A nurse is caring for a client who is scheduled for surgery and is experiencing anxiety. Which of the following interventions should the nurse identify as
... [Show More] the priority?
Determine the client's understanding of the procedure.
A nurse is contributing to the plan of care for a client who has peripheral arterial disease of the lower extremities. Which of the following interventions should the nurse include?
Dangle the extremities off the side of the bed.
A nurse is assisting in the plan of care for a client who had a recent left hemispheric stroke. Which of the following actions should the nurse include in the plan?
Use simple verbal cues when directing tasks.
A nurse is reinforcing teaching with the caregiver of a client who is terminally ill about manifestations of impending death. Which of the following manifestations should the nurse include?
Incontinence of the bowel and bladder
A nurse is preparing to remove a client's NG tube. Which of the following interventions should the nurse take to decrease the risk for aspiration?
Pinch the NG tube.
A nurse is caring for a client who is preoperative and is receiving an IV infusion of cefazolin. Ten minutes after beginning the infusion, the client reports intense itching. Which of the following actions should the nurse take first?
Stop the medication infusion.
A nurse is reinforcing discharge teaching with a client who has cirrhosis. Which of the following instructions should the nurse include?
"Consume foods that are low in sodium."
A nurse is reinforcing teaching with a client who is scheduled for a guaiac fecal occult blood test. Which of the following instructions should the nurse include in the teaching?
Avoid eating red meat for 3 days prior to the test.
A nurse is preparing to administer phytonadione 7 mg subcutaneously to a client who has an INR of 4. Available is phytonadione 10 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
0.7 mL
A nurse is reinforcing teaching with a client who is taking insulin glargine. Which of the following information should the nurse include in the teaching?
"This type of insulin should be given at the same time every day."
A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection in a surgical wound. Which of the following information should the nurse plan to share with visitors?
Visitors must don a gown and gloves prior to entering the client's room.
A nurse is collecting data from a 55-year-old female client who reports vaginal dryness and hot flashes. The client is interested in trying hormone replacement therapy (HRT). Which of the following should the nurse recognize as a contraindication to HRT?
History of treatment for blood clots
A nurse is reinforcing teaching about management of constipation with a client who has hypothyroidism. Which of the following instructions should the nurse include in the teaching?
Increase intake of fiber-rich foods.
A nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching?
Avoid stopping this medication suddenly.
A nurse is caring for a client who has an area indicating potential breakdown over the sacrum. Which of the following actions should the nurse take?
Minimize the time the head of the bed is elevated.
A nurse is assisting with the care of a client who is receiving 0.9% sodium chloride by continuous IV infusion. The client reports pain and swelling at the IV site. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Check IV site
Stop the infusion
Withdraw the IV catheter
Elevate the affected arm
Notify the charge nurse
Drag words from the choices below to fill in each blank in the following sentence.
During the emergent phase of burn care, the client is at risk for developing____________ and _____________.
Hypovolemia
Respiratory failure
A nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a client who has skin cancer. Which of the following information should the nurse include in the teaching?
Mohs surgery is a horizontal shaving of thin layers of the tumor.
A nurse is contributing to the plan of care for a client who is postoperative following a total knee arthroplasty. The client is using a continuous passive motion (CPM) machine. Which of the following interventions should the nurse recommend for the plan of care?
Keep a sheepskin pad between the client's extremity and the CPM machine.
A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. Which of the following information should the nurse include in the teaching?
Apply cold packs to the inflamed joints.
A nurse is caring for a client who has difficulty swallowing. Which of the following actions should the nurse implement to prevent aspiration?
Give the client liquids with increased viscosity.
A nurse is discussing health screening guidelines with an older adult client. Which of the following statements should the nurse include?
"You should have a pneumococcal immunization every 10 years."
A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis. Which of the following interventions should the nurse include when contributing to the plan of care?
Apply a mask on the client if transport is needed.
A nurse is contributing to the plan of care for a client who was admitted to the neurological unit following a stroke 3 hr ago. Which of the following interventions should the nurse identify as the priority?
Keep the client in a side-lying position.
A nurse is caring for a client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. Which of the following actions should the nurse take?
Perform pin site care daily.
A nurse is reinforcing discharge teaching about wound care with the caregiver of a client who is postoperative. Which of the following instructions should the nurse include in the teaching?
Report purulent drainage to the provider.
A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse identify as the priority?
Dysrhythmia
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Reduce the temperature in the clients room.
Limit visitors
Hyperthyroidism
Increased temperature
Weight daily
A nurse is caring for a client who reports stomatitis. Which of the following dietary recommendations should the nurse make?
"Eat soft foods."
A nurse is caring for a client who has a history of breast cancer. The client asks the nurse about birth control. Which of the following methods of birth control is contraindicated for this client?
