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Terms in this set (53)When providing care for a client following a bronchoscopy, which assessment finding should the nurse immediately report to the HCP? b) dyspnea and dysphagia To reduce the risk for pulmonary complication for a client with amyotrophic lateral sclerosis (ALS), what interventions should the nurse implement? C, E A male client who reports
feeling chronically fatigued has a Hgb of 11.0 grams/dl, hematocrit of 34%, and microcytic and hypochromic red blood cells. Based on these findings, which dinner selection should the nurse suggest to the client? b) beef steak with steamed broccoli and orange slices Two days following abdominal surgery a client c/o of cramping abdominal pain, and the nurse's inspection of the abdomen indicates slight distention. Which action should the nurse implement first? c) Auscultate the client's abdomen
A client with a liver abscess undergoes surgical evacuation and drainage of the abscess. Which lab value is most important for the nurse to monitor following the procedure? c. White blood cell count A male client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling
he is experiencing worsens at night. What client teaching should the nurse provide? c. Wear braces as both wriSts during the night A client returns to the unit following a suprapubic prostatectomy. He has a
three-way catheter in place with a continuous bladder irrigation infusing. Which assessment finding warrants immediate intervention by the nurse d. Urine leaking around the meatus An adult female client is diagnosed with restless leg syndrome and is referred to the sleep
clinic. The healthcare provider prescribes ferrous sulfate (Feosol) 325 mg PO daily. Which laboratory values should the nurse monitor? c. Serum iron and ferritin A client uses triamcinolone (Kenalog), a corticosteroid ointment, to manage pruritus caused by a chronic skin rash. The client
calls the clinic nurse to report increased erythema with purulent exudate at the site. Which action should the nurse implement? a. Schedule an appointment or the client to see the healthcare provider During preoperative teaching for a male client schedule for repair of an inguinal hernia, the client tells the nurse that he has had several surgeries and understand the need to perform coughing and deep breathing exercise after surgery. How should the nurse respond? a. Ask for a demonstration of these exercises A client with ulcerative colitis is admitted to the medical unit during an acute exacerbation. The nurse should instruct the unlicensed assistive personnel (UAP) to report which finding related to the client's bowel movements? c. Stool with fatty streaks The nurse is evaluating a male client understanding of diet teaching about the DASH (Dietary Approaches to Stop Hypertension) eating plan. Which behavior indicates that the client is adhering to the eating plan? d. Carefully cleans and peels all fresh fruit and vegetables An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action? d. Administer IV antibiotics as prescribed An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection (UTI). Prescriptions for intravenous antibiotics and an insulin infusion are initiated. Which serum laboratory value warrants the most immediate intervention by the nurse? d. Potassium of 2.5 mEq/L An older male client with long-standing lung disease is admitted to the medical unit for treatment of pulmonary infection. In assessing for signs of increasing hypoxia, which action should the nurse include? (select all that apply) B, C, E A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client plan of care? c. Evaluate level of consciousness A nurse assists a male client with Parkinson's disease (PD) to ambulate in the hallway. The client appears to "freeze" and then carefully lifts one leg and steps forward. He tells the nurse that he is pretending to step over a crack on the floor. How should the nurse respond? b. Confirm that this is an effective technique to help with ambulation In assessing a client with ulcers on the lower extremity, which findings indicate that the ulcers
are likely to be of venous, rather than arterial, origin? b. Irregular ulcer shapes and sever edema A client with acute renal injury (AKI) who weighs 50 kg and has potassium level of 6.7 mEq/L (6.7 mmol/l) is admitted to the hospital. Which
prescribed medication should the nurse administer first c. Sodium polystyrene (Kayexalate) 15 grams PO An older adult with heart failure is hospitalized during an acute exacerbation. To reduce cardiac workload, which
intervention should the nurse include in the client's plan of care? c. Provide a bedside commode for toileting Two days after a nephrectomy, the client reports abdominal pressure and nausea, which assessment should the nurse
implement? d. Auscultate bowels sounds. The nurse reviews the laboratory results of a client during an annual physical examination and identifies a positive guaiac test of stool. Which additional serum laboratory test result should the nurse review? b. Platelet count An older female client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment. To determine if the client is experiencing any long-term complication of DM, which assessments should the nurse obtain? (select all that apply) A, B, C, D An older adult man recently diagnosed with chronic obstructive pulmonary disease (COPD) is admitted with shortness of breath. The nurse observes the client sitting upright and leaning over the bedside table, using accessory muscles to assist in breathing. What action should the nurse take? d. Instruct the client to pursed lip breathing techniques A client's telemetry monitor indicates ventricular fibrillation (VF). After delivering one counter shock, the nurse resumes chest
compression. After another minute of compressions, the client's rhythm converts to supraventricular tachycardia (SVT) on the monitor. At this point, what is the priority intervention for the nurse? d. Give IV dose of adenosine rapidly over 1-2 seconds. An adult female with multiple sclerosis (MS) fells while walking to the bathroom. On transfer to the intensive care unit, she is confused and has had projectile vomiting twice. Which intervention should the nurse implement first? d. Complete head to toe neurological assessment. A hospitalized client with chemotherapy-induced stomatitis complains of mouth pain. What is the best initial nursing action? d. Administer a topical analgesic per PRN protocol. 1. A male client who had abdominal surgery 5 days ago, and hospitalized because of a surgical wound infection, tells the nurse that he feels like his insides just spilled out when he coughed. What action should the nurse take first? c. Visualize the abdominal incision 1. The nurse is preparing a client for discharge who recently diagnosed with Addison's disease. Which instruction is most important for the nurse to include in the client's discharge teaching plan? d. Take prescribed cortisone accurately When providing care for a client following bronchoscopy, which assessment finding should he nurse immediately report to the healthcare provider? d. No gag reflex after thirty minutes
