NURSING NUR 241 KAPLAN MED SURG 2 PAGES 2 LATEST 2021/2022
The nurse instructs a client diagnosed with SLE. Which statement by the client indicates
... [Show More] understanding of instructions?
"Stress and fatigue may make my symptoms worse"
The client recently diagnosed with Type 1 diabetes mellitus reports awakening with headache, frequent nightmares...
Instruct the client to check blood glucose between 0200 and 0400
The client diagnosed with lung cancer tells the nurse that he has replaced his prescribed medication with an herbal syrup recommended by an herbalist. Which is the initial action the nurse should take?
Tell the client to discuss the herbal syrup with the client's health care provider
The nurse cares for the client in the emergency department diagnosed with a traumatic amputation of the left leg and hypovolemic shock...
Administer Lactated Ringer's solution intravenously
The nurse instructs the client scheduled for cataract removal with a multifocal intraocular lens implant...
"Some itching and reddening of the eye is expected after the surgery"
The nurse cares for the 78-year old client with C. Diff...
"Wear a gown and gloves while assisting the client with bathing"
The nurse cares for the client immediately after a colonoscopy. Which action does the nurse take first?
Asks the client to describe the location and intensity of pain.
The nurse cares for the client with a diagnosis of acute adrenal insufficiency (Addison's crisis)...
Muscle cramps, fatigue, hypotension
The nurse instructs the adult client. The client is newly diagnosed with cystic fibrosis. The nurse should include... SATA
-An aerobic exercise is an important part of your treatment
-You should notify your health care provider if your exercise tolerance decreases
-The cystic fibrosis may cause you to have fertility problems
The nurse cares for the client diagnosed with BPH. Which clinical manifestation...
Difficulty initiating voiding
The nurse cares for the client who had a generalized tonic-clonic seizure lasting 90 seconds...
Administer diazepam as ordered
The nurse instructs the client who reports a frequent history of UTIs...
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You should drink at least 2000 mL of fluid every day
The nurse cares for the client diagnosed with a stroke 48 hours ago. What is the most appropriate position?
Supine with the head of the bed elevated 15-30º
The nurse cares for the client diagnosed with full-thickness burns of both legs...
Charred, waxy, white appearance
The nurse cares for the client starting peritoneal dialysis. Which action should the nurse take first?
Weigh the client
The nurse cares for the client diagnosed with right pneumothorax...
Rapid shallow respirations
The nurse cares for the client diagnosed with multiple sclerosis...
Forgetfulness and fatigue
The nurse cares for the client diagnosed with a left-sided stroke...
Impaired speech
The nurse cares for the client diagnosed with a closed head injury after a car accident. Which observation made after 48 hours requires an immediate intervention?
The client complains of dizziness and headache
The nurse instructs the client diagnosed with GERD...
Sleep with head and shoulders elevated on pillows
The nurse instructs the client starting hemodialysis. The client has an arteriovenous fistula in the right arm. SATA
-Your blood pressure should be checked on the left arm only
-You should not use your right arm to carry heavy objects
The nurse performs CPR on the 62 year old man. Which is the correct compression depth?
2 or more inches? 1.5-2 inches?
The nurse cares for the client with a chest tube drainage system. Which observation requires an intervention?
Continuous bubbling in the water-seal chamber is observed
The nurse instructs the client who had a subtotal gastrectomy. Which statement should be included?
Eat a low carbohydrate diet every day
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The nurse instructs the client scheduled for a transesophageal echocardiogram (TEE)
I will not be able to eat or drink for several hours after the test is completed
The nurse cares for the client diagnosed with severe acute pancreatitis SATA
-Nausea and vomiting
-Localized right quadrant abdominal pain
-Serum glucose 148 mg/dL Serum calcium 5.8 mg/dL
The nurse cares for the client immediately after a cardiac catheterization using the left femoral artery. Which finding requires immediate intervention by the nurse?
The left extremity is cooler to touch than the right extremity
The nurse cares for the client diagnosed with thrombophlebitis receiving a heparin infusion...
