A nurse is caring for a client who has hepatic encephalopathy and is being treated with lactulose. The client is experiencing excessive stools. Which of
... [Show More] the following is an adverse effect of this medication.
Hypokalemia
*Lactulose works by stimulating the production of excess stools to rid the body of excess ammonia. These excessive stools can result in hypokalemia 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.
Instruct the client to allow the machine to breathe for them.
*Use the least restrictive intervention.
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.
Add cabbage to the diet.
To help reduce the risk for colorectal cancer, the client should consume a diet that is high in fiber, low in fat, low in refined carbohydrates. Brassica vegetables, such as cabbage, cauliflower, and broccoli are high in fiber.
A home health nurse is assigned to a client who was recently discharged from a rehab center after experiencing a right-hemispheric stroke. Which of the following neurological deficits should the nurse expect to find when assessing the client? (Select all that apply)
Visual Spatial deficits
left hemianopsia
one sided neglect
A nurse is caring for a client who has viral pneumonia. The clients pulse o readings have fluctuated between 79% and 88% for the last 30 minutes. Which of the following O2 delivery systems should the nurse initiate to provide the highest concentration of O2?
Nonrebreather mask
The nurse should initiate this mask to deliver between 80% to 95% O2 to the client. A client who has an unstable respiratory status should receive oxygen via a non rebreather mask.
A nurse is caring for a client who has bilateral pneumonia and a 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?
Place the client in high Fowler's position. The clients greatest risk is airway obstruction. High Fowler's facilitates lung expansion and improves ventilation and gas exchange.
A nurse is planning care for a client who has extensive burn injuries and is immune compromised. Which of the following precautions should the nurse include in the plan of care to prevent a Pseudomonas aeruginosa infection?
Avoid placing plants or flowers in the client's 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?
A urine specific gravity of 1.045
A USG greater than 1.030 indicates a decrease injuries volume and an increase in Osmolality, which is a manifestation of hypertonic dehydration.
A nurse in an emergency department is viewing 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.
Administer an opioid analgesic to the client.
The nurse should expect a prescription to help with pain.
A nurse is assessing a client who has a suspected stroke. The nurse should place the priority on which of the following findings.
Dysphagia
Airway Aspiration
A nurse is teaching a young adult client how to perform testicular self examination. Which of the following instructions should the nurse include?
Roll each testicle between the thumb and fingers.
The nurse should instruct the client to roll each testicle horizontally between the thumbs and fingers to feel 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?
"I should take this medication with a meal"
The client should take metformin with or immediately following meals 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?
Compression stockings.
A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurses priority?
Tachycardia
When using the urgent vs. nonurgent 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 client's bed flat and report 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?
Current meds
The nurse should review the client's medication record and 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 client's reaction to the allergens. The nurse should notify the provider and instruct the client to discontinue prednisone for 2 weeks before allergy skin testing.
A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish a ureterostomy. Which of the following statements should the nurse include in the teaching?
You should cut the opening of the skin barrier one-eighth inch wider than the stoma
The client should cut the opening of the skin barrier 0.3 cm wider than the stoma to minimize irritation of the skin from exposure to urine.
A nurse is providing teaching for a female client who has recurrent urinary tract infections. Which of the following information should the nurse include in the teaching.
Void before and after intercourse
The nurse should instruct the client to empty her bladder before and after intercourse, which flushes bacteria out of the urinary tract and prevents the occurrence of infection.
A nurse and assistive personnel (AP) are caring for a client who has bacterial meningitis. The nurse should give the AP which of the following instructions?
Wear a mask.
Bacterial meningitis requires droplet precautions; therefore, the AP and the nurse should wear a mask when coming within 0.9 m (3 ft) of the client until 24 hr after the client has begun receiving antibiotic therapy.
A nurse is caring for a client who is 12 hours postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?
Place a pillow between clients legs to prevent hip dislocation
A nurse in a providers office is assessing a client who has migraine headaches and is taking feverfew to prevent headaches. The nurse should identify that which of the following client medications interact with feverfew?
Naproxen
Both naproxen and feverfew impair platelet aggregation and place the client at risk for bleeding.
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 providing discharge instructions to a client following an upper gastrointestinal series with barium contrast. Which of the following information should the nurse provide?
Increase fluid intake. This will help prevent constipation.
A nurse is assessing a client who has extracorporeal shock wave lithotripsy 6 hours ago. Which of the following fundings should the nurse expect
Stone fragments in the urine.
