Neurologic deficits that should be expected in right-hemispheric stroke - ANSWER 1. Visual Spatial Deficits
2. Left Hemianopsia
3. One sided
... [Show More] neglect
The nurse should postpone the allergy testing and report to the provider which of the following findings? - ANSWER Current Medications
"Clients should avoid corticosteroids and avoid antihistamines from 48hr to 2 weeks to prep for testing according to how long they last."
The nurse should plan to make a referral to physical therapy for which type of client? - ANSWER Client receiving prep teaching for a r-knee arthroplasty
"Client will need to be taught how to ambulate safely"
What is the nurses priority for a patient having a seizure? - ANSWER Turn the client to the side.
"The patient should be side-lying to prevent them from aspirating. This also allows oral secretions to come out that may obstruct the airway."
*Other actions - loosen clothing around neck, check pupils, and move furniture away from pt.
*Look for safety risks first. Follow ABC! Assess which risk is greater before acting.
Nursing actions for a patient 12 hr postoperative following a total hip arthroplasty? - ANSWER Place a pillow between the client's legs
"This action will allow the patient to avoid dislocation"
pg. 437
Caring for a client with dysphagia. (Difficulty swallowing) Bedside item? - ANSWER Suction machine
"This item should be in place to readily suction the patient if the airway starts to become obstructed."
Nursing teaching for a patient that will undergo a cutaneous diversion procedure to establish a ureterostomy.
*Cutaneous diversion - occurs when a patient has bladder cancer. The provider creates a reservoir from a section in the bowel that will allow the urine to flow to another area via the ureters instead of the bladder. - ANSWER Cut the opening of the skin barrier 1/8 inch wider than the stoma.
pg. 241
Nursing findings to indicate fluid volume deficit - ANSWER Heart rate 110/min
*In hypovolemia the HR will elevate and the BP will lower."
*The higher (> 1.030) the urine specific gravity the more dehydrated the patient.
Nursing actions to include in the clients plan of care for a patient receiving brachytherapy. (Internal radiation placed in a closed area of the body to target cancerous tissue) - ANSWER Wear a lead apron while providing care to the client.
"Protects the nurse from the radiation, must wear a dosimeter to measure exposure."
D/C Teaching
"The clients urine and feces can contain radioactive substances which can be harmful to other if disposed of improperly, will need to place urine and feces in a bio bag."
pg. 606
Older client who has hemianopsia; at risk for falls. Nursing teaching? - ANSWER Remind client to scan their complete range of vision during ambulation
"Hemianopsia cause a patient to experience vertical midline blindness in 1/2 of their visual field, usually caused by a stroke."
Interventions the nurse should include in the plan of care for a patient starting dialysis treatments for chronic kidney disease. - ANSWER Tell the client that it is possible to return to similar previous levels of activity.
"Other options are not therapeutic or medically correct. This statement can be true if patient has positive outcomes from the treatment which may be causing negative side effects."
Manifestations of ICP in a patient with a closed head injury - ANSWER 1. Sleepiness exhibited by the client.
2. Widening pulse pressure - late finding of Cushings triad w/severe HTN and bradycardia
3. Decereberate posturing - due to deteriorating motor function
pg. 81
Assessment for a patient suspected of hypertonic dehydration - ANSWER Urine specific gravity 1.045
*Patients may also have Na level > 145, and blood osmolality > 295.
pg. 278
Adverse effect of enlapril - ANSWER Orthostatic hypotension
"Calcium channel blocker"
Client teaching for a patient receiving sildenafil to treat erectile dysfunction. - ANSWER You will not be able to use sildenafil if you are taking nitroglycerin.
"This combination can cause severe hypotension and/or death."
Precautions for a patient who is immunocompromised to prevent a pseudomonas aeruginosa infection. - ANSWER Avoid placing plants or flowers in the client's room.
"These items can have harmful bacteria on them that can increase the r/4 infection."
Teaching about client rights. Instructions the nurse should include. - ANSWER A client should sign an informed consent before receiving a placebo during a research trial.
"The client should be informed although it is a placebo because they are being part of a clinical trial in which those who may not receive the placebo may experience side effects. Patients are not told they have the placebo for the trial to work so everyone is given the same info."
Pain management for a patient needing a dressing change. Patient is worried about getting addicted to morphine. What should the nurse say? - ANSWER Instruct the client on alternative therapies for pain reduction.
"This statement acknowledges the patient's concern and provides therapeutic options."
Medication to withhold for 48hr period to a cardio version for a patient with supra ventricular tachycardia ? - ANSWER Digoxin
"This helps bring the heart back to a normal rhythm for the critical first few hours after cardioversion. This will allow the physician to fix the original problem."
