PN ADULT MEDICAL SURGICAL 2023 WITH NGN AND PRACTICE EXAMS, Exams of Nursing

Download PN ADULT MEDICAL SURGICAL 2023 WITH NGN AND PRACTICE EXAMS and more Exams Nursing in PDF only on Docsity! 1 | P a g e PN ADULT MEDICAL SURGICAL 2023 WITH NGN AND PRACTICE EXAMS WITH ACTUAL CORRECT QUESTIONS AND VERIFIED DETAILED RATIONALES ANSWERS BY EXPERTS| FREQUENTLY TESTED QUESTIONS AND SOLUTIONS |ALREADY GRADED A+ |LATEST UPDATE| GUARANTEED PASS A nurse is assisting in the care of a client who is experiencing withdrawal from heroin. Which of the following medications should the nurse expect the provider to prescribe? Methadone A nurse is collecting data from a client who has hypothyroidism. Which of the following manifestations should the nurse anticipate? Bradycardia A nurse is contributing to the plan of care for a client who has just transferred to the medical-surgical unit from the PACU following a right total knee arthroplasty. Which of the following interventions should the nurse include in the plan? Assist the client to change positions at least every 2 hr. A nurse is collecting data from a client and notices several skin lesions. Which of the following findings should the nurse report as possible melanoma? Irregular borders A nurse is reinforcing teaching about gastroesophageal reflux disease (GERD) with a client. Which of the following statements by the client indicates an understanding of the teaching? "I should wait at least 2 hours after eating before going to bed." A nurse is assisting in the care of a client who has AIDS-related pneumonia. The client is receiving antibiotic therapy and albuterol nebulizer treatments daily. Which of the following findings should indicate to the nurse that the client's therapeutic regimen is effective? Decrease in exertional dyspnea 2 | P a g e A nurse is reinforcing teaching with a client who has asthma. Which of the following client statements indicates an understanding of the use of budesonide and albuterol inhalers? (Select all that apply.) "I never forget to rinse my mouth after using my budesonide inhaler." "Between office visits, I keep a record of how many times I use my albuterol inhaler." "I use my albuterol inhaler before I go swimming." "I should use my budesonide inhaler before using my albuterol inhaler." A nurse is reinforcing teaching with a client who has a new diagnosis of genital herpes. Which of the following information should the nurse include? "The virus can be transmitted without lesions being present." A nurse is assisting with the care for a client who has neutropenia. Which of the following nursing interventions should the nurse implement? Limit visitors to healthy adults. A nurse is assisting with the care for a client following a gastrectomy. Which of the following actions should the nurse take to decrease episodes of dumping syndrome? Place the client in the supine position after meals. A nurse in an orthopedic clinic is reinforcing teaching with a client who has osteoarthritis. Which of the following instructions should the nurse include to promote comfort? Sleep on a firm mattress. A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis. Which of the following interventions should the nurse include when contributing to the plan of care? Apply a mask to the client if transport is needed. A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus about glycosylated hemoglobin (HbA1c) testing. Which of the following information should the nurse include in the teaching? HbA1c results measure glucose control for the prior 3 months. A nurse is contributing to the plan of care for a client who has a head injury and is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse include in the plan? Use a turn sheet to reposition the client. A nurse is reinforcing discharge teaching with a client who has cirrhosis. Which of the following instructions should the nurse include? "Consume foods that are low in sodium." A nurse is reinforcing teaching with a client who has a new diagnosis of tuberculosis (TB) and a prescription for isoniazid and rifampin. Which of the following information should the nurse include in the teaching? 5 | P a g e Withdraw the iv catheter Elevate the affected arm Notify the charge nurse A nurse is assisting with the care of a client. Exhibit 1 Nurses' Notes 1200:Client was admitted to the unit with shortness of breath, a nonproductive cough, chest discomfort, and myalgia. Prefers orthopneic position. Client reports that manifestations began about 2 days ago.1215:Oxygen applied at 2 L/min via nasal cannula. Wheezes noted bilaterally. Use of accessory muscles noted. Client speaks in short phrases, with increased shortness of breath. Oral mucosa is pink; capillary refill is 4 seconds. Exhibit 2 Vital Signs 1200:Temperature 38.7° C (101.6° F)Blood pressure 104/64 mm HgHeart rate 100/minRespiratory rate 26/minOxygen saturation 88% on room air1215:Temperature 38.7° C (101.6° F)Blood pressure 106/64 mm HgHeart rate 104/minRespiratory rate 24/minOxygen saturation 93% on oxygen 2 L/min via nasal cannula For each finding, click to specify if the finding is consistent with emphysema, asthma, or pneumonia. Each finding may support more than 1 disease process. Findings: Temperature - pneumonia Breath sounds - emphysema, asthma, pneumonia Respiratory rate - emphysema, asthma, pneumonia Cough - emphysema, asthma and pneumonia A nurse is preparing to administer furosemide to a client who has heart failure. Which of the following findings should the nurse report before administering the medication? Decreased potassium A nurse is reviewing the chart of a client who is experiencing an adrenal crisis, which was precipitated by the client not taking their medication for several days. The nurse should identify that withdrawal from which of the following medications potentiated the adrenal crisis? Prednisone A nurse is assisting with the care for a client who has a prescription for digoxin 0.25 mg PO daily. While taking the client's apical pulse, the nurse notes a rate of 58/min. Which of the following actions should the nurse take? Withhold the dose. A nurse is reinforcing teaching about glycosylated hemoglobin (HbA1c) testing with a client who has diabetes mellitus. Which of the following statements indicates that the client understands the teaching? 6 | P a g e "I will have my HbA1c checked twice per year." A nurse is providing information regarding transmission-based precautions for a client who has Clostridium difficile to an assistive personnel (AP). Which of the following instructions should the nurse include? (Select all that apply.) "Provide the client with disposable utensils and dishes for meals." "Leave blood pressure equipment in the client's room." "Clean contaminated surfaces with a bleach solution." A nurse is reinforcing teaching with a client who has coronary artery disease. Which of the following instructions should the nurse include in the teaching? "Add oily fish to your diet twice weekly." A nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a client who has skin cancer. Which of the following information should the nurse include in the teaching? Mohs surgery is a horizontal shaving of thin layers of the tumor. A nurse is collecting data from an older adult client who has several concerns. Which of the following concerns should the nurse recognize as an expected change associated with aging? "My food tastes bland even after I add seasoning." A nurse is reinforcing dietary teaching with a client about increasing the intake of foods containing vitamin C to enhance absorption of oral iron supplements. Which of the following food choices should the nurse include in the teaching? 1 cup of boiled broccoli A nurse is assisting with the care for a client who is 2 hr postoperative following the amputation of a foot. Which of the following actions should the nurse take first? Check the incisional dressing. A nurse is assisting with the care of a client who is postoperative following abdominal surgery. Exhibit 1 Nurses' Notes 1100: Client received from PACU; initial vital signs recorded. Client is drowsy but arouses to verbal stimuli. Oriented to person, place, and time. Client is able to move all extremities. Normal sinus rhythm noted. Breath sounds are clear upon auscultation. Dressing to abdomen is intact with a small amount of serosanguinous drainage noted and marked. No bowel sounds in all four quadrants. Indwelling urinary catheter is in place and draining clear, yellow urine. Lactated Ringer's is infusing at 100 mL/hr via IV catheter in the right forearm.1200: Client reports nausea and pain as an 8 on a scale of 0 to 10. Abdominal dressing is intact with no further drainage noted. Urine output of 15 mL noted since arrival from PACU. Analgesic and antiemetic were administered as prescribed.1230: Client reports rel 7 | P a g e Which of the following actions should the nurse take? Select all that apply. Instruct the client to splint their abdomen with a pillow when coughing. Report the client's urinary output to the charge nurse. Monitor the client's pain level. A nurse is assisting with monitoring a client who is receiving dialysis treatment. Exhibit 1 Nurses' Notes 0530:Client is awake and alert. Arteriovenous fistula (AVF) to right forearm with thrill palpated and auscultated for bruit. Breath sounds are 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. Exhibit 2 Vital Signs 0530:Current weight 88 kg (194 lb)Temperature 37° C (98.6° F)Blood pressure• Lying - 152/92 mm Hg• Sitting - 148/90 mm Hg• Standing - 144/88 mm HgHeart rate 90/m For each potential nursing intervention, click to specify if the intervention is indicated or not indicated. Nursing Intervention Request a chest x-ray - not indicated Place the client in reverse Trendelenburg position - indicated Assist with administering a 0.9% sodium chloride 200 mL IV bolus - indicated Apply oxygen at 2 L/min via nasal cannula - indicated Notify the charge nurse immediately - indicated Obtain the client's blood glucose level - not indicated A nurse is contributing to the plan of care for a client who has a new prescription for nystatin suspension for oral candidiasis. Which of the following interventions should the nurse include in the plan? Remind the client to swish the medication in their mouth. A nurse is reinforcing teaching with the caregiver of a client who has a cervical injury and has a halo vest in place. Which of the following safety precautions should the nurse include in the teaching? Change the sheepskin liner weekly. A nurse is assisting in the care of a client who is receiving a continuous tube feeding of 60 mL/hr at 1.2 cal/mL. How many calories will the client receive in 12 hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) 864 cal 10 | P a g e rate 28/minTemperature 36° C (96.8° F)Blood pressure 145/90 mm HgOxygen saturation 90% on oxygen 2 L/min via nasal cannula Select the 3 findings that require follow-up by the nurse. Oxygen saturation Pain level Wound dressing The nurse is assisting with the care of the client. Exhibit 1 Progress ReportDay 1 2330:Report received from emergency department: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. Wound dressing has moderate serosanguineous drainage. Client reports pain as a 6 on a scale of 0 to 10. Shortness of breath noted. Exhibit 2 Graphic RecordDay 1 2330:Vital signs from the emergency department:Heart rate 125/minRespiratory rate 28/minTemperature 36° C (96.8° F)Blood pressure 145/90 mm HgOxygen saturation 90% on oxygen 2 L/min via nasal cannulaDay 1 2345:Heart rate 135/minRespiratory rate 34/minTemperature 35.9° C (96.6° F)Blood pressure 96/45 mm HgOxygen saturation 92% on oxygen 40% via face mask Exhibit 3 Nurses' NotesDay 1 2345:Client is alert and oriented with a CGS score of 15. Reinforced dressing over the chest wound with sangui The client is most likely experiencing a hemothorax as evidenced by the client's respiratory findings The nurse should first address the client's oxygenation , followed by the client's blood pressure oxygenation blood pressure For each potential provider prescription, click to specify if the potential prescription is anticipated or contraindicated for the client. Transfuse packed RBCs - anticipated Place the client in Trendelenburg position - contraindicated Prepare the client for chest tube insertion - anticipated Cover the client with a cooling blanket - contraindicated Initiate NPO status - anticipated 11 | P a g e The nurse is assisting with the care of the client following the placement of a chest tube for a hemothorax. Which of the following actions should the nurse take? Select all that apply. Ensure that all chest tube connections are securely attached. Palpate the chest tube insertion site for subcutaneous emphysema. Place two rubber-tipped hemostats in the client's room. Place the client in high-Fowler's position. The nurse is assisting with the care of the client 1 hr following chest tube insertion. Click to highlight the findings that indicate the client's condition is improving. To deselect a finding, click on the finding again. Client reports pain as a 3 on a scale of 0 to 10. Client reports shortness of breath has decreased. Wound dressing is dry and intact. Respiratory rate 24/min Blood pressure 108/74 mm Hg Oxygen saturation 95% on oxygen 2 L/min via nasal cannula A nurse is preparing to suction a client who has a tracheostomy. Which of the following actions should the nurse take first? Ventilate the client with 100% oxygen. A nurse in a health clinic is reinforcing teaching with a client about tuberculosis (TB). Which of the following client statements indicates an understanding of the teaching? "I can develop TB by breathing in the infection." A nurse is assisting with the care for a client who begins to have a seizure while ambulating in the hall. Identify the sequence of actions the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) Lower client to the floor. Place a pad beneath the client's head. Loosen the clothing around the client's neck. Time the length of the client's seizure. Reorient and reassure the client. A nurse is examining a client's IV site and notes a hardened vein above their IV site. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client's manifestations indicate which of the following complications of IV therapy? Thrombophlebitis A nurse is planning care for a group of clients after receiving change-of-shift report. Which of the following clients should the nurse plan to see first? 