HESI Med Surg Final Exam 2 Questions

Guaiac Occult Test. What lab is most important? Platelet Count Patient had BDP 3 months ago with dehydration. What would warrant the nurse immediate intervention? Positive Gastro Occult A patient with Parkinson's. "Freezes." Pretends there is a crack on the floor and Carefully lifts leg and steps over. Confirm that this is the correct and effective technique. Patient had Atrial Fibrillation and then AED was used. One minute later, Patient sudden goes in to ventricular Tachycardia. What should the nurse do? Administer Adenosine over 1-2 seconds IV Heart failure acute exacerbation. How to Reduce Cardiac Workload? Bedside Commode External Fixation Device- What should the nurse do first? Assess for peripheral pulse at the foot COPD patient is experience shortness of breath. Pursed Lip Breathing Client with CVA (stroke). Has only eaten half of their food. Family is concern about nutrition. What should the nurse tell the family? Demonstrate the use of Visual Scanning. A male client with asthma has bronchoconstriction and mucous production due to exercising. What should the nurse do? Determine if the client is using an inhaler before exercising. A client with liver abscess and drainage of abscess. Which lab value? White blood Cell Count Suprapubic prostatectomy. Three-way catheter. Which assessment? Urine Leaking meatus A client with ulcerative colitis. UAP report what finding? Stool with fatty streaks Flank pain and acute pyelonephritis. Priority nursing action. Administer IV antibiotics. Long-standing pulmonary infection. Assess for hypoxia. Select All That Apply. Breathing patterns, Check mentation, color of skin and nailbeds Traction applied, but client is frustrated because client keeps calling nurse for help with repositioning. Use a trapeze bar. Multiple Sclerosis and urinary retention. Self-Catheterization Client works as a data desk job with Raynaud's syndrome. What to do to prevent wrist injury? Space Heater C.K.D. Lab to report. Potassium 6.5 Client withy Gullian Barre is not blinking. Administer Lubricant Taking prednisone PO 5mg. What symptom? Rapid Weight Gain. Succinylcholine. High Temperature. Ice Pack axillary The nurse drops a sterile package of supplies on the floor in the operating room (OR) suite. The ... impervious wrapper. Which action should the nurse implement? Open contents to sterile field package intact. Client with Acute Glomerulonephritis. Restrict Sodium. Client ask about biopsy results from cancer cells well differentiated. What response? Ask Healthcare provider to gather more information. Right cataract and lens implant. Which intervention should the nurse first? Provide an eye shield to be worn while sleeping. The unlicensed assistive personnel (UAP) reports to the nurse that a client who was admitted with abdominal pain has just had a large black tarry stool. What intervention should the nurse implement first? Test the stool for occult blood. Which action is most important for the nurse to implement to reduce the risk for deep vein thrombosis in a postoperative client? Advise the client to perform leg exercises regularly. The nurse is preparing a client for a bronchoscopy. While obtaining consent, the client complains of thirst and admits to drinking a small amount of orange juice two hours ago. What action should the nurse take? Delay procedure for 6 hours. A client uses triamcinolone (kenalog), a corticosteroid ointment, to manage pruritis caused by a chronic skin rash. The client calls the clinic nurse to report increased erythema with purulent exudate at the site. What action should the nurse implement? Schedule an appointment for the client to the healthcare provider. The nurse learns in change of shift report that the x-ray report for a newly admitted client indicates consolidation in the left lower lung. What action should the nurse take? Administer a PRN dose of a bronchodilator. The nurse is monitoring the glucose q4h of an adult woman admitted with DKA. Two hours after receiving 10 units of regular insulin for glucose of 255, the client is perspiring and complaining of shakiness. What intervention should the nurse implement? Check Capillary glucose level. The chest x-ray for a client who is admitted for pneumonia shows pleural effusion with decreased air flow in the entire left upper lobe. What breath sounds that verify the x-ray findings should the nurse document after auscultation of the left upper lobe? Diminished breath sounds Which food is most important for the nurse to encourage a male patient with osteomalacia to include in his daily diet? Fortified milk and cereals. An older adult woman is seen in the clinic 3 months following her diagnosis of type 2 diabetes mellitus (DM). She tells the nurse that she has had a difficult time keeping her blood sugar in control. The nurse reviews the client's current finger-stick and daily log of blood glucose levels. Which intervention is most important for the nurse to implement? Review the client's glycosylated hemoglobin (A1c) level. The nurse is taking a client's blood pressure and observes carpal spasm after the sphygmomanometer cuff is inflated. What action should the nurse implement next? Assess the client's recent serum calcium level. 