A nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. The client is experiencing excessive stools. Which of t... [Show More] he following findings is an adverse effect of this medication? - ANSWER-Hypokalemia
Rationale: Lactulose works by stimulating the production of excess stores to rid the body of excess ammonia. These excessive stores can result in a hypo kalemia and dehydration.
A nurse is caring for a client who has emphysema and 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? - ANSWER-Instruct the client to allow the machine to breathe for them.
Rationale: When providing client care, the nurse should first use the least restrictive intervention. Therefore, the first action the nurse should take is to provide verbal instructions in emotional support to help the client relax and allow the ventilator to work. Clients can exhibit anxiety and restlessness we're trying to "fight the ventilator."
A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate this risk, which of the following dietary alterations should the nurse recommend? - ANSWER-Add cabbage to the diet.
Rationale: To help reduce the risk for colorectal cancer, the client should consume a diet that is high in fiber, low in fat, and low in refined carbohydrates. Brassica vegetables, such as cabbage, cauliflower, and broccoli, are all high in fiber.
A home health nurse is assigned to a client who was recently discharged from a rehabilitation center after experiencing a right-hemispheric stroke. Which of the following neurologic deficits should the nurse expect to find when assessing the client? (Select all that apply.) - ANSWER-Visual spatial deficits, Left hemianopsia, One-sided neglect.
Rationale: Visual spatial deficits and loss of depth perception occur secondary to a right hemispheric stroke. Left hemianopsia, or blindness in the left half of the visual field, occur secondary to right hemispheric stroke. One-sided neglect, or in unawareness of the affected side, occur secondary to a right hemispheric stroke.
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? - ANSWER-Nonrebreather mask
Rationale: The nurse should initiate a nonrebreather mask to deliver between 80% to 95% oxygen to the client. A client who has an unstable respiratory status should receive oxygen via non-rebreather mask.
A nurse is caring for a client who has bilateral pneumonia and an SaO2 of 85%. The client has dyspnea with a productive cough and is using accessory muscles to breathe. Which of the following actions should the nurse take first? - ANSWER-Place the client in high-Fowler's position.
Rationale: the greatest risk to this client is injury from airway obstruction. Therefore, their priority intervention the nurse should take us to move the client into high Fowlers position. High Fowlers position facilitate long expansion and improves been elation and gas exchange
A nurse is planning care for a client who has extensive burn injuries and is immunocompromised. Which of the following precautions should the nurse include in the plan of care to prevent a Pseudomonas aeruginosa infection? - ANSWER-Avoid placing plants or flowers in the client's room.
Rationale: live plants can harbor P. Aeruginosa, And this bacterium can infect burn moons and cause life-threatening complications. The nurse should ensure no one brings live plants or flowers into the clients room.
An older adult client is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration? - ANSWER-Urine specific gravity 1.045
Rationale: a urine specific gravity greater than 1.030 indicates a decrease in urine volume and an increase in osmolarity, which is a manifestation of hypertonic dehydration.
A nurse in an emergency department is reviewing the provider's prescriptions for a client who sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the nurse expect? - ANSWER-Administer an opioid analgesic to the client.
Rationale: the nurse should expect a prescription for an opioid analgesic to promote comfort following a rattlesnake bite.
A nurse is assessing a client who has had a suspected stroke. The nurse should place the priority on which of the following findings? - ANSWER-Dysphagia
Rationale: dysphasia indicates that this client is at greatest risk for aspiration due to impaired sensation and function within the oral cavity. Therefore, the nurse should place priority on this finding.
A nurse is teaching a young adult client how to perform testicular self-examination. Which of the following instructions should the nurse include? - ANSWER-Roll each testicle between the thumb and fingers.
Rationale: the nurse should instruct the client to roll each testicle horizontally between the thumbs and fingers to fill for any lumps deep in the center of the testicle.
A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new prescription for metformin. Which of the following statements by the client indicates an understanding of the teaching? - ANSWER-"I should take this medication with a meal."
Rationale: the client should take metformin with or immediately following Mills to improve absorption and to minimize gastrointestinal distress.
A nurse is teaching a client who has venous insufficiency about self-care. Which of the following statements should the nurse identify as an indication that the client understands the teaching? - ANSWER-"I will wear clean graduated compression stockings every day."
Rationale: the client should apply a clean pair of graduated compression stockings each day and clean stalls stockings with a mild detergent and warm water by hand.
A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurse's priority? - ANSWER-Tachycardia
Rationale: when using the urgent versus non-urgent approach to client care, the nurse should determine that the priority finding is tachycardia. Tachycardia is a manifestation of biliary colic, which can lead to shock. The nurse should position the head of the clients bed flat airport this finding immediately to the provider.
A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The nurse should postpone the testing and report to the provider which of the following findings? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) - ANSWER- Current medications
Rationale: the nurse should review the clients medication record to identify medications, including ace inhibitors , beta blockers,theophylline, nifedipine, And glucocorticoids, such as prednisone, that can alter the allergy skin test results. These medications can diminish the clients reaction to the allergens, and the nurse should notify the provider
and instruct the client to discontinue prednisone for two weeks before the allergy skin test.
A nurse is caring for a group of clients. The nurse should plan to make a referral to physical therapy for which of the following clients? - ANSWER-A client who is receiving preoperative teaching for a right knee arthroplasty.
Rationale: the nurse should make a referral to physical therapy so the client can begin understanding post operative exercises and physical restrictions.
A nurse is caring for [Show Less]