12 | P a g e A client who is dehydrated, has mental confusion, and has tried to get out of bed several times during the night A nurse is reinforcing teaching regarding the use of a continuous passive motion (CPM) machine with a client who is scheduled for a total knee arthroplasty. Which of the following information should the nurse include in the teaching? (Select all that apply.) "Your knee is flexed and extended as prescribed by your provider." "The machine is padded with sheep skin." A nurse is assisting with the care for a client who has difficulty swallowing. Which of the following actions should the nurse implement to prevent aspiration? Give the client liquids with increased viscosity. A nurse is contributing to the plan of care for a client who has Ménière's disease. Which of the following interventions should the nurse include in the plan of care? Administer an antiemetic to the client. A nurse is reinforcing teaching with a client who has chronic kidney disease about disease management. Which of the following statements by the client indicates an understanding of the teaching? "I will limit my daily intake of protein." A nurse is assisting with the discharge planning for a client who is postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the discharge plan? Obtain a raised toilet seat. A nurse is assisting with the care for a client who is suspected of having a myocardial infarction. Which of the following actions should the nurse take to prepare the client for an ECG? Cleanse the client's skin prior to electrode placement. Exhibit 1 Nurses' Notes 0730 Vital signs Temperature 38° C (100.4° F)Heart rate 72/min and regularRespiratory rate 16/minBlood pressure 128/78 mm HgPain rating 6/10 Exhibit 2 History and Physical History of type 2 diabetes mellitus and hypertension Allergies: 1) Penicillin reaction severe2) Aspirin3) Heparin Exhibit 3 Diagnostic Results Capillary blood glucose 102 mg/dL A nurse is preparing to administer scheduled medications to a client. Which of the following prescriptions should the nurse verify with the provider? 15 | P a g e A nurse is assisting with the care for a client who is undergoing testing for multiple sclerosis. Which of the following findings should the nurse expect? Muscle spasticity A nurse is reinforcing teaching with a client prior to the removal of a leg cast. Which of the following statements should indicate to the nurse that the client understands the teaching? "I will feel vibrations on my leg from the cast cutter." A nurse is reinforcing teaching with a client about preventing osteoporosis. Which of the following client statements indicates an understanding of the teaching? "I will limit my coffee intake 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 to assess the client's progress. The nurse should reduce the temperature in the client's room and limit visitors because the client has manifestations of hyperthyroidism. Clients who have hyperthyroidism have heat intolerance and require an environment with decreased stimuli. The nurse should monitor the client for an increased temperature which can indicate a thyroid storm, as well as the client's weight daily, to monitor for weight loss. A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking dantrolene to manage muscle spasms. Which of the following interventions should the nurse include? Encourage the client to complete ADLs. A nurse is assisting with the care for a client who has a new cast on their left forearm and reports severe pain in the affected arm with numbness in the fingers. The nurse finds the skin is pale and cold with sluggish capillary refill. Which of the following fracture complications should the nurse suspect? Compartment syndrome A nurse is assisting with the care for a client who has Cushing's syndrome and expresses concern regarding physical changes associated with the syndrome. Which of the following should the nurse recognize as a physical change caused by this disorder? Truncal obesity A nurse is reinforcing teaching with a client who is taking levothyroxine. Which of the following statements by the client indicates an understanding of the teaching? "The medication should be taken before I eat breakfast every morning." A nurse is collecting data from a client who is being treated for hypovolemia due to nausea and vomiting. Which of the following findings should the nurse report to the provider? Heart rate 120/min 16 | P a g e FLAG A nurse is assisting with the care for a client who reports stomatitis. Which of the following dietary recommendations should the nurse make? "Select foods that are low in protein." A nurse is reviewing the medical record for a client who is experiencing nausea and vomiting. Based on the client data, which of the following actions should the nurse take? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.) Notify the charge nurse of the client's blood pressure. A nurse is reinforcing discharge teaching for the caregivers of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching? Remind the client to avoid watching their feet when walking. A nurse is assisting with the care of a client who had a stroke and is unable to speak. The nurse should identify that the client's injury occurred in which of the following lobes of the brain? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) A is correct. A nurse observes a client who is lying in bed and experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? Loosen clothing around the client's neck. A nurse is assisting with the care for a client who has acute pancreatitis. While providing care, the nurse observes ecchymosis around the umbilicus. The nurse should identify that this is a manifestation of which of the following? Intra-abdominal bleeding A home health nurse is assisting with the care for a client who has COPD. The client reports shortness of breath while eating, despite the use of home oxygen. Which of the following recommendations should the nurse make? "Use a bronchodilator 30 minutes before your meal." A nurse is changing the dressing for a client who has an abdominal incision and a closed-suction drain. Which of the following actions should the nurse take? Cleanse the drainage plug with alcohol swabs. A nurse is contributing to planning care for a client who overdosed on oxycodone. Which of the following medications should the nurse recommend for the client? Naloxone A nurse is assisting with the care of a client who is at risk for developing pressure injuries. Which of the following actions should the nurse take? 17 | P a g e Position pillows between the bony prominences. A nurse is reinforcing teaching with an adolescent client regarding testicular self-examination. Which of the following statements by the client demonstrates an understanding of the teaching? "I understand that testicular cancer is typically painless." A nurse is reinforcing discharge teaching with a client who has leukemia and is receiving chemotherapy. Which of the following statements should the nurse include in the teaching? "You should place your toothbrush in hydrogen peroxide." A nurse is assisting with the care of a client who has restricted movement of the chest due to a burn injury. The nurse should anticipate preparing the client for which of the following procedures? Escharotomy A nurse is assisting in the plan of care regarding bowel retraining for a client who has a cervical spinal cord injury. Which of the following interventions should the nurse plan to implement first? Determine the client's daily elimination habits. A nurse is contributing to the plan of care for a client who was admitted to the neurological unit following a stroke 3 hr ago. Which of the following interventions should the nurse identify as the priority? Keep the client in a side-lying position. A nurse is performing an ECG on a client who is scheduled for surgery the following morning. In which of the following locations should the nurse place the V1 electrode? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) C is correct A nurse is reinforcing teaching with a client who is scheduled for a guaiac fecal occult blood test. Which of the following instructions should the nurse include in the teaching? Avoid eating red meat for 3 days prior to the test. A nurse in a clinic is collecting data from a client who has hyperthyroidism and has been taking methimazole for 4 weeks. Which of the following statements by the client indicates a therapeutic response to the medication? "I have gained 3 pounds since my last appointment." A nurse is reinforcing teaching with a client who has gonorrhea. Which of the following information should the nurse include? "You are at risk for infertility with this infection, regardless of treatment." A nurse is assisting with the care of a client who has hearing loss. Which of the following actions should the nurse take? 20 | P a g e A nurse is collecting data from a client who is receiving sumatriptan. Which of the following is an expected outcome? Diminished headache A nurse is contributing to the plan of care for a client who is postoperative following a total knee arthroplasty. The client is using a continuous passive motion (CPM) machine. Which of the following interventions should the nurse recommend for the plan of care? Keep a sheepskin pad between the client's extremity and the CPM machine. A nurse is assisting with the care for a client following a thyroidectomy. Which of the following findings should alert the nurse to the possibility of parathyroid gland injury? Muscle twitching A nurse is reinforcing teaching with a client who has systemic lupus erythematosus (SLE) and is to begin taking methylprednisolone orally. Which of the following statements should the nurse include in the teaching? "Limit contact with large groups of people." A nurse is monitoring a client who has a history of an enlarged prostate and is experiencing suprapubic discomfort. Which of the following actions should the nurse take first? Palpate the abdomen. A nurse is assisting with the care for a client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. Which of the following actions should the nurse take? Perform pin site care daily. A nurse is assisting with the care for a client who is scheduled for surgery and is experiencing anxiety. Which of the following interventions should the nurse identify as the priority? Determine the client's understanding of the procedure. A nurse is preparing to perform intermittent urinary catheterization for a female client who has been unable to void following surgery 6 hr ago. Which of the following catheters should the nurse use to perform this procedure? Straight catheter A nurse is preparing to administer an influenza vaccine to a client. Which of the following statements by the client should cause the nurse to postpone administration of the vaccine? "I had a low fever this morning." A nurse is monitoring a client who has a cast and reports intense itching underneath the cast. Which of the following actions should the nurse take? Blow cool air into the cast using a blow dryer on a cool setting. 21 | P a g e The nurse is reviewing the client's diagnostic results. Which of the following findings require follow up? Select all that apply. PaCO2 WBC Chest X-ray O2 sats BUN The nurse is reviewing the client's medical record. Click to highlight the findings below that indicate that the client has a potential problem. To deselect a finding, click on the finding again. Client is short of breath and has a productive cough with yellow mucus States, "I could barely breathe when I got up this morning and I had a throbbing headache" Client is diaphoretic Crackles heard in posterior lungs At 1000, the nurse should first address the client's _______, followed by the client's _______. O2 Heart rate The nurse is assisting with the plan of care for the client. For each potential provider prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. Cough and deep breathe every 2 hr is anticipated. Obtain a sputum culture and sensitivity is anticipated. Perform neurologic checks every 2 hr is nonessential. Titrate oxygen to keep oxygen saturation greater than 90% is anticipated. Place client on a 1,500 mL fluid restriction is contraindicated. Administer acetaminophen 500 mg PO every 6 hr PRN is anticipated. Administer famotidine 40 mg PO daily is nonessential. The nurse is reviewing the client's medical record. Select the 3 findings that require nursing intervention. Temperature WBC Potassium The nurse is reviewing the client's medical record from Day 5. Click to highlight the findings that indicate the client is improving. To deselect a finding, click on the finding again. Heart rate 72/min, regular; Respiratory rate 20/min; Blood pressure 128/56 mm Hg is correct. Oxygen saturation is 95% on room air is correct. 22 | P a g e A nurse is reinforcing teaching with the caregiver of a client who is terminally ill about manifestations of impending death. Which of the following manifestations should the nurse include? Incontinence of the bowel and bladder A nurse is assisting the charge nurse with developing an in-service about caring for clients who have internal sealed radiation implants. Which of the following information should the nurse include? Dispose of radiation implants in a lead container. A nurse is assisting in the care of a client who has manifestations of sepsis. Which of the following provider prescriptions should the nurse implement first? Initiate oxygen at 4 L/min via nasal cannula. A nurse is assisting with the care of a client who has a newly inserted water-seal closed chest tube. Which of the following findings should the nurse report to the provider? Chest drainage is greater than 70 mL/hr. A nurse is assisting with the care of a client who had a cardiac catheterization via the right femoral artery. Which of the following actions should the nurse take to prevent postprocedure complications? (Select all that apply.) Monitor the insertion site for bleeding is correct. Maintain the pressure dressing is correct. Check the client's peripheral pulses is correct. A nurse is reinforcing teaching about hospice care with a client who has terminal cancer. Which of the following statements should the nurse make? "Hospice care will provide support for you and your loved ones during the dying process." A nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching? Avoid stopping this medication suddenly. A nurse is assisting with the care for a client who has meningococcal pneumonia. Which of the following personal protective equipment should the nurse use? Mask A nurse is assisting with the care for a client who has an area indicating potential breakdown over the sacrum. Which of the following actions should the nurse take? Minimize the time the head of the bed is elevated. A nurse is assisting in the care of a client who is scheduled for a CT scan with an IV contrast agent. Which of the following laboratory test does the nurse anticipate that the provider will prescribe? Creatinine 25 | P a g e A nurse is reinforcing discharge teaching with a client who has hearing loss. Which of the following actions should the nurse take when communicating with the client? Rephrase client instructions when not understood. A nurse is assisting with the care of a client and administers penicillin IM. The client begins exhibiting hives and has severe difficulty breathing. After establishing a patent airway, which of the following actions should the nurse take next? Administer epinephrine. 