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? Tea and hot chocolate. During preoperative teaching for a male client scheduled for repair of an inguinal hernia, the client tells the nurse that he has had several surgeries and understands the need to perform coughing and deep breathing exercises after surgery. How should the nurse respond? Ask for demonstration of these exercises. A pt 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 pt's plan of care? Continuous cardiac monitoring. After 3 days of persistent epigastric pain, a female pt presents to the clinic. She has been taking oral antacids w/o relief. Her vital signs are HR 122 beats/min, respirations 16 breaths/min, O2 96% and BP 116/70. The nurse obtains a 12-lead ECG. Which assessment finding is most critical? ST elevation in three leads A male client with an external fixation device for a fractured left femur is complaining of left foot pain. Which intervention should the nurse implement first? Administer PRN pain medication. Two days following abdominal surgery a client begins to complain of cramping abdominal pain, and the nurse's inspection of the abdomen indicates slight distention. Which action should the nurse implement first? Auscultate abdomen quadrants 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. it is most important for the nurse to emphasize the need to observe for changes in which characteristic? Appearance of any moles. Math question: Order of 8,200 units. Each 1mL of solution contains 10,000 units of alfa. How many mL? (If Rounding is necessary, then round to the nearest tenth). Simply, divide 8200 and 10,000, which equals = 0.82mL after calculation. THEN ROUND TO THE NEAREST TENTH, and final answer is 0.8mL What instruction should the nurse include in the discharge teaching plan of a client who had a cataract extraction today? Light housekeeping is permitted, but avoid heavy lifting. When a nurse is caring for a client with acute hypothyroidism, which serum laboratory value requires immediate intervention? Serum sodium 122 mEq/L. A potential donor of corneal tissue for the eye bank has just died. The nurse enters the room prescribed antibiotic eye drops. What action should the nurse take next? Secure eye shields over the closed after instilling the eyedrops. 3 months following her diagnosis of type II diabetes...had a difficult time keeping her blood sugar is centered. The nurse reviews that..blood glucose levels. Which interventions in most important for the nurse to implement? Review the client's glycosylated hemoglobin (A1c) level. I forgot the question, but the answer was Prepare Discharging patient. Retinal Tear. What to do to avoid risk of retina damage? ... 2-year old boy is having health assessment. Which further assessment by nurse? "He refuses to feed, but I make him eat meats" 18. SIADH: Difficulty swallowing 19. Nephrotic syndrome: Monitor for weight 20. A patient with diabetes complains that he is unable to sleep at night because of cold feet. What should the nurse advice? Apply warm blankets to the feet 21. Carpel Tunnel Syndrome: Compression of median nerve 22. LAD, CAD, another artery that supply the heart have blockage of 95%, 99% and 99%. How should the nurse explain to the client: 1-5% of blood gets to your heart.[Explain in layman/simple terms to the patient] 23. Emphysema client teaching: Deep breathing and pursed lips 24. NG Tube: Fowler's position, 30-90 degrees sitting position 25. Paracentesis procedure- Sitting upright during procedure 26. Finger stick glucose check with milking: Check radial pulse 27. Eczema: Dog allergy - Grandson and the dog visited the client 28. A patient with ventricular tachycardia was given Lidocaine. How do the nurse measure the treatment is effective? Decrease episodes of ventricular tachycardia 29. A patient who had intercourse 4 days ago comes to the clinic with burning pain/sensation on urination: Obtain discharge in a swab for culture 30. Open angle glaucoma: Decrease in periphery vision 31. Obstruction of the common bile duct: Yellow sclera 32. A patient is having a seizure is assisted to the floor. Which is priority? Monitor for Apnea 33. A male client has urinary dripping at night: Palpate bladder above the pubic symphysis 34. Patient is unable to wear his shoes: Ask about weight 35. Sodium level is 117. Client may be in acute renal failure. With excessive water retention the sodium levels appear decreased (dilution). Nursing diagnosis: Excess fluid volume 36. Decreased peripheral pulses: Doppler sound 37. CVA occurs in: Carotid arteries A patient had abdominal surgery and states that after coughing it feels like his guts has spilled out. What should the nurse do first? Visualize the abdominal area A patient has been taking Kenalog (corticosteroid) with increase redness... Schedule an appointment A patient hd a BDP. What warrants further intervention? Positive gastro occult emesis A patient who has been taking B12 says he's fatigue. What lab to monitor? CBC A patient with Parkinson is walking .... ? Confirm that its effective Whats priority for a patient who is allergic to bananas? Replace latex How to prevent a renal calculi? limit tea and chocolate If a patient is in F-vib what medication to give? Adenosine A nurse is caring for a patient and is unable to palpate a pedal pulse. What should the nurse do next? Obtain a doppler A client with a history of COPD has established a walking program. How do we know that walking is effective? Cardiovascular improvement Post -op A client informs the nurse that he know all about how to breath. How should the nurse respond? ... ... .... Order 100 units in 250ml to infuse at 12units/hr 12/100 *250= 30 A client complains of pain in the right calf. What is the nurse's priority? Remain in bed A client just returned after having a TURP and has clot. What should the nurse do? slowly irrigate What's Priority for a client with Multiple Scerolosis and has urinary rention? Self cathetherization The nurse is monitoring drainainge of an abscess. What lab should the nurse monitor? WBCs What intervetion the nurse shoudl implement for a patient with Congestive Heart Failure? Use bedside commode when needing to void What intervention should be done for post op cataract extraction? implement deep breathing A client is discharged on Prednisolone. What should the patient report? Wt gain A client is diagnosed with Pyelinephritis. What is priority? IV antibiotics What is a diet for Osteomalacia? Milk and cereal What should the nurse instruct a client who has Raynuads Syndrome to do at work? Use space heater What to report with a Bronchoscopy? ... What should the nurse expect for a client who has unstable Angina who had a cardiac catheter? Thoro....... What to teach a client with acute glumoronepheritis/ Restrict Sodium What to teach a client with GERD? Wear loose clothing How should a client with COPD breath? Pursed lips A client presents with the s/s of Diabetes type 2 and feeling shaky. What is the