saunders

The nurse is reinforcing instructions to a client following mastectomy who will be discharged with an axillary drain in place. the client will be receiving home care vists from the nurse to monitor drainage and perform dressing changes. Which client statement indicates a need for further teaching

"I need to begin full rom exercises to my upper arm as soon as I get home

A client is admitted to the hospital with a diagnosis of neutropenia. Which interventions should the nurse include in planning care for this client? Select all that apply.

1 check,2monitor,4 remove

The prescription reads to give ondansetron hydrochloride 0.15 mg/kg of body weight 30 minutes before receiving chemotherapy. The client weighs 132 pounds. How many milligrams (mg) of ondansetron hydrochloride will the nurse administer? Fill in the blank.

9mg

A client has had a bone scan procedure. The nurse determines that the client understands the elements of follow-up care if the client states which postprocedural care?

Drink plenty of water for a day or two following the procedure

A client is admitted to a long-term care facility with the diagnosis of weight loss secondary to anorexia. The primary health care provider inserts a nasogastric tube and prescribes a tube feeding of a standard formula feeding to run at 50 mL/hr. The nurse plans care, knowing that which is true regarding enteral feedings

Enternal feedings require the normal digestive capabilities of gastrointestinal tract

The nurse checks the sternotomy incision of a client on the second postoperative day after cardiac surgery. The incision shows some slight "puffiness" along the edges and is nonreddened with no apparent drainage. The client's temperature is 99° F (37.2° C) orally. The white blood cell (WBC) count is 7500 mm3 (7.5 × 109/L). Which interpretation does the nurse make of these findings?

The incision is slightly edematous but shows no active signs of infection

a client's arterial blood gases reveal a pH of 7.51 and a bicarbonate level of 31 mEq/L. The nurse prepares for the administration of which medication that should be prescribed to treat this acid-base disorder?

acetazolamide

a client is scheduled for endoscopic retrograde cholangiopancreatography (ERCP). The nurse includes which intervention in the plan of care for the client?

after the procedure keep the client npo until gag reflux returns

a licensed practical nurse (LPN) attends a session about bioterrorism agents including anthrax. Which statement by an attendee demonstrates the need for further teaching about anthrax?

anthrax bacteria produces a neurotoxin leading to a serious possibly fatal paralysis

when performing a surgical dressing change of a client's abdominal dressing, the nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse should plan to take which action in the initial care of the wound?

apply a sterile dressing soaked in normal saline

the nurse is checking a client's surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of underlying tissue. Which actions should the nurse take to deal with this event? Select all that apply.

apply sterile dressing notify rn

A client will undergo a barium swallow to confirm a diagnosis of a hiatal hernia. In preparation for the test, which instruction should the nurse provide the client?

avoid eating or drinking after midnight before the test

nurse will perform a sterile dressing change after removing the old dressing with clean gloves. The nurse removes the gloves, uses alcohol-based hand sanitizer to perform hand hygiene, and prepares to perform open sterile gloving. The nurse removes the gloves from the outer package. The nurse is right-handed. The nurse opens the inner wrapper and flattens the wrapper to expose the gloves. Which is the next action the nurse takes when donning sterile gloves?

pick up right glove at cuff with left thumb and forefinger

a primary health care provider writes a prescription to apply a heating pad to a clients back. the nurse implements the prescription and avoids which action

placing the heating pad under the client

the nurse is instructing a group of unlicensed assistive personnel (UAP) in the principles of body mechanics. The nurse determines that a student is using the principles appropriately if the nurse observes the UAP doing which action?

positioning a box that is to be lifted between the knees

The nurse is assisting with collecting data from an African-American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which information about the client is of lowest priority during the data collection?

psychosocial

the nurse is assisting a client to ambulate when the client states he is feeling faint and cannot stand. Which action should the nurse take to assist the client now?

the nurse should extend one leg to use to slide the clients body down to the floor

The nurse is caring for a client with diagnosis of gout. which laboratory value should the nurse expect to note in the client

uric acid level of 8.4mg

A client returns from the recovery room following an abdominal surgical procedure. Following the arrival of the client to the nursing unit, the nurse observed the client has a patent airway. Which is the next nursing assessment?

vital signs

the nurse urse prepares to give a bath and change the bed linens for a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which should the nurse use during the bathing of this client

gown and gloves

the nurse is caring for an adult client with respiratory distress syndrome. A review of the arterial blood gas results indicates that the client is experiencing respiratory alkalosis. The nurse should then examine the results of serum electrolytes to see whether which electrolyte imbalance is present?

hypokalemia

after attending the same social function 5 days ago, 50 individuals arrive at the hospital over a 4-day period with fever; an itchy, reddish brown papule; and complaints of nausea, vomiting, and severe abdominal pain. Cutaneous anthrax is suspected by the health care team. Which is the nurse's priority for client care?

institute contact precautions

A client who has recently been started on enteral feedings begins to complain of abdominal cramping, followed by passage of two liquid stools. The nurse notes that the client has abdominal distention as well. The nurse reviews the nutritional content on the label of the can to see if it contains which ingredient?

lactose

the nurse is caring for a client with severe diarrhea. The nurse monitors the client closely, understanding that this client is at risk for developing which acid-base disorder?

metabolic acidosis

the nurse is caring for a client following an abdominal surgery performed 1 day ago. An intravenous (IV) line is infusing and a nasogastric (NG) tube is in place and attached to low intermittent suction. The nurse monitors the client and notes that the bowel sounds are absent. The nurse should perform which actions? Select all that apply.

