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A series of nursing care scenarios covering various aspects of patient care, including preoperative teaching for a right knee arthroplasty, conducting an admission history for a client undergoing a ct scan with iv contrast, assessing clients for indications of role changes, and providing change-of-shift report for a group of clients. The scenarios highlight the nurse's responsibilities in educating clients, gathering patient information, and monitoring client status. Insights into the nurse's role in ensuring patient safety, promoting client understanding, and delivering comprehensive nursing care across different healthcare settings.
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A nurse is instructing a client on home care after a culture for a bacterial infection and cellulitis. WHich of the following info should the nurse include?
Sustained burns over 35% of total body surface area. Voice is hoarse, a brassy cough has developed, and client is drooling. NUrse should ID these findings as...
A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit? - ansHeart rate 110/min A nurse in an emergency department is reviewing the provider's prescriptions for a client who sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the nurse expect? - ansAdminister an opioid analgesic to the client. A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing's triad? - ansBradycardia A nurse is assessing a client following the administration of magnesium sulfate 1 g IV bolus. For which of the following adverse effects should the nurse monitor? - ansRespiratory paralysis A nurse is assessing a client who had extracorporeal shock wave lithotripsy (ESWL) 6 hr ago. Which of the following findings should the nurse expect? - ansStone fragments in the urine A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurse's priority? - ansTachycardia A nurse is assessing a client who has Graves' disease. Which of the following images should indicate to the nurse that the client has exophthalmos? - ansD A nurse is assessing a client who has had a plaster cast applied to their left leg 2 hr ago. Which of the following actions should the nurse take? - ansCheck that one finger fits between the cast and the leg. To make sure the cast is not too tight, the nurse should be able to slide one finger under the cast. It is not uncommon for casts to loosen as swelling subsides, but that should not be an issue 2 hr after application. A nurse is assessing a client who has had a suspected stroke. The nurse should place the priority on which of the following findings? - ansDysphagia A nurse is assessing a group of clients for indications of role changes. The nurse should identify that which of the following clients is at risk for experiencing a role change? - ansA client who has multiple sclerosis and is experiencing progressive difficulty ambulating
X mL/hr = 166. Round if necessary. 166.67 = 167 mL/hr A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following assessment findings should the nurse expect? - ansHypoactive bowel sounds A nurse is caring for a client who has a prescription for enalapril. The nurse should identify which of the following findings as an adverse effect of the medication? - ansOrthostatic hypotension A nurse is caring for a client who has a stage III pressure injury. Which of the following findings contributes to delayed wound healing? - ansUrine output 25 mL/hr A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. Which of the following assessment findings is the nurse's priority? - ansIncreased respiratory secretions A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive cough. Which of the following actions should the nurse take first? - ansInitiate airborne precautions. A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following laboratory findings should the nurse expect? - ansBUN 32 mg/dL A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first? - ansInstruct the client to allow the machine to breathe for them. A nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. The client is experiencing excessive stools. Which of the following findings is an adverse effect of this medication? - ansHypokalemia A nurse is caring for a client who has pancreatitis. The nurse should expect which of the following laboratory results to be below the expected reference range? - ansCalcium A client who has pancreatitis is expected to have decreased calcium and magnesium levels due to fat necrosis. A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first?