nurse priority? Obtain glucose level What should the HCP order for a client with Hypothyroidism who has depression and can not sleep? Request PRN... What should a client with Ulcerative Colitis report? Stool with fatty streaks MRSA intervetions? contact precaution, culture & sensitivity, monitor WBCs CKD lab to report? K 6.5 A client has a positive guaic stool. What lab to review? Platelets Phenochrocytoma with HA Assess the blood pressure Suprapubic prostateomy concern? Urine leakacge Abdominal cramping after surgery .... A client tells the nurse that her biopsy results indicate that the cancer cells are well differentiated How should the nurse respond? Ask HCP Ulcer that is venous... Irregular.... What lab indicate a Diabetic is adhering to regiment? A1c A client has 40% of burns. Which fluid is needed during the acute phase? Latated Ringers A client has a pain of 8 out of 10 on the pain scale ... ? Administer opioids and non pharmacological interventions What should be included in the teaching for a client with Diabetes Mellitus with an ulcer? Check shoes before putting them on The HCP orders 8200 units and available is 2ml each 1ml. How much to give 0.8 A client with Gullian Barre is not blinking. What intervention to implement? Administer lubericant What is a concern for a client with Diabetes Insipidous? Sodium level 185 What would indicate a sign of dementia in a client with AIDS? A change in writing What should the nurse evaluate with a client that has ORIFSA? Select All Verify ... Monitor for manifestations of compartment syndrome What intervention will the nurse implement when caring for a client with a pulmonary infection? Select All Assess breathing, change in level of consciousness, monitor skin color What is needed for a client that has traction applied and need repositioning? A trapeze bar RA diagnosis? .... A client is being seen at the clinic for Tinea Pedia. What question to ask Are you taking the prescription Tolfnate What should the nurse do after reading the results of a TB test that read 5mm? Document the findings A client that had a CVA has visual impairment and has not be able to eat all of his food. What should the nurse instruct the family to do? Visual..... Meloma observe for what? Appearance 13. Parkinson's disease: Teach the client to make an intentional swallow 14. CushingSyndrome: Irregular apical pulse due to hypokalemia 15. Addison's Disease: Monitor glucose levels [Hypoglycemia] 16. Congestive Heart Failure: Daily weights 17. Sputum culture: Observe for color, quantity and consistency 18. SIADH: Difficulty swallowing 19. Nephrotic syndrome: Monitor for weight 20. A patient with diabetes complains that he is unable to sleep at night because of cold feet. What should the nurse advice? Apply warm blankets to the feet 21. Carpel Tunnel Syndrome: Compression of median nerve 22. LAD, CAD, another artery that supply the heart have blockage of 95%, 99% and 99%. How should the nurse explain to the client: 1-5% of blood gets to your heart.[Explain in layman/simple terms to the patient] 23. Emphysema client teaching: Deep breathing and pursed lips 24. NG Tube: Fowler's position, 30-90 degrees sitting position 25. Paracentesis procedure- Sitting upright during procedure 26. Finger stick glucose check with milking: Check radial pulse 27. Eczema: Dog allergy - Grandson and the dog visited the client 28. A patient with ventricular tachycardia was given Lidocaine. How do the nurse measure the treatment is effective? Decrease episodes of ventricular tachycardia 29. A patient who had intercourse 4 days ago comes to the clinic with burning pain/sensation on urination: Obtain discharge in a swab for culture 30. Open angle glaucoma: Decrease in periphery vision 31. Obstruction of the common bile duct: Yellow sclera 32. A patient is having a seizure is assisted to the floor. Which is priority? Monitor for Apnea 33. A male client has urinary dripping at night: Palpate bladder above the pubic symphysis 34. Patient is unable to wear his shoes: Ask about weight 35. Sodium level is 117. Client may be in acute renal failure. With excessive water retention the sodium levels appear decreased (dilution). Nursing diagnosis: Excess fluid volume 36. Decreased peripheral pulses: Doppler sound 37. CVA occurs in: Carotid arteries Shingles s/s sata pain skin functional ability xenograft for a jewish pt with burned skin its okay,b/c its from a non human source a pt with als? decreased cough Gerd teaching lose clothing head of the bed up lose weight high risk for sun cancer? fair skin construction worker Adapted from a Quizlet set created by theprodigalstudent1 What instruction should the nurse include in the discharge teaching plan of a client who had a cataract extraction today? a. Sexual activities may be resumed upon return home b. Light housekeeping is permitted but avoid heavy lifting c. Use a metal eye shield on operative eye during the day d. Administer eye ointment before applying eye drops Light housekeeping is permitted but avoid heavy lifting A male adult comes to the urgent care clinic 5 days after being diagnose with influenza. He is short of breath, febrile, and coughing green colored sputum. Which intervention should the nurse implement first? a. Obtain a sputum sample for culture b. Check his oxygen saturation level c. Administer an oral antipyretic d. Auscultate bilateral lung sound Obtain a sputum sample for culture An elder male client tells the nurse that he is loosing sleep because he has to get up several times at night to go to the bathroom that he has trouble starting his urinary stream and that he does not feel like his bladder is ever completely empty. Which intervention should the nurse implement? a. collect a urine specimen for culture analysis b. obtain a fingerstick blood glucose level c. palpate the bladder above the symphysis pubis d. review the client fluid intake palpate the bladder above the symphysis pubis An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary Tract infection (UTI) Prescriptions for intravenous antibiotics and insulin infusion are initiated. Which serum laboratory