1. 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
... [Show More] for client?
Normal saline 3%
Normal saline 0.9%
Dextrose 5% in water
Ringer solution
2. 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
3. Client reports difficultly moving right arm. Numbness and tingling in arm. Client has difficulty speaking and diagnosis of stroke is made. The nurse understands this is what type of stroke?
Double hemisphere stroke
Hemorrhagic stroke
Lef t brain stroke
R right brain stroke
4. 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
5. Client diagnoses with pulmonary embolism. Which priority does nurse apply?
Give supportive care during healin
Cardiac monitoring
Prevent further embolism
Administer thrombolytic agents
6. Client diagnoses with meniere disease. Client has sudden attack of vertigo, nausea, vomiting, and sweating. Nurse provides which interventions? Select all that apply
GLYCEROL TEST
D diet high in sodium and caffeine Warm, moist environment
Dark quiet environment
Lorazepam and meclizine
IV lfuids and medications
7. 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
8. 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
9. 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
10. 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 sharp burngin 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 [Show Less]