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 to assess the client's progress. The client is most likely experiencing hypovolemia as evidenced by their restlessness, tachycardia, hypotension, decreased pulses, cool extremities, and decreased urine output. Therefore, the nurse should insert a large gauge IV and initiate a fluid challenge. The nurse should also monitor the client's urine output and blood pressure to evaluate the effectiveness of treatment. A nurse in a telemetry unit is collecting data from a client who has a newly inserted permanent pacemaker. Which of the following findings should the nurse report to the provider? The client experiences hiccups when sitting. A nurse is reinforcing preoperative teaching with a client. Which of the following statements by the client indicates an understanding of the teaching? Select all that apply. " I will need to do the breathing exercises every 1 to 2 hrs after surgery." "I will use my PCA medication before my knee starts to hurt too bad." "I will probably be going home with a walker." Click to highlight the findings the nurse should report to the charge nurse immediately. To deselect a finding, click on the finding again. • Perineal pad is saturated with blood, and large clots are present is correct. The presence of vaginal bleeding and blood clots is a manifestation of vaginal hemorrhage. Therefore, the nurse should report this finding to the charge nurse. • Blood pressure 98/56 mm Hg is correct. Decreased blood pressure is a manifestation of vaginal hemorrhage. Therefore, the nurse should report this finding to the charge nurse. • Heart rate 102/min is correct, Tachycardia is a manifestation of vaginal hemorrhage. Therefore, the nurse should report this finding to the charge nurse. A nurse is assisting with the care for a client who reports shortness of breath and has an oxygen saturation 90%. Which of the following actions should the nurse take? 26 | P a g e Administer oxygen via nasal cannula R: The nurse should administer oxygen via nasal cannula to a client who reports shortness of breath and has an oxygen saturation below the expected reference range. The nurse should continue to monitor the client and adjust the oxygen flow rate as needed. A nurse is reinforcing teaching with the caregiver of a client who is terminally ill about manifestations of impending death. Which of the following manifestations should the nurse include? Incontinence of the bowel and bladder. Rationale:The nurse should inform the caregiver that incontinence of the bowel and bladder is a manifestation of impending death. Other manifestations include hypotension, bradycardia, restlessness, and coolness of the skin. A nurse in a clinic is collecting data from a client who has hyperthyroidism and has been taking methimazole for 4 weeks. Which of the following statements by the client indicates a therapeutic response to the medication? "I have gained 3 lbs since my last appointment" R: Hyperthyroidism can cause weight loss. Therefore, the nurse should identify weight gain as an indication that the methimazole therapy has been effective A nurse is contributing to the plan of care for a client who is postoperative following a total knee arthroplasty. The client is using a continuous passive motion (CPM) machine. Which of the following interventions should the nurse recommend for the plan of care? Keep a sheepskin pad between the client's extremity and the CPM machine. R: The nurse should plan to keep a sheepskin pad between the dient's extremity and the cOM madhune to protect the client's skin. The nurse should check the client's skin condition frequendy wile the cient is using the CPM machine. A nurse is reinforcing teaching with a client about testicular self-examination. Which of the following instructions should the nurse include in the teaching? "Perform testicular self-examination after taking a warm shower." Rationale: The nurse should instruct the client to perform testicular self-examination after taking a warm shower or bath. This causes relaxation of the scrotal skin, which allows for better palpation of the testes. A nurse is reinforcing discharge teaching for the caregivers of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching? Remind the client to avoid watching their feet when walking. 27 | P a g e R: The nurse should remind the client's caregivers to frequently remind the client to maintain correct posture and prevent falls by not watching their feet when walking. A home health nurse is assisting with the care for a client who has COPD. The client reports shortness of breath while eating, despite the use of home oxygen. Which of the following recommendations should the nurse make? "Use a bronchodilator 30 minutes before your meal." R: The dient should use a bronchodilator 30 min before meals to prevent shortness of breath while eating. A nurse is assisting with the care of a client who has a newly inserted water-seal closed chest tube. Which of the following findings should the nurse report to the provider? Chest drainage is greater than 70 mL/hr. RAT: The nurse should identify that chest drainage of greater the 70 mL/hr can indicate a complication and should be reported to the provider. Water fluctuates in the water-seal chamber. Water should fluctuate in the water-seal chamber. The water rises and falls upon the client's respiratory effort. Therefore, this finding does not need to be reported to the provider. A nurse is assisting with the care for a client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. Which of the following actions should the nurse take? Perform pin site care daily. R: The nurse should perform pin site care daily with chlorhexidine solution or use a solution according to facility protocol. The nurse should also monitor the pin sites for manifestations of infection. A nurse is reinforcing discharge teaching with a client who has leukemia and is receiving chemotherapy. Which of the following statements should the nurse include in the teaching? "You should place your toothbrush in hydrogen peroxide." R: Tieres who are receiving chemotherapy should clean their toothbrushes by soaking them in a hydrogen peroxide or bleach solution. This solution rids the toothbrush of bacteria and prevents infection. A nurse is assisting with an educational program for clients who have been newly diagnosed with diabetes mellitus. Which of the following instructions should the nurse include in the program regarding insulin? Opened insulin can be stored on a cool countertop away from light R: The nurse should reinforce teaching with the clients that opened insulin vials do not require refrigeration, but can be placed in a cool location for up to 4 weeks, out of direct sunlight. 30 | P a g e A nurse is contributing to the plan of care for a client who has peripheral arterial disease of the lower extremities. Which of the following interventions should the nurse include? Dangle the extremities o the side of the bed. R: The nurse should include in the plan of care to have the client dangle their lower extremities off the side of the bed to aid in reducing pain by increasing arterial blood flow. The client should not raise the lower extremities above the level of the heart when resting in bed because it impairs arterial blood flow. A nurse is assisting with the care for a client who reports stomatitis. Which of the following dietary recommendations should the nurse make? Eat soft foods R: The nurse should remind a client who has stomatitis to eat soft, nonirritating foods to decrease irritation to the oral mucosa. A nurse is reviewing the medical record for a client who is experiencing nausea and vomiting. Based on the client data, which of the following actions should the nurse take? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.) Notify the charge nurse of the client's BUN R: The client's BUN level is above the expected reference range of 10 to 20 mg/dL, which can indicate impaired renal function. The nurse should anticipate interventions to restore the client's fluid volume. A nurse is assisting with the care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) nfection in a surgical wound. Which of the following information should the nurse plan to share with visitors? Visitors must don a gown and gloves prior to entering the client's room. R: The nurse should provide teaching to the visitors regarding the infection control measures for a client who is on contact isolation precautions. Contact precautions require visitors to put on a gown and gloves prior to entering the room of a client who has MRS4 to prevent the spread of infection A nurse is reinforcing teaching with a client about increasing dietary fiber. The nurse should recommend which of the following foods as the best source of fiber? 1/2 cup cooked kidney beans R: The nurse should recommend kidney beans as the best source of fiber because 1/2 cup contains 6.5 g of fiber Complete the following sentence by using the lists of options. After reviewing the findings in the client's medical record, the nurse should first address the client's abdominal distention , followed by the client's 31 | P a g e Acute pain R: • Abdominal distention is correct. When using the greatest risk framework, the nurse should identify that a manifestation of an inflammatory intestinal disorder is abdominal distention. The nurse should address this finding to reduce the risk for life-threatening • Acute pain is correct. When using the greatest risk framework, the nurse should identify that a manifestation of an inflammatory intestinal disorder is acute abdominal pain. The nurse should address this finding to reduce the risk for life-threatening complications, such as obstruction or infection. The nurse is collecting data on the client. For each client finding, click to specify if the finding is consistent with Appendicitis, Diverticular disease, or Crohn's disease. Each finding may support more than 1 disease process. Blood in the stool is consistent with diverticular disease and Crohn's disease. Clients who have diverticular disease can have a decreased hemoglobin and hematocrit level from chronic or severe bleeding, and their stools should be checked for occult or frank bleeding. Anemia relating to Crohn's disease is common because of slow bleeding, and the stools of client's who have Crohn's disease might contain bright red blood. Pain in the right lower quadrant is consistent with appendicitis and Crohn's disease. Pain in the right lower quadrant is a manifestation of appendicitis. Clients who have inflammation from Crohn's disease usually have constant pain located in the right lower quadrant. Clients who have diverticular disease might experience pain in the left lower quadrant. Mucus in the stool is consistent with Crohn's disease. Clients who have Crohn's disease usually have mucus and fat in their stools. Nausea is consistent with appendicitis, diverticular disease, and Crohn's disease. Clients who have appendicitis, diverticular disease, or Crohn's disease might experience nausea. Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The nurse is caring for the client who has manifestations of peritonitis therefore, the priority finding for the nurse to report is laboratory values The nurse is contributing to the plan of care for the client who has peritonitis and Crohn's disease. For each potential intervention, click to specify if the intervention is indicated or contraindicated for the client. Obtain blood cultures - indicated obtain the client's vital signs every 15 min - indicated Administer a hypotonic IV solution - contraindicated insert a nasogastric tube - indicated 32 | P a g e The nurse is assisting with the care of the client who is preoperative for an exploratory laparotomy. Select the 4 actions the nurse should take. Administer phenytoin with a sip of water on the day of surgery. Assist with the administration of gentamicin 100 mg IV. Assist with the administration of dextrose 5% in lactated Ringer's. Contact the wound, ostomy, and continence nurse. The nurse is reinforcing discharge teaching with the client. Which of the following client statements indicates an understanding of the teaching? Select all that apply. "I should schedule several rest periods throughout the day" "I should notify my provider if my temperature is higher than 101 degrees Fahrenheit". A nurse is reinforcing discharge teaching with a client who has hearing loss. Which of the following actions should the nurse take when communicating with the client? Rephrase client instructions when not understood. Rationale: When communicating with a client who has hearing loss, the nurse should rephrase, rather than repeat, discharge instructions when they are not understood. When communicating with a client who has hearing loss, the nurse should keep their hands away from their mouth to promote lip reading. When communicating with a client who has hearing loss, the nurse should speak in a normal tone of voice. Higher pitched sounds can impede hearing by accentuating vowel sounds and concealing consonants. When communicating with a client who has hearing loss, the nurse should sit or stand facing the client on the same level so that the nurse's mouth and lips can be seen for lip reading. A nurse is assisting with the care of a client who has hearing loss. Which of the following actions should the nurse take? Lower voice pitch when speaking R: The nurse should lower their voice pitch when speaking to a client who has hearing loss. Clients who have hearing loss have difficulty hearing high-pitched sounds. 