2,4

a client on the medical unit tells the nurse of back discomfort but does not want any pain medication. Which nonpharmacological interventions should the nurse offer the client to help reduce the pain? Select all that apply.

2,4,5

The nurse is assigned to care for a client who has a nasogastric (NG) tube and is receiving tube feedings. When implementing nursing care for the client, the nurse remembers which information? Select all that apply

3. That aspiration as a complication is a primary concern 5. To determine correct placement by aspirating contents from the tube to observe characteristics and check pH

A seriously ill client in the hospital tells the nurse that he thinks he has lost some of his ability to hear over the past few days. The nurse reviews the medications the client is currently receiving. Which medications are known to be ototoxic? Select all that apply

Aspirin, Furosemide, Gentamycin

The student nurse is changing an abdominal dressing on a client with an open incision and notes the presence of sanguineous drainage. Which nursing action should be appropriate?

Notify the charge nurse

a client with a history of seizure disorder is receiving phenytoin in the hospital. The client has a seizure and the nurse reviews the laboratory results of the phenytoin level of 18 mcg/mL. The therapeutic level is 10 to 20 mcg/mL. The nurse understands from reviewing the medication level that which is the correct situation

Phenytoin alone is not effectively controlling seizures

The nurse is changing the neck ties on a tracheostomy tube which method is appropriate for the nurse to take.

Remove the old ties, clean the site, and then apply the new ties while a second health care team member holds the tracheostomy tube.

Which cardiovascular sign should the nurse expect to note in a client with a diagnosis of hypocalcemia?

Shortened QT intervals on ECG

the nurse reviews the clients laboratory results which abnormal findings should the nurse report

1,2,4,5

the nurse prepares a client for the lumbar puncture procedure by which interventions? Select all that apply.

1. review, 2. observe, 4 check

The nurse has reinforced instructions to a client with tuberculosis about proper handling and disposal of respiratory secretions. The nurse determines that the client understands the instructions if the client verbalizes to take which measure?

Discard the used tissues in a plastic bag

The nurse is explaining the concept of a time-out in the perioperative area. Which statement best describes the purpose of a time-out?

to allow the surgical team a chance to verbally verify its agreement about the client's name, the surgical procedure and the site

A licensed practical nurse (LPN) asks an unlicensed assistive personnel (UAP) to gather supplies in preparation for administering a tepid bath to a child with an elevated temperature. The LPN intervenes if the UAP obtains which unnecessary item(s)?

a bottle of alcohol

the nurse on a medical unit is instructing the unlicensed assistive personnel (UAP) regarding toileting needs of the assigned clients. The nurse should instruct the UAP to prepare to assist which client first?

a client who was admitted 2days ago with a pelvic fracture

the nurse receives a client in the surgical unit who was transferred from the postanesthesia care unit. The nurse checks the client for which data first?

a patent airway

The nurse reviews a client's serum sodium level and notes that the level is 150 mEq/L (150 mmol/L). The primary health care provider prescribes dietary instructions for the client based on the sodium level. Which food items should the nurse instruct the client to avoid? Select all that apply.

bacon, salami, processed oat cereal

A hospitalized client is a lacto-vegetarian. Which food item should the nurse remove from the meal tray?

eggs

the nurse is assisting with planning care for a client with an internal radiation implant. Which should be included in the plan of care? Select all that apply

1,2,3,4

Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report? Select all that apply.

1,2, 4,6

A client undergoing diagnostic testing for cancer is scheduled for magnetic resonance imaging. the nurse reinforces to the client which information about the procedure

expect the mri machine to make noises

a client enters the emergency department confused, twitching, and having seizures. Upon assessment, flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor is noted. The serum sodium level is 172 mEq/L (172 mmol/L). Which interventions should the primary health care provider (PHCP) likely prescribe? Select all that apply.

1,2,3,4,5

the nurse is preparing to administer an enema to an adult client. Which interventions should the nurse plan to perform for this procedure? Select all that apply

1,3,4,6

the nurse working in a human immunodeficiency virus (HIV)/acquired immunodeficiency (AIDs) clinic is reviewing modes of transmission for HIV for a new nurse to the clinic. Which potential modes of HIV transmission should the nurse review? Select all that apply.

1,3,5

a client is admitted to the hospital with a diagnosis of malnutrition. The nurse is told that blood will be drawn to determine whether the client has a protein deficiency. Which laboratory data indicate that the client is experiencing a protein deficiency? Select all that apply

1,4,5 albumin, trans, pre

the client is to receive soapsuds enema. which is the best position for administering an enema

1. A

The nurse is assigned to care for a client who is traditional Chinese. The nurse enters the room and following a greeting and introduction to the client, the nurse begins to discuss the plan of care for the day. During the discussion, the client turns away from the nurse. The nurse should take which action?

continue with the discussion

the licensed practical nurse (LPN) is assisting in the care of a client who overdosed on acetylsalicylic acid 24 hours ago. The LPN should report to the registered nurse (RN) which findings associated with an anticipated acid-base disturbance?

drowsiness, headache, and tachypnea

the nurse is reading a primary health care provider's prescription and notes that a client is to receive a medication at 1:00 pm. Using the military time clock, the nurse administers the medication at which time? Refer to figure. View Figure

1. 1300

whuch arterial blood gas (ABG) result should the nurse anticipate in the client who develops metabolic alkalosis after profuse vomiting for 2 days

pH 7.49; Pco2 45; HCO3- 30