Nurse notes the formation of a hematoma at the insertion site and a dec. pulse rate in the affected extremity 1hr after a cardiac Cath. Nursing priority? - ANSWER Apply firm pressure to the insertion site.
"Hold pressure at the site to control bleeding as assessed by the pt having a hematoma and dec. pulse rate at the extremity."
pg. 174
Findings contributing to delayed wound healing? - ANSWER Urine output 25 mL/hr
*Encourage patient to intake 2-3l of fluid if there aren't any present contraindications."
pg. 341
Normal albumin - 3.4 to 5.4
Normal WBC - 4,000 to 11,000
BMI should be between 18 and 25
Statement that indicates understanding in a patient with a new prescription for epoetin alfa. - ANSWER I will monitor my blood pressure while taking this medication.
"This medication can cause HTN due to the fast increase in rbc production; especially in those with kidney disease."
Information to provide to a patient following an upper GI series with barium contrast. - ANSWER Increase fluid intake.
Graves Disease can cause exophthalmos. "Bulging of the eye anteriorly out of the orbit." - ANSWER
Acute cholecystitis - Inflammation of the gallbladder wall.
Priority finding for the nurse? - ANSWER Tachycardia
"Rebound tenderness is also a priority but it can only be assessed by the provider; pain will only be in the r-upper quadrant and radiate to the right shoulder as an expected finding."
pg. 355
Diet alterations the nurse should recommend for colorectal cancer? - ANSWER Add cabbage to the diet?
"Patients need low fat, simple carbs, and high fiber. DASH Diet"
pg. 623
Patient on a vent appears anxious and restless; high pressure alarm is sounding. What is the nurses first action? - ANSWER Instruct patient to allow the machine to breathe for them
"Least invasive to most invasive"
Preop teaching for patient undergoing a open cholecystectomy. - ANSWER Demonstrate ways to deep breath and cough.
"Need to do this to prevent pneumonia and to protect incision from popping open."
Instructions for the AP caring for a pt with bacterial meningitis. - ANSWER Wear a mask.
"This type of meningitis can be infectious; can be transferred through droplets, initiate droplet precaution."
pg. 32
Nursing action for RBC infusion - ANSWER Remain with the client for the first 15 min of the infusion.
"Patient is at highest risk for dev. an allergic reaction."
Client teaching for patient with chronic kidney disease with a new prescription for erythropoietin. Client statement that indicates understanding of the teaching. - ANSWER I am taking this medication to increase my energy level.
"Chronic kidney disease can cause anemia due to low productions of rbcs. Patients may also loose blood through hemodialysis. Low rbc levels can cause fatigue."
Lactulose adverse effect?
Used to treat hepatic encephalopathy. (The liver is severly damaged causing a decline in the brain, and a b/u of toxins in the bloodstream.) - ANSWER Hypokalemia
"Lactulose is used to treat constipation; in return it can cause diarrhea and fluid/electrolyte loss leading to hypokalemia and hypernatremia. (Rxlist)"
BMI of 32 in a older adult female who has stress incontinence. Statement by client understanding teaching? - ANSWER I am dieting to lose weight.
"A normal bmi is 18 to 25; being overweight can cause excess pressure on the pelvic area leading to incontinence."
Type 1 diabetic with acute bronchitis for the past 3 days. Nursing instructions? - ANSWER Take insulin even if you are unable to eat your regular diet.
"Being sick can cause your blood glucose levels to rise without the patient being aware, they should check levels more often and call the dr. for bg above 250."
Nursing action for a patient with a new prescription of subQ enoxaparin. - ANSWER Inject the medication into the anterolateral abdominal wall.
"Do not expel the bubble in this type of syrine or massage site.
A patient undergoing hemodialysis for ESKD needs what med if they report muscle cramps and a tingling sensation in their hands. - ANSWER Calcium carbonate
"Hypocalcemia causes paresthesia.
Adverse effect of magnesium sulfate. - ANSWER Respiratory paralysis
"Have calcium gluconate on hand as the antidote."
Expected lab findings for a patient with DKA? - ANSWER BUN 32 mg/dL
"In dka the c02 may be high and the bicarb and ph will be low due to fluid loss. You pee/vomit out all the base leaving you acidic. Fluid loss also causes the BUN to be elevated. (10-20)"
Nursing teaching for a client with IBS. - ANSWER Increase fiber intake to at least 30 g per day.
pg. 340
"Soluble fiber will help promote good bowel function by slowing things down to help with diarrhea the ibs patient may have, they should avoid insoluble fiber because it can increase diarrhea."
