Client has vomiting and diarrhea. ABG analysis results are ph 7.48 paco2 40mmhg, hcos 35, pa02 95, sao2 98%. Which IV solution does nurse anticipate for cl... [Show More] ient?
Normal saline 3%
Normal saline 0.9%
Dextrose 5% in water
Client comes with difficultly breathing, runny nose, pulse of 100, sneezing and coughin. Diagnosis of asthma is made. Which information is most important for nurse to obtain? Select all that apply
Any previous attacks like this
Exposure to known allergans
Family history of allergies
Any symptoms while exercising
Past history of psychological problems
Current list of medications
Client reports difficultly moving right arm. Numbness and tingling in arm. Clitn has difficulty speaking and diagnosis of stroke is made. The nurse understands this is what type of stroke?
Double hemisphere stroke
Left brain stroke
R right brain stroke
Nurse teaches client who had stapedectomy. Teaching is understood when which client request is made.
Physical therapy for vertigo
Neck brace with padding
Diet sheet that lists high protein foods
Prescription for stool softener
Client diagnoses with pulmonary embolism. Which priority does nurse apply?
Give supportive care during healin
Prevent further embolism
Administer thrombolytic agents
Client diagnoses with meniere disease. Client has sudden attack of vertigo, nausea, vomiting, and sweating. Nurse provides which interventions? Select all that apply
D diet high in dosium and caffeine
Warm, moist environment
Dark quiet environment
Lorazepam and meclizine
IV lfuids and medications
Client has respiratory failure. Client becomes agitate, restless, and disoriented. Client has nasal flaring and RR of 26. Most important client goal for nurse to activate?
Will have clear breath sounds in all lyng areas
Will have pao2 of 90mmHg
Will have heart rate of at least 110 bpm
Will cough and deep breath 10 tims an hour
Client in middle stage of Parkinson. Client no long able to work at job held for years and gave up hand crafts. Client cries and says” this is to hard I cant do the things I want to do. I never thought I would be like this.” Which is the most important goal for this client?
Will indicate reduced feeling of depression
Will oibtain new job in preferred field of work
Will join Parkinson support group
Will maintain independence in activities of daily living
Clikent diagnoses with bell palsy. Client is concerned because facial appearance has changed. Feelings of fear and qanxiety are expressed to the nurse. Which is the best goal for this client?
Client will take meds as ordered
Client will state understanding of disease process
Client will share prognosis with spouse
Client will express decrease in fear and anxiety
Client has hypertension. Client says “I think I can stop taking my medication now. I don’t have those headcahces anymore, so I am over this.” Which is the nurses best response?
Remember, you can have hyptertension and not have any symptoms
Don’t you remember, I told you the medication would needc to be taken for life
We will see what your BP is. Maytbe you can stop. How about your diet?
Tell me thwat you remember from our conversation about hypertension
Client reports sharpburngin pain in lower gums and jaw. Client diagnoses with trigeminal neuralgia. Eating and brushing teeth often trigger pain. Carbamazepine is prescribed. Nurse knows the medication has the anticipated effects when the client makes which statement?
I have to have two new cavities filled in my back molars
I have regained the 10 punds lost before the treatment
I wish I could use my fan when the house gets hot
I miss seeing my friends at my bridge club every week
Client receives hearing aid because of decreased hearing in both ears. Nurse speak softly and high-pitched to turn right and go up the stairs. The client turns left and goes down the stairs. Which interpretation does the nurse make?
Hearing aid needs volume adjustment
Different type of hearing aid is needed
Mental changes should be assessed
Loud-speaking voice is needed
Client who is HIV positive receives a Mantoux test. Nurse identifies a 7mm induration at test site. Which interpretation does nruse make?