35 | P a g e system. Maintain the pressure dressing is correct. The nurse should maintain the client's pressure dressing to prevent hemorrhaging and allow for the cannulation site to heal. Check the client's peripheral pulses is correct. The nurse should assess the client's peripheral pulses to help identify signs of arterial occlusion. The nurse is reviewing the client's diagnostic results. Which of the following findings require follow up? Select all that apply. PaCO2 WBC count Chest x-ray Oxygen saturation BUN The nurse is reviewing the client's medical record. Click to highlight the findings below that indicate that the client has a potential problem. To deselect a finding, click on the finding again. Client is short of breath and has a productive cough with yellow mucus States, "I could barely breathe when I got up this morning and I had a throbbing headache" Client is diaphoretic Crackles heard in posterior lung A nurse is prioritizing care for the client. Complete the following sentence by using the lists of options. At 1000, the nurse should first address the client's Oxygen saturation followed by the client's Heart rate The nurse is assisting with the plan of care for the client. For each potential provider prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. Cough and deep breathe every 2 hr is anticipated Obtain a sputum culture and sensitivity is anticipated Titrate oxygen to keep oxygen saturation greater than 90% is anticipated. Place client on a 1,500 mL fluid restriction is contraindicated Administer acetaminophen 500 mg PO every 6 hr PRN is anticipated. Administer famotidine 40 mg PO daily is nonessential. 36 | P a g e The nurse is reviewing the client's medical record. Select the 3 findings that require nursing intervention. Temperature WBC Potassium Click to highlight the findings that indicate the client is improving. To deselect a finding, click on the finding again. A nurse is preparing to perform intermittent urinary catheterization for a female client who has been unable to void following surgery 6 hr ago. Which of the following catheters should the nurse use to perform this procedure? B- clear plastic with blue cap A nurse is contributing to the plan of care for a client who was admitted to the neurological unit following a stroke 3 hr ago. Which of the following interventions should the nurse identify as the priority? Keep the cleint in a side-lying position. Rationale: The greatest risk to the client following a stroke is aspiration. The nurse should position the client in a lateral, or side-lying, position to allow any secretions to drain out of the mouth, decreasing the risk for aspiration. Additionally, the nurse should have suction equipment available in the event that any secretions are present in the oral cavity. A nurse is assisting with the care of a client who had a stroke and is unable to speak. The nurse should identify that the client's injury occurred in which of the following lobes of the brain? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) A (red) is correct. FRONTAL LOBE Injury to the frontal lobe can result in alterations to motor function or voluntary movement. This involves the ability to speak and the ability to move purposefully. ----- (Yellow) The nurse should identify that injury to the parietal lobe results in alterations to higher-level activities, such as writing, and processing sensory information, such as proprioception, pain, temperature, touch, and pressure. (purple) The nurse should identify that injury to the occipital lobe results in alterations in visual 37 | P a g e perception and the ability to track movement of an object. Injuries to this area can result in an inability to recognize objects, faces, or the written word. (teal)The nurse should identify that injury to the temporal lobe results in alterations in the ability to understand the spoken language and impaired short-term memory. A nurse is assisting the charge nurse with developing an in-service about caring for clients who have internal sealed radiation implants. Which of the following information should the nurse include? Dispose of radiation implants in a lead container: Rationale: Lead impairs the emission of radiation. Therefore, the nurse should dispose of radiation implants in a lead container in accordance with facility protocol. ------------------------------ Pregnant women and children should not be allowed to visit a client who is receiving internal radiation therapy because of the risk for exposure to radiation emissions. The nurse should use forceps to pick up a radiation implant if it becomes dislodged. The nurse should limit time spent in the client's room to 30 min during an 8 hr shift. A nurse is assisting with the care for a client who has Cushing's syndrome and expresses concern regarding physical changes associated with the syndrome. Which of the following should the nurse recognize as a physical change caused by this disorder? Truncal obesity's R: Truncal obesity is a manifestation of Cushing's syndrome that occurs due to a redistribution of fat. The client also usually has fatty tissue edema between the scapula, also known as "buffalo hump". The nurse should use therapeutic communication techniques to investigate the client's body image concerns. A nurse is reviewing the medication record of a client who is taking digoxin. Which of the following medications should the nurse identify as increasing the risk for the client to develop digoxin toxicity? Furosemide The nurse should identify that loop diuretics, such as furosemide, increase the urinary excretion of potassium, which can lead to hypokalemia. Hypokalemia increases the risk for the development of digoxin toxicity. A nurse is assisting with the care for a client who is scheduled for surgery and is experiencing anxiety. Which of the following interventions should the nurse identify as the priority? Determine the client's understanding of the procedure. 40 | P a g e Herpes zoster The nurse should recommend the herpes zoster vaccine for adults who are 60 years of age and older. A nurse is collecting data from a client who is being treated for hypovolemia due to nausea and vomiting. Which of the following findings should the nurse report to the provider? Heart rate 120/min Rationale: The client's heart rate of 120/min is above the expected reference range and indicates that the client's hypovolemia has not resolved. Therefore, the nurse should report this finding to the provider to obtain additional prescriptions for fluid replacement. A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an IV contrast agent. Which of the following laboratory findings should the nurse report to the provider prior to the procedure? Creatinine 1.9 mg/dL R: Creatinine 1.9 mg/dL. is not within the expected reference range. Therefore, the nurse should report the finding to the provider before the client has a CT scan with an IV contrast agent. This finding places the client at risk for developing contrast-induced nephropathy. A nurse is assisting with the development of a plan of care to manage pain for a client who has herpes zoster with lesions on the lower extremities. Which of the following interventions should the nurse include in the plan of care? Keep bed linens off of the affected areas. Rationale: The nurse should keep bed linens off of the affected areas by using a bed cradle, which will relieve pain caused by the linens rubbing against the lesions. ------- The nurse should apply cool compresses to help relieve pain caused by the lesions. The nurse should initiate airborne and contact precautions for a client who is immunocompromised and has widespread herpes zoster lesions. Otherwise, the nurse should follow standard precautions. A nurse is reinforcing teaching with a client who has systemic lupus erythematosus (SLE) and is to begin taking methylprednisolone orally. Which of the following statements should the nurse include in the teaching? "Limit contact with large groups of people." Glucocorticoids cause immunosuppression and may mask infection. The client should limit contact with sources of possible infections, such as large groups of people. 41 | P a g e A nurse is reinforcing teaching with a client who is scheduled for a guaiac fecal occult blood test, Which of the following instructions should the nurse include in the teaching? Avoid eating red meat for 3 days prior to the test. A nurse is preparing to administer an influenza vaccine to a client. Which of the following statements by the client should cause the nurse to postpone administration of the vaccine? "I had a low fever this morning." Rationale:Clients who have a febrile illness should not receive the influenza vaccine. ----- Clients who recently received a tuberculosis skin test can receive the influenza vaccine. Clients who have an allergy to latex can receive the influenza vaccine. Clients who have an allergy to shrimp or shellfish can receive the influenza vaccine. A nurse is assisting with the care for a client who has end-stage liver disease and just underwent an abdominal paracentesis. For which of the following manifestations should the nurse monitor as an adverse effect of the procedure? Decreased blood pressure R: Following an abdominal paracentesis, the nurse should monitor the client for a decrease in blood pressure. This finding indicates hypovolemia as a result of excess fluid withdrawal. Depending on the amount of fluid withdrawn, hypovolemia can lead to shock. A nurse is collecting data from a client who has 30% body surface area deep partial-thickness and full- thickness burns. Which of the following findings indicates that fluid resuscitation is adequate? Urine output is 50 mL/hr. R: The nurse should closely monitor the client's urinary output as an indicator of effective fluid resuscitation. A urinary output greater than 30 to 50 mL/hr indicates that fluid resuscitation is adequate. 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 to assess the client's progress. Hypovolemia Insert a large gauge IV Initiate a fluid challenge blood pressure Urine output 42 | P a g e A nurse is assisting with the care for a client who has a new cast on their left forearm and reports severe pain in the affected arm with numbness in the fingers. The nurse finds the skin is pale and cold with sluggish capillary refill. Which of the following fracture complications should the nurse suspect? Compartment syndrome R: Compartment syndrome is a complication that involves increased pressure within a compartment (an area that supports blood vessels, bones, and nerves) leading to circulatory compromise to the limb. The pressure can be caused externally by a cast that is too tight or internally by the inflammation or edema from the injury. Circulatory impairment causes pallor and paresthesia of the extremities, a delay in capillary refill, and, without immediate treatment, can cause nerve damage and necrosis. A nurse is contributing to the plan of care to promote a restful night's sleep for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan? Offer a small snack at bedtime. Rationale: The nurse should offer the client a small snack of carbohydrates or a glass of milk as part of the bedtime routine, which can help the client relax and prepare for sleep. A nurse is assisting with the care for a client who has acute pancreatitis. While providing care, the nurse observes ecchymosis around the umbilicus. The nurse should identify that this is a manifestation of which of the following? Intra-abdominal bleeding R: Ecchymosis around the umbilicus is a sign of intra-abdominal bleeding, which is a finding consistent with pancreatitis. A nurse is reinforcing teaching with a client who is scheduled for a guaiac fecal occult blood test. Which of the Folliowing instractions should the nurse include in the teaching? Avoid eating red meat for 3 days prior to the test. R: The nurse should remind the client to avoid eating red meat for 3 days prior to the guaiac fecal occult blood test because this can lead to a false positive result. nurse is reinforcing discharge teaching with a client who had a mechanical mitral valve replacement. Which f the following statements by the client indicates an understanding of the teaching? 45 | P a g e For each finding, click to specify if the finding is consistent with emphysema, asthma, or pneumonia. Each finding may support more than 1 disease process. Temperature- Pneumonia Breath Sounds- Emphysema, Asthma, Pneumonia Respiratory Rate- Emphysema, Asthma, Pneumonia Cough- Emphysema, Asthma, Pneumonia A nurse is assisting with the care for a client who is suspected of having a myocardial infarction. Which of the following actions should the nurse take to prepare the client for an ECG? Cleanse the client's skin prior to electrode placement. Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is experiencing manifestations of peritonitis due to the client's abdominal x-ray results. A nurse is assisting in the care of a client who is experiencing withdrawal from heroin. Which of the following medications should the nurse expect the provider to prescribe? Methadone A nurse is preparing to remove a client's NG tube. Which of the following interventions should the nurse take to decrease the risk for aspiration? Pinch the NG tube. A nurse is reinforcing teaching with a client who is on a low-sodium diet and asks about how to improve the taste of bland food. Which of the following foods should the nurse recommend? Lemon Juice A nurse is assisting in the care of a client who has AIDS-related pneumonia. The client is receiving antibiotic therapy and albuterol nebulizer treatments daily. Which of the following findings should indicate to the nurse that the client's therapeutic regimen is effective? Decrease in exertion dyspnea. A nurse is assisting with the care for a client who is postoperative and has an epidural infusion. Which of the following findings should the nurse recognize as the priority? Dyspnea A nurse is providing information regarding transmission-based precautions for a client who has Clostridium Difficile to an assistive personnel (AP). Which of the following instructions should the nurse include? (Select all that apply.) "Provide the client with disposable utensils and dishes for meals." "Leave blood pressure equipment in the client's room" "Clean contaminated surfaces with a bleach solution" 46 | P a g e A nurse is contributing to the plan of care for a client who has just transferred to the medical-surgical unit from the PACU following a right total knee arthroplasty. Which of the following interventions should the nurse include in the plan? Assist the client to change positions at least every 2 hr. A nurse is preparing to administer scheduled medications to the client. Which of the following prescriptions should the nurse verify with the provider? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.) Ceftriaxone A nurse is examining a client's IV site and notes a hardened vein above their IV site. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client's manifestations indicate which of the following complications of IV therapy? Thrombophlebitis A nurse is reinforcing teaching with a client prior to the removal of a leg cast. Which of the following statements should indicate to the nurse that the client understands the teaching? "I will feel vibrations on my leg from the cast cutter." A nurse is collecting data from a client and notices several skin lesions. Which of the following findings should the nurse report as possible melanoma? Irregular borders A nurse is assisting with the care for a client who has difficulty swallowing. Which of the following actions should the nurse implement to prevent aspiration? Give the client liquids with increased viscosity. A nurse is reinforcing teaching regarding the use of a continuous passive motion (CPM) machine with a client who is scheduled for a total knee arthroplasty. Which of the following information should the nurse include in the teaching? (Select all that apply.) "Your knee is flexed and extended as prescribed by your provider." "The machine is padded with sheep skin." A nurse is assisting with the care for a client who has a prescription for digoxin 0.25 mg PO daily. While taking the client's apical pulse, the nurse notes a rate of 58/min. Which of the following actions should the nurse take? Withhold the dose. A nurse is collecting data from a 55-year-old female client who reports vaginal dryness and hot flashes. The client is interested in trying hormone replacement therapy (HRT). Which of the following should the nurse recognize as a contraindication to HRT? History of treatment for blood clots 47 | P a g e A nurse is reinforcing teaching with a client who has diabetes mellitus and a new prescription for regular and NPH insulin. Which of the following instructions on preparing the insulins should the nurse include? Withdraw the regular insulin before withdrawing the NPH insulin. A nurse is reinforcing teaching about glycosylated hemoglobin (HbA1c) testing with a client who has diabetes mellitus. Which of the following statements indicates that the client understands the teaching? "I will have my HbA1c checked twice per year." A nurse is assisting in the care of a client who is receiving a continuous tube feeding of 60 mL/hr at 1.2 cal/mL. How many calories will the client receive in 12 hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) 864 calories A nurse is assisting with the care for a client who is 2 hr postoperative following the amputation of a foot. Which of the following actions should the nurse take first? Check the incisional dressing. A nurse in a health clinic is reinforcing teaching with a client about tuberculosis (TB). Which of the following client statements indicates an understanding of the teaching? "I can develop TB by breathing in the infection." A nurse is preparing to assist a client out of bed 4 hr following a laparoscopic cholecystectomy. Which of the following actions should the nurse take first? Obtain the client's blood pressure. A nurse is contributing to the plan of care for a client who has Ménière's disease. Which of the following interventions should the nurse include in the plan of care? Administer an antiemetic to the client. A nurse is preparing to suction a client who has a tracheostomy. Which of the following actions should the nurse take first? Ventilate the client with 100% oxygen. A nurse is reinforcing teaching with a client who has chronic kidney disease about disease management. Which of the following statements by the client indicates an understanding of the teaching? "I will limit my daily intake of protein." A nurse is reinforcing teaching with a client who has mitral valve disease. Which of the following statements by the client indicates an understanding of the disease process? "I should call my doctor if my ankles swell." A nurse is assisting with the care of a client who has prostate cancer. The client asks the nurse why they are having difficulty with urination. Which of the following responses should the nurse make? 50 | P a g e A nurse is planning care for a group of clients after receiving change-of-shift report. Which of the following clients should the nurse plan to see first? A client who is dehydrated, has mental confusion, and has tried to get out of bed several times during the night. A nurse is assisting with the care for a client who has dementia due to Alzheimer's disease. Which of the following actions should the nurse take to reduce the client's confusion? Encourage reminiscence of past experiences. A nurse is assisting with the care of a client. Select the 3 findings that require follow-up by the nurse. Visual disturbances Headache Nausea For each finding below, click to specify if the finding is consistent with migraine, stroke, or meningitis. Each finding may support more than 1 disease process. Migraine- Nausea, Visual Changes, Pain, Family History Stroke- Visual Changes, Pain, Family History Meningitis- Nausea, Visual Changes, Pain Complete the following sentence by using the lists of options. The nurse should identify that the client is most likely experiencing a migraine, and the nurse should address the client's pain. A nurse is assisting with the care of 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. Complete the following sentence by using the list of options. Following the administration of sumatriptan, the nurse should monitor for chest pain due to the risk for myocardial ischemia. The nurse is evaluating the client's understanding of the discharge instructions. Click to highlight the client statements that indicate an understanding of the teaching. To deselect a statement, click on the statement again. "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." A nurse is contributing to the plan of care for a client who has COPD and is dyspneic. Which of the following interventions should the nurse include in the plan? Encourage abdominal breathing. 51 | P a g e A nurse is preparing to assist with the insertion of a double-lumen gastric sump tube for a client who has peptic ulcer disease and has developed gastrointestinal bleeding. Which of the following images depicts the tube that the nurse should select? the first one A nurse is reinforcing teaching about gastroesophageal reflux disease (GERD) with a client. Which of the following statements by the client indicates an understanding of the teaching? "I should wait at least 2 hours after eating before going to bed." A nurse is reinforcing teaching with a client who has asthma and a new prescription for a corticosteroid. Which of the following findings should the nurse include as an adverse effect of the medication. Frequent colds A nurse is collecting data from a client who has heart failure and is taking digoxin. Which of the following outcomes from the medication should the nurse expect? Decreased Shortness of breath A nurse is reinforcing teaching about pursed-lip breathing with a client who has a new diagnosis of COPD. The nurse should identify that which of the following client statements indicates an understanding of the teaching? "Pursed-lip breathing works best for activities like walking up stairs." A nurse is reviewing the chart of a client who is experiencing an adrenal crisis, which was precipitated by the client not taking their medication for several days. The nurse should identify that withdrawal from which of the following medications potentiated the adrenal crisis? Prednisone A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus about glycosylated hemoglobin (HbA1c) testing. Which of the following information should the nurse include in the teaching? HbA1c results measure glucose control for the prior 3 months. A nurse in an orthopedic clinic is reinforcing teaching with a client who has osteoarthritis. Which of the following instructions should the nurse include to promote comfort? Sleep on a firm mattress. A nurse is contributing to the plan of care for a client who has a new prescription for nystatin suspension for oral candidiasis. Which of the following interventions should the nurse include in the plan? Remind the client to swish the medication in their mouth. A nurse is assisting with the care for a client who is receiving chemotherapy. The client mentions that they have a loss of appetite because of sores in their mouth and that food no longer tastes good. Which of the following suggestions to the client should the nurse make? 52 | P a g e Eat several small-portioned meals daily. A nurse is assisting with the care for a client who begins to have a seizure while ambulating in the hall. Identify the sequence of actions the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) Lower the client to the floor. Place a pad beneath the client's head. Loosen the clothing around the client's neck. Time the length of the client's seizure. Reorient and reassure the client. A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis. Which of the following interventions should the nurse include when contributing to the plan of care? Apply a mask to the client if transport is needed. A nurse is reinforcing discharge teaching with a client who has Crohn's disease. Which of the following statements should the nurse include in the teaching? "Maintain a low-residue diet." A nurse is reviewing the medical record of a client who has acute pancreatitis. Which of the following findings should the nurse anticipate? Elevated serum amylase level A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. Which of the following information should the nurse include in the teaching? Apply cold packs to the inflamed joints. A nurse is preparing to administer furosemide to a client who has heart failure. Which of the following findings should the nurse report before administering the medication? Decrease potassium A nurse is contributing to the plan of care for a client who has tuberculosis (TB). Which of the following interventions should the nurse include? Place the client in a negative-pressure airflow room. A nurse is collecting data from a client who has hypothyroidism. Which of the following manifestations should the nurse anticipate? Bradycardia A nurse is assisting with the care for a client who has neutropenia. Which of the following nursing interventions should the nurse implement? Limit visitors to healthy adults. 55 | P a g e Levothyroxine interaction Instruct client to avoid taking calcium within 4 hr of levothyroxine administration, as calcium can interfere with the effectiveness of the medication. Mechanical ventilation anxiety Instruct client to allow the machine to breathe for them to reduce anxiety and restlessness associated with fighting the ventilator. Adverse effect of enalapril Identify orthostatic hypotension as an adverse effect of enalapril. Delayed wound healing Identify urine output of 25 mL/hr as a finding that contributes to delayed wound healing. Hypothyroidism and opioid analgesic Instruct client to void every 4 hours to decrease the risk of urinary retention, which is an adverse effect of opioid analgesics. Portal hypertension Obtain vital signs first when caring for a client who is vomiting blood mixed with food after a meal, as this indicates a potential rupture of esophageal varices. Gastrectomy postoperative instructions Instruct client to avoid drinking fluids with meals, eat several small meals per day, consume high-protein snacks, and avoid highly seasoned foods. Cushing's triad Identify bradycardia as a component of Cushing's triad in a client with increased intracranial pressure from a traumatic brain injury. Client coping with diabetes diagnosis Recognize the client's change in behavior of inspecting feet daily as an indication of successful coping with the diagnosis. Inguinal hernia assessment Palpate location C to verify the presence of an inguinal hernia. Rattlesnake bite treatment Expect a prescription for an opioid analgesic to promote comfort following a rattlesnake bite. Hemodialysis treatment Perform a 12-lead ECG, place the client in Trendelenburg position, administer a 0.9% sodium chloride 200 mL IV bolus, apply oxygen at 2 L/min via nasal cannula, and notify the provider immediately. 