The home health practical nurse is visiting with a client who has a history of second degree heart block and pacemaker placement six months ago. Which
... [Show More] symptom compliant by the client would be indicative of pacemaker failure?
Feelings of dizziness Feelings of dizziness may occur as the result of a decreased heart rate, leading to decreased cardiac output as a result of pacemaker failure.
Which foods should the practical nurse encourage a client to eat to increase their potassium intake? (Select all that apply.)
Green beans Milk Flounder Sweet potatoes Cantaloupe Flounder, sweet potatoes, milk, green beans, and cantaloupe are all potassium-rich foods.
The health care provider informed a client diagnosed with stage 4 liver cancer that the cancer has spread to their spine. The client states to the practical nurse, "I have a cancer, but it is not malignant." What is the best initial nursing action?
Ask the client to explain his understanding of the term malignancy. The best initial action is to assess the client's knowledge of the term malignancy when used to describe cancer. The client appears to have inaccurate knowledge. Stage 4 cancer means the cancer has spread (metastasized) from where it has started to another body part.
A client sustained a burn injury greater than 25% of total body surface with majority of it lower extremities during a house fire. During the acute phase of care, which intervention is most important for the practical nurse to implement?
Administer 0.5 mL of tetanus toxoid IM. Prevention of infection from Clostridium tetani by administering tetanus toxoid has the highest priority for care of a client in the acute phase of burn care.
In order to provide culturally competent care, what action must the practical nurse do first?
Understand one's own world views in addition to the client's. The nurse should understand their own values and views to prevent those beliefs being imparted to others, in addition to understanding the client's cultural views when providing cultural competent care. Treating every client the same or assuming that all clients share the same values does not exhibit cultural competence or sensitivity.
The practical nurse (PN) is interviewing a male client diagnosed with hypertension. Which finding places the client at the greatest risk for development of a cerebral vascular accident (CVA)?
A waistline greater than 40 inches (101.6 cm) Males with waist sizes larger than 40 inches (101.6 cm) and females with waist sizes larger than 35 inches (88.9 cm) are at greater risk of cardiac disease increasing the risk of CVA. The more abdominal fat an individual has the more the risk goes up.
A client diagnosed with prostate cancer is prescribed radioactive seed implantation (brachytherapy). What is the most important nursing action for the practical nurse (PN) to do?
Follow radiation exposure precautions. Clients being treated for prostate cancer with brachytherapy (radioactive seeds implant) should be placed on radiation exposure precautions. The PN needs to follow the institution's protocols put in place regarding the amount of time and distance needed to prevent excessive exposure that would pose a hazard to others.
A client diagnosed with diabetes has a prescription of 5 units of regular insulin and 15 units of NPH insulin. In which order should the practical nurse prepare to administer the insulin? List in order the nursing actions to be performed.
Perform hand hygiene according to facility policy. Inspect insulin vials for type and expiration dates. Inject 15 units of air into NPH insulin vial. Inject 5 units of air into regular insulin vial. Withdraw 5 units of regular insulin from vial. Withdraw 15 units of NPH insulin from vial. The first nursing action is to perform hand hygiene. The next action is to inspect vials for type and expiration dates and then add 15 units of air to NPH insulin vial. Next add 5 units of air into regular insulin vial, then withdraw 5 units of regular insulin from vial, and withdraw 15 units of NPH insulin from vial. Note that it is important to fill the syringe with regular insulin (shorter acting insulin) first to prevent contamination of the NPH insulin (intermediate-acting insulin).
The practical nurse (PN) is reviewing the health histories of the following individuals. Which [Show Less]