RN Adult Medical Surgical Online Practice 2023 A
A nurse is providing teaching to a female client who has stress incontinence and a BMI of 32. Which of the following statements by the client indicates an understanding of the teaching?
"A risk factor for my condition is obesity." Rational: Excess weight creates increased abdominal pressure that can result in stress incontinence.
Nurses' Notes 1000:Client presents to the ED with visual disturbances, expressive aphasia, and numbness and tingling of the lips. Manifestations started about 30 min ago. Client reports flashing lights in their vision, especially on the right side.Client's partner states the client had some difficulty with finding words when speaking. Client is alert and oriented x 3 and appears anxious. No facial drooping noted. Right hand grasp is weaker than left. Client denies pain. 1045:Client states the flashing lights, numbness, and tingling in the lips have gone away. Client states they now have throbbing pain behind the left eye, photophobia, and nausea. Client is requesting medication for pain that is 7 on a scale of 0 to 10.Hand grasps are equal and strong bilaterally. **The nurse is evaluating the client's understanding of discharge instructions. Which of the following client statements indicates an understanding of th
"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" Rational: "Foods that contain tyramine might trigger my headaches" is correct. Tyramine-containing foods, such as aged cheeses, smoked sausage, pickles, and beer are common triggers for migraines. "I will keep a food and headache diary" is correct. The nurse should instruct the client to keep a food and headache diary to identify migraine triggers. "I will place a cool cloth on my forehead when I experience a migraine" is correct. The nurse should instruct the client to lie down, dim the lights, and place a cool cloth on the forehead to relieve migraine pain. "I will take the sumatriptan once every day" is incorrect. Sumatriptan is not administered to prevent a migraine, rather, it is used to treat an occurring migraine. The nurse should instruct the client to take the sumatriptan only as needed for migraine pain. "I should stay awake until my headache is gone" is incorrect. The nurse should instruct the client to lie down, dim the lights, and place a cool cloth on the forehead to relieve migraine pain. The client should be encouraged to sleep until the migraine is resolved.
A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement. Which of the following statements should the nurse make?
"Ginkgo biloba can cause an increased risk for bleeding." Rational: Ginkgo biloba increases blood flow and is effective in decreasing the pain associated with peripheral artery disease. The supplement also decreases platelet aggregation, which in turn increases the risk for bleeding. Clients who have been prescribed antiplatelet medications, such as aspirin, should avoid taking ginkgo biloba without first speaking with their provider.
A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new prescription for metformin. Which of the following statements by the client indicates an understanding of the teaching?
"I should take this medication with a meal." Rational: The client should take metformin with or immediately following meals to improve absorption and to minimize gastrointestinal distress.
A nurse is providing discharge instructions to a client who has laryngeal cancer and is receiving radiation therapy. Which of the following statements by the client indicates an understanding of the teaching?
"I will avoid direct exposure to the sun." Rational: The client should avoid exposure of irradiated skin areas to the sun for at least 1 year after completing radiation therapy. Skin in the radiation path is especially sensitive to sun damage.
A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching?
"I will monitor my blood pressure while taking this medication." Rational: The client should monitor their blood pressure while taking this medication because hypertension is a common adverse effect and can lead to hypertensive encephalopathy.
A nurse is providing preoperative teaching for a client who is scheduled for a mastectomy. Which of the following statements should the nurse make?
"I will refer you to community resources that can provide support." Rational: The nurse should provide the client with support resources, including community programs, to assist the client with acceptance of body image changes.
A nurse is teaching a group of newly licensed nurses about pain management for older adult clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?
"Ibuprofen can cause gastrointestinal bleeding in older adult clients." Rational: A common adverse effect of ibuprofen is gastrointestinal bleeding, and older adult clients have an increased risk for gastrointestinal toxicity and bleeding.
A nurse in an emergency department is assessing a client who has a detached retina. Which of the following should the nurse expect the client to report?
"It's like a curtain closed over my eye." Rational: A retinal detachment is the separation of the retina from the epithelium. It can occur because of trauma, cataract surgery, retinopathy, or uveitis. Clients who have retinal detachment typically report the sensation of a curtain being pulled over part of the visual field.
A nurse is caring for a client who has homonymous hemianopsia as a result of a stroke. To reduce the risk of falls when ambulating, the nurse should provide which of the following instructions to the client?
"Scan the environment by turning your head from side to side." Rational: Homonymous hemianopsia is the loss of the same visual field in both eyes. Turning their head from side to side helps enlarge a client's visual field. This technique is also useful for the client during mealtimes.
A nurse is providing teaching to a client who has cancer and a new prescription for an opioid analgesic for pain management. Which of the following information should the nurse include in the teaching?
"You should void every 4 hours to decrease the risk of urinary retention." Rational: The nurse should instruct the client to void at least every 4 hr to decrease the risk of urinary retention, which is an adverse effect of opioid analgesics.
A nurse is providing teaching to a client who has stage II cervical cancer and is scheduled for brachytherapy. Which of the following instructions should the nurse include?
"You will need to stay still in the bed during each treatment session." Rational: The nurse should instruct the client that they will need to remain on bed rest with very limited movement because excessive movement can cause the radioactive source to become dislodged.
2330:Report received from ambulance crew: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. Client's shirt covered with bright red blood. Client reports pain as 6 on a scale of 0 to 10. Shortness of breath noted. 2345:Client is alert and oriented with a GCS score of 15. Client has a penetrating wound to the anterior right upper chest measuring 2.5 cm (1 in). No other wounds or injuries found.Bilateral radial and pedal pulses are +1. Left lung sounds are clear, right upper lung sounds diminished.Client still reports pain as 6 on a scale of 0 to 10 over anterior chest.Bowel sounds are present in all 4 quadrants.