ESWL is an effort to break the calculi so that the fragments pass down the ureter, into the bladder, and through the urethra during voiding. Following the procedure, the nurse should strain the client's urine to confirm the passage of stones.
A nurse is assessing a group of clients for indications of role changes. The nurse should identify that which of the following clients is at risk for experiencing a role change?
A client who has MS and is experiencing progressive difficulty ambulating.
The nurse should identify that progression of a neurologic disease such as multiple sclerosis can lead to a role change as the client becomes less independent.
A nurse is caring for a client who has a new diagnosis of hyperthyroidism. Which of the following is the priority assessment finding that the nurse should report to the provider?
Blood prsssure 170/80 mm Hg
A nurse is providing discharge instructions to a client who has partial thickness burn on the hand. Which of the following instructions should the nurse include?
The nurse should instruct the client to wrap the fingers individually to allow for functional use of the hand while healing occurs. The nurse should also instruct the client to perform range-of-motion exercises to each finger every hour while awake to promote function of the injured hand.
A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for sporting alpha. Which of the following client statements indicates and understanding of the teaching?
The client should monitor their blood pressure while taking this medication because hypertension is a common adverse effect and can lead to hypertensive encephalopathy.
A nurse is providing discharge teaching to a client who has heart failure and a new prescription for potassium sparing diuretics. Which of the following information should the nurse include in the teaching?
Try to walk at least three times per week for exercise
A nurse is caring for a client who has HIV. Which of the following findings indicates a positive response to the prescribed HIV treatment.
Decreased viral load
Viral load testing measures the presence of HIV viral genetic material. Therefore, a decreased viral load indicates a positive response to the prescribed HIV treatment.
A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of The following laboratory values should the nurse report to the provider?
Hgb 8
The nurse should report an Hgb level of 8 g/dL, which is below the expected reference range and is an indicator of postoperative hemorrhage or anemia.
A nurse is assessing a client who has had a plaster cast applied to their left leg 2 hours ago. Which of the following actions should the nurse take?
Check that one finger fits between the cast and the leg
A nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. Which of the following statements indicates an understanding of the teaching?
I am taking this medication to increase my energy level
A nurse is caring for a client who is undergoing hemodialysis to treat end stage kidney disease. The client reports muscle cramps and a tingling sensation in their hands. Which of the following medications should the nurse plan to administer?
Calcium carbonate
Hypocalcemia is a manifestation of ESKD and an adverse effect of dialysis. Often occurring late in the dialysis session, hypocalcemia can cause the client to experience muscle cramping and tingling to extremities. The nurse should plan to administer a calcium supplement, such as calcium carbonate, as a calcium replacement.
A nurse in a community clinic is caring for a client who reports an increase in the frequency of migraine headaches. To help reduce the risk for migraine headaches, which of the following foods should the nurse recommend the client avoid?
Aged cheese
Foods that contain tyramine, such as aged cheese and sausage, can trigger migraine headaches
A nurse is providing teaching to a female client who has a history of UTIs. Which of the following information should the nurse include in the teaching
Take daily cranberry supplements
The client should take cranberry supplements or drink low-fructose cranberry juice because it contains compounds that adhere to the urinary tract wall, decreasing the risk for developing a UTI.
A nurse is performing a dressing change for a client who is recovering from a hemicolectomy. When removing the dressing, the nurse notes that a large part of the bowel is protruding through the abdomen. Which of the following actions should the nurse take first?
Call for help. This is a medical emerg
A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take?
The nurse should remain with the client for the first 15 to 30 min of the infusion because hemolytic reactions usually occur during the infusion of the first 50 mL of blood.
A nurse is evaluating a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following client statements indicates the client is successfully coping with the challenge
I never used to worry about my feet. Now I inspect my feet every day with a mirror.
A nurse is caring for a client who has a closed head injury and has a intraventricular catheter placed. Which of the following findings indicates that the client is experiencing intracranial pressure? Select all that apply
Sleepiness
Widening pulse pressure
Decerebrate posturing
A nurse is planning to provide discharge teaching for the family of an older adult client who has hemianopsia and is at risk for falls. Which of the following instructions should the Rn include.
The nurse should instruct the family to remind a client who has hemianopsia, or blindness in half of the visual field, to use visual scanning to look over their complete range of vision during ambulation. This practice can accommodate for the loss of vision and help to reduce the risk for falls.