Expected lab findings for a patient with pancreatitis that will be lower than normal. - ANSWER Calcium
"Calcium and mag may be lower than normal due to fat necrosis (occurs when fatty tissue is damaged).
pg. 360
Expected findings 6hrs after etracorporeal shock wave lithotripsy (ESWL)? - ANSWER Stone fragments in the urine.
"The nurse should assess for hematuria and strain the urine after the procedure. Bruising will only be at the site where the waves were applied."
pg. 408
Nursing intervention for a patient who has neutropenia as a result of chemotherapy. - ANSWER Monitor the client's temperature every 4hr.
"They are at a high risk for infection. A rise in temp can indicate an infection brewing."
Client at risk for experiencing a role change. - ANSWER A client who has multiple sclerosis and is experiencing progressive difficulty ambulating.
"This patient may have to depend on other for help causing them to not be as independent as they are used too."
Feverfew is a plant used to treat migraines. Which medication will interact with feverfew? - ANSWER Naproxen
"Patients taking garlic, feverfew, and ginger may experience gi bleeding while also taking NSAIDS. Ginkgo biloba is also contraindicated due to the suppression of coagulation."
pg. 284
Finding requiring further assessement for a patient who is about to undergo a CT scan with an IV contrast agent. - ANSWER History of asthma
"?"
Which patient should the nurse assess first? - ANSWER A client who had a MI 4 days ago and is asking for a PRN sublingual nitro tablet.
"The nurse should treat this patient first because they can become unstable, at risk for another MI. Very painful. Seeing them first will be considered prophylactic treatment of chronic stable angina or variant angina."
*Pt with pneumonia is presenting with expected symptoms, still needs to be monitored though.
Client has anorexia, low grade fever, night sweats, and a productive cough. Which action should the nurse take first? - ANSWER Initiate airborne precaution.
"These symptoms are those of TB in which the nurse should immediately protect those around the patient until sputum samples come back which is the second action they should take."
TPN 2,000 kcal per day; 500 kcal/L. How many mL/hr? - ANSWER 167 mL/hr
"2,000/24hrs = 83.333
83.333/500= 0.1667*1000=166.666
Round to the nearest whole number =167"
A patient has a full-thickness burn over 20% of their total body surface area. After ensuring a patent airway and administering O2 what should the nurse do first? - ANSWER Iniate IV fluids
"Client is at risk for hypovolemic shock due to fluid loss through the purns. Client will need pain management next."
Nursing actions to take when planning to irrigate and dress a clean, a granulating wound for a client who has a pressure injury. - ANSWER Use a 30-mL syringe.
"Do not apply a wet to dry gauze because it will take off the good skin when dry, use a 30ml syringe to irrigate because it holds enough fluid to be able to irrigate."
Nursing teaching for a female client who has recurrent urinary tract infections. - ANSWER Void before and after intercourse.
"This will allow her to void bacteria that may contribute to her UTIs. Wear cotton underwear to absorb the moisture, take showers, and drink 2-3L of fluid."
Client has supraventricular tachycardia. HR of 200/min, BP 78/40, and Resp rate of 30/min. Nursing action? - ANSWER Perform synchronized cardioversion.
"You need to get the patients heart rhythm back regular. Cardioversion uses lower jules than defribrillation."
Older client with cancer and a new prescription for an opiod analgesic for pain management. Nursing teaching? - ANSWER You should void every 4 hours to decrease the risk of urinary retention.
"Pain meds can slow the body down."
Precautions the nurse should implement for a client at risk for seizures. - ANSWER Ensure that the client has a patent IV.
"If the patient starts to have a seizure they will need iv meds immediately."
Client has a new prescription for omeprazole for a gastric ulcer. Provides relief by which of the following actions? - ANSWER Suppressing gastric acid production.
"This medication is a proton pump inhibitor."
A client has bilateral pneumonia and an SaO2 of 85% with dyspnea, productive cough and is using accessory muscles to breathe. Which action should the nurse take first? - ANSWER Place the client in high-Fowler's position.
"This will help the client breathe better until further interventions are put into place."
Inguinal hernia - ANSWER A
"This hernia occurs from a weak area in the muscle. Protrusion common in the groin area, umbilicus, and a healed incision."
pg. 340
Manifestations of a thyroid storm? - ANSWER 1. Fever - report increase of 1 degree or more because this can become a thyroid crisis
2.Hypertension
3.Tachycardia
pg. 526
First action for the nurse to take after noting a large part of the bowel protuding through the abdomen? - ANSWER Call for help.