-Initiate NPO status is anticipated. -Prepare the client for chest tube insertion is anticipated. -Cover the client with a cooling blanket is contraindicated. -Transfuse packed RBCs is anticipated. -Place the client in Trendelenburg position is contraindicated. Rational: Transfuse packed RBCs is anticipated. The client's increased heart rate and decreased blood pressure indicate decreased circulating blood volume due to trauma. Therefore, the nurse should anticipate transfusing packed RBCs. Place the client in Trendelenburg position is contraindicated. Due to clinical manifestations of hypovolemia, the nurse should position the client flat or place their head of bed no more than 30° to promote venous return to the heart. Prepare the client for chest tube insertion is anticipated. The client has manifestations of a hemothorax. Therefore, a chest tube is indicated. Cover the client with a cooling blanket is contraindicated. The client's temperature is below the expected reference range, which is a manifestation of hypothermia. Therefore, covering the client with a cooling blanket is contraindicated. Initiate NPO status is anticipated. The client might require a surgical procedure. Therefore, the nurse should anticipate initiating NPO status.
1000:Client presents to the ED with visual disturbances, expressive aphasia, and numbness and tingling of the lips. Manifestations started about 30 min ago. Client reports flashing lights in their vision, especially on the right side.Client's partner states the client had some difficulty with finding words when speaking.Client is alert and oriented x 3 and appears anxious. No facial drooping noted. Right hand grasp is weaker than left. Client denies pain. **For each finding below, click to specify if the finding is consistent with migraine, stroke, or meningitis. Each finding can support more than one disease process.
1-Aphasia is consistent with migraine and stroke. 2-Numbness is consistent with migraine and stroke. 3-Hand grasps is consistent with migraine, stroke, and meningitis. 4-Visual changes are consistent with migraine, stroke, and meningitis. 5-Family history is consistent with migraine and stroke. Rational: Hand grasps is consistent with migraine, stroke, and meningitis. Unilateral weakness can occur due to neurological vascular changes and inflammation that can be present with migraine, stroke, and meningitis. Numbness is consistent with migraine and stroke. Numbness and tingling of the lips and tongue can occur with migraines due to neurological vascular changes and inflammation that can be present. Numbness can also occur with middle cerebral artery strokes. Aphasia is consistent with migraine and stroke. Aphasia can occur due to neurological vascular changes and inflammation that can be present with a migraine and stroke. Visual changes are consistent with migraine, stroke, and meningitis. Visual changes can occur with migraine, stroke, and meningitis due to neurological vascular changes and inflammation that can be present. Family history is consistent with migraine and stroke. Family history is a risk factor associated with migraine and stroke.
A nurse is caring for a client who has a leg cast and is returning to demonstrate on the proper use of crutches while climbing stairs. Identify the sequence the client should follow when demonstrating crutch use. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
1st- Places body weight on the crutches 2nd- advances the unaffected leg onto the stairs 3rd- shifts weight from the crutches to the unaffected leg 4th- brings the crutches and the affected leg up the stairs Rational: The client should first place their body weight on the crutches. Next, they should advance the unaffected leg onto the stair. Third, they should shift their weight from the crutches to the unaffected leg. Last, they should bring the crutches and the affected leg up to the stair.
A nurse is reviewing the laboratory results of a client who has aplastic anemia. Which of the following findings indicates a potential complication?
WBC count 2,000/mm3 Rational: A WBC count of 2,000/mm3 is below the expected reference range and indicates a risk for severe immunosuppression.
A nurse is teaching a class about client rights. Which of the following instructions should the nurse include?
A client should sign an informed consent before receiving a placebo during a research trial. Rational: A nurse should ensure a client has provided informed consent before administering a placebo. Placebos should not be used outside of approved clinical research in which the client has consented to participate.
A nurse is assessing a group of clients for indications of role changes. The nurse should identify that which of the following clients is at risk for experiencing a role change?
A client who has multiple sclerosis and is experiencing progressive difficulty ambulating. Rational: The nurse should identify that progression of a neurologic disease such as multiple sclerosis can lead to a role change as the client becomes less independent.
A nurse is evaluating the plan of care for four clients after 2 days of hospitalization. The nurse should identify the need to revise the plan for which of the following clients?
A client who is postoperative following abdominal surgery and reports feeling that something "popped" when they coughed. Rational: A feeling of something popping or loosening with coughing might indicate a wound dehiscence. This client will need to have revisions to the plan of care, which can include management of the dehiscence, prevention of evisceration, or possible surgical repair of an evisceration if one occurs.
A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate this risk, which of the following dietary alterations should the nurse recommend?
Add cabbage to the diet. Rational: To help reduce the risk for colorectal cancer, the client should consume a diet that is high in fiber, low in fat, and low in refined carbohydrates. Brassica vegetables, such as cabbage, cauliflower, and broccoli, are high in fiber.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A new bag is not available when the current infusion is nearly completed. Which of the following actions should the nurse take?
Administer dextrose 10% in water until the new bag arrives. Rational: TPN solutions have a high concentration of dextrose. Therefore, if a TPN solution is temporarily unavailable, the nurse should administer dextrose 10% or 20% in water to avoid a precipitous drop in the client's blood glucose level.
Nurses' Notes 1000:Client presents to the ED with visual disturbances, expressive aphasia, and numbness and tingling of the lips. Manifestations started about 30 min ago. Client reports flashing lights in their vision, especially on the right side.Client's partner states the client had some difficulty with finding words when speaking. Client is alert and oriented x 3 and appears anxious. No facial drooping noted. Right hand grasp is weaker than left. Client denies pain. 1045:Client states the flashing lights, numbness, and tingling in the lips have gone away. Client states they now have throbbing pain behind the left eye, photophobia, and nausea. Client is requesting medication for pain that is 7 on a scale of 0 to 10.Hand grasps are equal and strong bilaterally. **A nurse is caring for 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 Rational: Administer sumatriptan is correct. The nurse should plan to administer a medication, such as sumatriptan, to produce cerebral artery vasoconstriction and relieve the client's manifestations. Prepare the client for a lumbar puncture is incorrect. A lumbar puncture is indicated for clients who are having manifestations of meningitis. Administer phenobarbital is incorrect. Phenobarbital is indicated for clients who are experiencing seizures. Dim the lights in the client's room is correct. The nurse should plan to dim the lights in the client's room to promote comfort because the client is experiencing photophobia. Prepare to initiate fibrinolytic therapy is incorrect. The nurse should prepare to initiate fibrinolytic therapy for clients who are experiencing a stroke. Fibrinolytic therapy is administered during the acute phase of a stroke to decrease clot formation. Place the client in seizure precautions is incorrect. The nurse should initiate seizure precautions for clients who are at risk for a seizure.
