A client with a seizure disorder is receiving phenytoin and phenobarbital. What client statement indicates that the instructions regarding the medications are understood? Show
"Stopping the drugs can cause continuous seizures and I may die." Which information should be included in the teaching plan for the client diagnosed with epilepsy? People taking phenytoin must floss regularly. Rational: Gingival hyperplasia is a common side effect of phenytoin A client has a tonic-clonic seizure. Which is the priority nursing intervention during the tonic-clonic stage of the seizure? Protect the client from injury A client is admitted to the hospital after having a tonic-clonic seizure and is diagnosed with a seizure disorder. Which is most important for the nurse to include in a teaching program? Explain ways to prevent physical trauma from occurring during a seizure. A 2-year-old toddler is admitted to the pediatric unit with a diagnosis of bacterial meningitis. What is the most important safety measure for the nurse to institute immediately after the child has a seizure? Placing the child in the side-lying position A client has a tonic-clonic seizure at work and is admitted to the emergency department. Which question is most useful when planning nursing care related to the client's seizure? "Were you aware of anything different or unusual just before your seizure began?" Rationale: Identification of a sensation that occurs before each seizure (aura) is helpful in identifying the cause of the seizure and planning how to identify and avoid a future seizure. Warfarin is prescribed for the client who takes phenytoin for a seizure disorder. Why must the nurse observe the client closely during the initial days of treatment with warfarin? Warfarin affects the metabolism of phenytoin. What action should the nurse take when caring for a client who has a possible skull fracture as a result of trauma? Monitor the client for signs of brain injury. A client is admitted to the hospital with a head injury sustained while playing soccer. For which early sign of increased intracranial pressure should the nurse monitor this client? Lethargy A nurse should plan to maintain a client who has experienced a subarachnoid hemorrhage in what position? In bed with the head of the bed elevated Rationale: With the head of the bed elevated, the force of gravity helps prevent additional intracranial pressure, which will intensify the ischemic manifestations of hemorrhage. A nurse is caring for a client who had a traumatic brain injury with increased intracranial pressure. Which healthcare provider prescription should the nurse question? Teach isometric exercises Rationale: The prescription for isometric exercises should be questioned; isometric exercises increase the basal metabolic rate and intracranial pressure. Which clinical indicators should the nurse consider as evidence of increasing intracranial pressure? - Vomiting A nurse is precepting an orientee (newly hired nurse). The nurse observes the orientee caring for an unconscious client with increasing intracranial pressure. The nurse should question which intervention that the orientee performs? Suctioning the oropharynx routinely Rationale: Although suctioning is done to maintain an airway, it is not done routinely because it increases intracranial pressure. A nurse assesses a client for increasing intracranial pressure by monitoring the pulse pressure. What is the pulse pressure? Difference between systolic and diastolic readings The nurse is monitoring a client with a severe head injury for signs and symptoms of increasing intracranial pressure. Which finding is most indicative of increasing intracranial pressure? Increased restlessness Rationale: Increased restlessness indicates a lack of oxygen to the brainstem; cerebral hypoxia impairs the reticular activating system. When caring for a client who has sustained a closed head injury, it is important that the nurse assess for which clinical indicator(s)? Select all that apply. - Slowing of the hr
A client with a head injury has been receiving dexamethasone. The health care provider plans to reduce the dosage gradually and to continue a lower maintenance dosage. Which effect associated with the gradual dosage reduction of the drug should the nurse explain to the client? Promotes return of cortisone production by the adrenal glands What action should be included in the nursing care of an infant with increased intracranial pressure? Elevating the head higher than the hips Rationale: Elevation of the head helps decrease intracranial pressure by way of gravity. A nurse is caring for a client who is admitted to the hospital with a severe head injury. Which action is priority? Maintain respiratory exchange and ventilation. Mannitol is given to do what? Decrease fluid in the brain A nurse is assessing a 3-week-old infant who has been admitted to the pediatric unit with hydrocephalus. What finding denotes a complication requiring immediate attention? Tense anterior fontanel A construction worker fell off the roof of a two-story building and was taken to the hospital in an unconscious state. During the initial assessment, what clinical finding should the nurse report immediately? Bleeding from the ears A client is admitted to the hospital after sustaining a head injury. Which is the most reliable sign of increased intracranial pressure the nurse can monitor for? Decrease in the level of consciousness A client is at risk for increased intracranial pressure (ICP). Which assessment finding reflects an increase in ICP? Unequal pupil size A client with a head injury is admitted to the hospital. Which assessment finding alerts the nurse to increasing intracranial pressure? Widening pulse pressure Which assessment leads a nurse to suspect that a newborn with a spinal cord lesion has increased intracranial pressure (ICP)? Select all that apply. - Irritability A client is receiving
an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best? ANS:CA change in neurologic status in a client receiving t-PA could indicate intracranial hemorrhage. The nurse should stop the infusion and notify the provider immediately. A full assessment, including pupillary responses and vital signs, occurs next. The nurse may or may not need to call a neurologist.DIF:Applying/ApplicationREF:768KEY:Coronary artery disease| neurologic system| critical rescue| Rapid Response Team| thrombolytic agentsMSC:Integrated Process: Nursing Process: ImplementationNOT:Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an intravenous infusion of heparin. The client's spouse asks why the client needs this medication. What response by the nurse is best?a."The t-PA didn't dissolve the entire coronary clot." ANS:BAfter the original intracoronary clot has dissolved, large amounts of thrombin are released into the bloodstream, increasing the chance of the vessel reoccluding. The other statements are not accurate. Heparin is not a "blood thinner," although laypeople may refer to it as such.DIF:Understanding/ComprehensionREF:768KEY:Coronary artery disease| thrombolytic agents| patient educationMSC:Integrated Process: Teaching/LearningNOT:Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the client's O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. Whataction by the nurse is best? ANS:BThis client's physiologic parameters did not exceed normal during and after activity, so it is safe for the client to continue using the bathroom. There is no indication that the client needsoxygen, a commode, or a bedpan.DIF:Applying/ApplicationREF:769KEY:Coronary artery disease| activity intolerance| vital signs| nursing assessmentMSC:Integrated Process: Nursing Process: AssessmentNOT:Client Needs Category: Physiological Integrity: Reduction of Risk Potential A nursing student is caring for a client who had a myocardial infarction. The student is confused because the client states nothing is wrong and yet listens attentively while the student provides education on lifestyle changes and healthy menu choices. What response by the faculty member is best? ANS:AClients are often in denial after a coronary