"Call for help because this is a surgical emergency."
pg. 343
Discharge teaching for a client who has a partial thickness burn on the hand? - ANSWER Wrap fingers with individual dressings.
"You want to maintain active and passive ROM"
pg. 503
Finding that indicates positive response to the prescibed HIV treatment in a client with HIV? - ANSWER Decreased viral load
A client is receiving TPN and a new bag is not available and the current infusion is nearly completed. Which of the following actions should the nurse take? - ANSWER Administer dextrose 10% in water until the new bag arrives.
"The nurse should keep a bag of this solution near the bedside to prevent the risk for hypoglycemia due to abrupt changes in dextrose concentrations if the tpn runs out and nothing is being infused."
Priority finding for a client who has been suspected of having a stroke? - ANSWER Dysphagia
"This puts the client at a high risk of aspirating."
*Ataxia - lack of coordination in muscle movements, body does what it wants.
A client with hypertension and taking propranolol in a provider's office. What indicates the client is experiencing a adverse effect to the medication? - ANSWER Report of night cough.
"This medication can cause hypoglycemia and bronchospasms. Mon. BP and HR."
pg. 179
A client in the ER has a detached retina. What should the nurse expect the client to report? - ANSWER It's like a curtain closed over my eye.
"Retina has detached from the blood vessels that give it O2 and nutrients; medical emergency."
Teaching for a female client who has a history of UTIs? - ANSWER Take daily cranberry supplements.
"The compound in the fruit helps to avoid some bacteria from sticking to the mucous membranes in the urinary track to reduce r/4 infection."
pg. 401
A client sustained a rattlesnake bite to the lower leg. What prescription should the nurse expect? - ANSWER Administer an opiod analgesic to the client.
"The bite will cause pain and it should be managed as a priority;keep leg at the heart level to dec. circulation of the venom."
Manifestation of chronic glomerulonephritis? - ANSWER Hyperkalemia
What food from the list should the client avoid to reduce the risk of migraine headaches? - ANSWER Aged Cheese
"Tyramine products can increase r/4 headaches."
Nursing actions for a client with a plaster cast applied to the leg 2hrs ago? - ANSWER Check that one finger fits between the cast and the leg.
"This ensures that the cast isn't too tight. Document any drainage or sudden increase in drainage; report to provider. Inspect cast q 8-12hrs"
Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen? - ANSWER Nonrebreather mask
Assessment finding the nurse should report to the provider for a patient with a new diagnosis of hyperthyroidism? - ANSWER Blood pressure 170/80 mm Hg
"BP of 160/80 or higher needs to be reported, can indicate hypertensive crisis."
How to perform testicular self-examination. - ANSWER Roll each testicle between the thumb and fingers.
"Perform after a bath to allow for the testicles to drop, eval each separately."
Potassium level of 3 mEq/L. Expected nursing assessment? - ANSWER Hypoactive bowel sounds.
"Hypokalemia slows things down in the body. can cause n/v, abd distention."
pg. 286
Lab values for a client who has cirrhosis? - ANSWER Elevated bilirubin level
"Bilirubin increases because the liver cannot metabolize it properly to maintain blood levels. Can cause jaundice."
A client with HF a new prescription for a potassium-sparing diuretic. Nursing teaching? - ANSWER Try to walk at least three time per week for exercise.
Successfully coping with change in a client who has a new diagnosis of type 1 diabetes. - ANSWER I used to never worry about my feet. Now, I inspect my feet everyday with a mirror.
A client who has hypothyroidism and is receiving levothyroxine. What supplement can intefere with effectiveness of medication? - ANSWER Calcium
"Fiber, calcium, iron, and antacid supplements can interfere with absorption. FICA"
pg. 532
Client who has has esophageal cancer and is to udnergo radiation therapy. Client statement indicating understanding of teaching? - ANSWER "I will use my hands rather than a washcloth to clean the radiation area.
"This will prevent irritation to the area and removal of markings."
What action should the nurse take first after hearing the following sound? Client had a MI 2 days ago. - ANSWER Listen with the client on their left side.
"?"
Teaching a client with venous insufficiency about self care. Statement indicating understanding of teaching? - ANSWER I will wear clean graduated compression stockings every day.
"This will help to promote venous return, increasing blood flow."
A client is experiencing a tonic-clonic seizure. Nursing action? - ANSWER Loosen restrictive clothing.
"Prevent any obstructions to the airway."
1 week follow up for heart failure, report which finding? - ANSWER Heart rate 55/min
"HR is below the normal"
Understanding of the teaching for metformin? - ANSWER I should take this medication with a meal. [Show Less]