value warrants the most immediate intervention by the nurse? a. blood ph of 7.30 b. glucose of 350 mg /dl c. white blood cell count of 15000mm d. potassium of 2.5 meq/l potassium of 2.5 meq/l A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cell. When notifying the healthcare provider what information should the nurse provide first using the SBAR communication process? a. explain specific reason for urgent notification b. preface the report by stating the clients name and admitting diagnosis c. communicate the pre-transfusion temperatures d. optain prn prescription for acetaminophen for fever 101f explain specific reason for urgent notification An adult male client is admitted for pneumocystis carinil pneumonia (PCP) secondary to aids. While hospitalize he receives IV pentamidine isethionate therapy. In preparing this client for discharge what important aspect regarding his medication therapy should the nurse explain? a. AZT therapy must be stopped when IV aerosol pentamine is being used. b. IV pentamine will be given until oral pentamine can be tolerated c. It will be necessary to continue prophylactic doses of IV or aerosol pentamine every month d. Iv pentamine may offer protection to others aids related conditions such as kaposis sarcoma It will be necessary to continue prophylactic doses of IV or aerosol pentamine every month A client subjective data includes dysuria, urgency, and urinary frequency. What action should the nurse implement next? a. collect a clean catch specimen b. palpate the suprapubic region c. instruct to wipe from front to back d. inquire about recent sexual activity collect a clean catch specimen A client tells the nurse that her biopsy results indicate that the cancer cells are well differentiated How should the nurse respond? a. offer the client reassurance that this information indicates that the clients cancer cells are benign b. explain that these tissue cells often respond more effectively to radiation than to chemotherapy c. ask the client in the healthcare provider has giving her any information about the classification of her cancer d. help the client make plans to begin inmediate treatment since her cancer is likely to spread quickly ask the client in the healthcare provider has giving her any information about the classification of her cancer A client with a chronic kidney disease is treated on hemodialysis. During the 1 treatment clients blood pressure drops from 150/90 to 80/30. Which action should the nurse take first? a. monitor bp q45 minutes b. lower the head of the chair and elevate feet c. stop dialysis treatment d. administer 5%albumin IV stop dialysis treatment The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this diagnosis? a. upper mid abdominal gnawing and burning pain b. severe abdominal cramps and diarrhea after eating spicy foods c. marked loss of weight and appetite over the last few months d. use of chewable and liquid antacids for indigestion upper mid abdominal gnawing and burning pain The nurse is providing preoperative education for a jewish client schedule to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client? a. the xenograft is taken from nonhuman sources b. grafting increases the risk for bacterial infection c. as the burn heals the graft permanently attaches d. grafts are later removed by debriding procedure the xenograft is taken from nonhuman sources A client who took a camping vacation two weeks ago in a country with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse to report? a. jaundice sclera b. intestinal cramping c. weakness and fatigue d. weight loss jaundice sclera During a home visit the nurse assesses the skin of a client with eczema who reports than an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms? a. an old friend with eczema came for visit b. recently received an influenza immunization c. corticosteroid cream was applied to eczema d. a grandson and his new dog recently visited a grandson and his new dog recently visited When explaining dietary guidelines to a client with acute glomerulonephritis (AGN) which instruction should the nurse include in the dietary teaching? a. select a protein rich food daily b. restrict sodium intake c. eat high potassium foods d. Avoid foods high in carbohydrate restrict sodium intake A male client who is 24hr post operative for an exploratory laparoctomy complains that he is starving because he has had no real food since before surgery. Prior to advancing his diet which intervention should the nurse implememt? a. discontinue intravenous therapy b. Assess for abdominal distension and tenderness c. Obtain a prescription for a diet change d. Auscultate bowel sound in all four quadrants Auscultate bowel sound in all four quadrants A client diagnose with stable angina secondary to ischemic heart disease has a prescription for sublingual (SL) nitroglycerin (NTG). The nurse should tell the client to follow which instructions if chest pain is not relieved after taking 3 NTG tables 5 min apart? a. drive to the nearest emergency department b. take another NTG SL tablet and lie down until angina subsides c. call primary healthcare provider d. call 911 pain is unrelieved and chew a tablet of aspirin 325mg call 911 pain is unrelieved and chew a tablet of aspirin 325mg After taking orlistat (Xenical) for one week a femela client tells the home health nurse that she is experiencing increasingly frequent oily stools and flatus. What action should the nurse take? a. obtain stool specimen to evaluate for occult blood and fat content b. instruct the client to increase her intake of saturated fats over the next week c. ask the client to describe her dietary intake history for the last several days d. advice the client to stop taking the drug and contact the healthcare provider ask the client to describe her dietary intake history for the last several days Two days after an abscess of the chin was drained the client returns to the clinic with fever chills and a maculopapular rash with pruritis. The client has taken an oral antibiotic and cleansed the wound today with provide iodine (Betadine) solution. Which