event. The client who seems to be in denial but iscompliant with treatment may be using a healthy form of coping that allows time to process the event and start to use problem-focused coping. The student should not discourage this type of denial and coping, but rather continue providing education in a positive manner. Emphasizing complications may make the client defensive and more anxious. Telling the client that denial is normal is placing too much attention on the process. Forcing the client toverbalize understanding of the illness is also potentially threatening to the client.DIF:Understanding/ComprehensionREF:769KEY:Coronary artery disease| psychosocial response| coping| therapeutic communicationMSC:Integrated Process: Communication and DocumentationNOT:Client Needs Category: Psychosocial Integrity A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrialpressure of 0.5 mm Hg. What action by the nurse is most appropriate? ANS:DNormal right atrial pressures are from 1 to 8 mm Hg. Lower pressures usually indicate hypovolemia, so the nurse should prepare to administer a fluid bolus. The transducer should remain leveled at the phlebostatic axis. Positioning may or may not influence readings. Diuretics would be contraindicated. An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate? ANS:AOlder clients may have dysrhythmias due to age-related changes in the cardiac conduction system. They may have no significant hemodynamic effects from these changes. The nurse should first assess for the effects of the dysrhythmia before proceeding further. The alarms on a cardiac monitor should never be shut off. The other two actions may or may not be needed.DIF:Applying/ApplicationREF:769KEY:Coronary artery disease| older adult| pathophysiology| nursing assessmentMSC:Integrated Process: Nursing Process: AssessmentNOT:Client Needs Category: Health Promotion and Maintenance The nurse is preparing to change a client's sternal dressing. What action by the nurse is mostimportant?a.Assess vital signs. ANS:DTo prevent a sternal wound infection, the nurse washes hands or performs hand hygiene as a priority. Vital signs do not necessarily need to be assessed beforehand. A mask and gown arenot needed. The nurse should gather needed supplies, but this is not the priority.DIF:Applying/ApplicationREF:776KEY:Coronary artery disease| infection control| hand hygieneMSC:Integrated Process: Nursing Process: ImplementationNOT:Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control A client has an intra-arterial blood pressure monitoring line. The nurse notes
bright red blood on the client's sheets. What action should the nurse perform first? ANS:CFor the nurse's safety, he or she should put on a pair of gloves to prevent blood exposure. The other actions are appropriate as well, but first the nurse must don a pair of gloves. A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first? ANS:BHypertension after coronary artery bypass graft surgery can be dangerous because it puts toomuch pressure on the suture lines and can cause bleeding. The charge nurse should see this client first. The client who became dizzy earlier should be seen next. The client on the nitroglycerin drip is stable. The client going home can wait until the other clients are cared for.DIF:Analyzing/AnalysisREF:777KEY:Coronary artery disease| coronary artery bypass graft| collaborationMSC:Integrated Process: Nursing Process: AssessmentNOT:Client Needs Category: Safe and Effective Care Environment: Management of Care A client with coronary artery disease (CAD) asks the nurse about taking
fish oil supplements. What response by the nurse is best? ANS:BOmega-3 fatty acids have shown benefit in reducing lipid levels, in reducing the incidence of sudden cardiac death, and for stabilizing atherosclerotic plaque. The best source is fish three times a week or some fish oil supplements. The other options are not accurate.DIF:Understanding/ComprehensionREF:761KEY:Coronary artery disease| lipid-reducing agents| supplements| patient educationMSC:Integrated Process: Teaching/LearningNOT:Client Needs Category: Health Promotion and Maintenance A client has presented to the emergency department with an acute myocardial infarction (MI). What action by the
nurse is best to meet The Joint Commission's Core Measures outcomes? ANS:BThe Joint Commission's Core Measures set for acute MI require that aspirin is administered when a client with MI presents to the emergency department or when an MI occurs in the hospital. A rapid ECG is vital, but getting another one in the morning is not part of the Core Measures set. The Rapid Response Team is not needed if an emergency department provideris available. Thrombolytics may or may not be needed.DIF:Remembering/KnowledgeREF:766KEY:Coronary artery disease| Core Measures| The Joint CommissionMSC:Integrated Process: Nursing Process: ImplementationNOT:Client Needs Category: Safe and Effective Care Environment: Management of Care A nurse is caring
for four clients. Which client should the nurse assess first? ANS:BThe post-angioplasty client with tongue swelling and anxiety is exhibiting manifestations of an allergic reaction that could progress to anaphylaxis. The nurse should assess this client first. The client with a heart rate of 102 beats/min may have increased oxygen demands but is just over the normal limit for heart rate. The two post coronary artery bypass clients are stable.DIF:Analyzing/AnalysisREF:774KEY:Coronary artery disease| critical rescue| medical emergencies| hypersensitivities| allergic reactionMSC:Integrated Process: Nursing Process: AnalysisNOT:Client Needs Category: Safe and Effective Care Environment: Management of Care A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client is restless and agitated. What action should the nurse perform first for comfort? ANS:AAllowing the family to remain at the bedside can help calm the client with familiar voices (and faces if the client wakes up). A fan might be helpful but may also spread germs throughair movement. The TV should not be kept on all the time to allow for rest. Speaking loudly may agitate the client more.DIF:Applying/ApplicationREF:780KEY:Intra-aortic balloon pump| nonpharmacologic comfort measuresMSC:Integrated Process: Nursing Process:
Implementation The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage slows significantly. What action by the nurse is most important? ANS:BIf the drainage in the chest tube decreases significantly and dramatically, the tube may be blocked by a clot. This could lead to cardiac tamponade. The nurse should notify the provider immediately. The nurse should not independently increase the suction, re-position the chest tube, or take the tubing apart.DIF:Applying/ApplicationREF:778KEY:Coronary artery bypass graft| critical rescue| chest tubes| cardiovascular systemMSC:Integrated Process: Communication and DocumentationNOT:Client Needs Category: Safe and Effective Care Environment: Management of Care A home health care nurse is visiting an older client who lives alone after being discharged from the hospital after a coronary artery bypass graft. What finding in the home most causesthe nurse to consider additional referrals? ANS:BExpired food in the refrigerator demonstrates a safety concern for the client and a possible lack of money to buy food. The nurse can consider a referral to Meals on Wheels or another home-based food program. Dirty carpets may indicate the client has no household help and is waiting for clearance to vacuum. Old medications can be managed by the home health care nurse and the client working collaboratively. Having pets is not a cause for concern.DIF:Applying/ApplicationREF:781KEY:Home safety| referrals| coronary artery bypass graftMSC:Integrated Process: Communication and DocumentationNOT:Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control A client is on a dopamine infusion via a peripheral line. What action by the nurse takes priority for safety? ANS:A A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a
