set 9
The nurse is caring for a client who has been admitted with recurring migraine headaches period to assess the quality of the client's pain experience from the migraine headache, which approach should the nurse use?
"Ask the client to describe the pain"
In assessing a client's pain, which question, or statement is likely to elicit the most important information?
"Describe what the pain feels like"
A client with schizophrenia reports auditory hallucinations when admitted to the hospital. Which question is most important for the nurse to ask in the assessment of this client?
"What are the voices saying?"
When assessing a client, the nurse should establish which findings as objectives? Select all that apply.
- Edema - Diaphoresis - Hypertension - Urticaria (hives/rash)
The nurse is preparing an older male adult for discharge who does not read and has bilateral hearing loss period the client's daughter who lives close to her father tells the nurse that she will stop by daily to check on her father. Which interventions should the nurse implement. SATA
- Face client when speaking. - Provide the daughter with written instructions. - Include the family in discharge teaching.
A client is receiving ophthalmic drops preoperatively for a cataract extraction and asks the nurse why the health care provider has prescribed all these medications. Which information should the nurse include when responding to this client? Select all that apply.
- One of the medications is used to anesthetize the corneal surface - The iris must be paralyzed during surgery to prevent it from reacting to light - Pupillary dilation is necessary to access the eye chamber for lens removal
The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?
A client with a positive Mantoux and sputum cultures results positive for acid-fast bacillus (AFB).
The nurse administers the osmotic diuretic mannitol to a client who had a closed head injury. Which assessment finding indicates an immediate response to administration of the mannitol?
A decreased intracranial pressure
A client with atrial fibrillation is scheduled for an elective cardioversion . The nurse inserts two intravenous catheters and connects the monitoring lead wires to the client in preparation for the procedure. Which action is most important for the nurse to implement prior to deploying the current for the cardioversion?
Activate the synchronization mode
A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the emergency department and is transferred to the neurological unit to be monitored for symptoms of closed head injury. Which assessment finding is indicative of developing epidural hematoma?
Altered consciousness within the first 24 hours after injury
The nurse is assessing an adolescent female diagnosed with anorexia nervosa who is admitted to the unit with severe malnutrition and electrolyte imbalance. Which pathological process results from the adolescent's consistent maladaptive behavior?
Amenorrhea
After receiving the report, the nurse can most safely plan to assess which client last?
An adult client with no postoperative drainage in the Jackson-Prat drain with the bulb compressed.
The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child?
Apply baby lotion to the skin twice daily.
The primary caregiver of an older client calls the nurse at the outpatient clinic due to a sudden onset of changes in the client's behavior. The caregiver reports to the nurse that the client normally is oriented and able to answer questions but now is confused and agitated. Which actions should the nurse take? (Select all that apply.)
Ask if the client is experiencing any pain with urination Encourage increased intake of high protein foods. Provide instructions on taking the client's temperature. Review the client's current food and medication allergies. Determine if the client has recently experienced a fall.
A client with chronic kidney disease has an arterial venous (AV) fistula in his left forearm. Which observation by the nurse indicates that the fistula is pain?
Assessment of a bruit on the left forearm
A patient with a history of Chronic Obstructive Pulmonary Disease (COPD) is admitted with pneumonia. Vital signs include heart rate 122 beats/minute, respiratory rate 28 breaths/minute, and blood pressure 170/90mmHg. Which assessment finding warrants the most immediate intervention by the nurse?
Bilateral diffuse wheezing
The nurse is assessing a primigravida at 37-weeks gestation who believes she is in labor. Which assessment finding necessitates admission to the labor and delivery unit?
Cervix 50% effaced and 1 cm dilated.
A client is recovering in the critical care unit following a cardiac catheterization. Intravenous IV nitroglycerin and heparin are infusing. The client is sedated but responds to verbal instructions. After changing positions, the client complaints of pain at night groin insertion site. Which action should the nurse implement?
Check femoral site for hematoma information
A client with bleeding esophageal varices receives vasopressin (Pitressin) IV. What should the nurse monitor for during the IV infusion of this medication?
Chest pain and dysrhythmia
The mother of a child recently diagnosed with asthma asks the nurse how to help protect her child from having asthma. To avoid triggers for asthmatic attacks, which instructions should the nurse provide the mothers?
Close car windows and use air conditioner Avoid sudden changes in temperature Keep away from pets with long hair Stay indoors when grass is being cut
A client with a history of lung cancer reluctantly comes to the clinic because of persistent hoarseness and a chronic cough. The client's respirations are labored when speaking and the capillary refill is 3 seconds. Which additional finding warrants intervention by the nurse?
Coarse breath sounds.
A woman at 12 weeks gestation comes to the clinic for her first prenatal visit. After completing a health history, the nurse should discuss which topic about pregnancy at this initial visit?
Complications associated with childbirth
An adult female client is admitted to the psychiatric unit because of a complex handwashing ritual she performs daily that takes two hours or longer to complete. She worries about staying clean and refuses to sit on any of the chairs in the day area. This client's handwashing is an example of which clinical behavior?
