The client needs to see a health care provider for further care. Lactic acidosis can occur when taking Metformin in the presence of dehydration and renal
... [Show More] insufficiency, typically seen in type 2 diabetics. Manifestations of lactic acidosis include Kussmaul's breathing and severe muscle pain caused by the buildup of lactic acid in the muscles. - correct answer The triage nurse receives a call from a client with a history of type 2 diabetes mellitus controlled by metformin (Glucophage). The client is reporting muscle pain and shortness of breath with exercise. Which of the following is the most appropriate response from the nurse
b. Seek the assistance of a nurse on the floor who is fluent in the client's language. Correct
The nurse is responsible for ensuring that the client understands the information provided regarding the procedure. - correct answer A nurse is preparing a client who speaks limited English for surgery. Which of the following is the most appropriate nursing action in obtaining informed consent from this client?
d. "My Dilantin dose will be increased several days before the procedure." Correct
Because the therapeutic action of ECT is to induce seizures, any medications that affect the client's seizure threshold must be decreased or discontinued several days before the procedure - correct answer A nurse is performing initial teaching with a client who will be receiving electroconvulsive therapy (ECT). Which statement by the client indicates a need for further teaching?
"The living will documents your mother's wishes and must be followed." Correct
A living will is a document that expresses the client's wishes regarding medical treatment in the event the client becomes incapacitated and is facing end-of-life issues. The client's wishes should be followed by the health care provider. - correct answer daughter of a client with a terminal illness pulls a nurse to the side and says, "Although my mother's living will states she is not to be resuscitated, the family wants everything done to save her if she has a cardiac arrest." How should the nurse respond?
If the nurse believes the provider's actions are directly against the client's wishes, the nurse should contact the hospital's ethics committee. These committees are typically multidisciplinary and are organized to consciously and reflectively consider significant and often difficult issues related to client care. Any nurse can consult the hospital's ethics committee when deemed necessary. - correct answer A provider informs the wife of a comatose client with terminal cancer that she will need to sign the consent for insertion of a gastrostomy feeding tube. The nurse knows this is against the client's wishes. What is the appropriate action by the nurse?
. "I have excellent job skills; I just need to find a new employer." Correct
Cognitive reframing is a simple and effective technique for reducing stress by looking at things in a more positive light in order to experience them as less stressful. Cognitive reframing for this client would involve building confidence in job skills and searching for a new job. - correct answer Management of Care: Stress management; teaching stress management techniques
A client is seeking treatment for stress related to unexpected loss of employment and is engaging in the stress management technique of cognitive reframing. Which of the following statements would indicate to the nurse that the client understands this stress management technique
Contact the client's case manager - correct answer Management of Care: Act as a client advocate
A nurse is preparing a client with terminal illness for discharge to a nursing home when he states: "I don't want to go to a nursing home to die. I would rather die at home." What would be the most appropriate action by the nurse?
Assist the client to deep breathe, splinting with a pillow. Correct
The client is experiencing respiratory acidosis from hypoventilation caused by painful respirations due to fractured ribs. Splinting the chest wall with a pillow will decrease pain associated with deep breathing. Deeper breaths will allow for better gas exchange, which will correct the acidosis. - correct answer Management of Care: Safe and Effective Care Environment: Arterial Blood Gases Priority
A client is hospitalized for multiple rib fractures following a motor vehicle accident (MVA). The results of an arterial blood gas (ABG's) are; pH 7.30, pCO2 48, HCO3 26 and pO2 91 on 2 L/min of oxygen per nasal cannula. Which of the following interventions has the highest priority?