56 | P a g e Client rights Ensure a client signs informed consent before receiving a placebo during a research trial. Omeprazole action Instruct the client that omeprazole provides relief by suppressing gastric acid production. Physical therapy referral Refer a client who is receiving preoperative teaching for a right knee arthroplasty to physical therapy to begin understanding postoperative exercises and physical restrictions. Droplet precautions Instruct an assistive personnel (AP) to wear a mask when coming within 3 ft of a client who has bacterial meningitis. Stress incontinence and weight loss Recommend weight loss to reduce excess abdominal pressure and mitigate the risk of stress incontinence. Hypokalemia and bowel sounds Expect hypoactive bowel sounds in a client with hypokalemia. Diagnostic results follow-up Follow up on PCO2 level, WBC count, chest X-ray, and oxygen saturation level. Neurological event follow-up Follow up on visual disturbances, tingling of the lips, hand grasps, and expressive aphasia. Testicular self-examination Instruct the client to roll each testicle between the thumb and fingers to feel for any lumps deep in the center of the testicle. Hyperthyroidism assessment Report blood pressure of 170/80 mm Hg to the provider as a priority finding. Muscle cramps and tingling sensation Administer calcium carbonate to a client experiencing muscle cramps and tingling sensation in the hands. Seizure intervention Turn the client to the side during a seizure to prevent aspiration. Medication to withhold prior to cardioversion 57 | P a g e Instruct the client to withhold digoxin for 48 hr prior to cardioversion. Sildenafil and nitroglycerin Inform the client that they cannot use sildenafil if they are taking nitroglycerin due to the risk of significant hypotension. Magnesium sulfate adverse effects Monitor for respiratory paralysis as an adverse effect of magnesium sulfate. Erythropoietin therapy Explain that the medication is taken to increase energy levels by increasing hematocrit and reducing fatigue. Chronic glomerulonephritis manifestation Identify hyperkalemia as a manifestation of chronic glomerulonephritis. Feverfew interaction Advise the client that naproxen interacts with feverfew and can increase the risk of bleeding. Colorectal cancer risk reduction Recommend adding cabbage to the diet to help reduce the risk of colorectal cancer. Dysphagia bedside item Place a suction machine at the client's bedside to clear the airway as needed and reduce the risk of aspiration. Contrast dye assessment Further assess a client's history of asthma before a CT scan with IV contrast agent due to the risk of a reaction to the dye. Exophthalmos assessment Identify image D as indicating exophthalmos in a client with Graves' disease. Role change risk Recognize that a client with multiple sclerosis and progressive difficulty ambulating is at risk for experiencing a role change. Lactulose adverse effect Identify hypokalemia as an adverse effect of lactulose due to excessive stools. DKA laboratory findings Expect elevated BUN levels in a client with diabetic ketoacidosis. 60 | P a g e Hyperthyroidism assessment Report blood pressure of 170/80 mm Hg to the provider as a priority finding. Muscle cramps and tingling sensation Administer calcium carbonate to a client experiencing muscle cramps and tingling sensation in the hands. Seizure intervention Turn the client to the side during a seizure to prevent aspiration. Medication to withhold prior to cardioversion Instruct the client to withhold digoxin for 48 hr prior to cardioversion. Sildenafil and nitroglycerin Inform the client that they cannot use sildenafil if they are taking nitroglycerin due to the risk of significant hypotension. Magnesium sulfate adverse effects Monitor for respiratory paralysis as an adverse effect of magnesium sulfate. Erythropoietin therapy Explain that the medication is taken to increase energy levels by increasing hematocrit and reducing fatigue. Chronic glomerulonephritis manifestation Identify hyperkalemia as a manifestation of chronic glomerulonephritis. Feverfew interaction Advise the client that naproxen interacts with feverfew and can increase the risk of bleeding. Colorectal cancer risk reduction Recommend adding cabbage to the diet to help reduce the risk of colorectal cancer. Dysphagia bedside item Place a suction machine at the client's bedside to clear the airway as needed and reduce the risk of aspiration. Contrast dye assessment Further assess a client's history of asthma before a CT scan with IV contrast agent due to the risk of a reaction to the dye. Exophthalmos assessment 61 | P a g e Identify image D as indicating exophthalmos in a client with Graves' disease. Role change risk Recognize that a client with multiple sclerosis and progressive difficulty ambulating is at risk for experiencing a role change. Lactulose adverse effect Identify hypokalemia as an adverse effect of lactulose due to excessive stools. DKA laboratory findings Expect elevated BUN levels in a client with diabetic ketoacidosis. Follow-up findings Follow up on visual disturbances, tingling of the lips, hand grasps, and expressive aphasia. Epoetin alfa understanding Understand that taking the medication will increase energy levels. Pancreatitis laboratory findings Expect decreased calcium levels in a client with pancreatitis. TPN infusion rate calculation Set the IV pump at 167 mL/hr to deliver 2000 kcal/day with a TPN solution concentration of 500 kcal/L. Ureterostomy care Cut the opening of the skin barrier one-eighth inch wider than the stoma to minimize skin irritation. Fluid volume deficit assessment Identify a heart rate of 110/min as a finding indicating fluid volume deficit. Epoetin alfa understanding Monitor blood pressure while taking the medication due to the risk of hypertension. Postoperative care Instruct the client to splint the abdomen with a pillow for coughing, plan to ambulate the client as soon as possible, report urinary output to the provider, and ask the client to rate their pain on a 0 to 10 pain scale. Chronic kidney disease psychosocial care Tell the client that it is possible to return to similar previous levels of activity. Pseudomonas aeruginosa infection prevention 62 | P a g e Advise against placing plants or flowers in the client's room to prevent Pseudomonas aeruginosa infection. Role change risk Recognize that a client with multiple sclerosis and progressive difficulty ambulating is at risk for experiencing a role change. . Seizures and Epilepsy: Seizure precautions (62) During a seizure: Position client on the floor and provide a patent airway, turn client to side and loosen restrictive clothing Cancer treatment options: Protective Isolation (999) If WBC drops below 1,000, place the client in a private room and initiate neutropenic precautions. - Have client remain in his room unless be needs to leave for a diagnostic procedure, in case of transport place a mask on him - Protect from possible sources of infection (plants, change water in equipment daily) - Have client, staff and visitors perform frequent hand hygiene, restrict ill visitors - Avoid invasive procedures (rectal temps, injections) - Administer (neupogen, neulasta) to stimulate WBC production Infection control: Appropriate room assignment Standard Precautions: 1. applies to all patients 2. Hand washing a. alcohol based preferred unless hands visually soiled 3. Gloves - when touching anything that has the potential to contaminate. 4. Masks, eye protection & face shields when care may cause splashing or spraying of body fluids Droplet: 1. private room or with someone with same illness 2. masks Airborne: 1. private room 2. masks or respiratory protection devices a. use an N95 respirator for tuberculosis 3. Negative pressure airflow 4. full face protection if splashing or spraying is possible Contact: 1. private room or room with same illness 2. gloves & gowns 65 | P a g e Antibiotics affecting protein synthesis: Adverse effects of gentamicin -Ototoxicity: cochlear damage (hearing loss) and vestibular damage (loss of balance). -Nephrotoxicity (proteinuria, elevated BUN, creatinine levels). -Hypersensitivity ( rash, pruritis, parathesia of hands and feet, and urticaria). Electrolyte imbalance: manifestations of hypokalemia Weak, irregular pulse, hypotension, respiratory distress Premature ventricular contractions, bradycardia, inverted T waves, ST depression Decreased GI motility, abdominal distension, constipation, n/v, anorexia, polyuria Decreased K (<3.5) ABG: Metabolic alkalosis (pH > 7.45) Electrolyte imbalance: Priority assessment for hypokalemia Assessing for a patent and open airway Blood and blood product transfusions: Administering Fresh Frozen Plasma Initiate a large bore IV access: 20 gauge needle Complete transfusion withing 2-4 hours time frame If reaction occurs: -Stop transfusion immediately - Initiate 0.9% NaCl in a separate line - Save blood bag and blood tubing Cardiovascular Diagnostic and Therapeutic Procedures: Caring for a client who has a PICC -Assessing site every 8 hours. Note redness, swelling, drainage, tenderness and condition of dressing -Change tube and positive pressure cap per facility protocol -Using 10mL or larger syringe to flush the line -Cleanse with alcohol for 3 seconds before accessing it -Use transparent dressing Cardiovascular Diagnostic and Therapeutic Procedures: Teaching about a PICC -Advise client not to immerse arm in water, to cover dressing site to avoid water exposure -Avoid BP in the arm with PICC Cardiovascular Diagnostic and Therapeutic Procedures: PICC care - Apply an initial dressing of gauze and replace with transparent dressing within 24 hours - An initial x-ray should be taken to ensure proper placement Cardiovascular and Hematologic Disorders: teaching client about food interaction with Warfarin 66 | P a g e -Kale, spinach -Brussels sprouts -collard greens, mustard greens -green tea -grapefruit juice, alcohol Angina and MI: Client teaching about nitroglycerin Nitrogylcerin prevents coronary artery vasospasm and reduces preload and afterload. Used to treat angina and help with BP. - Place nitro under tongue to dissolve - Take up to two more doses of nitro at 5-min intervals - Stop activity and rest Headache is a common side effect Orthostatic hypotension Osteoporosis: Teaching about self administration of Alendronate Take with 8oz water in the early morning before eating Remain upright for 30 minutes after taking medication Diabetes Mellitus Management: teaching about self administration of insulin - Rotate injection sites - Inject at a 90 degree angle. Aspiration is not necessary - Advise client to eat at regular intervals, avoid alcohol intake and adjust insulin to exercise and diet to avoid hypoglycemia - When mixing insulin's, draw up the shorter acting insulin into the syringe first and then the longer acting insulin. IV therapy: Performing Venipuncture on an older adult client a 22-24 gauge catheter is best to use on older adults Tie the tourniquet sparingly and try to avoid veins in the hand Dosage calculations: Calculating IV infusion rate Ex: nurse is preparing to administer dextrose 5% in water 500 mL IV to infuse over 4 hours. The nurse should set the IV infusion pump to deliver how many mL/hr> -Volume (mL)/Time (hr) = X -500 mL/5hr = 125 mL/hr IV therapy: Medication administration Know -Right Patient -Right drug -Right Dose -Right Time -Right Route 67 | P a g e Arthoplasty: Pain control Analgesics - opiods (epidural, PCA, IV, Oral) NSAIDS Continuous peripheral nerve block Ice or cold therapy to reduce swelling Head of bed slightly elevated and the affected leg in a neutral position. place a pillow or abduction device between the legs when turning to the unaffectedNe side Pain management: PCA Small frequent dosing ensure consistent plasma levels Morphine and Dilaudid Let nurse know if the pump doesn't control the pain Client is the only person to push the button Pain management: Interventions to promote postoperative recovery Managing acute severe pain with short term around the clock administration of opiods parental route is best for immediate short term relief GI therapeutic procedures: D/C TPN therapy Never abruptly stop TPN, gradually decrease (10%) to allow body adjustment. Monitor vital signs q 4-8 hours GI therapeutic procedures: Shortage of TPN Solution Clients receiving TPN frequently need supplemental regular insulin. Keep dextrose 10% in water at the bedside in case the solution runs out. this minimizes the risk of hypoglycemia Nutrition Assessment: Caring for a client with pancreatitis -increased serum glucose -reduce pancreatic stimulation through NPO; NG tube is inserted to suction gastric contents -snacks high in calories in order to maintain weight ECG and Dysrthymia monitoring: Analyzing ECG Watch for manifestations of dysrhythmias (chest pain, decreased LOC, SOB) and hypoxia. Remove leads, print ECG report and notify the provider ECG and Dysrthymia monitoring: Performing 12 lead ECG Prepare client for 12 lead if prescribed - Position client in supine position with chest exposed - wash skin to remove oils - Attach one electrode to each of the clients extremities by applying electrodes to flat surfaces above the wrist and ankles and the other 6 electrodes to the chest, avoiding chest hair. Instruct client to remain still 70 | P a g e Diabetes mellitus management: Recognizing Hypoglycemia Confusion Shaking (tremors) Hunger Diaphoresis Tachycardia Meningitis: Assessing for client findings - Constant Headache -Stiff neck - Photophobia - Fever and chills - Nausea and vomiting - Altered LOC - Positive Kernigs and Brudzinski's signs Peripheral Vascular Diseases: Arterial Revascularization used for severe claudication and or limb pain at rest - maintain adequate circulation - check pedal and dorsalis pulse -Note color, temperature, sensation and cap refill Diagnostic and therapeutic procedures for female reproductive disorders: Discharge teaching for abdominal hysterectomy well balanced diet (high in protein) Hormonal therapy restrict activity for as long as 6 weeks avoid use of tampons look for foul smelling drainage and temp > 100F Arthroplasty: Preventing complications following hip arthoplasty Follow position restrictions to avoid dislocation - use elevated seating - straight chairs with arms - abduction pillow or a pillow between client legs - externally rotate toes Cancer disorders: client teaching following partial glossectomy -Client need for alternate communication following surgery -head of bed elevated to reduce edema -report leakage of fluid from the suture line or swallowing difficulty -thicken liquids -frequent oral hygiene 71 | P a g e Meningitis: Planning interventions for care (53) -Isolate client as soon as meningitis is expected -Implement fever reduction measures -report to public health department -Bed rest with HOB 30 degrees -Provide quiet environment and minimize exposure to bright light -Avoid coughing and sneezing which increased ICP -Maintain safety and seizure precautions Chest tube insertion and monitoring: Maintaining drainage system First Chamber: Drainage collection Second Chamber: Water seal Third Chamber: Suction control Position client in semi-fowlers to high-fowlers position to promote optimal lung expansion - Tidaling with movement is expected in the water seal chamber - Cessation of tidaling in the water seal chamber signals lung reexpansion - Continuous bubbling in the water seal chamber (air leak finding) Diabetes Mellitus Management: Sick Day Management Monitor blood glucose every 3-4 hours Continue to take insulin