A client with a productive cough has obtained a sputum specimen for culture as instructed. What is the best initial nursing action? Answer: Administer the first dose of prescribed antibiotic therapy
A client is brought to the Emergency Department by ambulation in cardiac arrest with cardiopulmonary resuscitation (CPR) in progress. The client is intubated and receiving 100% oxygen per self‐inflating (ambu) bag. The nurse determines that the client is cyanotic, cold, and diaphoretic. Which assessment is most important for the nurse to obtain? Answer: deep tendon reflexes.
After hospitalization for Syndrome of Inappropriate Antidiuretic hormone (SIADH), a client develops myelinolysis. Which intervention should the nurse implement first? Answer: Reorient client to hisroom.
A male client with heart failure (HF) calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain? Answer: Has his weight changed in the last several days?
An older adult woman with a long history of COPD is admitted with progressive shortness of breath and a persistent cough. She is anxious and is complaining of a dry mouth. Which intervention should the nurse implement? Answer: Apply a high‐flow venturi mask.
A client with a history of asthma and bronchitis arrives at the clinic with SOB, productive cough with thickened, tenacious mucous, and the inability to walk up flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self‐care? Answer: Increase the daily intake of oral fluids to liquefy secretions.
A cardiac catheterization of a client with heart disease indicates the following blockages: 95% LAD, 99% proximal circumflex, and 95% proximal RCA. The client later asks the nurse “what does all that mean for me?” Answer: Three main arteries have major blockage with only 1 to 5% of the blood flow getting through to the heart muscle.
A client who weighs 175 pounds is receiving an IV bolus dose of heparin 80 units/kg. The heparin is available in a 2 mL vial, labeled 10,000 units/mL. How many mL should the nurse administer? (enter numeric value only. If rounding, round to nearest tenth.) Answer: 1.3 mL after calculations: the calculator will show 1.272727272727273, but you must round to the nearest tenth. So, the answer is 1.3 mL.
What information should the nurse include in the teaching plan of a client diagnosed with gastroesophageal reflux disease (GERD)? 1 | P a g e 2 / 4 Answer: minimize symptoms by wearing loose, comfortable clothing.
The nurse is caring for a client with a lower left lobe pulmonary abscess. Which position should the nurse instruct the client to maintain? Answer: Left Lateral.
A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider? Answer: Yellow Sclera
While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse? Answer: Increasing anxiety.
The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft to promote burn healing. Which information should the nurse provide this client? Answer: The xenograft is taken from nonhuman sources.
A male client who had colon surgery 3 days ago is anxious and request assistance to reposition. The wound dehiscences and eviscerates. The nurse moistens an available sterile dressing and palaces it over the wound. Which intervention should the nurse implement next? answer: prepare the client to return to the operating room.
A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117 mEq/L. Which nursing problem should the nurse include in this client’s plan of care? answer: fluid volume excess 16.A female client enters the clinic and insists on being seen. She is weak, nervous, and reports a racing heart beat and recent weight loss of 15 pounds. After ruling out substance withdrawal, the healthcare provider suspects hyperthyroidism. Which action should the nurse implement? answer:space the client’s care to provide periods of rest
The nurse is teaching a client with glomerulonephritis about self‐care. Which dietary recommendations should the nurse encourage the client to follow? answer: restrict intake by limiting meats and other high‐protein foods.
An overweight, young adult male who has recently diagnosed with type diabetes mellitus is admitted for a hernia repair. He tells the nurse he is feeling very weak and jittery. Which actions should the nurse implement? (select all that apply). ☒Assess hisskin temperature and moisture. ☒Document anxiety on the surgical checklist. ☒Administer a PRN dose of regular insulin 2 | P a g e 3 / 4
A client with Cushing’ssyndrome isrecovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse? answer: irregular apical pulse
An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red and the client reports a burning sensation. What action should the nurse take? answer:secure a pulse oximeter to monitor the client’s oxygen saturation.
A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are temperature 101° F, heart rate 128 beats/minute, respirations 28 breaths/minute, and blood pressure 122/82, which intervention is most important for the nurse to implement first? Answer: assess lower extremity circulation. 22.The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic cholecystectomy under general anesthesia. Which finding warrants notification ofthe healthcare provider prior to proceeding with the scheduled procedure? answer: the client’s blood pressure is 184/88 mm Hg.
A client who has a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse? answer: hematocrit of 30%
Following surgical repair of the bladder, a female client is being discharged from the hospital to home with an indwelling urinary catheter. Which instruction is most important for the nurse to provide to this client? answer: keep the drainage bag lower than the level of the bladder
Which client has the highest risk for developing skin cancer? answer: a 65‐year‐old fairskinned male who is a construction worker.
When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain? answer: level of consciousness
A female client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). (select all that apply). ☒Verify pedal pulses using a doppler pulse device. ☒Monitor left leg for pain, pallor, paresthesia, paralysis, pressure. ☒Evaluate the application of the splint to the left leg.
A male client with herpeszoster (shingles) on his thorax tellsthe nurse that he is having difficulty sleeping. What is the probably etiology of this problem?