A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? - ansLoosen restrictive clothing. A nurse is caring for a client who is having a seizure. Which of the following interventions is the nurse's priority? - ansTurn the client to the side. A nurse is caring for a client who is on bed rest and has a new prescription for enoxaparin subcutaneous. Which of the following actions should the nurse take? - ansInject the medication into the anterolateral abdominal wall. A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following laboratory values should the nurse report to the provider? - ansHgb 8 g/dL A nurse is caring for a client who is postoperative. Which of the following actions should the nurse take? Select all that apply. - ansInstruct the client to splint the abdomen with a pillow for coughing Plan to ambulate the client as soon as possible Report urinary output to the provider Ask the client to rate their pain on a 0 to 10 pain scale A nurse is caring for a client who is receiving morphine for daily dressing changes. The client tells the nurse, "I don't want any more morphine because I don't want to get addicted." Which of the following actions should the nurse take? - ansInstruct the client on alternative therapies for pain reduction. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A new bag is not available when the current infusion is nearly completed. Which of the following actions should the nurse take? - ansAdminister dextrose 10% in water until the new bag arrives. A nurse is caring for a client who is undergoing hemodialysis to treat end-stage kidney disease (ESKD). The client reports muscle cramps and a tingling sensation in their hands. Which of the following medications should the nurse plan to administer? - ansCalcium carbonate A nurse is caring for a client who presents to a clinic for a 1-week follow-up visit after hospitalization for heart failure. Based on the information in the client's chart, which of the following findings should the nurse report to the provider? - ansHeart rate 55/min A nurse is caring for a client who was just admitted from the emergency department (ED) - ansAcute chest syndrome and pneumonia
A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure injury. Which of the following actions should the nurse take? - ansUse a 30- mL syringe A nurse is planning to provide discharge teaching for the family of an older adult client who has hemianopsia and is at risk for falls. Which of the following instructions should the nurse include? - ansRemind the client to scan their complete range of vision during ambulation. The nurse should instruct the family to remind a client who has hemianopsia, or blindness in half of the visual field, to use visual scanning to look over their complete range of vision during ambulation. This practice can accommodate for the loss of vision and help to reduce the risk for falls. A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Which of the following prescribed medications should the nurse instruct the client to withhold for 48 hr prior to cardioversion? - ansDigoxin A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take? - ansRemain with the client for the first 15 min of the infusion. A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place which of the following items at the client's bedside? - ansSuction machine A nurse is providing discharge instructions to a client following an upper gastrointestinal series with barium contrast. Which of the following information should the nurse provide? - ansIncrease fluid intake. A nurse is providing discharge instructions to a client who has a partial-thickness burn on the hand. Which of the following instructions should the nurse include? - ansWrap fingers with individual dressings. A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new prescription for metformin. Which of the following statements by the client indicates an understanding of the teaching? - ans"I should take this medication with a meal." A nurse is providing preoperative teaching for a client who is scheduled for an open cholecystectomy. Which of the following actions should the nurse take? - ansDemonstrate ways to deep breathe and cough. A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for omeprazole. The nurse should instruct the client that the medication provides relief by which of the following actions? - ansSuppressing gastric acid production
A nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. Which of the following statements by the client indicates an understanding of the teaching? - ans"I am taking this medication to increase my energy level." A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which of the following statements should the nurse identify as an indication that the client understands the teaching? - ans"I will use my hands rather than a washcloth to clean the radiation area." The client should gently wash the radiation area with their hands using warm water and mild soap to protect the skin from further irritation. A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medication? - ansCalcium A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching? - ans"I will monitor my blood pressure while taking this medication." A nurse is providing teaching to a female client who has a history of urinary tract infections (UTIs). Which of the following information should the nurse include in the teaching? - ansTake daily cranberry supplements. A nurse is providing teaching to an older adult client who has cancer and a new prescription for an opioid analgesic for pain management. Which of the following information should the nurse include in the teaching? - ans"You should void every 4 hours to decrease the risk of urinary retention." A nurse is providing teaching to an older adult female client who has stress incontinence and a BMI of 32. Which of the following statements by the client indicates an understanding of the teaching? - ans"I am dieting to lose weight." A nurse is reviewing the laboratory results of a client who has cirrhosis. Which of the following laboratory values should the nurse expect? - ansElevated bilirubin level A nurse is teaching a class about client rights. Which of the following instructions should the nurse include? - ansA client should sign an informed consent before receiving a placebo during a research trial.