significant complication has occurred? ANS:CPoor peripheral pulses and cool skin may be signs of impending cardiogenic shock and should be reported immediately. A blood pressure drop of 20 mm Hg is not worrisome. An oxygen saturation of 94% is just slightly below normal. A urine output of 1.2 mL/kg/hr for 4hours is normal.DIF:Remembering/KnowledgeREF:772KEY:Coronary artery disease| critical rescue| nursing assessmentMSC:Integrated Process: Nursing Process: AnalysisNOT:Client Needs Category: Physiological Integrity: Reduction of Risk Potential A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory abilities. To meet The
Joint Commission's Core Measures set, by what time should the client have a percutaneous coronary intervention performed? ANS:CThe Joint Commission's Core Measures set for MI includes percutaneous coronary intervention within 90 minutes of diagnosis of myocardial infarction. Therefore, the client should have a percutaneous coronary intervention performed no later than 1630 (4:30 PM).DIF:Remembering/KnowledgeREF:774KEY:Coronary artery disease| Core Measures| The Joint CommissionMSC:Integrated Process: Communication and DocumentationNOT:Client Needs Category: Safe and Effective Care Environment: Management of Care The provider requests the nurse start an infusion of an inotropic agent on a client. How does the nurse explain the action of these drugs to the client and spouse? ANS:CA positive inotrope is a medication that increases the strength of the heart's contractions. The other options are not correct.DIF:Remembering/KnowledgeREF:772KEY:Coronary artery disease| inotropic agents| patient educationMSC:Integrated Process: Teaching/LearningNOT:Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies A nurse is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the nurse hears the following sound. What action by the nurse is most appropriate?(Click the media button to hear the audio clip.) ANS:DThe sound the nurse hears is an S3 heart sound, an abnormal sound that may indicate heart failure. The nurse should next assess the client's lung sounds. Assessing for chest pain is notdirectly related. There is no indication that the Rapid Response Team is needed. Having the client sit up will not change the heart sound.DIF:Applying/ApplicationREF:762KEY:Coronary artery disease| respiratory assessment| respiratory system| nursing assessmentMSC:Integrated Process: Nursing Process: AssessmentNOT:Client Needs Category: Physiological Integrity: Reduction of Risk Potential26 A client had an inferior wall myocardial infarction (MI). The nurse notes the client's cardiac rhythm as shown below:What action by the nurse is most important? a.Assess the client's blood pressure and level of consciousness An
emergency room nurse assesses a female client. Which assessment findings should alert the nurse to request a prescription for an electrocardiogram?(Select all that apply.) ANS:B, C, EWomen may not have chest pain with myocardial infarction, but may feel discomfort or indigestion. They often present with a triad of symptoms—indigestion or feeling of abdominal fullness, feeling of chronic fatigue despite adequate rest, and feeling unable to catch their breath. Frequently, women are not diagnosed and therefore are not treated adequately. Hypertension and abdominal pain are not associated with acute coronary syndrome.DIF:Applying/ApplicationREF:635KEY:Cardiac electrical conductionMSC:Integrated Process: Nursing Process: AssessmentNOT:Client Needs Category: Physiological Integrity: Physiological Adaptation
A nurse assesses a client's electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How should the nurse interpret this observation?a.The client has hyperkalemia causing irregular QRS complexes. ANS:DNormal rhythm shows one P wave preceding each QRS complex, indicating that all depolarization is initiated at the sinoatrial node. QRS complexes without a P wave indicate adifferent source of initiation of depolarization. This finding on an electrocardiograph tracingis not an indication of hyperkalemia, ventricular tachycardia, or disconnection of leads.DIF:Understanding/ComprehensionREF:649KEY:Cardiac electrical conductionMSC:Integrated Process: Nursing Process: AnalysisNOT:Client Needs Category: Physiological Integrity: Physiological Adaptation A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification should the nurse suggest to avoid further slowing ofthe heart rate? ANS:BBearing down strenuously during a bowel movement is one type of Valsalva maneuver, which stimulates the vagus nerve and results in slowing of the heart rate. Such a response is not desirable in a person who has bradycardia. The other instructions are not appropriate for this condition.DIF:Applying/ApplicationREF:663KEY:Functional abilityMSC:Integrated Process: Nursing Process: ImplementationNOT:Client Needs Category: Physiological Integrity: Basic Care and Comfort A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation? ANS:B Atrial fibrillation occurs commonly in clients with cardiac disease and is a common occurrence after coronary artery bypass graft surgery. The other conditions do not place these clients at higher risk for atrial fibrillation.DIF:Applying/ApplicationREF:666KEY:Health screening| cardiac electrical conductionMSC:Integrated Process: Nursing Process: AssessmentNOT:Client Needs Category: Safe and Effective Care Environment: Management of Care A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition? ANS:BClients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in mentation, speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance.DIF:Applying/ApplicationREF:666KEY:Cardiac electrical conduction| vascular perfusionMSC:Integrated Process: Nursing Process: AssessmentNOT:Client Needs Category: Physiological Integrity: Reduction of Risk Potential A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medicationshould the nurse expect to find on this client's medication administration record to prevent a common complication of this condition? ANS:BAtrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol, atropine, and lidocaine are not appropriate for this complication.DIF:Applying/ApplicationREF:667KEY:Cardiac electrical conduction| medicationMSC:Integrated Process: Nursing Process: AnalysisNOT:Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies A nurse administers prescribed adenosine (Adenocard) to a client. Which response
should the nurse assess for as the expected therapeutic response? ANS:CClients usually respond to adenosine with a short period of asystole, bradycardia, hypotension, dyspnea, and chest pain. Adenosine has no conclusive impact on intraocular pressure.DIF:Applying/ApplicationREF:662KEY:Cardiac electrical conduction| medicationMSC:Integrated Process: Nursing Process: AnalysisNOT:Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment shouldthe nurse complete next? ANS:CA heart rate of 40 beats/min or less with widened QRS complexes could have hemodynamicconsequences. The client is at risk for inadequate cerebral perfusion. The nurse should assess for level of consciousness, light-headedness, confusion, syncope, and seizure activity.Although the other assessments should be completed, the client's level of consciousness is the priority.DIF:Applying/ApplicationREF:670KEY:Cardiac electrical conduction| vascular perfusionMSC:Integrated Process: Nursing Process: AssessmentNOT:Client Needs Category: Physiological Integrity: Reduction of Risk Potential A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the client's electrocardiogram. Which action should the nurse take next? ANS:BIn temporary pacing, the wires are threaded onto the epicardial surface of the heart and exit through the chest wall. The pacemaker spike should be followed immediately by a QRS complex. Pacing spikes seen without subsequent QRS complexes imply loss of capture. If there is no capture, then there is no ventricular depolarization and contraction. The
nurse should assess for cardiac output via vital signs and level of consciousness. The other interventions would not determine if the client is tolerating the loss of capture. A nurse prepares to defibrillate a client who is in ventricular fibrillation.