or oral hypoglycemia agents consume 4oz sugar free liquid every 30 minutes meet carb needs with soft foods Test urine for ketones Head Injury: indications of increased intracranial pressure -Severe headache - Deteriorating LOC - Dilated, pinpoint or asymmetric pupils - Alteration in breathing pattern - Abnormal posturing - cerebrospinal fluid leakage Hemodialysis and Peritoneal Dialysis: Intervening for decreased dialysate flow rate -Reposition client -milk tubing -check tubing for kinks or closed clamps -Tell client to avoid constipation by taking stool softeners and consuming a diet high in fiber Respiratory management and mechanical ventilation: caring for a client who has an ET tube 72 | P a g e Maintain a patent airway -assess the position and placement of tube - Suction oral and tracheal secretions to maintain tube patency - Soft wrist restraints - Maintain cuff pressure below 20mm Hg TB: Discharge teaching about TB -Continue medication therapy for its full duration of 6-12 months -continue with follow-up care for 1 year -Sputum samples every 2-4 weeks, no longer contagious after 3 neg samples -proper hand hygiene -wear N95 Electrolyte imbalances: Treatment of hypokalemia IV potassium supplement Never administer IV bolus Encourage foods high in K Fluid imbalances: Assessment findings Hypo: Increased Hct Increased urine specific gravity increased serum sodium Hyper: Decreased Hct Normal sodium decreased electrolytes, BUN and creatinine Respiratory alkalosis Fluid Imbalances: Clinical manifestations of hypervolemia Tachycardia bounding pulse hypertension muscle weakness headache ascites orthopnea crackeles distended neck veins Fluid Imbalances: Clinical manifestations of Dehydration Hyperthermia tachycardia 75 | P a g e - severe pain and nausea - photophobia Posterior Pituitary Disorders: Medications to treat diabetes insipidus Desmopressin acetate (DDAVP) - Notify weight gain >2 lbs in 24 hours Cabamazepine (Tegretol) -Notify sore throat, fever or bleeding Vasopressin (Pitressin) - Notify headache or confusion Head injury: Identification of altered respiratory patterns Cheyne stokes respirations central neurogenic hyperventilation apnea Emergency Nursing principles and management: Priority action for abdominal trauma (9) ABCDE (Airway, breathing, circulation, disability and exposure) Hemodynamic Shock: Priority intervention for hypovolemic shock Continuously monitor airway and vital signs Administer fluids (0.9% NaCl or Lactated Ringers) Have resuscitation equipment available Hypertension: Action for hypertensive crisis Administer IV anti-hypertensives therapies, such as nitroprusside, nicardipine and labetaolol Monitor BP every 5-15 minutes Assess neurological status Monitor Cardiac status Emergency Nursing principles and management: Emergency Illness management (9) Always assess airway, breathing and circulation FIRST Fractures and immobilization devices: Assessing for compartment syndrome (795) Compartment Syndrome assessment: Pain Paralysis Paresthesia Pallor Pulselessness Intense pain with movement numbness, burning and tingling are early signs 76 | P a g e Asthma: Identifying pathophysiology Chronic inflammatory disorder of the airways -Mucosal edema - Bronchoconstriction - Excessive mucus production - Dyspnea - Chest tightness - Anxiety/Stress -Wheezing -Coughing - Poor O2 Parkinsons disease: Expected findings - Stooped posture - Slow, Shuffling gait - Slow speech - Tremors - Muscle rigidity - Bradykinesia/ Akinesia -Autonomic Symptoms - Difficulty chewing and swallowing - Drooling - Dysarthria - Difficulty with ADL's - Mood swings - Dementia Rheumatoid Arthritis: Client teaching about early indications Pain at rest with movement Morning stiffness fatigue joint swelling warmth and erythema Acute kidney injury and chronic kidney disease: Metabolic changes associated with chronic kidney disease Metabolic acidosis Heart Failure and Pulmonary Edema: Recognizing manifestations of left sided heart failure - Dyspnea, Orthopnea (SOB while laying down), nocturnal dyspnea - Fatigue - Displaced apical pulse (hypertrophy) 77 | P a g e - S3 heart sound (gallop) - Pulmonary congestion - Frothy sputum - Altered mental status - Decrease in urine output Respiratory Failure: Manifestations of Acute respiratory failure ABG values: Room air, PaO2 <60 and SaO2 <90 PaO2 >50 in conjunction with a pH less than 7.30 - lack of perfusion to the capillary bed Blood and blood product transfusions: Monitoring for adverse response to multiple blood transfusions cute Hemolytic: chills, fever, low back pain, tachycardia, flushing, hypotension Febrile: chiils, fever, flushing, headache Mild Allergic: itching, urticaria and flushing Anaphylactic: wheezing, dyspnea, chest tightness cyanosis and hypotension Hemodialysis and Peritoneal Dialysis: Assessment of an arteriovenous fistula - Alert nurse of signs of disequilibrium syndrome such as nausea and headache - Check for thrill or bruit - Eat well balanced meals that include foods high in folate (beans, green vegetables) and increase protein An adult client who is hospitalized after surgery reports sudden onset of chest pain and dyspnea. the client appears anxious, restless, and mildly cyanotic. the nurse should further assess the client for which condition? Pulmonary embolism which information should the nurse obtain when performing an initial assessment of a client who presents to the emergency department with a painful ankle injury? (select all that apply) Quality of the pain Signs of inflammation Ankle range of motion Visible deformities of the joint 80 | P a g e Use daily reminders to take immunosuppressants The nurse is assessing a client with chronic kidney disease (CKD). Which finding is most important for the nurse to respond to first? Potassium 6.0 mEq Which finding should the nurse identify as most significant for a client diagnosed with polycystic kidney disease (PKD)? 3+ bacteria in urine The nurse is planning care for a client with newly diagnosed diabetes mellitus that requires insulin. Which assessment should the nurse identify before beginning the teaching session? Willingness of the client to learn the injections sites When providing discharge teaching for a client with osteoporosis, the nurse should reinforce which home care activity? Elimination of hazards to home safety A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep. Which recommendation by the nurse is most effective to assist the client? Raising the head of the bed on blocks An older adult female client is brought to the clinic by her daughter for a flu shot. She has lost significant weight since the last visit. She has poor personal hygiene and inadequate clothing for the weather. the client states that she lives alone and denies problems or concerns. Which action should the nurse implement? Collect further data to determine whether self-neglect is occuring The nurse is assisting a client out of bed for the first time after surgery. Which action should the nurse do first? Allow the client to sit with the bed in a high Fowler's position After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 ml for the last 2 hours. What priority nursing action should be implemented? Report the findings to the surgeon A client who is fully awake after a gastroscopy asks the nurse for something to drink. After confirming that liquids are allowed, which assessment action should the nurse consider a priority? Check the client's gag and swallow reflexes 81 | P a g e During an interview with a client planning elective surgery, the client asks the nurse, "What is the advantage of having a preferred provider organization insurance plan?" Which response is best for the nurse to provide? An individual may select healthcare providers from outside of the PPO network The nurse is providing dietary instructions to a 69 year old client who is at high risk for development of coronary heart disease (CHD). Which information should the nurse include? Increase intake of soluble fiber to 10 to 25 grams per day A male client receives a local anesthetic during surgery. During the post-operative assessment, the nurse notices the client is slurring his speech. Which action should the nurse take? Evaluate his blood pressure, pulse, and respiratory status A client who is sexually active with several partners requests an intrauterine device (IUD) as a contraceptive method. Which information should the nurse provide? Using an IUD offers no protection against sexually transmitted disease (STD), which increase the risk for pelvic inflammatory disease (PID). A female client requests information about using the calendar method of contraception. Which assessment is most important for the nurse to obtain? An accurate menstrual cycle diary for the past 6 to 12 months A 32 year old female client complains of severe abdominal pain each month before her menstrual period, painful intercourse, and painful defecation. Which additional history should the nurse obtain that is consistent with the client's complaints? Inability to get pregnant A 20 year old female client calls the nurse to report a lump she found in her breast. Which response is the best for the nurse to provide? Most lumps are benign, but it is always best to come in form an examination. The nurse is working with a 71-year-old obese client with bilateral osteoarthritis (OA) of the hips. What recommendation should the nurse make that is most beneficial in protecting the client's joints? Initiate a weight-reduction diet to achieve a health body weight A 58 year old client who has been post menopausal for five years is concerned about the risk of osteoporosis because her mother has the condition. Which information should the nurse offer? Calcium loss from bones can be slowed by increasing calcium intake and exercise During assessment of a client with amyotrophic lateral sclerosis (ALS), which finding should the nurse identify when planning care for this client? muscle weakness 82 | P a g e The nurse formulates the nursing problem of urinary retention related to sensorimotor deficit for a client with multiple sclerosis. Which nursing intervention should the nurse implement? Teach the client techniques of intermittent self-catheterization The nurse is caring for a client with a stroke resulting in right-sided paresis and aphasia. The client attempts to use the left hand for feeding and other self-care activities. The spouse becomes frustrated and insists on doing everything for the client. Based on this data, which nursing problem should the nurse document for this client? Disabled family coping related to dissonant coping style of significant person A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg. Which action should the nurse implement? Give an antihypertensive medication A client with a 16-year history of diabetes mellitus is having renal function tests because of recent fatigue, weakness, elevated blood urea nitrogen, and serum creatinine levels. Which finding should the nurse conclude as an early symptom of renal insufficiency? Nocturia The nurse is caring for a client with a continuous feeding through a percutaneous endoscopic gastrostomy (PEG) tube. Which intervention should the nurse include in the plan of care? Check for tube placement and residual volume q4 hours The nurse is planning care to prevent complications for a client with multiple myeloma. Which intervention is most important for the nurse to include? Maintain a fluid intake of 3 to 4 L per day When teaching diaphragmatic breathing to a client with chronic obstructive pulmonary disease (COPD), which information should the nurse provide? Place a small book or magazine on the abdomen and make it rise while inhaling deeply During suctioning, a client with an uncuffed tracheostomy tube begins to cough violently and dislodges the tracheostomy tube. Which action should the nurse implement first? Attempt to reinsert the tracheostomy tube A client is admitted for further testing to confirm sarcoidosis Which diagnostic test provides definitive information that the nurse should report to the HCP? Lung tissue biopsy How should the nurse position the electrodes for modified chest lead one (MCL I) telemetry monitoring? Negative polarity left shoulder, positive polarity right chest nipple line, ground left chest nipple line 85 | P a g e A client taking furosemide (Lasix), reports difficulty sleeping. What question is important for the nurse to ask the client? At what time do you take your medication A client taking a thiazide diuretic for the past six months has a serum potassium level of 3. The nurse anticipates which change in prescription for the client? A potassium supplement will be prescribed A client experiencing uncontrolled atrial fibrillation is admitted to the telemetry unit. What initial medication should the nurse anticipate administering to the client? Digoxin A client receiving cholestyramine (Questran) for hyperlipidemia should be evaluated for what vitamin deficiency? K A client who is receiving chemotherapy asks the nurse, "Why is so much of my hair falling out each day?" Which response by the nurse best explains the reason for alopecia? Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant The nurse is preparing a teaching plan for a client who is newly diagnosed with type 1 diabetes mellitus. Which clinical cues should the nurse describe when teaching the client about hypoglycemia? Sweating, trembling, tachycardia A female client taking oral contraceptives reports to the nurse that she is experiencing calf pain. What action should the nurse implement? Advise the client to notify the HCP for immediate medication attention The HCP prescribes aluminum and magnesium hydroxide, 1 tablet PO PRN, for a client with chronic kidney disease (CKD) who is complaining of indigestion. which intervention should the nurse implement? Question the HCP's prescription A client has been taking oral corticosteroids for the past five days because of seasonal allergies. Which assessment finding is of most concern to the nurse? Purulent sputum A client with multiple sclerosis has experienced an exacerbation of symptoms, including paresthesias, diplopia, and nystagmus. Which instruction should the nurse provide? Schedule extra rest periods The nurse is assessing a client with bacterial meningitis. Which assessment finding indicates the client may have developed septic emboli? 