intervention should the nurse implement first? a. determine if the client has a history of diabetes b. assess airway patency and oxygen saturation c. review recent medication history and allergies d. obtain samples for complete blood count and cultures assess airway patency and oxygen saturation A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the health care provider? a. low back pain and hypotension b. rhinitis and nasal stuffiness c. delayed painful rash with urticarial d. arthritic joint changes and chronic pain low back pain and hypotension A young adult male who has had type 2 diabetes mellitus (DM) is admitted to the intensive care unit with hyperglycemic nonketotic syndrome (HHNS). A sliding scale protocol for an isotonic IV solution with regular insulin is prescribed based on the results of a continuous blood glucose monitoring device that is attached to the client's central venous catheter. When the client's respirations become labored and his lungs sound indicate crackles what action should the nurse take? a. collect a specimen for a white blood cell count and cultures b. determine the clients glycosylated hemoglobin (A1C) c. administer insulin IV push until the clients fluid volume is adjusted d. decrease infusion rate to address fluid overload decrease infusion rate to address fluid overload When preparing to apply a fentanyl (Duragesic) transdermal patch the nurse notes that the previously applied patch is intact on the client's upper back and the client denies pain. What action should the nurse take? a. Remove the patch and consult with the healthcare provider about the client pain resolution b. Place the patch on the clients shoulder and leave both patches in place for 12 hours c. Administer an oral analgesic and evaluate its effectiveness before applying a new patch d. Apply a new patch in a different location after removing the original patch Apply a new patch in a different location after removing the original patch A client who had a myocardial infarction is admitted to the coronary critical care unit (CCU) with a nitroglycerin drip infusing. The clients last blood pressure measurements was 78/36.What action should the nurse implement? a. obtain blood pressure q5 minutes using duranap machine b. change the dilution of the nitroglycerin infusion c. reduce the rate of the nitroglycerin infusion d. begin dopamine infusion at 5mcg/kg per minute reduce the rate of the nitroglycerin infusion An adolescent is admitted to the hospital because of a suicide attempt with an overdose of acetaminophen (Tylenol). Which blood values are most important for the nurse to monitor during the first 72 hours following ingestion of this overdose? a. BUN creatinine specific gravity b. White blood count, hemoglobin hematocrit c. PH,PCO2, HC03 d. LDH OR LD, SGOT OR ALT, SGPT OR AST LDH OR LD, SGOT OR ALT, SGPT OR AST An elderly post-operative female client is receiving morphine sulfate via a PCA pump. Which assessment finding should prompt a nurse to administer the prescribed PRN medication naloxone? a. her respiratory rate is 7 breath/minute b. she indicates that she feels as if she cannot get enough air to breath c. she has intercostal retractions and bilateral wheezing is auscultated d. her pulse oximeter is 89% on room air her respiratory rate is 7 breath/minute Which assessment finding indicates to the nurse that the muscarinic agent bethanechol (Urecholine) is effective for a client diagnose with urinary retention? a. urinary output equal to intake b. no terminal urinary dribbling c. denies stress incontinence d. absence of xerostomia urinary output equal to intake Following involvement in a motor vehicle collision, a middle aged adult client is admitted to the hospital with multiple facial fractures. The client's blood alcohol level is high on admission. Which PRN prescription should be administer if the clients begins to exhibit signs and symptoms of delirium tremens (DT s)? a. Lorazepam (Ativan) 2mg IM b. Chlorpromazine (thorazine) 50 mg IM c. Prochlorperazine (Compazine) 5 mg IM d. Hydromorphone (Dilaudid) 2 mg IM Lorazepam (Ativan) 2mg IM Which instructions should the nurse include in the teaching plan of a client who is taking the diuretic spironolactone (Aldactone)? a. call the healthcare provider f you develop gynecomastia b. Take the medication in the morning c. Avoid caffeine and smoking d. Increase your consumption of bananas and oranges Take the medication in the morning A glucagon emergency kit is prescribed for a client with type 1 diabetes mellitus. When should the nurse instruct the client to take the glucagon? a. after meals to increase endogenous insulin secretion b. after insulin administration to prevent hypoglycemia c. when recognized signs of severe hypoglycemia occur d. when unable to eat during sick days when recognized signs of severe hypoglycemia occur A client with hyperthyroidism is being treated with radioactive iodine (I- 131). Which explanation should be included in preparing this client for this treatment? a. describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider b. explain the need for using lead shields for 2 to 3 weeks after the treatment c. describe the signs of goiter because this is a common side effects of radioactive iodine d. explain that relief of the signs/ symptoms of hyperthyroidism will occur immediately describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider A female client is being treated for tuberculosis with rifampin (rifadin) which statement indicates that further teaching is needed? I will take my usual contraceptive for birth control A client is discharged with a prescription for warfarin (Coumadin). What discharge instructions should the nurse emphasize to the client? a. take a multi vitamin supplement daily b. use an astringent for superficial bleeding c. avoid going barefoot especially outside d. include large amounts of spinach in the diet avoid going barefoot especially outside In caring for a client with diabetes insipidus who is receiving an antidiuretic hormone intranasal which serum lab test is most important for the