Which priority intervention should the nurse perform prior to defibrillating this client? ANS:DTo avoid injury, the rescuer commands that all personnel clear contact with the client or the bed and ensures their compliance before delivery of the shock. A precordial thump can be delivered when no defibrillator is available. Defibrillation is done in asynchronous mode. Equipment should not be tested before a client is defibrillated because this is an emergency procedure; equipment should be checked on a routine basis. Epinephrine should be administered after defibrillation.DIF:Applying/ApplicationREF:668KEY:Cardiac electrical conduction| safetyMSC:Integrated Process: Nursing Process: ImplementationNOT:Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching? ANS:BThe client being discharged with an ICD is instructed to avoid strong sources of electromagnetic fields. Clients should avoid tight clothing, which could cause irritation over the ICD generator. The client should be encouraged to exercise but should not engage in strenuous activities that cause the heart rate to meet or exceed the ICD cutoff point because the ICD can discharge inappropriately. The client should continue all prescribed medications.DIF:Applying/ApplicationREF:674KEY:Cardiac electrical conductionMSC:Integrated Process: Teaching/LearningNOT:Client Needs Category: Health Promotion and Maintenance A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this client's
concerns? ANS:CClients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when completing activities of daily living. The nurse should schedule periods of exercise and rest during the day to decrease fatigue. The other interventions will not assist the client with self-care activities.DIF:Applying/ApplicationREF:658KEY:Cardiac electrical conductionMSC:Integrated Process: Teaching/LearningNOT:Client Needs Category: Physiological Integrity: Basic Care and Comfort A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Whichaction should the nurse take prior to the initiation of
cardioversion?a.Administer intravenous adenosine. ANS:BFor safety during cardioversion, the nurse should turn off any oxygen therapy to prevent fire. The other interventions are not appropriate for a cardioversion. The client should be placed in a supine position.DIF:Remembering/KnowledgeREF:668KEY:Assessment/diagnostic examination| safetyMSC:Integrated Process: Nursing Process: ImplementationNOT:Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 13.A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care services. Which priority information should be communicated to the home healthnurse upon discharge? ANS:AThe home health nurse needs to know current medications the client is taking to ensure assessment, evaluation, and further education related to these medications. The other information will not assist the nurse to develop a plan of care for the client.DIF:Applying/ApplicationREF:673KEY:Hand-off communicationMSC:Integrated Process: Communication and DocumentationNOT:Client Needs Category: Safe and Effective Care Environment: Management of Care A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse?a.Mid-sternal chest pain ANS:AChest pain, possibly angina, indicates that tachycardia may be increasing the client's myocardial workload and oxygen demand to such an extent that normal oxygen delivery cannot keep pace. This results in myocardial hypoxia and pain. Increased urinary output andmild orthostatic hypotension are not life-threatening conditions and therefore do not require immediate intervention. The P wave touching the T wave indicates significant tachycardia and should be assessed to determine the underlying rhythm and cause; this is an important assessment but is not as critical as chest pain, which indicates cardiac cell death.DIF:Applying/ApplicationREF:663KEY:Cardiac electrical conductionMSC:Integrated Process: Nursing Process: AssessmentNOT:Client Needs Category: Safe and Effective Care Environment: Management of Care A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. Which statement should the nurse include in this client's teaching? ANS:APACs usually have no hemodynamic consequences. For a client experiencing infrequent PACs, the nurse should explore possible lifestyle causes, such as excessive caffeine intake and stress. Lying on the side will not prevent or resolve PACs. Oxygen is not necessary. Although medications may be needed to control symptomatic dysrhythmias, for infrequent PACs, the client first should try lifestyle changes to control them.DIF:Applying/ApplicationREF:663KEY:Patient education| cardiac electrical conductionMSC:Integrated Process: Teaching/LearningNOT:Client Needs Category: Health Promotion and Maintenance The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, "Why do you want to know if I use cocaine?" How should the
nurse respond? ... Which action should the nurse take first? ANS:CThis client is stable and therefore does not require any intervention except to determine the cause of the bradycardia. Bradycardia is often caused by medications. Clients who have multiple chronic diseases are often on multiple medications that can interact with each other.The nurse should assess the client's current medications first.DIF:Applying/ApplicationREF:658KEY:Cardiac electrical conduction| medications| adverse effectsMSC:Integrated Process: Nursing Process: AssessmentNOT:Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below:After calling for assistance and a defibrillator, which action should the nurse take
next? ANS: b A nurse is caring for a client who had a gastroscopy. What response indicates a major concern associated with this surgery? 1.Projectile vomiting 3.Abdominal distention A nurse is assisting a health care provider to perform a sigmoidoscopy. In which position should the nurse place the client for this procedure? 1.Sims 4.Knee-chest A client is admitted to the ambulatory surgery unit for a liver biopsy. The nurse recalls that which assessment finding will be a cause for the biopsy to be postponed? 1.Signs of bruising 1.Signs of bruising A client with a history of alcoholism and cirrhosis is admitted with severe dyspnea as a result of ascites. The nurse concludes that the ascites is most likely the result of increased: 1.Secretion of bile salts 2.Pressure in the portal vein A client is diagnosed with gastric cancer, and a subtotal gastrectomy is performed. After surgery the client begins to hemorrhage. What clinical findings support the nurse's conclusion that the client is experiencing hypovolemic shock? (Select all that apply.) 1.Oliguria 1.Oliguria A client is admitted with the diagnosis of acute pancreatitis. For which clinical manifestations should a nurse assess the client? (Select all that apply.) 1.Jaundice 1.Jaundice A client is admitted to the hospital with a history of cancer of the liver and jaundice. In relation to the jaundice, the nurse expects the client to report the presence of: 1.Pruritus 1.Pruritus A client diagnosed with gastroesophageal reflux disease (GERD) is being treated with antacid therapy. When teaching the client about the therapy, the nurse reinforces that antacid tablets: 1.Are as effective as the liquid form 4.Are known to interfere with the absorption of other drugs A client who had surgery for a ruptured appendix develops peritonitis. What clinical findings related to peritonitis should the nurse expect the client to exhibit? (Select all that apply.) 1.Fever 1.Fever When performing the initial history and physical examination of a client with a tentative diagnosis of peptic ulcer, the nurse expects the client to describe the pain as: 1.Gnawing epigastric pain or boring pain in the back 1.Gnawing epigastric pain or boring pain in the back Discharge instructions for the client diagnosed with cirrhosis with varices should include information about the importance of: (Select all that apply.) 1.Adhering to a low carbohydrate diet 2.Avoiding aspirin and aspirin containing products A client follows a vegetarian diet and must compensate for the lack of vitamin B12 found in food of animal origin. Which food should the nurse encourage the client to consume each day? 1.One orange 2.One glass of soy milk A client with severe Crohn's disease develops a small bowel obstruction. Which clinical finding should the nurse expect the client to report? 1.Bloody vomitus 2.Projectile vomiting Steroid therapy is prescribed for a client with an exacerbation of ulcerative colitis. The nurse evaluates that teaching is effective when the client says, "I should take this medicine: 1.At bedtime with a snack." 2.In the early morning with food."