PTT
The nurse cares for the client receiving parenteral nutrition. Which laboratory test should the nurse monitor...
Blood glucose
The nurse supervises the nursing assistive personnel caring for the client immediately following a radioactive implant for uterine cancer. Which observation requires an intervention by the nurse?
The NAP leaves the door open when leaving the room
The nurse instructs the client diagnosed with chronic kidney disease. Which foods are most appropriate for this client?
Rice cereal and strawberries
The nurse cares for the 75-year old client who has limited mobility. Which finding would most concern the nurse?
An area over the coccyx blanches with pressure?
The nurse evaluates client's compliance with the diabetic diet, insulin, and activity regimen over 2 month period...
Obtain HbA1c
A total hip arthroplasty is scheduled for the client diagnosed with degenerative joint disease of the left femoral head...
Abduct with the toes pointing upward
The nurse cares for the client just admitted after a car accident. The family reports that the client hit his head on the dashboard...
Clear fluid is dripping from the ear
The nurse plans care for the client who is recovering from a gunshot wound
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Turkey meat, mashed potatoes, oranges, and ice cream.
The nurse teaches the client after a surgical repair of a detached retina...
Avoid reading and writing for one week
The nurse cares for the client diagnosed with ulcerative colitis. Which finding should the nurse expect the client to report?
Mild lower abdominal pain with episodes of diarrhea
The nurse cares for the client after a subtotal thyroidectomy procedure...
Ask the client to speak
The nurse cares for the client who had a tracheostomy performed the previous day. Which most concerns the nurse?
The client's secretions from the tracheostomy are thick, yellow, and dry
The nurse notes the client's cardiac rhythm suddenly shows ventricular tachycardia...
Lidocaine
The nurse cares for the client with atrial fibrillation...
Are you experiencing any dizziness at this time?
The nurse cares for the client recently diagnosed with a tumor in the frontal lobe of the brain. Which statement would the nurse expect the client to make?
I feel like my concentration is not very good
Hip fracture
The left leg is shorter than right leg and is externally rotated
Lyme Disease
Raised rash on palms of hands
Bell’s Palsy
Nurse states “you seem upset”, therapeutic communication
Sickle Cell Anemia
Patient states they will restrict fluid intake (further education)
Thrombophlebitis
Patient should flex/extend leg Q2h
Abdominal Pain
Ask the patient to show the nurse where it hurts
Bone marrow biopsy
Patient in prone position
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Buck’s Traction
Used to reduce muscle spasms
Acute Kidney Injury
Potassium is 6.2, monitor heart rate and rhythm
Cast care
Intervene if patient states toes are tingling
Pain management
Best indicator f pain is to ask patient their pain level
Migraine headache
Unilateral eye pain
ABG Puncture
Apply pressure to puncture site for 3-5 minutes
Glomerulonephritis
Protein in the urine
Meningitis
Patient temperature is 101.2 F
Cardiac dysrhythmias
Patient in A fib, need to assess level of consciousness
Fluid volume overload
82 year old female given 125 mL/hr, weigh the patient daily
Meniere’s disease
Vertigo, tinnitus, unilateral hearing loss
Appendicitis
Contact physician if patient has increase in pain
Closed head injury
Priority intervention if apical pulse rate drops from 88 to 60
Fluid volume deficit
25ml of urine per hour
Type 2 diabetes
Nurse is concerned that sores on feet heal slowly
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Hepatitis A
Wash hands
Alzheimer’s disease
Give patient teddy bear from home
Iron deficiency anemia
Take supplement before meals
Care after death
Nurse should wash patient, remove secretions, insert dentures before family views body
Ileal conduit
Ureters attached to intestine and to outside of the body into urine bag
COPD
Further teaching is the patient states they will cut down to only smoking 3 packs a day
EGD
NPO 8 hours prior to procedure
Paralytic ileus
Abdominal distention and pressure
Parkinson’s disease
Increased salivation
Fat emboli syndrome
Patient is post fracture and confused, contact the doctor [Show Less]