A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After ensuring a patent airway, which of the following nursing interventions is the priority?
Administering epinephrine Rational: Evidence-based practice indicates that the priority intervention is for the nurse to administer epinephrine quickly to dilate the bronchioles and prevent circulatory shock.
A nurse is admitting a client who has active tuberculosis. Which of the following types of transmission precautions should the nurse initiate?
Airborne Rational: Airborne precautions are required for clients who have infections due to micro-organisms that can remain suspended in air for lengthy periods of time, such as tuberculosis, measles, varicella, and disseminated varicella zoster.
A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following nonpharmacological interventions should the nurse suggest to the client to reduce pain?
Alternate application of heat and cold to the affected joints. Rational: The nurse should instruct the client to alternate heat and cold applications to decrease joint inflammation and pain. The application of cold can relieve joint swelling and the application of heat can decrease joint stiffness and pain.
A nurse on a medical-surgical unit is reviewing the medical record of an older adult client who is receiving IV fluid therapy. Which of the following client information should indicate to the nurse that the client requires re-evaluation of the IV therapy prescription? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)
Answer: BUN Rational: The client's Hct and BUN levels indicate dehydration and require an increase in the IV fluid infusion rate.
A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurse's priority
Apply firm pressure to the insertion site. Rational: The greatest risk to the client is bleeding. Therefore, the priority intervention is for the nurse to apply firm pressure to the hematoma to stop the bleeding.
0530:Client is awake and alert.Arteriovenous fistula (AVF) to right forearm with thrill palpated and auscultated for bruit. Lung sounds 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.
Apply oxygen at 2 L/min via nasal cannula. INDICATED Perform a 12-lead ECG. NOT INDICATED Administer a 0.9% sodium chloride 200 mL IV bolus. INDICATED Place the client in Trendelenburg position. INDICATED Notify the provider immediately. INDICATED Obtain the client's blood glucose level. NOT INDICATED Rational: Perform a 12-lead ECG is not indicated. The client is not reporting chest pain; therefore, a 12-lead ECG is not indicated at this time. Place the client in Trendelenburg position is indicated. The client should be placed in the Trendelenburg position to increase blood flow to the heart, improving cardiac output and organ perfusion. Administer a 0.9% sodium chloride 200 mL IV bolus is indicated. The nurse should administer 200 mL of 0.9% sodium chloride IV bolus to increase fluid volume and the client's blood pressure. Apply oxygen at 2 L/min via nasal cannula is indicated. The nurse should administer oxygen at 2 L/min via nasal cannula to increase the amount of oxygen carried in the blood. Notify the provider immediately is indicated. The nurse should notify the provider immediately as part of the nurse's role to provide an update on the client's condition. Obtain the client's blood glucose level is not indicated. There is no indication that the client is experiencing hypoglycemia; therefore, obtaining a blood glucose level is not indicated.
A nurse is performing a dressing change for a client who is recovering from a hemicolectomy. When removing the dressing, the nurse notes that a large part of the bowel is protruding through the abdomen. Which of the following actions should the nurse take first?
Call for help Rational: Evidence-based practice indicates that the nurse should first stay with the client and call for assistance. The client will require emergency surgery and is at risk for shock. Therefore, the nurse should obtain immediate assistance.
A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the following actions should the nurse take first?
Check for the type and number of units of blood to administer. Rational: According to evidence-based practice, the nurse should first confirm that the type and number of units of blood to administer matches what is indicated in the client's medication administration record.
A nurse in an emergency department is assessing an older adult client who has a fractured wrist following a fall. During the assessment, the client states, "Last week I crashed my car because my vision suddenly became blurry." Which of the following actions is the nurse's priority?
Check the client's neurologic status. Rational: The first action the nurse should take using the nursing process is to assess the client. Therefore, the nurse should first check the neurologic status of the client.
2330:Report received from ambulance crew: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. Client's shirt covered with bright red blood. Client reports pain as 6 on a scale of 0 to 10. Shortness of breath noted. 2345:Client is alert and oriented with a GCS score of 15. Client has a penetrating wound to the anterior right upper chest measuring 2.5 cm (1 in). No other wounds or injuries found.Bilateral radial and pedal pulses are +1. Left lung sounds are clear, right upper lung sounds diminished.Client still reports pain as 6 on a scale of 0 to 10 over anterior chest.Bowel sounds are present in all 4 quadrants.
Client reports pain as 3 on a scale of 0 to 10 is correct. Client reports shortness of breath has decreased is correct. Wound dressing is dry and intact is correct. Respiratory rate 24/min is correct blood pressure 108/74 mm Hg is correct oxygen saturation 95% on 2 L/min via nasal cannula is correct. Rational: Client reports pain as 3 on a scale of 0 to 10 is correct. The nurse should identify that the client's pain has decreased, indicating their condition is improving. Client reports shortness of breath has decreased is correct. The nurse should identify that the client's shortness of breath has decreased, indicating their condition is improving. Client reports nausea, awaiting prescription for nausea is incorrect. The nurse should identify that nausea is an indication that the client's condition is not improving. Transfused 1 unit of packed RBCs, awaiting second unit is incorrect. The transfusion of 1 unit of packed RBCs is not an indication that the client's condition is improving. Wound dressing is dry and intact is correct. The nurse should identify that a dry and intact wound dressing indicates the client's wound is no longer bleeding. Respiratory rate 24/min, blood pressure 108/74 mm Hg, and oxygen saturation 95% on 2 L/min via nasal cannula are correct. The nurse should identify that the client's vital signs have improved, indicating improved hemodynamic function.
A nurse is caring for a client who is postoperative. Client admitted to medical-surgical unit from PACU. Client reports incisional pain as 2 on a scale of 0 to 10. Client appears restless and frequently asks for water. Bilateral lower extremities cool with +1 pedal pulses. Urine output is 40 mL for the past 2 hr. Moderate amount of bright red drainage noted on surgical incision dressing.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress. Answer: *Insert a large-gauge *IV.Initiate a fluid challenge. *Hypovolemia *Urine output *Blood pressure Rational: The nurse should insert a large-gauge IV and initiate a fluid challenge because the client is most likely experiencing hypovolemia as evidenced by the client's restlessness, tachycardia, hypotension, decreased pulses, cool extremities, and decreased urine output. The nurse should monitor the client's urine output and blood pressure to evaluate the effectiveness of treatment.