A client who recently immigrated to the United States has a chronic vitamin A deficiency. What information about vitamin A should the nurse consider when assessing this client for clinical indicators of this deficiency? 1.Vitamin A is an integral part of the retina's pigment called melanin. 4.It is a necessary element of rhodopsin, which controls responses to light and dark environments A client is admitted via the emergency department with the tentative diagnosis of diverticulitis. Which test commonly is prescribed to assess for this problem? 1.Computed tomography (CT)
scan 1.Computed tomography (CT) scan A nurse is caring for a client with a diagnosis of acute pancreatitis and alcoholism. The client asks, "What does my drinking have to do with my diagnosis?" What effect of alcohol should the nurse include when responding? 1.Promotes the formation of calculi in the cystic duct 4.Increases enzyme secretion and pancreatic duct pressure that causes backflow of enzymes into the pancreas The nurse teaches the client about foods to help prevent constipation after pelvic surgery. Which foods selected by the client indicate that the teaching is understood? (Select all that apply.) 1.Ripe bananas 3.Green vegetables A nurse is planning a community health program about screening for cancer. Which information recommended by the American Cancer Society (ACS) should the nurse include? 1.Mammography should be performed annually after age 35 years for women. 2.Fecal occult blood testing should be performed yearly beginning at age 50 years. Which interventions should the nurse anticipate will be prescribed initially for a client who had a hemorrhoidectomy? (Select all that apply.) 1.Giving an enema 2.Applying moist heat Famotidine (Pepcid) is prescribed for a client with peptic ulcer disease. The client asks the nurse what this medication does. The nurse responds, "It: 1.Increases gastric motility. 4.Inhibits gastric acid secretion A nurse is teaching a group of adults about the signs and symptoms of colorectal cancer. What is the most common clinical manifestation that the nurse should include in the teaching program? 1.Rectal bleeding 3.Change in bowel habits During a client's paracentesis, 1500 mL of fluid is removed. The nurse monitors the client for which sign of a potentially severe response? 1.Abdominal
girth decrease 3.Heart rate increases from 80 to 135 A client with Crohn's disease is admitted to the hospital with abdominal pain, fever, poor skin turgor, and diarrhea, with 10 stools in the past 24 hours. Which signs are evidence that the client probably is dehydrated? (Select all that apply.) 1.Moist skin 2.Sunken eyes To help prevent long-term complications associated with gastric bypass surgery, the nurse needs to educate the client. Identify the factors that should be included in the nurse's teaching plan for this client. (Select all that apply.) 1.Eat
foods rich in calcium. 1.Eat foods rich in calcium. A client develops peritonitis and sepsis after the surgical repair of a ruptured diverticulum. What signs should the nurse expect when assessing the client? (Select all that apply.) 1.Fever 1.Fever A client says, "I take baking soda in water when I get heartburn." The nurse suggests an antacid containing aluminum and magnesium hydroxide instead of baking soda. What is the advantage these antacids have over baking soda? 1.They contain little, if any, sodium. 3.There is no direct effect on the systemic acid-base balance when taken as directed. A nurse is assisting a client to plan a therapeutic diet that is high in vitamin C. What excellent sources of vitamin C should be included in the plan? (Select all that apply.) 1. Lettuce 2.Oranges A nurse is preparing to administer a nasogastric tube feeding. List the steps of the procedure in the order in which they should be performed. 1.Verify the solution to be administered. 1.Wash the hands A client has circumgastric banding, a bariatric surgical procedure. The nurse provides discharge teaching about signs and symptoms of dumping syndrome and includes what physiological response? 1.Fever 3.Palpitations A client is to be discharged after a laser laparoscopic cholecystectomy. The nurse evaluates that the discharge instructions are understood when the client states: 1."I should stay on a full liquid diet for three days." 4."I may have mild shoulder pain for about a week." A nurse is evaluating a client who has been receiving medical intervention for the diagnosis of Crohn's disease. Which expected outcome is most important for this client? 1.Does skin care 3.Gains a half pound per week The menu for a client with malabsorption syndrome must be limited because of a sensitivity to gluten. Which foods cannot be served to this client? (Select all that apply.)
