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A nurse has just received change-of-shift report on four clients. Which of the following clients should the nurse assess first? A client who is postoperative with abdominal distention and no bowel sounds A client who has diabetes mellitus and a blood glucose level of 105 mg/dL A client who has heart failure and 2+ pitting edema A client who is receiving maintenance IV fluids and needs a new IV catheter A client who is postoperative with abdominal distention and no bowel sounds Using the acute vs. chronic approach to client care, the nurse should first assess the client who is postoperative with abdominal distention and no bowel sounds because these manifestations are indications of a paralytic ileus. For each assessment finding, click to specify if the finding is consistent with attention deficit hyperactivity disorder (ADHD) or intellectual disability (ID). Each finding may support more than 1 disease process. Assessment Findings Intellectual impairment Interrupting others Impaired language skills Hyperreactivity to sensory input Losing necessary things A nurse is caring for a school-age child. Nurses' Notes First visit: A child is brought to the clinic accompanied by guardians. The guardians have

RN Comprehensive Online Practice 2019 B

with NGN-with 100% verified solutions- 2024

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received feedback from the child's teacher that the child has become disinterested in schoolwork and has difficulty paying attention during class. The child often loses their school supplies. The guardians report that the child demonstrates these behaviors at home as well. The child refuses to participate in household chores, keeps their room untidy, does not clean up when told to, and is generally careless and disinterested. On assessing, the child is found to be talkative, restless, and easily distracted. 2 weeks later: The child's guardians report that the child seems to be doing better at school. The child is improving at paying attention during class and completing assignments on time. Vital Signs First visit: Blood pressure 94/56 mm Hg Heart rate 90/min Respiratory rate 24/min Temperature 37.2° C (99° F) SaO2 99% on room air 2 weeks later: Blood pressure 98/60 mm Hg Heart rate 88/min Respiratory rate 22/min Temperature 37° C (98.6° F) SaO2 99% on room air Provider Prescriptions Atomoxetine 10 mg PO daily with breakfast for 5 days, then increase dose to 18 mg PO daily with breakfast ADHD Hyperreactivity to sensory input Losing necessary things Interrupting others Intellectual impairment ID Intellectual impairment Hyperreactivity to sensory input

When analyzing cues, the nurse should identify that manifestations of ADHD include losing necessary things, interrupting others, intellectual impairment, and hyper reactivity to sensory input. In ADHD, the client often loses necessary things in daily life, such as pencils, erasers, and books. The client often interrupts others and has difficulty waiting for their turn in conversation. The client might have an intellectual impairment, which can lead to poor academic performance and difficulties with socialization. The client might exhibit hyperreactivity or hyporeactivity to stimuli. A charge nurse is providing an educational session about infection control for a group of staff nurses. Which of the following statements by one of the staff nurses indicates an understanding of isolation precautions? "Droplet precautions should be initiated for a client who tests positive for measles." "A client who requires airborne precautions should be placed in a negative-pressure airflow room." "Airborne precautions should be initiated for a client who has Clostridium difficile." "A client who is immunocompromised should be placed in a negative-pressure airflow room." A client who requires airborne precautions should be placed in a negative-pressure airflow room." Airborne precautions require a negative-pressure airflow room that has at least six to 12 air exchanges each hour using a HEPA filtration system. A nurse is admitting a client who has pneumonia. The nurse should initiate which of the following isolation precautions for the client? Droplet Airborne Contact