False positive, previous bacilli Calmette-guerin vaccine
Negative reaction, less than 10 mm
Negative ractio, less than 15 mm
Posititve reaction, greater than 5 mm
Client diagnosed with liver cancer has partial hepatectomy. Client has anorexia, nauseam and vomiting with weight loss prior to surgery. The nurse communicates which intervention to the client? Select all
Here is a sheet we wily se to track I and O and calories for the day
We will ask the dietitian to help you select foods that are low in protein and calories
We will help you plan your diet around foods you like
Let ys plan for 6 small meals each day to help with the nausea
Lets talk about how to decrease your fluid intake to 1000 ml per day
You can help us watch your skin to make sure it is not excoriated or sore
Client is diagnosed with glaucoma. Client asks “why do I need to take these eye drops? They hurt my eyes.” Which is the nurses best response?
Drops help preserve your vision. Maybe less painful medication can be found.
The eye care provider says you need to take them. I am sorry they hurt you
Lets talk to your eye care provider to see if there is a medication that is less irritating.
You will lose your vision if you don’t use the drops as prescibred.
Client diagnosed with stroke. Nurse observes while client eats lunch. Client coughs after many bites, swallows solids very slowly, swallows liquids without difficulty. The client makes stranged movements with tongue during eating. Which action does the nurse take next?
Asks client for favorite food choices
Encourages client to chew slowly
Requests dietary consult
Rquests occupational therapy consult
Nurse teaches a class about circulatory disease. Which symptom of peripheral arterial disease does te nurse include? Select all
Pain in lower extremeties
Yellow toe nails
Numbness and tngling in toes
Thin, shiny, skin on legs
Pale foot when leg is elevated
Chest pain and dyspnea
Client diagnosed with inefetive endocarditis is discharged home on IV antibiotic therapy. The nurse knows the client understands the discharge treatment plan when the client makes which statement?
When I get home, I can take off these compression stockings when I am walking
I can go back to my job next week and start back traveling
I will tell my dentist about this illness before havng my teeth cleaned
I can help care for my grandchildren whenthey are sick and stay home from school
Client undergoes brachytherapy. Which action is most important for the nurse to take?
Werar film badge dosimeter
Deliver all client care at one time
Place client in neutropenic precautions
Provide meals using disposable dishes
Dlient is to receive 2 unites of blood. Client has an IV in the right forearm with D5W in normal saline that is used to administer an antibiotic every 4 hours. Which does the nurse do first?
Insert a microdrip chamber into IV
Start a second IV with isotonic saline
Use a filtered tubing to administer the blood
Receive the first unit of blood from the blood bank
Client experiences a right-brain stroke. Which is the priorty intervention for the nruse when giving care?
Assess emotional status
Give range of motion exercises
Keep client safe
Provide communication assistance
Client receives low-flow oxygen at 10 L/min at concentration of 50%. Which is the best oxygen administration for the nurse to chose.
Partial non rebreathing mask
Simple face mask
Client unresponsive after a closed-head injury. Glascow coma scle is 7. Nurse identifies the clients state as which best description?
Shows signs of visual and hearing impairment
Identified as comatose
Has subdural hematoma
Is alert with impaired motor function
Client receives information priord to having a PET scan done. Nurse recognizes further teaching is needed when the client makes which statement?
I will need to drink lots of fluid after the test
I am glad I will be asleep during the test
I know I must lie still and only move when told to move
The IV lines in my arms will give me glucose dye
Client is paraplegic because of spinal cord injury. Nurse identities nursing diagnosis “ineffective coping” based on which client statemtn
How can I ever get a job now that I am in a wheelchair
How long will I need physical therapy before I am discharged
When can I start playing wheelchair basketball
What are my limitations? I don’t want to be held back
A client is discharged to home following a lung wedge resection for stage IIB lung cvancer. The nurse provides information regaridn signs and symptoms to report if they occur. Which nursing statement is best?
If you have chest pain, make syre your spouse goes outside to smoke
Watch for decreasing pain levels, and let the health care provider know
If you have difficulty breating or eating, call the health care providr
Please call the health care provider if you have hemoptysis
Client diagnosed with myasthenia gravis. Client says “I am tired all the time and don’t want to live anymore. If I stop taking my medicaitons, I can stop breathing.” Which is the nurses best response?
Place client on suicide watch
Teach client about new medication
Give client information about myasthenia gravis group
Ask client about feelings of hopelessness
Client is diagnoses with immune thrombocytopenia purpura. Client receives corticosteroids. Nurse know the treatment is effections when which observation is made?