A nurse is planning care for a client who is postoperative following a laparotomy and has a closed-suction drain. Which of the following actions should the nurse take to manage the drain?
Compress the drain reservoir after emptying. Rational: Compressing the reservoir creates a vacuum that draws fluid out of the wound, through the drain, and into the reservoir.
A nurse is caring for a client who has hypothyroidism. Which of the following manifestations should the nurse expect?
Constipation Rational: A client who has hypothyroidism can experience constipation due to the decrease in the client's metabolism, resulting in slow motility of the gastrointestinal tract. The nurse should instruct the client to increase fiber and fluid intake to reduce the risk for constipation.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) and is NPO. When reviewing the chart, the nurse notes the following prescription: capillary blood glucose AC and HS. Which of the following actions should the nurse take?
Contact the provider to clarify the prescription. Rational: Mealtimes do not pertain to this client due to the NPO status. The nurse should monitor the client's glucose levels on a set schedule, either every 6 hr or per facility protocol. Thus, the prescription requires clarification.
A nurse is caring for a client who is 4 hr postoperative following an open reduction internal fixation of the right ankle. Which of the following assessment findings should the nurse report to the provider?
Extremity cool upon palpation Rational: The nurse should report indicators of reduced circulation, such as pallor, cool temperature, or paresthesia of the client's extremity. These findings can indicate that the client is at risk for developing acute compartment syndrome.
A nurse is caring for a client who has increased intracranial pressure (ICP) and is receiving mannitol via continuous IV infusion. Which of the following findings should the nurse report to the provider as an adverse effect of this medication?
Crackles heard on auscultation Rational: Mannitol is an osmotic diuretic that prevents the reabsorption of water in the kidneys, thus increasing urinary output. With the exception of the brain, mannitol can leave the vascular system at the capillary site, which can result in edema. The nurse should identify crackles as a manifestations of pulmonary edema and notify the provider. Other manifestations include dyspnea and decreased oxygen saturation.
A nurse is providing education to a client who has tuberculosis (TB) and their family. Which of the following information should the nurse include in the teaching?
Family members in the household should undergo TB testing. Rational: Family members who live in the same household with the client have been exposed to TB. Therefore, the nurse should recommend TB screening to foster early detection and treatment of TB.
A nurse is providing preoperative teaching for a client who is scheduled for an open cholecystectomy. Which of the following actions should the nurse take?
Demonstrate ways to deep breathe and cough. Rational: The nurse should demonstrate deep breathing and coughing exercises and explain the importance of splinting the incision to reduce the risk for respiratory complications.
A nurse is caring for a client who has terminal cancer. The client tells the nurse, "I wish I could stop these treatments. I am ready to die." Which of the following statements should the nurse make?
Discontinuing with the treatments is your choice if it is your wish to do so. Rational: The nurse should recognize the client's right to refuse the treatments and inform the client of this right. The nurse should advocate for the client and offer to contact the provider for the client.
A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the following instructions should the nurse include?
Flex the foot every hour when awake Rational: The nurse should instruct the client to flex the foot every hour to reduce the risk for thromboembolism and promote venous return.
1800:Emergency medical team removed client's shirt at the scene and initiated 18-gauge IV therapy in the right antecubital space.Client has full-thickness burns over the upper half of the chest and both forearms; partial-thickness burns are present on the client's face and neck.Sinus tachycardia, pulses to brachial extremities palpable. 1+ edema to upper extremities.Respirations even, labored with scattered rhonchi. Soot noted to the client's mouth and nose. Oxygen 40% via face tent applied.Hypoactive bowel sounds.16 French indwelling urinary catheter inserted with return of 250 mL of yellow urine.Lactated Ringer's infusing to right antecubital. Provider preparing to insert right femoral central line catheter.1830:Client's voice is becoming hoarse and reports difficulty swallowing. Wheezes present to upper lobes bilaterally. Provider notified. Client positioned upright, oxygen via face tent. Blood collected for ABGs.
During the emergent phase of burn care, the client is at risk for developing hypovolemia and respiratory failure Rational: Hypovolemia and respiratory failure are correct. Plasma volume is lost immediately during a burn injury, which can lead to a lack of perfusion to all body organs. Hypovolemia is indicated by the client's blood pressure declining and heart rate increasing. If fluid resuscitation is not initiated successfully, hypovolemic shock can occur. The initial priority following a burn injury is to assess and protect the airway. The client has burns to the face and chest, which will compromise respiratory function, placing them at risk for respiratory failure. The client's respiratory function is decompensating as edema to the airway increases. Continued decompensation might indicate the need for the client to be intubated. Hypokalemia, Curling's ulcer, and hyperthermia are incorrect. During the emergent phase, the client is at risk for hyperkalemia as a result of cellular destruction of the burn area. The nurse should identify that the client is at risk for Curling's ulcer, which usually develops 72 hr following the burn, not during the emergent phase. Following a burn injury, clients are at risk for hypothermia, as heat is lost through the damaged skin. The vital signs indicate that the client's temperature is decreasing.
A nurse is assessing a client who has had a suspected stroke. The nurse should place the priority on which of the following findings?
Dysphagia Rational: Dysphagia indicates that this client is at greatest risk for aspiration due to impaired sensation and function within the oral cavity. Therefore, the nurse should place priority on this finding.
A nurse is assessing a client who has advanced lung cancer and is receiving palliative care. The client has just undergone thoracentesis. The nurse should expect a reduction in which of the following common manifestations of advanced cancer?
Dyspnea Rational: Thoracentesis, the removal of pleural fluid, can temporarily relieve hypoxia and thus ease the client's breathing and improve comfort.
A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following interventions should the nurse include in the plan?
Encourage the client to take deep breaths after the procedure. Rational: After a thoracentesis, the client should deep breathe to re-expand the lung.
A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the following precautions should the nurse implement?
Ensure that the client has a patent IV. Rational: The nurse should ensure the client has IV access in the event that the client requires medication to stop seizure activity.