Protective environment Droplet The nurse should initiate droplet precautions for this client by placing the client in a private room and wearing a surgical mask when caring for the client. Pneumonia is transmitted by droplet particles. A nurse in a community center is providing an educational session to a group of clients about ovarian cancer. Which of the following manifestations of ovarian cancer should the nurse include in the teaching? Diarrhea Urinary retention Purulent discharge Abdominal bloating Abdominal bloating The nurse should include the presence of abdominal bloating as an early manifestation of ovarian cancer. Other manifestations include an increase in abdominal girth, pelvic or abdominal pain, early satiety, and urinary frequency or urgency. A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, PaCO2 of 60 mm Hg, and HCO3- of 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances? Respiratory alkalosis Metabolic alkalosis Respiratory acidosis Metabolic acidosis Respiratory acidosis A client who has respiratory acidosis will have a decreased pH below the expected

reference range of 7.35 to 7.45, an increased PaCO2 above the expected reference range of 35 to 45 mm Hg, and an HCO3- within the expected reference range of 22 to 26 mEq/L. A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling off a stepstool at home. Which of the following prescriptions should the nurse clarify with the provider? Obtain capillary blood glucose level every 2 hr. Check the neurovascular status of the client's lower extremities every hour. Apply a cold pack to the client's ankle for 30 min every hour. Maintain the affected ankle elevated and immobilized. Apply a cold pack to the client's ankle for 30 min every hour. The nurse should clarify a prescription for a cold pack to the client's ankle because type 1 diabetes mellitus is a contraindication for receiving cold therapy. A client who has type 1 diabetes mellitus can have impaired circulation due to arteriosclerosis and a loss of sensory perception due to neuropathy. Ice can further impair circulation. A nurse is caring for a client who has active tuberculosis (TB). Which of the following actions should the nurse plan to take to prevent the transmission of the disease? Initiate contact precautions for the client upon admission. Restrict visitors from entering the client's room during hospitalization. Wear a surgical mask while providing care for the client. Have the client wear a surgical mask while being transported outside the room. Have the client wear a surgical mask while being transported outside the room. A client who has active TB should wear a surgical mask while being transported to prevent transmission of the disease. A nurse manager is reviewing clients' rights with the nurses on the unit. The nurse manager should tell the nurses that informed consent promotes which of the following ethical principles?

Autonomy Nonmaleficence Justice Fidelity Autonomy Autonomy refers to a client's ability to make their own decisions about treatment. Informed consent promotes autonomy by providing clients with complete information about treatment. A nurse is caring for a client who is taking valproic acid for seizure control. For which of the following adverse effects should the nurse monitor and report? Weight loss Jaundice Bradycardia Polyuria Jaundice The nurse should monitor the client for jaundice and report any indication to the provider. Clients who take valproic acid are at risk for liver damage, which can lead to jaundice. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client. Potential Order Keep the client supine. Oxygen therapy to keep oxygen saturation above 95%. Maintain the client's hips in flexion. Keep the lights in the client's room dim. Cluster nursing care. Monitor blood glucose every 4 hr.

Nurses' Notes Day 1, 1000: Client presents to the emergency department (ED) with right-sided hemiparesis, lethargy, and aphasia. The client's symptoms started 1 hr prior to arrival at the ED. Client received fibrinolytic therapy and was transferred to the ICU. Day 2, 0800: Client is awake and alert to person, place, and time. Client has weak right-side hand grasp. However, this is improved from admission. Client to be evaluated by speech therapy due to aphasia. Day 2, 1930: Called to the client's room by a family member. Client is lethargic and restless, oriented to person and place. Client reports headache. The client's family member also reports that the client just vomited in an emesis basin. Client's speech is slurred. Anticipated Oxygen therapy to keep oxygen saturation above 95% Monitor blood glucose every 4 hr Keep the lights in the client's room dim. Contraindicated Cluster nursing care. Maintain the client's hips in flexion. Keep the client supine. Oxygen therapy to keep oxygen saturation above 95% is anticipated. The nurse should titrate oxygen therapy to maintain the oxygen saturation level above 95% to avoid hypoxia. The client is exhibiting manifestations of increased intracranial pressure (ICP). Therefore, oxygenation and perfusion are the priority for this client. Cluster nursing care is contraindicated. This client is exhibiting manifestations of increased ICP. The nurse should spread out nursing care out because clustering can contribute to increased ICP. Keep the client supine is contraindicated. The nurse should elevate the head of the bed to promote blood return to the heart of the client who has increased ICP. Monitor blood glucose every 4 hr in anticipated. The client is exhibiting manifestations of increased ICP. Therefore, the nurse should frequently monitor the client's vital signs and blood glucose to avoid secondary brain injury.