Combination oral contraceptives
A nurse is collecting data from a client and notices several skin lesions. Which of the following findings should the nurse report as possible melanoma?
Irregular borders
A nurse is contributing to the plan of care for a client who has COPD and is dyspneic. Which of the following interventions should the nurse include in the plan?
Encourage abdominal breathing
A nurse is assisting with the care of a client who has a newly-inserted water-seal closed chest tube. Which of the following findings should the nurse report to the provider?
Chest drainage is greater than 70 mL/hr.
A nurse is reinforcing teaching with a client who is to begin using an insulin pump. Which of the following instructions should the nurse include?
"Use rapid-acting insulin in the infusion device."
Which of the following actions should the nurse take?
Select all that apply.
Instruct the client to splint their abdomen with a pillow when coughing
plan to ambulate the client as soon as possible
report the client's urinary output to the charge nurse
monitor the client's pain level
A nurse is caring for a client who is in Buck's traction. Which of the following interventions should the nurse perform to reduce skin breakdown?
Keep the skin dry and free of perspiration.
A nurse is monitoring a client who is taking acarbose. Which of the following findings should the nurse identify as an adverse effect of the medication?
Abdominal cramps
A nurse is reinforcing teaching with a client who is on a low-sodium diet and asks about how to improve the taste of bland food. Which of the following foods should the nurse recommend?
Lemon juice
A nurse is reinforcing discharge teaching for the caregivers of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching?
Remind the client to avoid watching their feet when walking.
A nurse is reinforcing teaching with a client who has systemic lupus erythematosus (SLE) and is to begin taking methylprednisolone orally. Which of the following statements should the nurse include in the teaching?
"Limit contact with large groups of people."
A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an IV contrast agent. Which of the following laboratory findings should the nurse report to the provider prior to the procedure?
Creatinine 1.9 mg/dL
Complete the following sentence by using the lists of options.
After reviewing the findings in the client's medical record, the nurse should first address the client's_____________ followed by the client's ________.
Abdominal distention
Acute pain
The nurse is collecting data on the client
For each client finding, click to specify if the finding is consistent with appendicitis, diverticular disease, or Crohn's disease. Each finding may support more than 1 disease process.
Blood in the stool - Diverticular disease
Drag 1 condition and 1 client finding to fill in each blank in the following sentence.
The client has manifestations of ___________ ; therefore, the priority finding for the nurse to report is the __________.
peritonitis
laboratory values
The nurse is contributing to the plan of care for the client who has peritonitis and Crohn's disease.
For each potential intervention, click to specify if the intervention is indicated or contraindicated for the client.
Obtain blood cultures - indicated
obtain the client's vital signs every 15 min - indicated
Administer a hypotonic IV solution - contraindicated
insert a nasogastric tube - indicated
The nurse is assisting with the care of the client who is preoperative for an exploratory laparotomy.
Select the 4 actions the nurse should take.
Administer phenytoin with a sip of water on the day of surgery.
Assist with the administration of gentamicin 100 mg IV.
Assist with the administration of dextrose 5% in lactated Ringer's.
Contact the wound, ostomy, and continence nurse.
The nurse is reinforcing discharge teaching with the client. Which of the following client statements indicates an understanding of the teaching?
Select all that apply.
"I should schedule several rest periods throughout the day"
"I should notify my provider if my temperature is higher than 101 degrees Fahrenheit".
A home health nurse is reinforcing teaching about preventing asthma attacks with a client who has asthma. Which of the following instructions should the nurse include in the teaching?
"Do not allow visitors to smoke cigarettes in your home."
A nurse is caring for a client who has a new cast on their left forearm and reports severe pain in the affected arm with numbness in the fingers. The nurse finds the skin is pale and cold with sluggish capillary refill. Which of the following fracture complications should the nurse suspect?
compartment syndrome
A nurse is contributing to the plan of care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection and is on contact isolation precautions. Which of the following actions should the nurse take?
Have a designated stethoscope in the client's room.
A nurse is collecting data from a client who has heart failure and is taking digoxin. Which of the following outcomes from the medication should the nurse expect?
Decreased shortness of breath.
A nurse is contributing to the plan of care for a client who has a new prescription for nystatin suspension for oral candidiasis. Which of the following interventions should the nurse include in the plan?
Instruct the client to swish the medication in their mouth.
A nurse is reviewing the laboratory results of a client who has type 2 diabetes mellitus. The nurse should identify that which of the following laboratory values indicates the client is at risk for delayed wound healing?
Prealbumin 12 mg/dL
A nurse is caring for a client who had an acute ischemic stroke 1 day ago. Which of the following actions should the nurse take to reduce the risk for aspiration?
Allow for 30 min of rest before meals. [Show Less]