A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the past three days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit
Elevated HR
injecting enoxaparin
The nurse should inject the medication into the anterolateral or posterolateral abdominal wall to enhance medication absorption and prevent hematoma formation
A nurse is in a providers office caring for a client who requests sildenafil to treat erectile dysfunction. Which of the following statements should the nurse make?
You will not be able to use sildenafil if you are taking nitroglycerin
A nurse in an ED is assessing a client who has a detached retina. Which of the following should the nurse expect the client to report?
It's like a curtain closed over my eye.
A retinal detachment is the separation of the retina from the epithelium. It can occur because of trauma, cataract surgery, retinopathy, or uveitis. Clients who have retinal detachment typically report the sensation of a curtain being pulled over part of the visual field.
A nurse is providing teaching to an older adult client who has cancer and a new prescription for an opioid analgesic for pain management. Which of the following information should the nurse include in the teaching?
You should void every 4 hours to decrease the risk of urinary retention.
The nurse should instruct the client to void at least every 4 hours to decrease the risk of urinary retention, which is an adverse effect of opioid analgesics.
A nurse is assessing a client following the administration of magnesium sulfate 1 g IV bonus. For which of the following adverse effects should the nurse monitor?
Respiratory Paralysis
The nurse should monitor a client who is receiving magnesium sulfate via IV bolus closely as the adverse effects can impact the CNS, the cardiovascular system, and the respiratory system. Respiratory paralysis is a life-threatening adverse effect of magnesium sulfate.
A nurse is assessing a male client for an in guitar hernia. Which of the following areas should the nurse palpate to verify that the client has an inguinal hernia.
C is correct. The nurse should palpate this location to assess the client for an inguinal hernia. An inguinal hernia forms from the peritoneum, which contains part of the intestine, and can protrude into the scrotum in men.
A nurse is caring for a client who has type 1 diabetes mellitus and has had acute bronchitis for the past 3 days. Which of the following statements should the nurse include when instructing the client?
Take insulin even if you are unable to eat your regular diet.
The client should continue the prescribed medication regimen when ill to prevent hyperglycemia.
A nurse has received change-of-shift report for a group of clients. Which of the following clients should the nurse assess first?
A client who has a MI 4 days ago and is asking for aPRN sublingual nitroglycerin tablet.
When using the stable vs. unstable approach to client care the nurse should assess this client first. A client who had a myocardial infarction 4 days ago and is asking for a PRN sublingual nitroglycerin tablet could be unstable. This client might be experiencing angina or could be having another MI.
A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. Which of the following assessment findings is the nurses priority?
Increased respiratory secretions
AIRWAY, BREATHING, CIRCULATION approach.
A nurse is creating a plan of care for a client who has neutropenia as a result of chemotherapy. Which of the following interventions should the nurse include in the plan?
Monitor the clients temp every 4 hours.
The nurse should monitor the temp of a client who has neutropenia every 4 hours because the clients reduced amount of leukocytes gradually increases the clients risk for infection.
A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medication?
Calcium.
Calcium limits the development of osteoporosis in clients who are post menopausal and works as an antacid. Calcium supplements can interfere with the metabolism of a number of medications, including levothyroxine. The nurse should instruct the client to avoid taking calcium within 4 hours of levothyroxine administration.
A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive cough. Which action should the nurse take first?
Administer airborne precautions.
This client is exhibiting manifestations of TB. The greatest risk in this client situation is for other people in the facility to acquire an airborne disease from this client. Therefore, the first action the nurse should take is to initiate airborne precautions.
A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the following precautions should the nurse implement?
Make sure that the patient has a patent IV.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A new bag is not available when the current infusion is nearly completed. Which of the following actions should the nurse take?
Administer dextrose 10% in water until the new bag arrives.
A nurse is providing dietary teaching to a client who is postoperative following a thyroidectomy with removal of the parathyroid glands. The nurse should instruct the client to include which of the following foods that has the greatest amount of calcium in her diet?
12 almonds.
The nurse should determine that almonds are the best source of calcium to recommend because 12 almonds contain 36 mg of calcium. Removal of the parathyroid glands, which regulate calcium in the body can result in hypocalcemia.
A nurse is caring for a client who is experiencing a tonic-clinic seizure. Which of the following actions should the nurse take?
Loosen restrictive clothing.
A nurse is performing a cardiac assessment for a client who had a MI 2 days ago. Which of the following actions should the nurse take first after hearing the following sound?
Listen with the client on their left side.
Auscultation of the murmur while the client is laying on their left side is the least invasive approach initially so the nurse can hear the murmur more clearly [Show Less]