Maintain the client's hips in flexion is contraindicated. The client has manifestations of increased ICP. Extreme hip flexion leads to increased intrathoracic pressure and subsequently a decrease in cerebral outflow. Keep the lights in the client's room dim is anticipated. The nurse should dim the lights in the client's room because many clients with have increased ICP experience photophobia. A nurse is preparing to administer lactated Ringer's 1,500 mL IV to infuse at 50 mL/hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is providing client teaching about the basal body temperature method of birth control. Which of the following information should the nurse include in the teaching? "Your body temperature will drop approximately 1 degree 1 week after ovulation." "You should take your body temperature each evening prior to going to sleep." "Your body temperature might decrease slightly just prior to ovulation." "Your body temperature is at its highest during menstruation." "Your body temperature might decrease slightly just prior to ovulation." The nurse should teach the client that a decrease in body temperature of approximately 0.5° C (1° F) commonly occurs immediately prior to ovulation. A nurse is creating a plan of care for a newly admitted child. Which of the following actions should the nurse include in the plan? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) Initiate droplet isolation precautions. Keep the child on NPO status for 12 hr. Maintain the child on bed rest for 24 hr.

Administer high-dose antibiotic therapy. History and Physical 8-year-old male admitted with cystic fibrosis Reports shortness of breath Wheezing throughout lung fields Productive cough with thick sputum Graphic Record Heart rate 108/min Respiratory rate 26/min Temperature 37.2°C (98.9°F) Blood pressure 100/62 mm Hg Oxygen saturation 92% Diagnostic Results Sputum culture: Burkholderia cepacia The nurse should include administering high-dose antibiotic therapy in the child's plan of care. Children who have cystic fibrosis metabolize antibiotics more rapidly and require higher doses of antibiotics to help fight aggressive infections such as Burkholderia cepacia. A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect? Pink, frothy sputum Bradycardia Flushed, dry skin Wheezing Pink, frothy sputum A client who has manifestations of pulmonary edema can have pink, frothy sputum due to fluid leaking across the pulmonary capillaries and into the lung tissue. A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical aseptic technique?

Hold hands folded below the waist after donning sterile gloves. Pick up and pour solutions with the palm of the hand covering bottle labels. Keep sterile items within a 1.3 cm (0.5 in) border of the sterile drape. Maintain sterile objects within the line of vision. Maintain sterile objects within the line of vision. Objects out of the line of vision are not considered sterile. Therefore, the nurse should keep sterile objects in direct sight to maintain surgical asepsis. A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take? Perform ADLs for the client to promote rest. Allow for frequent rest periods throughout the day. Use heat to reduce joint inflammation. Develop a daily schedule for acetaminophen up to 6 g/day that covers peak periods of pain. Allow for frequent rest periods throughout the day. The nurse should encourage clients who have rheumatoid arthritis to balance rest with exercise to maintain muscle strength, joint function, and range of motion. Which of the following interventions should the nurse implement? Select all that apply. Raise the knee position on the client's bed. Use an automated blood pressure cuff on the client's arm. Administer IV fluids. Prepare for platelet transfusion. Assess the client's mouth every 8 hr. Assess peripheral circulation hourly.