Notify the client's health care provider Correct
The client is febrile, tachycardic and hypotensive with verbalization of increased worsening abdominal pain. These are signs of possible rupture of the diverticulum, pelvic abscess, or bowel obstruction and the provider needs to be notified. - correct answer Management of Care: Assessment of Bowel Disorders
The nurse is caring for a client admitted with diverticulitis. The client reports severe abdominal pain and assessment reveals that the client's abdomen is rigid and tender. The client's vital signs are: T: 101.8 F (38C); HR: 120; B/P: 100/50. Urine output was less than 300 ml during the previous eight hours. The client states the pain is "worse than before". What is the priority nursing intervention for this client?
c. A client with breast cancer and a sodium level of 115 mEq/L Correct
A sodium level less than 120 mEq/L is considered a medical emergency and needs immediate assessment and treatment. - correct answer Management of Care: Cancer: Chemotherapy
The nurse is caring for four clients receiving chemotherapy. Which of the following clients should the nurse see first?
Collaborate with the health care team and the referring agency to assess client needs. Correct
The nurses who receive the referrals need to work collaboratively with the health care team and the referring agency or persons. Continuous coordinated care among all health care providers involved in a client's care is essential to avoid duplication of effort by the various personnel caring for the client. Understanding client needs is the first step in the referral process. - correct answer Management of Care: Safe and Effective Care Environment : Coordinating Client Care: Referrals
A community based nurse receives a client referral. Which of the following actions should be performed first?
a. A client with diabetes mellitus type I waiting for a breakfast tray at 0745. Correct
The diabetic client waiting for breakfast should be assessed first. Prior to breakfast the client's blood glucose needs to be drawn and if insulin coverage is required it is administered before breakfast. Once the client begins to eat and digest food they will be at risk for increasing blood glucose levels without their insulin coverage. - correct answer Management of Care: Creating and Maintaining a Therapeutic and Safe Environment: Group of clients
At 0715 the nurse is assigned to care for the following four clients. Which of the following clients should the nurse plan to see first?
c. The client has the right to refuse treatment, unless he has been judged to be incompetent. Correct
Clients admitted under involuntary commitment are still considered competent and have the right to refuse treatment, unless they have gone through a legal competency hearing and have been judged incompetent. The client who has been judged incompetent has a temporary or permanent guardian, usually a family member if possible, appointed by the court. The guardian can sign informed consent for the client. The guardian is expected to consider what the client would want if they were still competent. - correct answer Management of Care: Educate Client and staff about client's rights and responsibilities
A nurse is caring for a client who has been committed to an acute Mental Health facility with an involuntary emergency commitment order. What should the nurse include when orienting the client to the facility
. A 48 year-old male complaining of chest pain, cardiac monitor showing sinus tachycardia with occasional PVC's. Correct
While all of these clients require nursing care, the 48 year-old male with c/o chest pain and a cardiac rhythm of sinus tachycardia with occasional PVC's needs immediate attention! Chest pain is an indication of myocardial ischemia and this client has other factors that put him at risk for sudden death: gender, age and PVC's. PVC's are not normal in a 48 year old. PVC's occur when the myocardium is irritated, usually from hypoxia but also from electrolyte imbalance, usually involving K+. This client is young and as a result has not had sufficient time to develop adequate collateral circulation. - correct answer Management of Care: Emergency Department Triage
The following clients have been assessed in the emergency department. Which of the following clients requires immediate attention?
. Mulitipara with contractions occurring every 3 minutes, lasting 45 seconds. The cervical os is dilated 5 cms. Correct
An epidural is indicated in the active phase of labor. Active labor is defined as: cervical dilation of 4-7 cms, contractions occurring every 3-5 minutes and lasting 30-60 seconds. - correct answer Safe and Effective Care Environment: Management of Care: Epidural
A nurse is caring for four laboring clients. Each of the clients is requesting an epidural. Which of the following clients should receive her epidural first?
Seek the assistance of a nurse on the floor who is fluent in the client's language. Correct
The nurse is responsible for ensuring that the client understands the information provided regarding the procedure. - correct answer Management of Care: Informed Consent: Ensure Informed Consent: Ethical and Legal Issues
A nurse is preparing a client who speaks limited English for surgery. Which of the following is the most appropriate nursing action in obtaining informed consent from this client? [Show Less]