Perform neurological checks every 2 hr is nonessential. Administer oxygen at 3 L/min via nasal cannula is anticipated. Limit the client's fluid intake to 1,500 mL per day is contraindicated. Acetaminophen 500 mg PO every 6 hr as needed is anticipated. Famotidine 40 mg PO daily is nonessential. Select the 4 findings that require follow-up by the nurse. - ansVirtual disturbances Tingling of the lips Hand grasps Expressive aphasia The client is experiencing manifestations of.. due to.. - ansPeritonitis X-ray results The nurse is evaluating the client's understanding of discharge instructions. Which of the following client statements indicates an understanding of the teaching? - ans"Foods that contain tyramine might trigger my headaches" "I will keep a food and headache diary" "I will place a cool cloth on my forehead when I experience a migraine" The nurse is reviewing the client's diagnostic results. Which of the following findings requires follow-up by the nurse? Select all that apply. - ansPCO WBC Chest X-ray Oxygen saturation BUN The nurse is reviewing the client's medical record from Day 5. Click to highlight the findings below that indicate the client is improving. To deselect a finding, click on the finding again. - ansHeart rate is 72/min Respiratory rate is 20/min Blood pressure is 128/ Oxygen saturation is 96% The nurse is reviewing the client's medical record. Select the 3 findings that require nursing intervention. - ansTemperature WBC Potassium The nurse should first address the client's .. followed by the client's.. - ansOxygen saturation Temperature
The nurse should identify that the client is most likely experiencing Select... and the nurse should address the client's Select... - ansA migraine Pain A nurse and an assistive personnel (AP) are caring for a client who has bacterial meningitis. The nurse should give the AP which of the following instructions? - ansWear a mask. A nurse at a provider's office is caring for a client who is 2 weeks postoperative following a gastrectomy A nurse is providing teaching for the client. Which of the following instructions should the nurse include? - ansAvoid drinking fluids with meals Eat several small meals per day Consume high-protein snacks Avoid highly seasoned foods A nurse has received change-of-shift report for a group of clients. Which of the following clients should the nurse assess first? - ansA client who had a myocardial infarction (MI) 4 days ago and is asking for a PRN sublingual nitroglycerin tablet A nurse in a community clinic is caring for a client who reports an increase in the frequency of migraine headaches. To help reduce the risk for migraine headaches, which of the following foods should the nurse recommend the client avoid? - ansAged cheese A nurse in a provider's office is assessing a client who has hypertension and takes propranolol. Which of the following findings should indicate to the nurse that the client is experiencing an adverse reaction to this medication? - ansReport of a night cough A nurse in a provider's office is assessing a client who has migraine headaches and is taking feverfew to prevent headaches. The nurse should identify that which of the following client medications interacts with feverfew? - ansNaproxen A nurse in a provider's office is caring for a client who requests sildenafil to treat erectile dysfunction. Which of the following statements should the nurse make? - ans"You will not be able to use sildenafil if you are taking nitroglycerin." A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the following precautions should the nurse implement? - ansThe nurse should ensure the client has IV access in the event that the client requires medication to stop seizure activity.
A nurse is assessing a male client for an inguinal hernia. Which of the following areas should the nurse palpate to verify that the client has an inguinal hernia? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) - ansC A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurse's priority? - ansApply firm pressure to the insertion site. A nurse is caring for a client has who has chronic glomerulonephritis with oliguria. Which of the following findings should the nurse identify as a manifestation of chronic glomerulonephritis? - anshyperkalemia A nurse is caring for a client in the emergency department (ED). - ansAdminister morphine Ensure the patient is NPO Cholecystitis Monitor the color of the client's stools Monitor the client for dark urine A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which of the following findings indicates that the client is experiencing increased intracranial pressure (ICP)? (Select all that apply.) - ansSleepiness exhibited by the client Widening pulse pressure Decerebrate posturing A nurse is caring for a client who has a migraine. Which of the following interventions should the nurse anticipate? Select all that apply. - ansAdminister sumatriptan is correct. Dim the lights in the client's room is correct A nurse is caring for a client who has a new diagnosis of hyperthyroidism. Which of the following is the priority assessment finding that the nurse should report to the provider?
X mL/hr = 166. Round if necessary. 166.67 = 167 mL/hr A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following assessment findings should the nurse expect? - ansHypoactive bowel sounds A nurse is caring for a client who has a prescription for enalapril. The nurse should identify which of the following findings as an adverse effect of the medication? - ansOrthostatic hypotension A nurse is caring for a client who has a stage III pressure injury. Which of the following findings contributes to delayed wound healing? - ansUrine output 25 mL/hr A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. Which of the following assessment findings is the nurse's priority? - ansIncreased respiratory secretions A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive cough. Which of the following actions should the nurse take first? - ansInitiate airborne precautions. A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following laboratory findings should the nurse expect? - ansBUN 32 mg/dL A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first? - ansInstruct the client to allow the machine to breathe for them. A nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. The client is experiencing excessive stools. Which of the following findings is an adverse effect of this medication? - ansHypokalemia A nurse is caring for a client who has pancreatitis. The nurse should expect which of the following laboratory results to be below the expected reference range? - ansCalcium A client who has pancreatitis is expected to have decreased calcium and magnesium levels due to fat necrosis. A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first?