A nurse is preparing to present a program about prevention of atherosclerosis at a health fair. Which of the following recommendations should the nurse plan to include? (Select all that apply.) Follow a smoking cessation program. Maintain an appropriate weight. Eat a low-fat diet. Increase fluid intake. Decrease intake of complex carbohydrates.
Follow a smoking cessation program Maintain an appropriate weight Eat a low-fat diet Rational: Follow a smoking cessation program is correct. Smoking cessation is an important lifestyle modification to prevent atherosclerosis. Maintain an appropriate weight is correct. Preventing obesity through diet and exercise can help to prevent atherosclerosis. Eat a low-fat diet is correct. Eating a low-fat diet decreases LDL cholesterol and can prevent atherosclerosis. Increase fluid intake is incorrect. Increasing intake of fruits, vegetables, and grains can prevent atherosclerosis. Decrease intake of complex carbohydrates is incorrect. Decreasing intake of simple sugars and sweetened foods and increasing complex carbohydrates, such as fiber, can reduce the risk of heart disease.
Nurses' Notes 1000:Client presents to the ED with visual disturbances, expressive aphasia, and numbness and tingling of the lips. Manifestations started about 30 min ago. Client reports flashing lights in their vision, especially on the right side.Client's partner states the client had some difficulty with finding words when speaking. Client is alert and oriented x 3 and appears anxious. No facial drooping noted. Right hand grasp is weaker than left. Client denies pain. 1045:Client states the flashing lights, numbness, and tingling in the lips have gone away. Client states they now have throbbing pain behind the left eye, photophobia, and nausea. Client is requesting medication for pain that is 7 on a scale of 0 to 10.Hand grasps are equal and strong bilaterally.
Following the administration of sumatriptan, the nurse should monitor for chest pain due to the risk of myocardial ischemia Rational: Dropdown 1 Dehydration is incorrect. Sumatriptan does not cause fluid loss, which could lead to dehydration. Chest pain is correct. The nurse should monitor the client for chest pain because sumatriptan can cause coronary vasospasms. Reflux is incorrect. Reflux is not an adverse effect of sumatriptan. Dropdown 2 Peptic ulcer disease is incorrect. Peptic ulcer disease is not an adverse effect of sumatriptan. Diuresis is incorrect. Fluid loss is not an adverse effect of sumatriptan. Myocardial ischemia is correct. Sumatriptan can cause coronary vasospasms, which can lead to myocardial ischemia.
A nurse is caring for a client who has DKA. Which of the following findings should indicate to the nurse that the client's condition is improving?
Glucose 272 mg/dL Rational: A glucose reading less than 300 mg/dL indicates improvement in the client's status.
A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit?
Heart rate 110/min Rational: A client who has a 3-day history of vomiting and diarrhea is likely to have fluid volume deficit and an elevated heart rate.
A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following laboratory values should the nurse report to the provider?
Hgb 8 g/dL Rational: The nurse should report an Hgb level of 8 g/dL, which is below the expected reference range and is an indicator of postoperative hemorrhage or anemia.
A nurse is caring for a client has who has chronic glomerulonephritis with oliguria. Which of the following findings should the nurse identify as a manifestation of chronic glomerulonephritis?
Hyperkalemia Rational: The nurse should identify that a client who has chronic glomerulonephritis can experience hyperkalemia as a result of kidney failure. Kidney failure results in decreased excretion of potassium.
A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following assessment findings should the nurse expect?
Hypoactive Bowel Sounds Rational: Hypokalemia decreases smooth muscle contraction in the gastrointestinal tract leading to decreased peristalsis.
A nurse in an emergency department is caring for a client who has full-thickness burns over 20% of their total body surface area. After ensuring a patent airway and administering oxygen, which of the following items should the nurse prepare to administer first?
IV Fluids Rational: After establishing that the client's airway is secure and administering oxygen, evidence-based practice indicates that the nurse should prepare to administer IV fluids to provide circulatory support.
A nurse is providing discharge instructions to a client following an upper gastrointestinal series with barium contrast. Which of the following information should the nurse provide?
Increase fluid intake Rational: Increasing fluid intake will help to prevent constipation. Therefore, the nurse should instruct the client to increase fluid intake to facilitate the elimination of the barium used during the test.
A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. Which of the following assessment findings is the nurse's priority?
Increased respiratory secretions Rational: Using the airway, breathing, circulation approach to client care, the nurse should determine that the priority assessment finding is increased respiratory secretions. Clients who have ALS may experience respiratory muscle weakness and dysphagia, and excessive respiratory secretions can impair the ability to clear the airway, which increases the client's risk for aspiration.
A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive cough. Which of the following actions should the nurse take first?
Initiate airborne precautions. Rational: This client is exhibiting manifestations of tuberculosis. The greatest risk in this client situation is for other people in the facility to acquire an airborne disease from this client. Therefore, the first action the nurse should take is to initiate airborne precautions.
A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?
Loosen restrictive clothing. Rational: The nurse should loosen tight, restrictive clothing to prevent injury and suffocation.
A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction?
Low back pain and apprehension Rational: Hemolytic transfusion reactions result from the infusion of incompatible blood products and create a systemic inflammatory response. Manifestations include low back pain, hypotension, tachycardia, and apprehension.
A nurse is creating a plan of care for a client who has neutropenia as a result of chemotherapy. Which of the following interventions should the nurse include in the plan?
Monitor the client's temperature every 4 hr. Rational: The nurse should monitor the temperature of a client who has neutropenia every 4 hr because the client's reduced amount of leukocytes greatly increases the client's risk for infection.
A nurse is providing discharge teaching to a client who is postoperative following a modified radical mastectomy. Which of the following instructions should the nurse include?
Numbness can occur along the inside of the affected arm. Rational: The nurse should instruct the client that numbness can occur near the incision and along the inside of the affected arm due to nerve injury.
A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first?
Obtain vital signs. Rational: The first action the nurse should take using the nursing process is to assess the client's vital signs. A client who has portal hypertension can develop esophageal varices, which are fragile and can rupture, resulting in large amounts of blood loss and shock. Obtaining vital signs provides information about the client's condition that can contribute to decision making.
2330:Report received from ambulance crew: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. Client's shirt covered with bright red blood. Client reports pain as 6 on a scale of 0 to 10. Shortness of breath noted. **Select the 3 findings that require follow-up by the nurse.