Compulsion
An adult client is admitted to the critical care unit with systemic inflammatory response syndrome (SIRS) as a result of a postbur infection. The client has a long line peripherally inserted IV catheter for fluid and medication administration and current vital signs include temperature 102.8° F (39.3° C), heart rate 108 beats/minute, respirations 32 breaths/minute. Which action should the nurse implement first?
Culture sputum, urine, burn wound, and all intravenous access sites.
The nurse is preparing to administer a histamine 2-receptor antagonist to a client with peptic ulcer disease. What is the primary purpose of this drug classification?
Decreases the amount of HCL secretion by the parietal cells in the stomach
An unlicensed assistive personnel (UAP) is a sign to provide personal care for a client whose prescribed activity is bed rest in a bedside commode use. The UAP reports to the nurse that the client is so obese that the UAP feels unable to safely assist the client in transferring from the bed to the bedside commode. How should the nurse respond?
Determine the client's level of mobility and need for assistance
A client arrives at a hurricane disaster medical area seeking treatment for diarrhea. Which source of contamination should the nurse consider when interviewing the client about exposure?
Drinking water contaminated by sewage.
A nine-year-old female client was recently diagnosed with diabetes mellitus. Which symptom will her parents most likely report?
Drinks more soft drinks than previously
A newly hired unlicensed assistive personnel UAP is assigned to a home health care team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients?
Evaluate the newly hired UAP's level of competency by observing the UAP deliver care.
An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies. What is the best response by the nurse?
Explain that the client will start to lose consciousness and his body system will slow down
A nurse is providing discharge teaching to a client who underwent a pneumonectomy, The client wants to resume social activities with family. How should the nurse respond?
Explain the need to avoid persons with respiratory infections.
When conducting diet teaching for a client who was diagnosed with hypertension, which foods does the nurse encourage the client to eat? (select all that apply)
Fruits without sauce Fresh or frozen vegetables without sauce
When developing a teaching plan for a client with newly diagnosed type one diabetes, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis DKA. Which action should the nurse instruct the client to implement if this sign of DKA occurs?
Give a dose of regular insulin as prescribed
The nurse is caring for a client newly diagnosed with emphysema. The nurse should prioritize which potential complication?
Ineffective airway clearance.
A client with history of adrenal insufficiency is admitted to the ICU with an acute adrenal crisis. The client is complaining of nausea and joint pain. Vital Signs: are T 102 F, P 138 bpm, BP 80/60. Which intervention should the nurse implement first?
Infuse an intravenous fluid bolus
A mother brings her 3-week-old son to the clinic because he is vomiting "all the time." In performing a physical assessment, the nurse notes that the infant has poor skin turgor, has lost 20% of his birth weight, and has a small palpable oval-shaped mass in his abdomen. What intervention should the nurse implement first?
Initiate a prescribed IV for parental fluid
Four days after exposure to the coronavirus COVID-19 a client has a negative COVID-19 test results. Eight days after the negative test result, the client presents with fever, fatigue, and cough and the nurse performs a second COVID-19 test period. Which action is most important for the nurse to take?
Institute droplet precautions, place client in the private room, and keep the door closed.
A client with a long history of migraine headaches asked the nurse if there are non- pharmaceutical ways to help obtain pain relief period which intervention should the nurse offer?
Lie down in a dark, quiet room
A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implements while administering this medication?
Measure urinary output every hour.
A client with ureterolithiasis is preparing for discharge after a ureteroscopic removal. Which interaction should the nurse include in the postoperative discharge teaching?
Monitor urinary stream for decrease in output
A patient with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention(s) should the nurse implement? (Select all that apply.)
Monitoring abdominal girth Report serum albumin and globulin levels Note signs of swelling and edemas
A five-year-old child with a history of waddling gait and frequent falls is brought into the hospital for diagnostic testing period when explaining the diagnostic testing to the parents, the nurse should provide information based on which understanding of the underlying disease pathology?
Muscle fiber degeneration
The nurse completes percussion of the abdomen on an older adult client. Which finding is considered normal for this client?
Musical and drumlike
After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?
Note the presence of an auscultatory gap.
The nurse is planning discharge instructions for a client with type 2 diabetes who will be starting exenatide. Which information should be included in the discharge destructions?
Notify your healthcare provider if you start having abdominal pain
The client is admitted to the intensive care unit (ICU) with a spinal cord injury (SCI) following a motor vehicle collision. Which nurse should be contacted to coordinate the progression of the client's care?
Nurse case manager.
A client is admitted to the hospital after experiencing a stroke or cerebrovascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding?
Persistent coughing while drinking.
An older client with a history of cataracts is recovering from intraocular lens implant (OL) surgery to the left eye. During the post-procedure period, which intervention should the nurse implement?
Provide an eye shield to be worn while sleeping.