nurse to monitor? a. osmolality b. calcium c. platelets d. glucose osmolality After administering dihydroergotamine (Migranal) 1 mg subcutaneously to a client with a severe migraine headache the nurse should explain that relief can be expected within what time frame? a. 2 hours b. 5 minutes c. 1 hour d. 15 minutes 15 minutes A client with hypertension who has been taking labetalol for two weeks, reports a five pound (2.2 kg) weight gain. Which follow up assessment is most important for the nurse to obtain? a. capillary refill b. body temperature c. muscle strength d. breath sounds breath sounds A male client is receiving pilocarpine hydrochloride (Isopto Carpine) ophthalmic drops for glaucoma. He calls the clinic and ask the nurse why he has difficulty seeing at night. What explanation should the nurse provide? a. The eye drops slow pupil response to accommodate for darkness b. The drops increase the fluid in the eyes and cloud the visual field c. The drug can cause lens to become more opaque d. The medication causes pupils to dilate which reduces night vision The eye drops slow pupil response to accommodate for darkness A client who is taking and oral dose of tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline? a. toasted wheat bread and jelly b. cheese and crackers c. cold cereal with skim milk d. fruit flavored yogurt toasted wheat bread and jelly The therapeutic effect of insulin in treating type 1 diabetes mellitus is based on which physiologic action? a. Facilitates transport of glucose into the cell b. Increases intracellular receptor site sensitivity c. Stimulates function of beta cells in the pancreas d. Delays carbohydrates digestion and absorption Facilitates transport of glucose into the cell The health care provider prescribe a medication for an older adult client who is complaining of insomnia. And instructs the client to return in 2 weeks. The nurse should question which prescription? a. Eszoplicone (Lunesta)10 mg orally at bed time b. Zolpidem 10 mg orally at bed time c. Temazepan orally at bed time d. Ramelteon orally at bedtime Eszoplicone (Lunesta)10 mg orally at bed time A male client reports to the nurse that he is experiencing GI distress from high dose of a corticosteroid and is planning to stop taking the medication. In response to the client's statement what nursing action is most important for the nurse to take? a. Encourage the client to take medication with food to decrease GI distress b. Advice the client that the medication should be stopped gradually rather than abruptly. c. Review the clients dosing schedule to ensure he is taking the prescribed amount d. Assess the client for other indication of adverse effects of corticosteroid Advice the client that the medication should be stopped gradually rather than abruptly. Fifteen minutes after receiving sulfa athenozole. A male client report a burning sensation over his abdomen chest and groin. Which intervention is most important for the nurse to implement? a. Auscultate lung sounds for wheezing b. Review the clients list if drugs allergies c. Add sulfamethinozole to clients allergies d. Check neurological vital signs Review the clients list if drugs allergies Antibiotic resistant organism are a major infection control problems. To help minimize the emergence of resistant bacteria what instruction should the nurse provide to the clients? a. stop taking prescribed antibiotics when symptoms decrease b. avoid using antibiotics when suffering from colds or the flu c. ask the healthcare provider to prescribe the newest antibiotic when needed d. request a prescription for first time vancomysin for a sore throat avoid using antibiotics when suffering from colds or the flu A client with symptoms of influenza that started the previous day ask the clinic nurse about taking oseltamivir (Tamiflu) to treat the infection. Which response should the nurse provide? a. Advise the client once symptoms occur is too late to receive an influenza vaccination b. Refer the client to the healthcare provider at the clinic to obtain a medication prescription c. Explain to the client that antibiotics are not useful in treating viral infections such as influenza d. Instruct the client that over the counter medications are sufficient to manage influenza symptoms Refer the client to the healthcare provider at the clinic to obtain a medication prescription Twenty minutes after the nurse starts a secondary IV infusion of cafepime (maxipime) 2 grams using an infusion pump to deliver the dose in one hour, the client reports feeling nauseated. What action should the nurse implement? a. stop medication infusion and notify the healthcare provider of the adverse effect b. increase the rate of the infusion to complete the dose of the medication more rapidly c. continue the infusion and administer a prn antiemetic prescription d. reassure the client that the nausea is not related to the iv infusion continue the infusion and administer a prn antiemetic prescription The nurse administer donepezil hydrochloride (Aricept) to a client with Alzheimer's disease as an intervention for which client problem? a. fluid volume excess b. disturbed thought processes c. chronic pain d. altered breathing patterns disturbed thought processes To prevent deep vein thrombosis following knee replacement surgery, an adult male client is receiving enoxaparin (Lovenox) subcutaneously daily. Which laboratory finding requires immediate action by the nurse? a. blood urea nitrogen (BUN) 20mg/dl or 7.1 mmol/L (SI) b. Hematocrit 45% c. Serum creatinine 1.0 mg/dl or 88.4 mol/L (SI) d. Platelet count of 100,000/mm3 or 100x10??/ L (SI) Platelet count of 100,000/mm3 or 100x10??