Oxygen saturation Pain level Wound drainage Rational: GCS score is incorrect. The nurse should identify a GCS score of 15 indicates intact neurological functioning. Temperature is incorrect. The client's temperature is within the expected reference range. Oxygen saturation is correct. The client has an oxygen saturation that is less than the expected reference level, indicating hypoxia. The nurse should plan to increase the client's supplemental oxygen. Pain level is correct. The nurse should follow up on the client's pain level. Wound drainage is correct. The nurse should apply a pressure dressing to control bleeding.
A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the following results should the nurse expect?
PaCO2 56 mm Hg Rational: A client who has COPD retains PaCO2 due to the weakening and the collapse of the alveolar sacs, which decreases the area in the lungs for gas exchange and causes the PaCO2 to increase above the expected reference range.
A nurse is assessing a client who has Grave's disease. Which of the following images should indicate to the nurse that the client has exophthalmos?
Picture of a person with bulging eyes Rational: The nurse should identify an outward protrusion of the eyes as exophthalmos, a common finding of Graves' disease. An overproduction of the thyroid hormone causes edema of the extraocular muscle and increases fatty tissue behind the eye, which results in the eyes protruding outward. Exophthalmos can cause the client to experience problems with vision, including focusing on objects, as well as pressure on the optic nerve.
A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?
Place a pillow between the client's legs. Rational: The nurse should place a pillow between the client's legs to prevent hip dislocation.
A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take?
Place a pressure bag around the flush solution. Rational: The nurse should place a pressure bag around the flush solution of 0.9% sodium chloride because the pressure from an artery is greater than that of the line.
2330:Report received from ambulance crew: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. Client's shirt covered with bright red blood. Client reports pain as 6 on a scale of 0 to 10. Shortness of breath noted. 2345:Client is alert and oriented with a GCS score of 15. Client has a penetrating wound to the anterior right upper chest measuring 2.5 cm (1 in). No other wounds or injuries found.Bilateral radial and pedal pulses are +1. Left lung sounds are clear, right upper lung sounds diminished.Client still reports pain as 6 on a scale of 0 to 10 over anterior chest.Bowel sounds are present in all 4 quadrants.
Place the client in high-Fowler's position is correct. Place two rubber-tipped hemostats in the client's room is correct. Palpate the chest tube insertion site for subcutaneous emphysema is correct. Ensure that all chest tube connections are securely attached is correct. Rational: Place the client in high-Fowler's position is correct. The nurse should place the client in high-Fowler's position to promote drainage of the hemothorax. Ensure there is continuous bubbling in the water seal chamber is incorrect. The nurse should monitor the water seal chamber for continuous bubbling because this is an indication of a leak in the chest tube system. Monitor drainage every 30 min for the first hour is incorrect. The nurse should monitor the drainage from the chest tube every 15 min for the first 2 hr to identify excessive drainage. Strip the drainage tubing to ensure it is patent is incorrect. The nurse should not strip the chest tube because this can cause increased intrathoracic pressure. Place two rubber-tipped hemostats in the client's room is correct. The nurse should place two rubber-tipped hemostats in the client's room to use in case of an emergency, such as chest tube dislodgment. Palpate the chest tube insertion site for subcutaneous emphysema is correct. The nurse should palpate the chest tube insertion site for subcutaneous emphysema because this is a manifestation of an air leak. Ensure that all chest tube connections are securely attached is correct. The nurse should ensure that all connections between the chest tube and drainage system are secure and intact to reduce the risk of a tension pneumothorax.
A nurse in a provider's office is assessing a client who has hypertension and takes propranolol. Which of the following findings should indicate to the nurse that the client is experiencing an adverse reaction to this medication?
Report of a night cough Rational: The nurse should recognize that a night cough is an early indication of heart failure and report this adverse reaction to the provider.
1100:Client received from PACU; initial vital signs recorded. Client is drowsy, but arouses to verbal stimuli. Oriented x3, moves all extremities. Normal sinus rhythm. Chest clear. Dressing to abdomen intact, small amount of serosanguinous drainage noted and marked. No bowel sounds x 4 quadrants. Indwelling urinary catheter in place, draining clear yellow urine. Lactated Ringer's infusing at 100 mL/hr via IV catheter to right forearm.1200:Client reports nausea and pain as 8 on a scale of 0 to 10. Abdominal dressing intact, no further drainage noted. Urine output 15 mL since arrival from PACU. Analgesic and antiemetic administered as prescribed.1230:Client reports relief from nausea and pain as 4 on a scale of 0 to 10. SaO2 96%. Repositioned for comfort. Encouraged to turn, cough, and deep breathe.1300:No additional urine output since 1200.
Report urinary output to the provider Plan to ambulate the client as soon as possible Instruct the client to splint the abdomen with a pillow for coughing Ask the client to rate their pain on a 0 to 10 pain scale Rational: Apply oxygen via a face mask is incorrect. It is not necessary to place a face mask on the client because their SaO2 is within the expected reference range of 95% to 100%. Instruct the client to splint the abdomen with a pillow for coughing is correct. It is important for the client to turn, cough, and deep breathe to reduce the risk for respiratory complications. The nurse should instruct the client to splint the incision while performing these actions to reduce the risk of complications to the surgical incision. Plan to ambulate the client as soon as possible is correct. The nurse should plan to ambulate the client as soon as possible to promote ventilation and decrease the risk of thrombosis. Report urinary output to the provider is correct. The client should produce at least 30 mL of urine per hour. Therefore, the nurse should report this finding to the provider. Ask the client to rate their pain on a 0 to 10 pain scale is correct. The nurse should have the client rate their pain prior to and following the administration of pain medication to evaluate its effectiveness.
A nurse is assessing a client following the completion of hemodialysis. Which of the following findings is the nurse's priority to report to the provider?
Restlessness Rational: Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding to report to the provider is restlessness, which can be an indication the client is experiencing disequilibrium syndrome. Disequilibrium syndrome is caused by the rapid removal of electrolytes from the client's blood and can lead to dysrhythmias or seizures. Other manifestations include nausea, vomiting, fatigue, and headache.