1.Cheese omelet 3.Roast beef sandwich A client with severe Crohn's disease develops a small bowel obstruction. Which clinical finding should the nurse expect the client to report? 1.Bloody vomitus 2.Projectile vomiting Which interventions should the nurse anticipate will be prescribed initially for a client who had a hemorrhoidectomy? (Select all that apply.) 1.Giving an enema 2.Applying
moist heat A client is scheduled for ligation of hemorrhoids. Which diet does the nurse expect to be prescribed in preparation for this surgery? 4.Low-residue Drink only bottled water Which instruction should the nurse provide the client who is concerned about contracting amoebic dysentery during foreign travel? call poison control The parent of a 2-year-old calls a nurse who is a neighbor and reports that the child just ate several multivitamins with iron. What should the nurse say to the parent? furosemide A client is admitted to the intensive care unit with acute pulmonary edema. Which diuretic does the nurse anticipate will be prescribed? offer pacifier A 4-month-old infant is on nothing-by-mouth status in preparation for surgery. What should the nurse do when the infant starts crying? Checking for residual stomach contents The nurse is preparing to administer a nasogastric tube feeding to a client via infusion pump. What is the most important assessment the nurse needs to perform before beginning the pump? Directing ancillary departments to deliver resources to meet service demands What is the function of the emergency department nurse leader? I am glad that I only have to take the medication once a day. Immediately after a bilateral adrenalectomy a client is receiving corticosteroids that are to be continued after discharge from the hospital. Which statement by the client indicates to the nurse that additional education is needed? Red Which tag is suitable for a client with high priority during a disaster with mass casualties? Teratogenic drugs act during all periods of gestation Which statement regarding a teratogenic drug is incorrect Clay-colored stools A client is diagnosed with hepatitis A. The nurse provides the client with information about untoward signs and symptoms related to hepatitis. The nurse instructs the client to contact the primary healthcare provider if the client develops what symptom? Rapid, thready pulse A client with ascites has a paracentesis, and 1500 mL of fluid is removed. For which immediate response is it most important for the nurse to monitor? Have the potential for physiologic and psychological dependence An antianxiety medication is prescribed for an extremely anxious client. The client says, "I'm afraid to take this medication because I heard they're addictive." The nurse teaches the client that antianxiety medications have what properties? Elevate the head of the bed between 30 and 45 degrees When caring for a client who is receiving enteral feedings, the nurse should take which measure to prevent aspiration? To minimize gastric irritation After several days of intravenous (IV) therapy for chloroquine-resistant malaria, the health care provider replaces the IV medication with oral quinine, 2 g per day in divided doses. The nurse advises the client to take this medication after meals for what purpose? assess respiratory status The nurse is preparing to administer an intravenous piggyback antibiotic that has been newly prescribed. Shortly after initiation, the client becomes restless and flushed and begins to wheeze. The nurse determines the that appropriate priority action will be to stop the antibiotic infusion and then do what? Dexamethasone A pregnant client at 30 weeks' gestation begins to experience contractions every 5 to 7 minutes. She is admitted with a diagnosis of preterm labor. Although the client is being given tocolytic therapy, her cervix continues to dilate, and it is determined that a preterm birth is inevitable. Which medication does the nurse expect the primary healthcare provider to prescribe? The client belongs to class III The nurse finds a green triage tag on a client. What does the nurse infer from this finding foxglove The nurse is educating the parents of a preschooler on various poisonous plants that children may be exposed to. Which plants does the nurse mention as poisonous? Select all that apply. Constant one-on-one supervision A nurse is caring for a client admitted to a mental health unit because of suicidal ideation. Which intervention provides the greatest safety for this client? blurred vision A nurse is providing discharge instructions about digoxin. Which response should a nurse include as a reason for a client to withhold the digoxin? disturbances in hearing A client with arthritis is taking large doses of aspirin. What symptom does the nurse include when teaching the client about the clinical manifestations of aspirin toxicity? penicillin g Which is the preferred drug of choice for the treatment of syphilis in a pregnant adolescent? Priority upon arrival A local emergency department (ED) recently implemented an automated tracking system for triage during mass casualty incidents (MCIs). Which items can the nurse track using this system? Select all that apply. For short periods in the prone position A client returns from surgery after a right below-the-knee amputation with the residual limb elevated on a pillow to prevent edema. In which position should the nurse place the client after the first postoperative day?
Immediately contact the primary healthcare provider A client with a history of hemoptysis and cough for the last six months is suspected of having lung cancer. A bronchoscopy is performed. Two hours after the procedure the nurse identifies an increase in the amount of bloody sputum. What is the nurse's priority? Don an N95 respirator mask before entering the room A client is admitted to the hospital with a tentative diagnosis of infectious pulmonary tuberculosis. What infection control measures should the nurse take? Watching cartoon videos and listening to stories A nurse on the pediatric unit is planning recreational activities for a 4-year-old with an exacerbation of nephrotic syndrome. What are the most appropriate activities in light of the child's developmental level and physical status? Treatment error A student nurse receives an order for diazepam to be given intravenously. Diazepam tablets are available. The student nurse crushes a tablet and mixes it with sterile water for injection. The instructor notes that the solution is cloudy and asks to see the medication vial. When the student produces the vial of sterile water for injection and the instructor stops the medication from being given, what type of error is prevented? Near misses in health care are used to improve care. In an agency with a culture of safety, when an error or patient safety issue is identified, the individual who reports the problem knows which information? attitude The three elements of nursing competency described in the Quality and Safety for Nurses (QSEN) initiative are knowledge, skill, and which other element? care coordination To promote safety, the nurse manager sensitive to point-of-care (sharp-end) and systems-level (blunt-end) exemplars works closely with administrators to address which organizational system exemplar? communication Which of the following concepts would a nurse think has the strongest link to safety 32. what is a nurse's responsibility when administering prescribed opioid analgesics? (select all that apply) a,b,d 55. based on the client's reported pain level, the nurse administers 8mg of the prescribed morphine. The medication is available in a 10mg syringe. Wasting of the remaining 2mg of morphine should be done by the nurse and a witness. Who should be the witness? b 59. what are the desired outcomes that the nurse expects when administering a nonsteroidal antiinflammatory drug (NSAID)? (select all that apply) b,c,f 172. a client with arthritis increases the dose of ibuprofen (motrin, advil) to abate joint discomfort. After several weeks the client becomes increasingly weak. The health care provider determines that the client is severely anemic and admits the client to the hospital. What clinical indicators does the nurse expect to identify when performing an admission assessment? (select all that apply) a,b 189. a client reports severe pain 2 days after surgery. Which INITIAL action should the nurse take after assessing the character of pain? b 192. a
client who had abdominal surgery is receiving patient-controlled analgesia (PCA) intravenously to manage pain. The pump is programmed to deliver a basal dose and bolus doses that can be accessed by the client with a lock-out time frame of 10 minutes. The nurse assesses use of the pump during the last hour and identifies that the client attempted to self-administer the analgesic 10 times. Further assessment reveals that the client is still experiencing pain. What should the nurse do FIRST? b 193. a client with an inflamed sciatic nerve is to have a conventional transcutaneous electrical nerve stimulation (TENS) device applied to the painful nerve
pathway. When operating the TENS unit, which nursing action is appropriate? c 587. a client who had a total hip
replacement asks the nurse about the continuous regional analgesia being used. What information should the nurse include when explaining the benefits of the treatment over conventional methods to control pain? c 732. in the PACU it is reported
that the client recieved intrathecal morphine intraoperatively to control pain. Considering the administration of this medication, what should the nurse include as pert of the client's INITIAL 24-hour postoperative care? b 741.
