement of Teaching) I will drink 1 liter of fluid each day. (Requires Reinforcement of Teaching) "A persistent or recurring fever is normal after starting antibiotics." (Requires Reinforcement of Teaching) "I will perform deep-breathing exercises once per day."
