Which assessment findings would be of concern to the nurse who is caring for a client who has an arterial line to the radial artery?
Capillary refill:
... [Show More] Left hand-2 seconds; Right hand- 4 seconds.
Blue tinged color to finger tips of the right hand
Left radial pulse-88/min; Right radial pulse-82/min
Blanching to right hand
While making evening rounds, the nurse discovers an elderly, confused client standing next to the bed with the IV pulled out, gown wet with urine and the side rails still in the up position. The client’s arm band is on the floor. To ensure client safety, what is the most important intervention for the nurse to include in the plan of care?
Provide for scheduled toileting intervals.
The nurse has been caring for a client who is confused. Upon entering the room, the nurse finds the client on the floor. The side rails are up, there is urine on the floor, and an abrasion is noted on the client's forehead. Which information should the nurse include in the incident report?
Abrasion on the clients forehead
Clients confused state
Presence of urine on the floor
Side rails were up
The emergency department nurse is assigned to care for four pediatric clients with varying symptoms. Which client should the nurse examine first?
6 month old with respiratory rate of 68/min while sleeping
A client, post laparoscopic cholecystectomy, develops pain in their right shoulder. Vital signs, laboratory studies, and an electrocardiogram are within normal limits. What does the nurse recognize as a contributing cause of the pain?
Carbon dioxide used intraperitoneally is irritating the phrenic nerve.
A nurse is attempting to develop trust with a psychiatric client exhibiting concrete thinking. Which nursing intervention would promote trust in this individual?
Attend an activity with the client who is reluctant to go alone.
Consider client preferences when possible in decisions concerning care.
Provide a blanket when the client is cold.
Provide food when the client is hungry.
A 65 year old client is admitted for management of dehydration with an IV infusion of LR @ 125 mL/hr. What assessment findings would be of concern to the nurse?
Anxiety
Crackles noted right posterior lung field
S3 heart sound
A client comes to the clinic reporting palpitations, as well as nausea and vomiting while taking metronidazole. The nurse notes that the client is flushed and has a heart rate of 118 bpm. Based on this information, what is the most important question for the nurse to ask the client?
"Are you using any products that contain alcohol?"
A client who has chronic renal failure has been prescribed synthetic erythropoietin for the prevention of anemia. Which assessment finding should be reported to the primary healthcare provider?
Swelling of feet and ankles
Parents of school-aged children are working toward a goal of healthy family TV viewing. Which parental statement indicates adequate understanding of appropriate use of TV in the family?
I don't allow my kids to watch violent TV shows.
The nurse initiates cardiac monitoring on a 6 year old immediately after the child has a seizure. How should the nurse document the rhythm?
Sinus arrhythmia
The emergency department called the labor and delivery unit to give report on a 24 year old primigravida at term, having contractions every 5-8 minutes. The unit is very busy, and all the RNs are with other clients. What action by the charge nurse would be most appropriate?
Instruct the LPN/VN to obtain initial vital signs and connect the client to a fetal monitor, then report this data to the charge nurse.
What action should the nurse take first for the 5 year old client brought to the urgent care clinic with a blistering sunburn?
Apply cool water soaks.
The charge nurse on the Labor and Delivery unit is making morning assignments. What client would be most appropriate for a newly hired licensed practical nurse (LPN)?
Completing perineal care for post-delivery clients.
The nurse is teaching a community health class for cancer prevention and screening. Which individual does the nurse recognize as having the highest risk for colon cancer?
Has a family history of colon polyps
A client with a history of cardiac disease has safely delivered a full-term infant. When discussing discharge instructions, the nurse knows the teaching was successful when the client makes what statement?
I must include lots of fiber to prevent constipation
A client with a history of cardiac disease has safely delivered a full-term infant. When discussing discharge instructions, the nurse knows the teaching was successful when the client makes what statement?
I should return to my previous dose of cardiac medication
The nurse is caring for a client taking benazepril. Which symptoms would be important for the nurse to report to the primary healthcare provider?
Weight gain of 5 pounds in one week
Angioedema
Serum potassium of 5.8
Which action by a nurse would require the charge nurse to intervene?
Walking in the hallway outside the operating room without a hair covering.
The nurse is planning daily activities for a client who has a diagnosis of schizophrenia. The client tends to spend most of the time in bed and is very uncomfortable when other clients are in the day area of the unit. What activity would be most therapeutic for this client?
Spending time in brief one on one interactions with the nurse
A client with Graves' disease and exophthalmos returns to the clinic for evaluation. Which assessment indicates to the nurse that the client is adhering to the teaching plan?
An absence of corneal irritation
0245 Called to room by client’s mother. Reports, “My son has been coughing and wheezing for the past 15 minutes”. Client anxious, sitting on side of bed. Skin pale, lips cyanotic. Nonproductive cough noted every 1-2 minutes. Diffuse, audible expiratory wheezes with coarse rhonchi in upper and lower bilateral lung fields. Mild retractions. Peak flow is 90 L/min (Expected peak flow 240 L/min). Difficulty speaking.
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