Use humidification with oxygen therapy. A nurse is caring for a client during a follow up visit at a gastrointestinal clinic Nurses' Notes 0600: Client admitted to the ED with fatigue, shortness of breath, and weakness for the last 2 days. Client states that they have a history of sickle cell disease (SCD). Client is alert and orientated to person, place, and time. Restless. Client rates generalized pain as a 9 on a scale of 0 to 10. Vital signs taken and blood drawn for laboratory tests. Oxygen 2 L via nasal cannula applied. Awaiting prescription for pain management. 0615: Client still rates pain as a 9 on a scale of 0 to 10. Hydromorphone 4 mg IV administered. Vital Signs 0600: Temperature 37.8° C (100° F) Heart rate 104/minR espiratory rate 26/min Blood pressure 88/56 mm Hg Oxygen saturation 90% on 2 L via nasal cannula Diagnostic Results 0645: Hematocrit 25% (37% to 52%) Hemoglobin 8.3 g/dL (12 to 16 g/dL) WBC count 18,000/mm3 (5,000 to 10,000/mm3) Reticulocytes 8% (0.5% to 2%) Total bilirubin 1.9 mg/dL (0.3 to 1.0 mg/dL) Administer IV fluids is correct. Hydration is a priority when caring for a client in sickle cell crisis because it decreases the rate of cell sickling and can reduce pain. Hypotonic fluids are typically infused at 250 mL/hr for 4 hr. Use humidification with oxygen therapy in correct. Oxygen administered without humidification can cause drying of the mucous membranes, especially in clients who are already fluid-depleted. Placing humidification on the oxygen therapy promotes comfort and reduces the risk of sores and lesions of the mucous membranes.

Assess peripheral circulation hourly is correct. The nurse should assess the client's peripheral circulation because of the risk of venous occlusion caused by the sickling and clumping of the red blood cells. Assess the client's mouth every 8 hr is correct. The nurse should assess the client's mouth at least every 8 hr for the presence of sores or lesions and any other signs of infection. A nurse is caring for a group of clients. Which of the following clients should the nurse attend to first? An older adult client who is anxious and attempting to pull out an IV line A middle adult client who is reporting nausea after receiving pain medication An older adult client who has kidney failure and returned from dialysis 4 hr ago A middle adult client who has a terminal illness and is requesting a visit from the chaplain An older adult client who is anxious and attempting to pull out an IV line A client who is anxious and attempting to pull out an IV line is at greatest risk for injury. Therefore, the nurse should attend to this client first. A home health nurse is caring for a group of older adult clients. The nurse should initiate a referral to the Program of All-Inclusive Care for the Elderly (PACE) for which of the following clients? A client whose family requests hospital-based hospice care A client who requires transfer to a skilled care facility A client who qualifies for telehealth for pacemaker diagnostics A client whose caregiver requests adult day care services A client whose caregiver requests adult day care services The nurse should initiate a referral for PACE for this client because PACE provides adult day care services along with in-home assessments and supportive services.

A nurse is teaching about adverse effects with a client who is starting to take captopril. Which of the following findings should the nurse identify as an adverse effect of the medication to report to the provider? Tinnitus Cough Polyuria Blurred vision Cough The client can develop a cough due to a buildup of bradykinin in the lungs. The client should report this finding to the provider. A nurse is providing teaching for a client who has a fracture of the right fibula with a short-leg cast in place and a new prescription for crutches. The client is non- weight- bearing for 6 weeks. Which of the following instructions should the nurse include in the teaching? Adjust the crutches for comfort as needed. Use a three-point gait. Wear leather-soled shoes. Advance the affected leg first when walking upstairs. Use a three-point gait. A three-point crutch gait allows the client to be mobile without bearing weight on the affected extremity. A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurse's priority? Assess fluid intake every 24 hr. Ambulate three times a day.