/ L (SI) A client with type 2 diabetes mellitus is managed with metformin (Glucophage), an oral hypoglycemic agent. The primary health care provider prescribes ad additional medication injected exenatide (byetta). Which information is most important for the nurse to teach this client? a. Administer subcutaneously after meals b. Consume additional sources of potassium c. Notify the healthcare provider if anorexia occurs d. Watch for signs of jitteriness or diaphoresis Consume additional sources of potassium A client is who is diagnose with schizophrenia receives a prescription for an atypical antipsychotic drug aripipazole (Abilify). Which assessment should the nurse perform to monitor for an adrenergic receptor antagonist side effect that commonly occurs atypical antipsychotic agents? a. observe the client hallucinatory behaviors b. obtain the client finger stick glucose levels c. measure the clients lying and standing blood pressure d. determine the clients abnormal involuntary movements scale (AIMS) obtain the client finger stick glucose levels A client with pheocromocytoma reports the onset of a severe headache. The nurse observes that the client is very diaphoretic. Which assessment data should the nurse obtain first? Blood pressure The drainage in the chest tube of a client with emphysema has changed from clear watery fluid. What action would be best for the nurse to take Maintain the current IV antibiotic schedule A client in the operating room received succinylcholine. The client is experiencing muscle rigidity and has an extremely high temperature. What action should the nurse implement? Call the PACU nurse to prepare for prolonged ventilatory support Also know that PACU is BP, Respiration and Pulse A client is admitted with a sudden onset of right sided the nurse complete first? Observe for peripheral edema When planning care for a client newly diagnose with open angle glaucoma, the nurse identifies a priority nursing diagnosis of " Visual sensory/perceptual alterations". This diagnosis is based on which etiology? Decreased peripheral vision A client who is receiving packed red blood cells develops nausea and vomiting. What action should the nurse take first? Stop the infusion of blood After suctioning the patient with an endotracheal tube, which assessment finding indicates to the nurse that the intervention was effective? Increase in breath sounds A client with type 2 diabetes mellitus is admitted to the hospital for uncontrolled DM. Insulin therapy is initiated with initial dose of Humulin insulin at 8:00 at 16:00 the client complains of diaphoresis, rapid heart beat, and feeling shaky. What should the nurse do first? Determine the client current glucose level The nurse observes an increase number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). What is the best initial nursing action? Provide additional oral fluid intake Also with TURP you must know that 3l of water a day is needed Which nursing diagnosis should be selected for a client who is receiving thrombolytic infusions for treatment of an acute myocardial infarction? Risk for injury related to effects of thrombolysis When caring for a client with nephrotic syndrome which assessment is most important for the nurse to obtain? Daily Weight The nurse is assessing a client who has returned from surgery following a thoracotomy. Which finding indicates the client is experiencing adequate gas exchange? The client demonstrates effective coughing and deep breathing exercises A client who had a biliopancreatic diversion procedure (BOP) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse? Gastroccult positive emesis A female client with possible acute renal failure (ARF) is admitted to the hospital and mannitol (Osmitrol) is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement? • No specific nursing action is required • Instruct the client to empty the bladder • Collect a clean catch urine specimen • Obtain vital signs and breathe sounds Obtain vital signs and breathe sounds When teaching a client with osteoporosis to increase weight-bearing exercise, how should the nurse explain the purpose of this activity? • Strengthen leg muscles • Promote venous return • Increase bone strength • Restore range of motion Increase bone strength The nurse positions a male client for a lumbar puncture by placing him in the side-lying position with his knees flexed and pulled toward his trunk. What action should the nurse implement next? • Call another nurse to assist the healthcare provider • Provide a small pillow for the client to curl around • Instruct the client to perform a Valsalva maneuver • Support the client's head bent forward to the chest Support the client's head bent forward to the chest A male tells the clinic nurse that he is experiencing burning on urination, and assessment that he had sexual intercourse four days ago with a woman he casually met. Which action should the nurse implement? • Observe the perineal area for a chancroid-like lesion • Obtain a specimen of urethral drainage for culture • Identify all sexual partners in the last four days • Assess for perineal itching, erythemia, and excoriation Assess for perineal itching, erythemia, and excoriation An older female client with long term type 2 diabetes mellitus (DM) is seen in the doctor routine health assessment. To determine if the client is experiencing any long-term complications of DM, which assessments should the nurse obtain? Select all that apply: • Visual acuity • Serum creatinine and blood urea nitrogen (BUN) • Signs of respiratory tract infection • Sensation in feet and legs • Skin condition of lower extremities A, B, D, E Which laboratory test result is most important for the nurse to report to the surgeon prior to a client's scheduled abdominal surgery? • Potassium level of 4 mEq/liter • Blood glucose of 90 mg/dl • Serum creatinine of 5 mg/dl • Hemoglobin level of 13 grams Hemoglobin level of 13 grams Which change in lab values would indicate to the nurse that treatment for gout is successful? • Decreased serum uric acid • Decreased serum purine • Increased serum uric acid • Increased serum purine Decreased serum uric acid A client who has a history of long-standing back pain treated with methadone (Dolophine), is admitted to the surgical unit following urological surgery. What modifications in the plan of care should the nurse make for this client's pain management during the postoperative period? • Use minimal parenteral opioids for surgical pain, in addition to oral methadone • Maintain client's methadone, and