86 | P a g e Cyanosis of the fingertips A 58 year old client, who has no health problems, asks the nurse about the Pneumovax vaccine. The nurse's response to the client should be based on which information? The immunization is administered once to older adults or persons with a history of chronic illness An elderly client is admitted with a diagnosis of bacterial pneumonia. When observing the client for the first signs of decreasing oxygenation, the nurse should assess for which clinical cues? Confusion and tachycardia An older adult male client comes to the geriatric screening clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg which is warm to the touch and suspects it might be thrombophlebitis. Which type of pain would further confirm this suspicion? Pain in the calf upon exertion who is relieved by rest and elevating the extremity An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that his tongue is somewhat cracked and his eyeballs are sunken into his head. What nursing intervention is indicated? Help the client to determine ways to increase his fluid intake We have an expert-written solution to this problem! A 77 year old female client is admitted to the hospital. She is confused, has no appetite, is nauseated and vomiting, and is complaining of a headache. Her pulse rate is 43 beats per minute. It is most important for the nurse to assess for which finding? Takes digitalis The nurse knows that lab values sometimes vary for the older client. Which data would the nurse expect to find when reviewing lab values of an 80 year old male? Increased protein in the urine, slightly increased serum glucose levels The nurse is planning to initiate a socialization group for older residents of a long-term facility. Which information would be most useful to the nurse when planning activities for the group? The usual activity patterns of each member of the group We have an expert-written solution to this problem! While working in the emergency room, the nurse is exposed to a client with active tuberculosis. When should the nurse plan to obtain a tuberculin skin test? 87 | P a g e Four to six weeks after the exposure A client has taken steroids for 12 years to help manage chronic obstructive pulmonary disease (COPD). When making a home visit, which nursing function is of greatest importance to this client? Assess the client's temperature During lung assessment, the nurse places a stethoscope on a client's chest and instructs him/her to say "99" each time the chest is touched with the stethoscope. What should be the correct interpretation if the nurse hears the spoken words "99" very clearly through the stethoscope? May indicate pneumonia The nurse is performing an ophthalmoscopic examination on a hypertensive client. When assessing the client, which finding indicates the severity of hypertension? Amount of retinal vessel damage that has occurred The nurse is receiving report from surgery about a client with a penrose drain who is to be admitted to the postoperative unit. Before choosing a room for this client, which information is most important for the nurse to obtain? If the client's wound is infected The nurse notes that the only ECG for a 55-year-old male client scheduled for surgery in two hours is dated two years ago. The client reports that he has a history of "heart trouble," but has no problems at present. Hospital protocol requires that those over 50 years of age have a recent ECG prior to surgery. What nursing action is best for the nurse to implement? Call for an ECG to be performed immediately The nurse is interviewing a male client with hypertension. Which additional medical diagnosis in the client's history presents the greatest risk for developing a cerebral vascular accident (CVA)? Diabetes mellitus The nurse is completing an admission interview and assessment on a client with a history of Parkinson's disease. Which question provides information relevant to the client's plan of care? Have you ever been 'frozen' in one spot, unable to move? The nurse is assessing a client who has a history of Parkinson's disease for the past 5 years. Which symptoms would this client most likely exhibit? Shuffling gait, mask-like facial expression and tremors of the head Which intervention should the nurse plan to implement when caring for a client who has just undergone a right above the knee amputation? Place a large tourniquet at the client's bedside 90 | P a g e Obstructed Bartholin's glands A client is admitted to the emergency department after falling from a high roof. Which finding should the nurse report immediately? Clear, watery drainage from the ear A client with early breast cancer receives the results of a breast biopsy and asks the nurse to explain the meaning of staging and the type of receptors found on the cancer cells. Which explanation should the nurse provide? The tumor's estrogen receptor guides treatment options A client has a staging procedure for cancer of the breast and ask the nurse which type of breast cancer has the poorest prognosis. Which information should the nurse offer the client? Inflammatory with peau d'orange Which nail color alteration should the nurse expect to observe in a client with chronic kidney disease? Horizontal white banding Which instruction should the nurse give a client who is diagnosed with fibrocystic changes of the breast? Perform a breast self-exam (BSE) procedure monthly Which information about mammogram is most important to provide a post-menopausal female client? Yearly mammogram should be done regardless of previous normal x-rays A 49 year old female client arrives at the clinic for an annual exam and asks the nurse why she becomes excessively diaphoretic and feels warm during nighttime. What is the nurse's best response? Discuss perimenopause and related comfort measures Which assessment finding by the nurse during a client's clinical breast examination requires follow-up? Newly retracted nipple In preparing a discharge plan for a 22-year-old male client diagnosed with Buerger's disease (thromboangiitis obliterans), which referral is most important? Smoking cessation program A 67 year old woman who lives alone tripped on a rug in her home and fractured her hip. Which predisposing factor probably led to the fracture in the proximal end of her femur? Osteoporosis resulting from hormonal changes During a health fair, a 72-year-old male client tells the nurse that he is experiencing shortness of breath. Auscultation reveals crackles and wheezing in both lungs. Suspecting that the client might have chronic bronchitis, which classic symptom should the nurse expect this client to have? Productive cough with grayish-white sputum 91 | P a g e A client with diabetes mellitus is experiencing polyphagia. Which outcome statement is the priority for this client? Adequate cellular nourishment A nurse is receiving report on a client who is postoperative following an open repair of Zenker's Diverticulum. The nurse should anticipate the surgical incision to be in which of the following locations? Throat 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 A nurse is providing discharge instructions to a client who has a partial thickness burn of the hand. Which of the following instructions should the nurse include? Wrap fingers with individual dressings A nurse is assessing a client following the administration of magnesium sulfate 1g IV bolus. For which of the following adverse effects should the nurse monitor? Respiratory Paralysis A nurse is assessing a client's hydration status. Which of the following findings indicate fluid volume overload? Distended neck veins A nurse is assessing a client following the administration of IV penicillin G. Which of the following findings should indicate to the nurse that the client is experiencing an anaphylactic reaction? Flushing A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Which of the following statements made by the client reflects an understanding of the teaching? My joints ache because I have Lyme Disease 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 A nurse is assessing a client following IV urography. Which of the following findings is the priority? swollen lips 92 | P a g e A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following statements by the client indicates an understanding of the teaching? I will count my heart beats before taking this medication. 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. A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following should the nurse plan to administer? Regular insulin 20 units IV bolus A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago. The nurse should identify which of the following findings as an indication of a myocardial infarction(MI)? Troponin 8 ng/mL A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take? Remain with the client for the first 15 minutes of the infusion. 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 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. 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 A nurse is assessing a client who has Cushing's disease. Which of the following findings should the nurse expect? Muscle atrophy A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure ulcer. Which of the following actions should the nurse take? Use a 30 mL syringe 95 | P a g e Grilled chicken breast 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? Increased fluid intake A nurse in an emergency department is caring for a client who reports chest pain of 8 on a pain scale of 0 to 10. Which of the following actions should the nurse take first? Administer morphine A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect? Low urine specific gravity A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following findings is an indication of lung re-expansion? Bubbling in the water-seal chamber has ceased. A nurse is caring for a client who has HIV. Which of the following findings indicates a positive response to the prescribed HIB treatment? Decreased viral load 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 A home health nurse is assigned to a client who was recently discharged from a rehabilitation center after experiencing a right-hemispheric cerebrovascular accident(CVA). Which of the following neurologic deficits should the nurse expect to find when assessing the client? Visual spatial deficits Left hemianopsia One-sided neglect A nurse in an ICU is planning care for a client who is in cariogenic shock. The nurse should prepare to administer which of the following medications to increase cardiac output? Dopamine A nurse is caring for a client who has viral pneumonia. The client's pulse oximeter readings have fluctuated between 79% and 88% for the last 30 min. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen? Non-rebreather mask 96 | P a g e A client who has emphysema is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first? Instruct the client to allow the machine to breathe for him. A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following non pharmacological interventions should the nurse suggest to the client to reduce pain? Alternate application of heat and cold to the affected joints A nurse is assessing a client who is taking carvedilol for heart failure. which of the following findings is the priority for the nurse to report to the provider? Weight gain A client who has a diagnosis of Clostridium difficile is placed on contact precautions. Which of the following actions should the nurse take? Leave a stethoscope in the room for blood pressure monitoring. A nurse is teaching a client who has a cardiac dysrhythmia about the purpose of undergoing continuous telemetry monitoring. Which of the following statements by the client reflects an understanding of the teaching? This identifies if the pacemaker cells of my heart are working properly. A nurse is caring for a client who has pancreatitis. The nurse should expect which of the following laboratory results to be below the expected reference range? Calcium A nurse is caring for a client who has a stage III pressure ulcer. Which of the following findings contributes to delayed wound healing? Urine output 25 mL/hr 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 A nurse is caring for a client who has a cervical spinal cord injury sustained 1 month ago. Which of the following manifestations indicates that the client is experiencing autonomic dysreflexia (AD)? Heart rate 52/min A nurse is reviewing the laboratory results of a client who has cirrhosis. Which of the following laboratory plus should the nurse expect? Elevated bilirubin level 97 | P a g e A nurse is assessing a client who is at risk for development of pernicious anemia resulting from peptic ulcer disease. Which of the following images depicts a condition caused by pernicious anemia? A.) depicts oral candidiasis/thrush B.) depicts dry oral mucous membrane C.) depicts glossitis D.) depicts a healthy tongue dull in color Glossitis A nurse is caring for a client who is experiencing an acute myocardial infarction. The nurse should identify which of the following findings as a manifestation of cardiogenic shock? Hypotension A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and note clots in the client's indwelling urinary catheter and a decrease in urinary output. Which of the following actions should the nurse take? Irrigate the indwelling urinary catheter A nurse is obtaining the health history of a client who has an abdominal aortic aneurysm. Which of the following findings should the nurse expect? Bruit heard over the middle upper abdomen A nurse is administering meperidine IM in the right deltoid of a client. The nurse aspirates the pulse back blood in the syringe. Which of the following actions should the nurse take? Dispose of the medication A nurse is caring for a client who is undergoing renal dialysis to treat end-stage kidney disease (ESKD). The client reports muscle cramps and a tingling sensation in his hands. Which of the following medications should the nurse plan to administer? Calcium carbonate A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following laboratory findings should the nurse expect? BUN 32 mg/dL 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 A nurse is planning care for a client who has community-acquired pneumonia. Which of the following interventions should the nurse include in the plan of care? Monitor the client for confusion