A nurse is providing follow-up care for a client who sustained a compound fracture 3 weeks ago. The nurse should recognize that an unexpected finding for which of the following laboratory values is a manifestation of osteomyelitis and should be reported to the provider?
Sedimentation rate Rational: An increased sedimentation rate occurs when a client has any type of inflammatory process, such as osteomyelitis.
A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions should the nurse anticipate taking?
Slow the infusion rate. Rational: Dyspnea, restlessness, and the onset of crackles during a blood transfusion are manifestations of circulatory overload. The nurse should slow or stop the infusion to improve the client's ability to breathe, place the client in an upright position, and notify the provider. The provider might prescribe a diuretic to alleviate the fluid overload.
A nurse is assessing a client who had extracorporeal shock wave lithotripsy (ESWL) 6 hr ago. Which of the following findings should the nurse expect?
Stone fragments in the urine Rational: ESWL is an effort to break the calculi so that the fragments pass down the ureter, into the bladder, and through the urethra during voiding. Following the procedure, the nurse should strain the client's urine to confirm the passage of stones.
A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for omeprazole. The nurse should instruct the client that the medication provides relief by which of the following actions?
Suppressing gastric acid production Rational: Omeprazole is a proton pump inhibitor. It relieves manifestations of gastric ulcers by suppressing gastric acid production.
A nurse is planning care to decrease psychosocial health issues for a client who is starting dialysis treatments for chronic kidney disease. Which of the following interventions should the nurse include in the plan?
Tell the client that it is possible to return to similar previous levels of activity. Rational: The nurse should help the client develop realistic goals and activities to have a productive life.
A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the nurse's priority?
Temperature 38.9° C (102° F) Rational: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is an elevated temperature. An elevated temperature is a manifestation of excessive thyroid hormone release, or thyroid storm, due to an increase in metabolic rate. The nurse should report this finding immediately to the provider because it can lead to seizures and coma.
A nurse is providing teaching for a female client who has recurrent urinary tract infections. Which of the following information should the nurse include in the teaching?
Void before and after intercourse. Rational: The nurse should instruct the client to empty her bladder before and after intercourse, which flushes bacteria out of the urinary tract and prevents the occurrence of infection.
NGN *0900:Client presents with abdominal pain in the upper left quadrant for the past 2 days. States pain became worse this morning and is radiating to the back. Rates pain as 8 on a scale of 0 to 10.Hypoactive bowel sounds; reports nausea, no vomiting; client is passing flatus.Febrile, oriented to person, place, and time.Tachypnea with diminished breath sounds.Sinus tachycardia.Client voids 300 mL of clear, amber urine. *0930:Client vomited 100 mL brown liquid.
The client is experiencing manifestations of pancreatitis as evidenced by the amylase and lipase. Rational: Drop Down 1: Pancreatitis is correct. The client's laboratory results and physical assessment indicate the client is experiencing manifestations of pancreatitis. Clients who have pancreatitis experience an increase in pancreatic enzymes, amylase, and lipase. Paralytic ileus, adult respiratory distress syndrome (ARDS), cardiogenic shock, and a cerebral vascular accident (CVA) are incorrect. The client is not experiencing manifestations of paralytic ileus because they have bowel sounds and are passing flatus. The client is not experiencing manifestations of ARDS because there is no indication the client is in respiratory distress. The client is not experiencing manifestations of cardiogenic shock because there is no indication from the client's medical record that there is a risk for cardiogenic shock. The client is not experiencing manifestations of a CVA because there is no indication from the client's medical record that there is a risk for a CVA. Drop Down 2: Amylase and lipase is correct. The client's laboratory results and physical assessment indicate the client is experiencing manifestations of pancreatitis. Clients who have pancreatitis experience an increase in pancreatic enzymes, amylase, and lipase. Oxygen saturation, urine output, platelet levels, and blood pressure are incorrect. These findings do not indicate pancreatitis.
*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 dialysate appeared cloudy this morning.Reports abdominal pain as 4 on a scale of 0 to 10.Bowel sounds active in all quadrants.Peritoneal dialysis access site red, warm to touch, with a small amount of purulent drainage noted on dressing. *1300:Client is lying in bed with the knees flexed, guarding the abdomen. Abdomen is slightly distended, hypoactive bowel sounds. Client reports nausea. Reports pain as 6 on a scale of 0 to 10. Provider notified and updated with client condition and diagnostic results.
The client is experiencing manifestations of peritonitis due to x-ray results Rational: Dropdown 1 Peritonitis is correct. The client is experiencing manifestations of peritonitis, such as abdominal pain, cloudy dialysate, and an elevated white blood cell count. Myxedema coma, hemorrhage, dysrhythmias and pneumonia are incorrect. The client does not exhibit manifestations of any of these conditions based on assessment and laboratory findings. Dropdown 2 X-ray results are correct. The client's abdominal x-ray shows fluid in the abdomen along with inflammation, both of which are indications of peritonitis. Thyroid level, platelet count, potassium level and oxygen saturation are incorrect. These laboratory findings and the oxygen saturation are within the expected reference range and do not indicate peritonitis.
2330:Report received from ambulance crew: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. Client's shirt covered with bright red blood. Client reports pain as 6 on a scale of 0 to 10. Shortness of breath noted. 2345:Client is alert and oriented with a GCS score of 15. Client has a penetrating wound to the anterior right upper chest measuring 2.5 cm (1 in). No other wounds or injuries found.Bilateral radial and pedal pulses are +1. Left lung sounds are clear, right upper lung sounds diminished.Client still reports pain as 6 on a scale of 0 to 10 over anterior chest.Bowel sounds are present in all 4 quadrants.
The client is most likely experiencing a hemothorax as evidenced by the client's respiratory findings Rational: Dropdown 1 A traumatic brain injury is incorrect. The client is alert and oriented and has a GCS score of 15. Therefore, a traumatic brain injury is unlikely. A hemothorax is correct. The client has shortness of breath, hypoxia, diminished breath sounds, and a decreased hematocrit. Therefore, the client is likely experiencing a hemothorax. A ruptured spleen is incorrect. The client's puncture wound is not located near their spleen. Therefore, the client is unlikely to have a ruptured spleen. Dropdown 2 Gastrointestinal findings is incorrect. The client's gastrointestinal findings are expected. GCS score is incorrect. The client's GCS score indicates intact neurological function. Respiratory findings is correct. The client has shortness of breath, hypoxia, diminished breath sounds, and a decreased hematocrit. Therefore, the client is likely experiencing a hemothorax.