Assist with deep breathing and coughing. Monitor the incision site for findings of infection. Assist with deep breathing and coughing. The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to assist the client with deep breathing and coughing, which reduces the risk for postoperative pneumonia. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client. Prescription for discharge Apply heat for abdominal pain as needed Ondansetron 4 mg PO for nausea Encourage deep breathing exercises every hour Change dressing when soiled A nurse is caring for a client following a laparoscopic cholecystectomy. Nurses' Notes 1030: 33-year-old client is 1 hr postoperative following a laparoscopic cholecystectomy. Alert and oriented to x 3. Skin warm and dry. Lungs clear auscultated throughout all lung fields. Normal sinus rhythm. Denies nausea and vomiting, bowel sounds hypoactive in all four quadrants. Peripheral pulses +2 bilaterally. Incision dressing clean and dry, incision upon inspection intact, no redness, swelling, or drainage noted. Client Education 1230: Discharge instructions given to client. Instructions on incision/wound care and proper hand washing. Client to report swelling, redness, drainage, bleeding, or warmth at operative site to surgeon. Client expected to experience carbon dioxide retention in the abdomen. Instructed the client to rest for 24 hr following surgery. Client can bathe or shower the day after surgery. Instructed the client to avoid lifting 2.3 kg (5 lb) or more for 1 week. Diet as tolerated. Provider Prescriptions 1030:

Acetaminophen 500 mg PO every 4 hr as needed for pain Cefaclor 250 mg PO every 8 hr Vital Signs 1030: Temperature 36.0° C (96.8° F) Heart rate 82/min Respiratory rate 16/min Blood pressure 122/64 mm Hg Oxygen saturation 96% on room air Anticipated Change dressing when soiled Apply heat for abdominal pain as needed Encourage deep breathing exercises every hour Contraindicated Ondansetron 4 mg PO for nausea When taking actions for a client who is postoperative following a laparoscopic cholecystectomy, the nurse should anticipate prescriptions for the client to apply heat for abdominal pain as needed, to encourage deep breathing, and to change the dressing when soiled. The client can use heat for abdominal pain related to carbon dioxide retention. During the procedure, carbon dioxide is inflated into the abdominal cavity for visualization for the provider. The client's dressing should be changed when soiled as needed. The dressing should be clean, dry, and intact to prevent infection. The nurse should identify that medication for nausea should be provided as needed and is contraindicated for scheduled administration. A nurse is providing teaching about advance directives to a middle adult client. Which of the following client responses indicates an understanding of the teaching? "I can designate my partner as my health care surrogate." "I am only 40 years old, so I don't need to worry about this yet." "I will need a lawyer's help to draw up the documents."

"I understand that my family can alter my advance directives if I become incapacitated." "I can designate my partner as my health care surrogate." This statement indicates that the client recognizes that designating a health care surrogate is part of advance directives. A nurse is updating the plan of care for a client who is 48 hr postoperative following a laryngectomy and is unable to speak. Which of the following actions should the nurse plan to take first? Determine the client's reading skills. Instruct the client on the technique for esophageal speech. Provide the client with an alphabet board. Show the client how to use an artificial larynx. Determine the client's reading skills. The first action the nurse should take when using the nursing process is to assess the client. By determining the client's level of reading skills and cognition, the nurse can best provide the client with a variety of customized techniques to practice and use after verbal skills are lost. Complete the following sentence by using the lists of options. The client is at highest risk for developing Select... as evidenced by the Select.... A nurse is caring for a client who is 1 day postoperative following a total thyroidectomy. Laboratory Results 0700: Sodium 143 mEq/L (136 to 145 mEq/L) Potassium 3.5 mEq/L (3.5 to 5.0 mEq/L) Chloride 104 mEq/L (98 to 106 mEq/L ) BUN 15 mg/dl (10 to 20 mg/dl) Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L ) Total calcium 8.0 mg/dL (9.0 to 10.5 mg/dL) Phosphate 4.6 mg/dL (3.0 to 4.5 mg/dL) Glucose 95 mg/dL (74 to 106 mg/dL) WBC 9,500/mm (5,000 to 10,000/mm3)