Bleeding is minimal after injection
Purpuric lesions fade to white
Platelet count is 175,000
Erythrocyte count is 5.1 million
A client with heart failure is to be weighed daily. Client asks why this is necessary. Which is the best information for the nurse to give?
Determines the number of calories for the diet
Indication of the fluid status in the body
Shows activity affects activity tolerance
Helps determine if the medication is working
Client diagnoses with flaccid neurogenic bladder due to spinal cord injury. Client has had severl urinary tract infections. Bladder traiing program ahs been establish. Which documentation indicates the clients bladder function is currently satisfactory?
Client has had no UTI in 3 days
Client verbalizes when to empty bladder
Client empties baldder completely every 2-3 hours
Client correctly demonstrates bladder emptying technique
Client diagnosed with COPD. Client has had asthma for 10 years, has smoked for 40 years, and has frequent episodes of bronchitis. Nurse identiing a nursing diagnosis based on which most important client problem?
Life-style that exacerbates COPD
Problems with oxygen intake causing confusion
Low self esteem because of health status changes
Interest in seeking behavior changes
Nurse teaches client diagnoses with venous thromboembolism in the right calf. The nurse knows the cleitn understands the teaching when the client makes which statement?
I need to exorcise vigorously for at least 15 minutes twice a day
I may continue to take my fish oil and saw palmetto
I may stop taking my anticoagulants when I no longer have pain
I need to limit the amount of ginger and garlic I eat
Nurse plans care for the client with tuberculosis. Cloient says it is difficult to remember to take ehe medications every day since they are not helping with the cough. The nurse adds which nursing diagnosis to the clients care plan?
Activity intolerance related to cough and fatigue from disease
Ineffective breathing patterns related to disease process and coughing
Noncomplienace related to lack of understanding of management regime
Ineffective self-health management related to lack of motivation
Nruse suctions a clienets tracheostomy. Which nechnigue does the nurse use? Select all that apply
Suctions client every hour
Use sterile technique when suctioning
Uses intermittent suctioning
Routintely instills sterile normal saline before suctioning
Rotates the catheter when withdrawing
Applies suction when inserting catheter
Client diagnoses with epilpsey. Client talks to the nurse about difficulties of managing the disorder. Which is the most important goal for this client?
Will maintin seizure free status for 1 year
Will demonstrate methods of managing self during a seizure
Will describe ways to effectively manage the disease
Will meet requirements to get driving license again
Client with pancreatic cancer receives radiation as palliative care. The nurse knows the treatment is effective when they notice which observation?
Client requests less pain medication
Famiy says patient looks less ill
Client requests special meal
Client sleeps 4 hours in afternoon
Client has sustaintedinjurty from industrial accident. Client says large metal beam cause the contusions to the chest, arms, and legs. The client is heaving chest pain and dyspnea. Which addition symptom does the nurse anticipate? Select all that ap-ply
Flushed face and arms
Cough with hemoptysis
Client with viral pneumonia is palce on 4 L of oxygen. The nruseenteres which nursing diagnosis in the clients plan of care.
Ineffective breathing pattern related to inflammatory process
Excess fluid volume related to edema in lungs
Chromic pain related to inflammatory process and congestion
Disturbed sleep pattern related to oxygen therapy
Client sustained spinal cord injury at c6 level. Client wear halo vest to stabilize the vertebrae folliwngsurrgey. Which is most important nursing action for client
Maintina adequate fluid volume
Maintina adequate respirations
Faciliatating bladder management
Facilitating adequate bowel function
Client diagnosed with sickle cell disease. The nurse teaches information for which most common complication?
Client on chemotherapy has an absolute neutrophil count of 900 cells. Neutropenic precautions are instituted. The client asks why the family needs to wear gowns, masks, and gloves when they visit. Which is the nruses best response?
This is to keep you from getting an infection
I know you want to touch and to be close to them but that is not possible
You are very likely to become infefcted, and this keeps you away from their germs
You seem upset. Tell me what you know about your condition. [Show Less]