The nurse is monitoring a client with Cushing's disease in the post anesthesia care unit (PACU) after a hypophysectomy. Which intervention is most important for the nurse to include in the client's plan of care?
Provide frequent mouth care.
The nurse is preparing a 50 mL dose of 50% Dextrose IV for a client with insulin shock. How should the nurse administer the medication?
Push the undiluted Dextrose slowly through the currently infusing IV.
The nurse is caring for a client who reports sudden right-sided numbness and weakness of the arm and leg. The nurse also observes a distinct right-sided facial droop. After reporting the findings to the healthcare provider, the nurse receives several prescriptions for the client, including a STAT computerized tomography (CT) scan of the head. Which action should the nurse take first?
Raise the head of the bed to 30 degree keeping head and neck in neutral alignment
The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having sex with someone who had many partners. Which response should the nurse provide?
Remain non-judgmental and assure the client of confidentiality.
The nurse observes an unlicensed assistive personnel (UP) applying an alcohol-based hand rub while leaving a client's room after taking vital signs. Which action should the nurse take?
Remind the UAP to continue rubbing the hands together until they are dry.
A client is admitted to the mental health unit for feelings of depression secondary to a positive human immunodeficiency virus HIV report period to provide a safe milieu or this client, which action should the nurse take?
Remove soft drink cans from the nurse's desk & patient lounge
A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair. Which intervention is most important for the nurse to include in the plan of care?
Replace fluids intravenously based on intake and output
A client is admitted following a motor vehicle collision. When assessing the client's level of consciousness, the nurse notes that the client no longer responds to commands. The nurse initiates a painful stimulus, and a client responds by pulling the arms inward with elbows and wrists flexed and extending the legs with the toes pointed downward. Which action should the nurse implement?
Report the finding to the healthcare provider
A client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assisted personnel (UAP) donning gloves and a gown to assist the client. Which action should the nurse take?
Review the need for the UP to wear a face mask while in close contact with the client.
A female client is admitted with complaints of abdominal pain, loss of appetite, and a weight loss of 25 pounds (11 kg) in the last four months. During the admission assessment, the client tells the nurse that she has no interest in playing cards with her friends anymore and feels worthless most days. Which nursing problem should the nurse address first?
Risk for self-directed violence as evidenced by feelings of hopelessness.
A client with intestinal obstruction has a nasogastric tube to low intermittent suction and is receiving an intravenous IV infusion of lactated ringers at 10mL/hour. Which finding is most important for the nurse to report to the health care provider? Reference range (Potassium 3.5 5 mEq/L)
Serum potassium level of 3.1 mEq/L (3.1 mmol/L)
Which laboratory test results should the nurse monitor in a client who has end stage renal disease (ESRD)?
Serum potassium, calcium, and phosphorus
The nurse receives report on four clients who are complaining of increased pain. Which client requires immediate intervention by the nurse?
Sharp pain related to a crushed femur
The nurse on the medical-surgical unit is receiving a transfer report from the post anesthesia care unit (PACU) nurse for a client who had an exploratory laparotomy. The PACU nurse provides the following information: 1000mL normal saline is infusing at 125mL/hr into the left wrist with 600mL remaining. Ondansetron 4mg intravenously every eight hours is prescribed for nausea. The last dose was administered at 0700. The client is currently describing pain at a level 2 on a 0 to 10 pain scale. The client has a prescription for hydromorphone 1mg intravenously every 2 hours as needed for pain. The last dose was administered at 1000." Which additional information should the PACU nurse report?
Soft abdomen, absent bowel sounds, no bleeding on dressing
In providing nursing care for a client after gastric endoscopy, which commonly occurring problem should the nurse include intervention for the post procedure plan of care?
Sore throat
The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom. The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action?
Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.
The nurse is providing education to a client who receives a prescription for zolpidem. Which information about the medication should the nurse include?
Take before bedtime
A male client returns to the mental health clinic for assistance with his anxiety reaction that is manifested by a rapid heartbeat, sweating, shaking, and nausea while driving over the bay bridge. What action in the treatment plan should the nurse implement?
Teach the client to listen to music or audiobooks while driving
The nurse provides three positive responses to items on the CAGE (Cut down, Annoyed, Guilty, Eye- opened) questionnaire. Which interpretation should the nurse provide the client?
The CAGE questionnaire is a tool used to identify general substance abuse.
The mother of a 2-day-old infant girl expresses concern about a "flea bite" type rash on her daughter's body. The nurse identifies a pink popular rash with vesicles superimposed over the thorax, back, buttocks, and abdomen. Which explanation should the nurse offer?
This is a common newborn rash that will resolve after several days.
The nurse is caring for 4 PTs: Patient A, who has emphysema and whose O2 saturation is 94%; Patient B, w/ a postoperative hemoglobin of 8.2 mg/dL; Patient C, newly admitted w/ a potassium level of 3.8 mEq/L; and Patient D, scheduled for an appendectomy who has a WBC count of 14,000 mm3. What intervention should the nurse implement?
Verify that Patient B has two units of packed cells available