To reduce the risk for pulmonary complication for a client with Amyotrophic Lateral Sclerosis (ALS), what interventions should the nurse implement? (Select all that apply) c. Teach the client breathing exercises A male client who reports feeling chronically fatigued has a hemoglobin of 11.0 grams/dl (110mmol/L), hematocrit of 34%, and microcytic and hypochromic red blood cells (RBCs). Based on these findings, which dinner selection should the nurse suggest to the client? b. Beef steak with steamed broccoli and orange slices Two days following abdominal surgery a client begins to report camping abdominal pain, and the nurse's inspection the abdomen indicates slight distention. Which action should the nurse implement first? c. Auscultate the client's abdomen The healthcare provider prescribes and IV solution of regular insulin (Humulin-R) 100 units in 250 ml of 0.45% saline to infuse at 12 units/hour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only) ... A
nurse is caring for a client with Diabetes Insipidus (DI). Which data warrants the most immediate intervention by the nurse? a. Serum sodium of 185 mEq/L Which instruction should the nurse include in the discharge teaching for a client who has gastroesophageal
reflux? a. Teach the client to elevate the head of the bed on blocks The clinic nurse is reviewing strategies for blood glucose monitoring with a client who is newly diagnosed
with diabetes mellitus. When helping the client select a blood glucose meter, which client assessments should the nurse complete? a. Manual dexterity and visual acuity A fair-skinned female client who is an avid runner is diagnosed
with malignant melanoma, which is located on the lateral surface of the lower leg. After wide margin resection, the nurse provides discharge teaching. I t is most important for the nurse to emphasize the need to observe for changes in which characteristic? b. Appearance of any moles A male
client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about the dietary restriction he should follow. In discussing fluid intake, the nurse should include which type of fluid limitation c. Tea and hot chocolate A client who is receiving chemotherapy is
vomiting. Which nursing intervention should the nurse implement first? c. Administer ondansetron hydrochloride (Zofran) The nurse calculates the body mass index (BMI) for an obese adult. Which
additional assessment finding places the client at high risk for cardiac disease? a. Large waist circumference with central fat An adult male client is admitted for Pneumocystis carinal pneumonia (PCP) secondary to AIDSs. While hospitalized, he receives IV pentamidine
isethionate therapy. In preparing this client for discharge, what important aspect regarding his medication therapy should the nurse explain? b. It will be necessary to continue prophylactic doses of IV or aerosol pentamidine every month 1. A client who has a history of long-standing back pain treated with methadone (Dolophines), is admitted to the surgical unit following urological surgery. Which modifications in the plan of care should the nurse make for this client's pain management during the postoperative period? c. Maintain client's methadone, and medicate surgical pain based on pain rating When
planning care for a client with rheumatoid arthritis, which intervention is most important for the nurse to include in the plan of care? b. Implement measures to manage chronic pain A
male client with a history of asthma reports having episodes of bronchoconstriction and increased mucous production while exercising. Which action should the nurse implement? c. Determine if the client is using an inhaler before exercising An older woman who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and she only eats half of the food on her meal tray. Her family expresses concern about her nutritional status. How should the nurse respond to the family's concern? d. Demonstrate the use of visual scanning during meals to the client and family. A client who had a biliopancreatic diversion procedure (BDP) 3 months ago is admitted with a severe dehydration. Which
assessment finding warrants immediate intervention by the nurse. b. Gastroccult positive emesis Three days after a female client with multiple sclerosis (MS) is admitted to the hospital with a severe urinary tract infection, she reports experiencing double vision. Which
intervention should the nurse implement? a. Patch one eye and then the other every few hours The nurse is collecting information from a client with chronic pancreatitis who reports persistent
gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain? a. Eating patterns and dietary intake A male client with chronic kidney disease (CKD) is beginning his first hemodialysis 3
times per week. Which short-term goal is most important for the nurse to include in the plan of care for this client as he begins the series? d. Verbalizes understanding of the reasoning for dialysis An older client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement? c. Provide an eye shield to be worn while sleeping An ER nurse is completing an assessment on a patient that is alert but struggles to answer questions. When she attempts to talk, she slurs her speech and appears very frightened. What additional clinical manifestation does the nurse expect to find if Nancy's symptoms have been caused by a brain attack (stroke)? A. A carotid bruit Which clinical manifestation further supports an assessment of a left-sided brain attack? D) Global aphasia. Sets found in the same folderPharm HESI Practice55 terms woahitsquizLITPLUS Chapter 50: Male Reproductive Disorders29 terms iloveualatte123 MS HESI*55 terms howardkathryn Fundamentals HESI Practice55 terms woahitsquizLITPLUS Other sets by this creator1 General Principles of Pharmacology34 terms iloveualatte123 2 Administration of Drugs33 terms iloveualatte123 3 Making Drug Dosing Safer27 terms iloveualatte123 5 Patient and Family Teaching35 terms iloveualatte123 Other Quizlet setsComm 388: Suspense16 terms nickfessenden Respiratory system- Sherwood48 terms yyongle geology40 terms coachroach22 SPED 225: FINAL REVIEW59 terms bbstrand Related questionsQUESTION what does adequate oxygenation depend on? 15 answers QUESTION What are some of the causes of Swan Neck Deformity? 10 answers QUESTION Why is a hip dislocation rare? 15 answers QUESTION what is the space in between the visceral and parietal pleura 15 answers |
When providing care for a client following bronchoscopy which assessment finding should he nurse immediately report to the healthcare provider?
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