a nurse is taking the health history of a client who is to have surgery in one week. The nurse identifies that the client is taking ibuprofen (advil) for discomfort associated with osteoarthritis and notifies the health care provider. Which drug does the nurse expect with MOST likely be prescribed instead of the Advil? d
765. a nurse is caring for a client after a total knee replacement who is requesting Vicodin in addition to the patient-controlled analgesia (PCA). The client reports having taken 2 Vicodin tablets every 4 hours for several weeks before surgery. If each tablet contains 500mg of acetaminophen, how much acetaminophen had the client been ingesting per day? (round to the nearest whole number) 12 tablets 775. a client receiving morphine by patient-controlled analgesia has a respiratory rate of 6 breaths/min. What intervention should the nurse anticipate? c 789. a terminally ill client in a hospice unit for several weeks is receiving a morphine drip. The dose is now above
the typical recommended dosage. The client's spouse tells the nurse that the client is again uncomfortable and needs the morphine increased. The prescription states to titrate the morphine to comfort level. What should the nurse do? c 1. which information obtained by the nurse is most likely to influence Natalie's perception of her pain? a 2. to assess the quality of Natalie's pain, the nurse asks which question? b 3.
Which behavior does Natalie exhibit , that the nurse documents as objective signs of acute pain? d 4. to determine the etiology of Natalie's anxiety, what is the priority nursing intervention? b 5. which is the best goal for the nurse to include in the plan of care related to the problem statement of "acute pain related to strain on muscles with movement?" a 6. the nurse considers interventions to include in the plan of care. Before implementing any interventions, what action is most important for the nurse to take? d 7. Which medication should the nurse suggest as a common NSAID? d 8. what information should the nurse include in responding to Natalie? c Natalie tells the nurse that she has an electric heating pad at home that she used when she sprained her ankle. 9. Which response by the nurse is
accurate? d Natalie states that she has also been applying a cold pack an hour at a time to help heal her back as quickly as possible. 10. Which instruction is most important for the nurse to provide? d 11. how should the nurse explain the mechanism that causes the skin to become reddened from prolonged exposure to cold? a 12. Which explanation by the nurse best describes how the TENS unit soothes paint? b 13. after the nurse explains how the TENS unit soothes pain, Natalie wants to know the best way to apply and use the unit. Which instructions should the nurse include? (select all that apply) b,e 14. what characteristic of scheduled drugs results in the need for these specific protocols? c the clinic stocks a small number of scheduled medications, so the nurse obtains a dose of the prescribed medication for Natalie. At the end of the shift, the nurse counts the remaining medications with the oncoming nurse and notes that the count is not accurate. 15. what action
should the nurse implement? c 16. when Natalie is in the ED, the HCP prescribes an intramuscular injection of 30mg of ketorolac, a nonsteroidal antiinflammatory agent. The medication comes in a preloaded syringe labeled "20mg/mL." How many mL should the nurse expect to administer? ( round to the tenth) 1.5 17. since
Natalie is fairly thin, which site is the best choice for the injection? b 18. the nurse will first place the palm of the hand on what anatomical spot to locate the injection site? c 19. once the needle is inserted in the skin, what intervention should the nurse perform? (select all that apply) c,d 20. to ensure that the(guided imagery) exercise is most effective, what action should the nurse implement? c Natalie states that the guided imagery exercise was helpful, and she is interested in learning additional exercises. The nurse guides Natalie in a progressive relaxation activity. After first establishing a regular breathing pattern, the nurse tells Natalie to locate an area where she can feel muscle tension. 21. What instruction should the nurse provide next? d 22. when is the best time to teach Natalie about the use of the PCA? a 23. what is the total dosage of morphine that Natalie has received in the last 4 hours? (0.5mg/hour, and demand doses of 1mg/6min <hourly limit of 10mg>)(Natalie had 4 demand doses each hour for the last 4 hours) a) 6mg c on the second postop day, the nurse observes that Natalie is no longer self-administering demand doses of the morphine. 24. what is the most likely
reason for this change? a 25. the nurse assesses Natalie's pain and determines that the evaluation of her use of the PCA pump
is correct. Natalie's pain has lessened, and she no longer needs any demand doses of morphine. The nurse consults with the surgeon, and the morphine is discontinued. Natalie's new prescription is for hydrocodone/acetaminophen. What is the rationale for combing these two ingredients? b Natalie has also been receiving docusate sodium, a stool softener. She asks the nurse if this needs to be continued. 26. how should the nurse respond? d the nurse overhears two other nurses discussing Natalie's pain management in the hallway. One nurse states that Natalie is exhibiting drug-seeking behavior and is probably already addicted to her pain medications. 27. what is the priority nursing intervention? c Natalie's nurse believes that the other nurses are incorrect in their understanding of Natalie's pain management. The nurse explains this to the other nurses, providing the nurses with accurate information about the pain management and addiction. 28. the nurse's response demonstrates what ethical principle? a You are the charge nurse. A client with chronic pain reports to you that the nurses have not been responding to requests for pain medication. What is your initial action? a) Check the medication administration records (MARs) for the past several days. d Family members are encouraging your client to "tough out the pain" rather than risk drug addiction to narcotics. The client is stoically abiding. You recognize that the sociocultural dimension of pain is the current priority for the client. Which question will you ask? a) "Where is the pain located, and does it radiate to other parts of your body?" c A client with diabetic neuropathy reports a burning, electrical-type pain in the lower extremities that is worse at night and not responding to nonsteroidal anti-inflammatory drugs. Which medication will you advocate for first? a) Gabapentin (Neurontin) a Which client is most likely to receive opioids for extended periods of time? a) A client with fibromyalgia c As the charge nurse, you are reviewing the charts of clients who were assigned to the care of a newly graduated RN. The RN has correctly charted dose and time of medication, but there is no documentation regarding nonpharmaceutical measures. What action should you take first? a) Make a note in the nurse's file and continue to observe clinical
performance. d Which clients must be assigned to an experienced RN? (Select all that apply.) a) Client who was in an automobile crash and sustained multiple injuries a,c,d,e In application of the principles of pain treatment, what is the first consideration? a)