Nurses' Notes 0700: Client alert and oriented x 3. Respirations even and unlabored with no adventitious sounds. Bowel sounds active in all 4 quadrants. Surgical dressing dry, slight edema at incision site noted. Client rates dull pain in neck of 2 on a 0 to 10 scale. Declines pain medication.1100: Client alert and oriented to person, place, and time. Respirations even and unlabored with no adventitious sounds. Bowel sounds active in all 4 quadrants. Surgical dressing dry, slight edema at incision site noted. Client reports muscle cramps in legs as a pain level of 5 on a 0 to 10 scale. Morphine 5 mg IV administered. Encouraged client to ambulate with assistance.1200: Client alert and oriented to person, place, and time. Respirations even and unlabored with no adventitious sounds. Bowel sounds active in all 4 quadrants. Surgical dressing dry, slight edema at incision site noted. Client ambulated down the hall with assistance. Client reports numbness around lips. Vital Signs 0700: Temperature 37.6° C (99.6° F)Heart rate 65/minRespiratory rate 16/minBlood pressure 115/70 mm HgOxygen saturation 98% on room air0900: Temperature 37.2° C (99.0° F)Heart rate 72/minRespiratory rate 18/minBlood pressure 110/72 mm HgOxygen saturation 100% on room air1100: Temperature 37.7° C (99.86° F)Heart rate 76/minRespiratory rate 16/minBlood pressure 108/70 mm HgOxygen saturation 100% on room air Medication Administration Record 1100: 0.9% Sodium chloride at 150 mL/hr Morphine sulfate 5 mg IV The client is at highest risk for developing hypocalcemia as evidenced by the report of numbness around lips. The nurse should recognize cues and determine that the client is at highest risk for developing hypocalcemia as evidenced by the client's report of muscle spasms, numbness around lips, and decreased calcium level. Hypocalcemia is more likely to occur in clients who have experienced a thyroidectomy, due to accidental damage to the parathyroid. Numbness around the lips is a clinical manifestation specific to hypocalcemia. Hypocalcemia presents as muscle spasms and can lead to cardiac dysrhythmias.

Hypocalcemia is the highest priority, as it requires immediate treatment with calcium gluconate to avoid dysrhythmias and other complications. A nurse is conducting group therapy with clients who have breast cancer. The nurse should recognize which of the following statements by a client as an example of altruism? "I have experienced physical discomfort when intimate with my partner since my diagnosis." "I wish other women would stop socializing with my partner." "I told my doctor that I would like to start a support group for other women who are sick in my community." "I used to mistrust my doctor, but now I know that she is the best one to care for me during my illness." "I told my doctor that I would like to start a support group for other women who are sick in my community." This statement indicates that the client is demonstrating altruism by reaching out and helping others. A nurse on a pediatric unit has received change-of-shift report for four children. Which of the following children should the nurse assess first? A 6-month-old infant who has croup and an O2 saturation of 92% on room air A 15-year-old adolescent who is 2 hr postoperative following an open reduction and internal fixation of the left ankle and is requesting pain medication A 3-year-old toddler who has gastroenteritis, moderate dehydration, and had two loose bowel movements over the past 24 hr A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain Using the urgent vs. nonurgent approach to client care, the nurse should determine

that the client to assess first is the child awaiting an appendectomy who suddenly experiences pain relief as this can be an indication of peritonitis from a ruptured appendix. The nurse should notify the provider immediately. A nurse in an emergency department is assessing a school-age child who was brought in by their parents and has scald burns to both hands and wrists. The nurse suspects physical abuse. Which of the following actions should the nurse take? Discuss the suspicion of physical abuse with the provider. Confront the parents with the suspicion of physical abuse. Ask the hospital security to detain and question the parents. Contact Child Protective Services. Contact Child Protective Services. The nurse has a legal responsibility to report suspected physical abuse to Child Protective Services. A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse plan to take? Select a 1-inch needle. Use a 45º angle when inserting the needle. Use the ventrogluteal site. Pinch the skin up during injection. Use the ventrogluteal site. The nurse should use the ventrogluteal site because it has a thick area of muscle and contains no large nerves or blood vessels. Select the 4 client findings that lead the nurse to suspect that the client is experiencing thyroid storm. Wound drainage Mental status Temperature

