Studying for finals

The nurse is working with a client admitted with shock in a critical care unit. What assessment findings indicate fluid volume deficit and would need to be reported to the health care provider? Select all that apply. a. oxygen saturation of 65% b. heart rate 136 beats per minute c. central venous pressure 1 mm Hg d. mean arterial pressure of 75 mm Hg e. urine output 40 mL for the last two hours

b, c, e

The nurse is assessing a client receiving levodopa-carbidopa for treatment of Parkinson's disease. The nurse should document which assessment findings as evidence of a positive response to treatment? Select all that apply. a. improved visual acuity b. decreased dyskinesia c. reduced blood presusre d. reduced rigidity and tremor e. less frequent "freezing"

b, d

A client with renal insufficiency is being treated with intravenous antibiotics. Which laboratory value should be monitored closely? a. blood urea nitrogen (BUN) and creatinine levels b. arterial blood gas (ABG) levels c. platelet count d. potassium level

a

An older adult is admitted with new-onset confusion, headache, poor skin turgor, bounding pulse, and urinary incontinence and has been drinking copious amounts of water. Upon reviewing the lab results, the nurse discovers a sodium level of 122 mEq/L (122 mmol/L). A report to the health care provider (HCP) should include what recommendations? Select all that apply. a. fluid restriction b. vital signs every 2 hours c. bed alarm d. Foley catheter e. 2-g sodium diet

a, b, c, d

The nurse is caring for a client with chronic hypertension who struggles with medication compliance due to financial issues. Which laboratory result(s) will the nurse prioritize when assessing for complications of unmanaged hypertension? Select all that apply. a. blood urea nitrogen (BUN) b. glomerular filtration rate (GFR) c. creatinine d. erythrocyte sedimentation rate e. alanine aminotransferase (ALT) f. routine urinalysis

a, b, c, f

What side effects are important for the nurse to mention when teaching a client about long-term use of antipsychotics? Select all that apply. a. constipation b.sedation c. headache d. blurred vision e. nausea

a, b, d

A 22-year-old female client has lactose intolerance. After teaching her about foods that will help her maintain adequate calcium intake, which client responses identifying foods to eat or drink indicates to the nurse that the client understands the teaching plan? Select all that apply. a. broccoli b. canned sardines c. ice cream d. soy milk e. almonds

a, b, d, e

After teaching a client about collecting a stool sample for occult testing, which client statement indicates effective teaching? Select all that apply. a. "I will avoid eating meat for 1 to 3 days before getting a stool sample." b. "I need to eat foods low in fiber a few days before collecting the sample." c. "I will take the sample from different areas of the stool that I have passed." d. "I need to send the stool sample to the lab in a covered container right away." e. "I can continue to take all of my regular medications at home."

a, c

A client is receiving a tube feeding and has developed diarrhea, cramps, and abdominal distention. What should the nurse do? Select all that apply. a. Change the feeding apparatus every 24 hours. b. Use a higher volume of formula because the formula may be too hypotonic. c. Slow the administration rate. d. Use a diluted formula, gradually increasing the volume and concentration. e. Anticipate changing to a lactose-free formula.

a, c, d, e

A client has early signs of oral cancer. What should the nurse include in a focused assessment? Select all that apply. a. an infection or inflammation in the mouth b. lost the sense of taste c. difficulty swallowing d. significant weight loss e. changes in frequency of urination f. numbness of the tongue

a, c, d, f

Which nursing interventions would be appropriate when caring for a client during the first 24 hours after an appendectomy? Select all that apply. a. Place the client in a semi-Fowler's position. b. Maintain a clear-liquid diet for 48 hours. c. Monitor temperature every 2 hours. d. Teach the client how to care for the incision. e. Apply an abdominal binder.

a, d

After being hospitalized with peritonitis for 1 month, a client is being discharged unable to prepare meals, requiring physical assistant and IV therapy. Which nursing instructions are most appropriate? Select all that apply. a. "Fluids and foods should be increased gradually." b. "A home health nurse will need to change your IV site every 5 days." c. "Physical therapy can only do as much as you would let them." d. "Meals on Wheels will not prepare meals specific to your needs initially." e. "Physical therapy will work with you short-term, but you will have to be motivated."

a, d, e

A client with pancreatic cancer is prescribed fentanyl by patch with subcutaneous doses for breakthrough pain. The client asks the nurse why the fentanyl cannot just be provided by pill form. How should the nurse respond? a. "Because your pancreas is impaired, your body is not able to properly metabolize the medication if taken orally." b. "This medication's effects are greatly reduced if taken in oral forms so topical and parenteral forms must be used." c. "The patch form of fentanyl is much stronger than pill form to provide you with better overall pain control." d. "Oral forms of opioids like fentanyl are more likely to cause nausea than the topical and parenteral formulations."

b

A client is receiving oral prednisolone. Which side effects would the nurse expect to see from prolonged use of this medication? Select all that apply. a. hypoglycemia b. hyperglycemia c. osteoporosis d. hirsutism e. cataract f. weight loss

b, c, d, e

An adult has been admitted to the emergency department diagnosed with food poisoning following an outdoor picnic. What should the nurse do? Select all that apply. a. Tell the family to discard contaminated food. b. Collect specimens for lab examination. c. Assess vital signs. d. Initiate support for the respiratory system. e. Monitor fluid and electrolyte status. f. Provide anti-emetics, as prescribed.

b, c, d, e, f

Fluoxetine has been prescribed for a client with an eating disorders. Which symptoms would alert the nurse to the development of serotonin syndrome? Select all that apply. A. sleepiness b. hallucinations c. fever d. anxiety e. tremors f.. diaphoresis

b, c, d, e, f

A client with chronic renal failure who receives hemodialysis twice a week is experiencing severe nausea. What should the nurse advise the client to do to manage the nausea? Select all that apply. a. Drink fluids before eating solid foods. b. Have limited amounts of fluids only when thirsty. c. Limit activity. d. Keep all dialysis appointments. e. Eat smaller, more frequent meals.

b, d, e

The nurse is caring for a client who had an open cholecystectomy 24 hours ago. The client's vital signs have been stable for the past 24 hours, but the client now has a temperature of 101.1 degrees F (38.4 degrees C), a heart rate of 116 beats/min, and a respiratory rate of 26 breaths/min. Using SBAR communication, which of the following recommendations should the nurse make when calling the health care provider? Select all that apply. a. Continue to check vital signs every 4 hours. b. Draw stat blood cultures x 2. c. Assist with a CT scan of the abdomen. d. Start broad-spectrum I.V. antibiotics 4 hours after blood cultures are drawn. e. Draw CBC, CRP, ESR, and UA with culture and sensitivity if indicated. f. Ensure patent I.V. access for fluid bolus.

b, e, f

antagonist for magnesium sulfate a. oxytocin b. terbutaline c. calcium gluconate d. sodium phosphate

c

A client with a gastrointestinal bleed has vomited 600 mL of rank red blood and is now pale and diaphoretic. Place nursing interventions in order of priority for this client. All options must be used. Match the letter with the statement in order from "a" through "e". a. prepare for emergent intervention to treat the site of bleeding b. intiate large-bore intravenous access c. notify the healthcare provider d. position the client on the left side e. assess vital signs and oxygen saturation

d, e, b, c, a