Treatment is based on client goals. c Which client has the most immediate need for IV access to deliver immediate analgesia with rapid titration? a) Client who has sharp chest pain that increases with cough and shortness of breath c When an analgesic is titrated to manage pain, what is the priority goal? a) Titrate to the smallest dose that provides relief with the fewest side effects. a For client education about nonpharmaceutical alternatives, which topic could you delegate to an experienced LPN/LVN, who will function with your continued support and supervision? a) Therapeutic touch b A client received "as needed" (PRN) morphine, lorazepam (Ativan), and cyclobenzaprine (Flexeril). The UAP reports that the client has a respiratory rate of 10/min. What is the priority action? a) Call the physician to obtain an order for naloxone (Narcan). b Which client is at greatest risk for respiratory depression while receiving opioids for analgesia? a) Elderly client with chronic pain who has a hip fracture d A client is crying and grimacing but denies pain and refuses pain medication, because "my sibling is a drug addict and has ruined our lives." What is the priority intervention for this client? a) Encourage expression of fears and past experiences. a A client's opioid therapy is being tapered off, and the nurse is watchful for signs of withdrawal. What is one of the first signs of withdrawal? a) Fever c In the care of clients with pain and discomfort, which task is most appropriate to delegate to the UAP? a) Assisting the client with preparation of a sitz bath a The physician has ordered a placebo for a client with chronic pain. You are a newly hired nurse and you feel very uncomfortable administering the medication. What is the first action that you should take? a) Prepare the medication and hand it to the physician. d For a cognitively impaired client who cannot accurately report pain, what is the first action that you should take? a) Closely assess for nonverbal signs such as grimacing or rocking. b You have received the shift report from the night nurse. Prioritize the order in which you will check on the following clients. a) Adolescent who is alert and oriented. He was admitted 2 days ago for treatment of meningitis. He reports a continuous headache that is partially relieved by medication. e,c,a,b,d On the first day after surgery, a client receiving an analgesic via PCA pump reports that the pain control is inadequate. What is the first action you should take? a) Deliver the bolus dose per standing order. d The team is providing emergency care to a client who received an excessive dose of narcotic pain medication. Which task is best to delegate to the LPN/LVN? a) Calling the physician and reporting the situation using the SBAR (situation, background, assessment, recommendation) format d What is the best way to schedule medication for a client with constant pain? a) PRN at the client's request d
Which clients can be appropriately assigned to an LPN/LVN who will function under the supervision of an RN or team leader? (Select all that apply.) a) Client who needs preoperative teaching for the use of a PCA pump b,c,f You are caring for a client who had abdominal surgery yesterday. The client is restless and anxious and tells you that the pain is getting worse despite the pain medication. Physical assessment findings include the following: temperature, 100.3° F (38° C); pulse rate, 110 beats/min; respiratory rate, 24 breaths/min; and blood pressure, 140/90 mm Hg. The abdomen is rigid and tender to the touch. You decide to notify the client's provider. Place the following report information in the correct order according to the SBAR format. a) "He is restless and anxious: temperature is 100.3° F (38° C); pulse is 110 beats/min; respiratory rate is 24 breaths/min; blood pressure is 140/90 mm Hg. Abdomen is rigid and tender to touch with hypoactive bowel
sounds." e,b,a,c,d Which clients can be appropriately assigned to a newly graduated RN who has recently completed orientation? (Select all that apply.) a) Anxious client with chronic pain who frequently uses the call button b,e,f A client's family member says to you, "He needs more pain medicine. He is still having a lot of pain." What is your best response? a) "The physician
ordered the medicine to be given every 4 hours." c Pain disorder and depression have been diagnosed for a client. He reports chronic low back pain and states, "None of these doctors has done anything to help." Which client statement concerns you the most? a) "I twisted my back last night, and now the pain is a lot worse." b A client has severe pain and bladder distention related to urinary retention and possible obstruction. An experienced UAP states that she received training in Foley catheter insertion at a previous job. What task can be delegated to this UAP? a) Assessing the bladder distention and the pain associated with urinary retention d You are caring for a young man with a history of substance abuse who had exploratory abdominal surgery 4 days ago for a knife wound. There is an order to discontinue the PCA-delivered morphine and to start oral pain medication. The client begs, "Please don't stop the morphine. My pain is really a lot worse today than it was yesterday." What is the best response? a) "Let me stop the pump and we can try oral pain medication to see if it relieves the pain." c
You are caring for a young client with diabetes who has sustained injuries when she tried to commit suicide by crashing her car. Her blood glucose level is 650 mg/dL, but she refuses insulin; however, she wants the pain medication. What is the best action? a) Notify the charge nurse and obtain an order for a transfer to intensive care. b What action should the nurse take when caring for a client who has a possible skull fracture as a result of trauma?Apply firm pressure to the wound with sterile gauze or a clean cloth. But don't apply direct pressure to the wound if you suspect a skull fracture. Watch for changes in breathing and alertness. If the person shows no signs of circulation — no breathing, coughing or movement — begin CPR.
Which nursing care is priority for a client admitted to the hospital with a severe head injury?The first priority in any emergency is always an adequate airway. The nurse is involved in clearing the mouth, inserting an oral airway, assisting with intubation, oxygen therapy and assessing continually the patient's respiratory system.
Which of the following types of drugs might be given to control increased intracranial pressure ICP )?Osmotic diuretics, (e.g., urea, mannitol, glycerol) and loop diuretics (e.g., furosemide, ethacrynic acid) are first-line pharmacologic agents used to lower elevated ICP.
How would the nurse describe the clonic phase of a tonic clonic seizure?The tonic phase of a tonic-clonic seizure is described as stiffening of the body for several seconds. During the tonic phase, extraocular movements, apnea, and tongue biting may occur. This phase is also associated with activation of the sympathetic nervous system.
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A client who has experienced a subarachnoid hemorrhage would be maintained in which position
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