Pain Blood pressure Heart rate A nurse is caring for a client who is immediately postoperative following a subtotal thyroidectomy. Vital Signs 1100: Temperature 37.4° C (99.4° F)Heart rate 98/minRespiratory rate 18/minBlood pressure 128/68 mm HgPulse oximetry 97% on room air 1115: Temperature 37.8° C (100.1° F)Heart rate 110/minRespiratory rate 16/minBlood pressure 138/74 mm HgPulse oximetry 95% on room air1130: Temperature 38.6° C (101.5° F)Heart rate 136/minRespiratory rate 16/minBlood pressure 154/86 mm HgPulse oximetry 95% on 2 L/min via nasal cannula Medication Administration Record 1110: Morphine 4 mg IV bolus Nurses' Notes 1100: The client is asleep, easily aroused. Rates pain at incision site as 8 on a scale of 0 to

10. Portable wound bulb suction device in place with scant serosanguinous drainage present. Dressing to neck dry and intact.1115: Client asleep. Arousable with name called loudly multiple times. Client rates pain as 7 on a scale of 0 to 10. Reports having a hard time staying awake.1130: Client asleep. Arousable with name called loudly several times. Client rates pain as 5 on a scale of 0 to 10. Restless upon awakening, oriented to person. Mental status Temperature Blood pressure Heart rate When analyzing cues, the nurse should identify that thyroid storm can be caused by trauma to the thyroid gland, such as surgery, and excessive release of thyroid hormone greatly increases the metabolic rate. Fever greater than 38.5° C (101.3° F), heart rate greater than 130/min, systolic hypertension, and mental status changes, such as confusion, restlessness, and sleepiness, are characteristic of thyroid storm.

A nurse preceptor is evaluating the performance of a newly licensed nurse. Which of the following actions by the newly licensed nurse requires intervention by the preceptor? Documents client tasks upon completion Starts a task then determines what supplies are needed Completes a client assessment while infusing an IV antibiotic over 30 min Returns to the nurses' station after completing several tasks in the same location Starts a task then determines what supplies are needed The preceptor should intervene and instruct the newly licensed nurse to gather supplies before performing client tasks to practice effective time management. A nurse is assessing a client who has major depressive disorder and is taking amitriptyline. Which of the following findings should the nurse identify as an adverse effect of the medication? Diarrhea Frequent urination Excessive salivation Blurred vision Blurred vision The nurse should identify blurred vision as an adverse effect of amitriptyline and notify the provider. A nurse is providing education to the parent of a school-age child who has asthma. Which of the following statements by the parent indicates an understanding of the teaching? "I will administer aspirin to my child to treat pain or fever." "I will record an average of three readings from my child's peak expiratory flow meter."

"I will place carpet in my child's bedroom to control allergens." "I will make sure my child receives a yearly influenza immunization." "I will make sure my child receives a yearly influenza immunization." Children who have asthma should be immunized and protected from infections. Therefore, the nurse should educate the parent to ensure the child receives a yearly influenza immunization. A nurse in an outpatient mental health facility is assessing a child who has autism spectrum disorder. Which of the following manifestations should the nurse expect? Strict adherence to routines Difficulty paying attention to tasks Disobedience to authority figures Excessive anxiety when separated from parents Strict adherence to routines The nurse should identify that a child who has autism spectrum disorder can exhibit strict adherence to routines or rituals, a fixation to specific objects, and resistance to change. A nurse is caring for a client who has active pulmonary tuberculosis. Which of the following actions should the nurse take? Wear a surgical mask when providing client care. Have visitors maintain a distance of 1.8 m (6 feet) from the client. Restrict fresh flowers from the client's room. Assign the client to a private room with negative air pressure. Assign the client to a private room with negative air pressure. To control the spread of active tuberculosis, the nurse should assign the client to a private room with negative air pressure.