A nurse is caring for a client who had a nephrostomy tube inserted 12 hr ago. Which of the following findings should the nurse report to the provider?
The client reports back pain. Rational: The nurse should notify the provider if the client reports back pain, which can indicate that the nephrostomy tube is dislodged or clogged.
A nurse is assessing a client while suctioning the client's tracheostomy tube. Which of the following findings should indicate to the nurse the client is experiencing hypoxia?
The client's heart rate increases. Rational: Hypoxia related to suctioning can cause the client's heart rate to increase. If this occurs, the nurse should discontinue the suctioning and manually oxygenate the client with 100% oxygen. The nurse should instruct the client to take three or four deep breaths prior to suctioning to reduce the risk for hypoxia.
2330:Report received from ambulance crew: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. Client's shirt covered with bright red blood. Client reports pain as 6 on a scale of 0 to 10. Shortness of breath noted. 2345:Client is alert and oriented with a GCS score of 15. Client has a penetrating wound to the anterior right upper chest measuring 2.5 cm (1 in). No other wounds or injuries found.Bilateral radial and pedal pulses are +1. Left lung sounds are clear, right upper lung sounds diminished.Client still reports pain as 6 on a scale of 0 to 10 over anterior chest.Bowel sounds are present in all 4 quadrants.
The nurse should first address the client's oxygenation followed by the client's blood pressure Rational: Oxygenation and blood pressure are correct. Using the airway, breathing, circulation priority framework, the nurse should first address the client's oxygenation, followed by the client's blood pressure. The client's oxygenation is below the expected reference range and is the priority. The nurse should then address the client's circulation because the client's blood pressure is below the expected reference range. Pedal pulses, temperature, and pain are incorrect. The nurse should address the client's pedal pulses because they are diminished. The nurse should address the client's temperature because it is below the expected reference range. The nurse should address the client's pain to promote comfort. However, using the airway, breathing, circulation priority framework, the nurse should address pedal pulses, temperature, and pain after oxygenation and blood pressure.
Nurses' Notes 1000:Client presents to the ED with visual disturbances, expressive aphasia, and numbness and tingling of the lips. Manifestations started about 30 min ago. Client reports flashing lights in their vision, especially on the right side.Client's partner states the client had some difficulty with finding words when speaking. Client is alert and oriented x 3 and appears anxious. No facial drooping noted. Right hand grasp is weaker than left. Client denies pain. 1045:Client states the flashing lights, numbness, and tingling in the lips have gone away. Client states they now have throbbing pain behind the left eye, photophobia, and nausea. Client is requesting medication for pain that is 7 on a scale of 0 to 10.Hand grasps are equal and strong bilaterally.
The nurse should identify that the client is most likely experiencing a migraine and the nurse should address the client's pain Rational: Dropdown 1 A migraine is correct. The client is exhibiting manifestations of a migraine. The client presented initially with neurological manifestations of flashing lights, aphasia, unilateral weakness, and numbness of the lips. These findings are consistent with the first phase, or aura phase, of a migraine. These changes resolved after an hour and were followed by throbbing pain with nausea and vomiting. A stroke is incorrect. A client who is experiencing a stroke will have neurological manifestations; however, these changes would not resolve after 1 hr. Meningitis is incorrect. A client who is experiencing meningitis will have neurological manifestations; however, these changes would not resolve after 1 hr. Dropdown 2 Blood pressure is incorrect. Although the client's blood pressure is mildly elevated, it does not require intervention by the nurse. Pain is correct. The client reports pain as 7 on a scale of 0 to 10, which indicates significant discomfort. The nurse should address the client's pain level to promote comfort. Neurological status is incorrect. The client's neurological changes have resolved. Therefore, this finding does not require intervention by the nurse.
A nurse is caring for a client who is having a seizure. Which of the following interventions is the nurse's priority?
Turn the client to the side. Rational: The greatest risk to this client is hypoxia from an impaired airway. Therefore, the priority intervention the nurse should take is to place the client in a side-lying position to prevent aspiration.
A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure injury. Which of the following actions should the nurse take?
Use a 30-mL syringe. Rational: The nurse should use a 30-mL to 60-mL syringe with an 18- or 19-gauge catheter to deliver the ideal pressure of 8 pounds per square inch (psi) when irrigating a wound. To maintain healthy granulation tissue, the wound irrigation should be delivered at between 4 and 15 psi.
NGN1000:Temperature 36.8° C (98.4° F)Heart rate 98/min Respiratory rate 18/min Blood pressure 134/75 mm Hg Oxygen saturation 98% on room air **Select the 4 findings that require follow-up by the nurse.
Visual disturbances Tingling of the lips Hand grasps Expressive aphasia Rational: Visual disturbances is correct. Visual disturbances are manifestations of a neurological event. Therefore, the nurse should follow-up on this finding. Blood pressure is incorrect. The client's blood pressure is within the expected reference range. Therefore, this finding does not require follow-up by the nurse. Tingling of the lips is correct. Tingling in the face is a manifestation of a neurological event. Therefore, the nurse should follow-up on this finding. Orientation is incorrect. The client is alert and orientated x3, which is an expected finding. Therefore, this finding does not require follow-up by the nurse. Hand grasps is correct. The client's hand grasps are unequal, which could indicate a neurological deficit. Therefore, this finding requires follow-up by the nurse. Expressive aphasia is correct. Expressive aphasia is a manifestation of a neurological event. Therefore, the nurse should follow-up on this finding. Pain is incorrect. The client denies pain. Therefore, this finding does not require follow-up by the nurse.
A nurse is planning care for a client who is undergoing brachytherapy via a sealed vaginal implant to treat endometrial cancer. Which of the following actions should the nurse include in the client's plan of care?
Wear a lead apron while providing care to the client. Rational: The nurse should wear a lead apron when providing direct care to provide protection from the radiation source and not turn their back toward the client, because the apron only shields the front of the body. The nurse should also wear a dosimeter film badge to measure radiation exposure.