A nurse is caring for a client with diabetes insipidus (DI). Which data warrants the most immediate intervention by the nurse?
A. Serum sodium of 185
... [Show More] mEq/L
B. Dry skin with inelastic turgor
C. Apical rate of 110 beats per minute
D. Polyuria and excessive thirst - A.
The nurse is obtaining the admission history for a client with suspected peptic ulcer disease. Which subjective data reported by the client supports the medical diagnosis?
A. Frequent use of chewable and liquid antacids for indigestion.
B. Severe abdominal cramps and diarrhea after eating spicy foods.
C. Upper mid-abdominal pain described as gnawing and burning.
D. Marked loss of weight and appetite over the last 3-4 months - C.
The nurse assesses a client who is newly diagnosed with hyperthyroidism and observes that the client's eyeballs are protuberant, causing a wide-eyed appearance and eye discomfort. Based on this finding, which action should the nurse include in this client's plan of care?
A. Assess for signs of increased intracranial pressure.
B. Prepare to administer intravenous levothyroxine
C. Review the client's serum electrolyte values
D. Obtain a prescription for artificial tear drops. - D.
To reduce the risk for pulmonary complication for a client with Amyotrophic Lateral Sclerosis (ALS), which interventions should the nurse implement? SATA
A. Perform chest physiotherapy
B. Teach the client breathing exercises
C. Initiate passive range of motion exercises
D. Establish a regular bladder routine
E. Encourage use of incentive spirometer. - A., B., E.
A client is hospitalized with heart failure. Which intervention should the nurse implement to improve ventilation and reduce venous return?
A. Perform Passive range of motion exercises
B. Place the client in High Fowler Position
C. Administer oxygen per nasal cannula
D. Increase the client's activity level. - B
A client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that the client's distal pulses are diminished in the left foot. Which interventions should the nurse implement? SATA
A. Verify pedal pulses using a doppler pulse device.
B. Evaluate the application of the splint to the left leg.
C. Offer ice chips and oral clear liquids
D. Monitor left leg for pain, pallor, paranesthesia, paralysis, pressure.
E. Administer oral antispasmodics and narcotic analgesics - A., B., D.
The healthcare provider prescribes diagnostic tests for a client whose chest x-ray indicates pneumonia. Which diagnostic test should the nurse review for implementation in the most therapeutic treatment of the pneumonia?
A. Sputum culture and sensitivity
B. Blood cultures
C. Arterial blood gases
D. Computerized Tomography (CT) of the chest - A.
A client with a history of asthma and bronchitis arrives at the clinic with SOB, productive cough, with thickened, tenacious mucous, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care?
A. Call the clinic if undesirable side effects of medications occur.
B. Avoid crowded enclosed areas to reduce pathogen exposure.
C. Increase the daily intake or oral fluids to liquefy secretions.
D. Teach anxiety reduction methods for feelings of suffocation - C.
The nurse observes a increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a trans-urethral resection of the prostate (TURP). What is the best initial nursing action?
A. Provide additional oral fluid intake.
B. Measure the client's intake and output.
C. Increase the flow of the bladder irrigation.
D. Administer a PRN dose of an antispasmodic agent. - C.
Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?
A. Elevate extremities on pillows.
B. Evaluate edema for pitting.
C. Assess pulses with a vascular doppler.
D. Wrap the feet with warmed blankets. - C. [Show Less]