Complete the following sentence by using the lists of options. The client is at risk for experiencing Select... due to the client's Select.... A nurse is providing phone advice for a client who is pregnant Nurses' Notes Week 6 of gestation: Spoke with client over the phone. Client reports nausea and vomiting with a weight loss of 0.9 kg (2 lb) from their pre-pregnancy weight. Client reports no noted change in voiding pattern and denies dry mucus membranes. Advised client to eat small frequent meals of nongreasy, dry, sweet or salty foods, such as dry toast, crackers, and pretzels. Encouraged client to call back if nausea and vomiting worsens.Week 10 of gestation: Spoke with client over the phone. Client reports a 6.8 kg (15 lb) weight loss over the past month. Client states nausea continues, making it difficult to eat. They describe a diet of water, toast, and pretzels because other foods are unappealing. They report tolerating a cup of black coffee each morning. Advised client to be seen by the provider today. The client is at risk for experiencing metabolic acidosis due to the client's weight loss. When prioritizing hypotheses, the nurse should identify that the client is at risk for developing metabolic acidosis due to excessive weight loss. The intake and retention of food is not meeting the client's nutritional requirements. Undernutrition can lead to the breakdown of fatty tissue which increases the release of nonvolatile acids into the blood stream. A nurse is teaching a client who is at 20 weeks of gestation about common discomforts associated with pregnancy. Which of the following statements by the client indicates an understanding of the teaching? "I will decrease my intake of high-fiber foods." "I will apply hydrocortisone cream if I develop a rash on my face." "I will sleep flat on my back if I develop back pain." "I will wear a supportive bra overnight." "I will wear a supportive bra overnight."

The nurse should teach the client that wearing a supportive bra even while sleeping can promote comfort by providing support to enlarged breasts during pregnancy. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor for that condition. Actions to Take Assist client with menu selection of fresh fruits and vegetables. Encourage oral fluid intake. Prepare to administer IV fluids. Assist client to semi-Fowler's position. Prepare to insert a feeding tube. Potential Condition Intestinal obstruction Renal calculi Inguinal hernia Joint contracture Parameters to Monitor Hematuria Palpable bulge in abdomen Urine output Range of motion Bowel sounds Nurses' Notes 1300: Client reports intermittent abdominal pain as 5 on a scale of 0 to 10 on left side of abdomen. Last bowel movement 5 days ago. Client reports usual pattern is one bowel movement daily. Oral fluid intake 1,950 mL/24 hr. Urine output 1,820 mL/24 hr. 1900: Client reports nausea and constant abdominal pain as 5 on a scale of 0 to 10 throughout abdomen. Pain began after eating dinner. Physical Examination 1300: Abdomen distended, dull to percussion, firm and nontender on palpation.

Hypoactive bowel sounds in lower quadrants. Skin warm and dry to touch in trunk and all extremities. Pedal pulses strong and equal bilaterally. Capillary refill less than 3 seconds in toes bilaterally.1900: Abdomen distended, dull to percussion, firm and nontender on palpation. Hypoactive bowel sounds in all quadrants. Vital Signs 1400: Temperature 37° C (98.6° F) Heart rate 88/min and regular Respiratory rate 18/min Blood pressure 130/84 mm Hg Oxygen saturation 97% on room air Medical History History of osteoarthritis, hypertension, GERD, and iron-deficiency anemia. Medication Administration Record 0800: Ferrous sulfate 325 mg PO once daily 0900: Lisinopril 10 mg PO once daily Atorvastatin 40 mg PO once daily Docusate sodium 200 mg PO twice daily 1100: Hydrocodone 5 mg/acetaminophen 325 mg PO every 4 hr as needed for postoperative pain Diagnostic Results 0700: Hct 42% (42% to 52%) Hgb 14 g/dL (14 to 18 g/dL) Potassium 3.7 mEq/L (3.5 to 5 mEq/L) Sodium 140 mEq/L (136 to 145 mEq/L) Actions to Take Assist client to semi-Fowler's position Prepare to administer IV fluids.