Respiratory Alkalosis S/S
lethargy
lightheadedness
confusion
tachycardia
dysrhythmias related to hypokalemia
nausea
vomiting
epigastric
... [Show More] pain
numbness and tingling of the extremities
hyperventilation (tachypnea)
A nurse is contributing to the plan of care for an older adult client who is at risk for Osteoporosis. Which intervention should the nurse include to prevent bone loss?
Encourage weight bearing exercises (such as walking because it can help maintain bone mass by reducing bone demineralization, thus helping to prevent osteoporosis.)
A nurse is caring for a client who has meningococal pneumonia. Which of the following personal protective equipment should the nurse use?
Mask (this disease requires droplet precautions)
A nurse is reinforcing teaching with a client who is taking insulin Glargine. What information should the nurse include in the teaching?
This type of insulin should be given at the same time everyday. (It is released over a 24hr period)
A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. What statement by the client indicates that they are adhering to the nurse's instructions?
"I don't cross my legs anymore".
A nurse is caring for a client who has a methicillin-resistant Staphlococcus aureus (MRSA) infections in a surgical wound. What information should the nurse plan to share with visitors?
Visitors must don a gown & gloves prior to entering the client's room.
A nurse is reinforcing teaching with a client who has heart failure and a new prescription for hydrochlorothiazide. What should the client report to the provider?
Onset of nausea
A nurse is reinforcing discharge teaching with a client who has hearing loss. What action should the nurse take when communicating with the client?
Rephrase client instructions when not understood.
A nurse is caring for a client who is 1 day post operative following a hip arthroplasty. The client is exhibiting hypotension, tachycardia, & tacky-nearly. The nurse should recognize these findings as what complication?
Pulmonary Embolism
A nurse is monitoring a client who recently had a cast placed on the right lower extremity for a bone fracture. What finding should the nurse recognize as abnormal?
Lack of sensation between the first and second toes
A nurse reinforcing teaching with a client who has systemic lupus erythematosus (SLE) and is to begin taking methylprednisolone orally. What should the nurse include in the teaching?
Limit contact with large groups of people
A nurse is caring for a client who is 24hr postoperative following abdominal surgery & has an NG tube. What action should the nurse plan to take to decrease the risk of postoperative complications?
Encourage the client to use an incentive spirometer every hour while awake
A nurse is collecting data from a client who has chronic kidney disease with hyperkalemia. What finding should the nurse expect related to hyperkalemia?
Bradycardia
A nurse is assisting in the care of a client who has manifestations of sepsis. What provider prescriptions should the nurse implement first?
Initiate oxygen at 4 L/min via nasal cannula
A nurse is caring for a client who has terminal pancreatic cancer. The client states, "I don't think I can go on any longer." What response should the nurse make?
"Tell me more about the way you are feeling."
A nurse is collecting data from a client who has hypokalemia. What finding should the nurse identify as the priority?
Dysrhythmia
A nurse is caring for a client who is in Buck's traction. What intervention should the nurse perform to reduce skin breakdown?
Keep the skin dry and free of perspiration
A nurse is contributing to the plan of care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infections and is on contract isolation precautions. What action should the nurse take?
Have a designated stethoscope in the client's room
A nurse enters the room of a client whose transfusion of packed RBCs was initiated 15 min ago by the RN. The client reports dyspnea and urticaria. What action should the nurse perform first?
Stop the infusion
A nurse is preparing to auscultate the bowel sounds of a client who has a mechanical bowel obstruction in the descending colon. When listening in the left upper quadrant, the nurse should identify this sound as what?
Hyperactive bowel sounds
A nurse is preparing to administer furosemide to a client who has heart failure. What should the nurse report before administering the medication?
Decreased potassium
A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. What information should the nurse include in the teaching?
Apply cold packs to the joints
A nurse is collecting data from a client who has hypothyroidism. What manifestation should the nurse expect?
Bradycardia
A nurse is reinforcing teaching with an older adult client who has osteoporosis. What instructions should the nurse include in the teaching?
Take the calcium supplements with meals
A nurse is reviewing the medical record for an older adult client who is experiencing nausea & vomiting. Based on the client data, what action should the nurse take?
(Na 142 mEq, K+ 4.2 mEq/L, BUN 36 mg/dL, Creatinine 1.4 mg/dL)
Notify the charge nurse of the client's BUN level
A nurse is admitting a client who is suspected having active tuberculosis (TB). What action should should the nurse take first?
Institute airborne precautions
A nurse is monitoring a client who has a wrist cast and reports intense itching underneath the cast. What action should the nurse take?
Blow cool air into the cast using a blow dryer on a cool setting
A nurse is planning care for a group of clients after receiving change-of-shift report. What client should the nurse see first?
A client who is dehydrated, has mental confusion, & was found getting out of bed several times during the night.
A nurse is caring for a client who reports shortness of breath and has an oxygen saturation of 90%. What action should the nurse take?
Administer oxygen via nasal cannula
A nurse is caring for a client who has a prescription for digoxin 0.25mg PO daily. While taking the client's apical pulse, the nurse notes a rate of 58/ min. What action should the nurse take?
Withhold the dose
A nurse is caring for a client who has an intestinal obstruction & reports a new onset of nausea. The client has an NG tube set at low intermittent suction & is receiving continuous IV infusion of 0.9% sodium chloride. What action should the nurse take first?
Check for kinks in the NG tube
A nurse is reinforcing teaching with a client who is postoperative following a cemented total hip arthroplasty. What instructions should the nurse include in the teaching?
Maintain hip flex ion to 90 or less when sitting
A nurse is caring for a client who is 24hr postoperative following an abdominal surgery. What finding requires immediate attention from the nurse?
Oxygen saturation of 88%
A nurse is caring for a client following a gastrectomy. What action should the nurse take to decrease episodes of dumping syndrome?
Place the client in the supine position after meals [Show Less]