medicate surgical pain based on pain rating • Consult with surgeon about increasing methadone in lieu of parenteral opioids • Make no changes in standard pain management for this surgery and hold methadone Maintain client's methadone, and medicate surgical pain based on pain rating The nurse applies an automatic external defibrillator (AED) to a client who collapsed in an exam room at a community clinic. What action should the nurse take next? • Determine the defibrillator reading • Assess the client's oxygen saturation • Bring a crash cart to the exam room • Measure the client's blood pressure Assess the client's oxygen saturation The nurse reports that a client is at risk for a brain attack (stroke) finding? • Jugular vein distention • Palpable cervical lymph node • Carotid bruit • Nuchal rigidity Nuchal rigidity The nurse is assessing a group of older adults. What factor in a male client's history puts him at greatest risk for developing colon cancer? • Is excessively exposed to sunlight • Eats a high-fat diet • Smokes cigars • Has intestinal polyps Has intestinal polyps While taking routine vital signs at 0400 AM, the nurse notes that a client who had a total knee replacement the previous day has a heart rate of 126 beats/minute. What action should the nurse take first? • Compare heart rate trends with blood pressure trends • Review the medical record for a history of cardiac disease • Check surgical drainage system and bandage for bleeding • Determine current pain level using a 10-point scale Check surgical drainage system and bandage for bleeding A client with eczema is using an over-the-counter (OTC) topical product with urea 10% OTC (Aqua Care Cream) to the affected skin areas. Which finding reflects the expected therapeutic response? • Decreased weeping of ulcerations in affected area • Healing with a return to normal skin appearance • Reduced pain in eczematous areas • Hydration of affected dry skin areas Healing with a return to normal skin appearance A client who suffered an electrical injury on the left foot is admitted to the burn include in this client's plan of care? • Assess lung sounds q4 hours • Perform passive range of motion • Evaluate level of consciousness • Continuous cardiac monitoring Continuous cardiac monitoring The nurse is taking a client's blood pressure sphygmomanometer cuff is inflated. What (incomplete) • Administer a prescribed PRN antianxiety • Assess the client's recent serum calcium • Notify the healthcare provider of the • Prepare to implement seizure precautions Administer a prescribed PRN antianxiety or B During an annual health check, the clinic nurse updates an adult female's health history. When discussing the woman's history of lactose intolerance, the client reports that it has been years since she last consumed dairy products. What dietary suggestions should the nurse recommend to help ensure that the client receives an adequate intake of calcium? Select all that apply: • Increase intake of salmon, sardines, tofu, and leafy green vegetables • Sip a half-cup of mil during a mid-day meal at least every other day • Eat at least six servings of citrus fruits weekly • Include 2 to 3 servings of yellow and green squash weekly • Take a calcium supplement with vitamin D daily A, C, E In planning care for a client with pneumonia, which nursing problem should the nurse identify as the priority? • Impaired gas exchange related to the effects of alveolar-capillary membrane changes • Acute pain related to the effects of inflammation of the parietal pleura • Deficient fluid volume related to fever, infection, and increased metabolic rate • Disturbed sleep pattern related to pain, dyspnea, and hospitalization Impaired gas exchange related to the effects of alveolar-capillary membrane changes A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis skin test. The nurse's assessment of the test after 72 hours indicates 5mm of erythema without induration. What is the best initial nursing action? • Review client's history for possible exposure to TB • Instruct the client to return for a repeat test in 1 week • Refer client to a healthcare provider for isoniazid (INH) therapy • Document negative results in the client's medical record Review client's history for possible exposure to TB A male client in skeletal traction tells the nurse that he is frustrated because he needs help repositioning himself in bed. Which intervention should the nurse implement? • Inform the client that it is the nurse's responsibility to reposition • Provide an overhead trapeze to the bed for the client to use • Place a draw sheet under the client to assist with repositioning • Administer an intravenous PRN anti-anxiety medication Provide an overhead trapeze to the bed for the client to use A hospitalized client with chemotherapy-induced stomatitis complains of mouth pain. What is the best initial nursing action? • Encourage frequent mouth care • Administer a topical analgesic per PRN protocol • Cleanse the tongue and mouth with glycerin swabs • Obtain a soft diet for the client Administer a topical analgesic per PRN protocol The nurse admits a client who has a medical diagnosis of bacterial meningitis to the unit. Which intervention has the highest priority in providing care for this client? • Administer initial dose of broad-spectrum antibiotic • Instruct the client to force fluids hourly • Obtain results of culture and sensitivity of CSF • Assess the client for symptoms of hyponatremia Obtain results of culture and sensitivity of CSF A client returns from surgery following a hiatal hernia repair via Nissen fundoplication. Which position should the nurse implement for this client? • Right side-lying to promote stomach emptying • Prone to apply external pressure to the suture line • Left side-lying to reduce stress on the suture line • 30 degree semi-Fowler's to drop the diaphragm 30 degree semi-Fowler's to drop the diaphragm An adult woman with Grave's disease is admitted with severe dehydration is currently restless and refusing to eat. Which action is most important for the nurse to implement? • Keep room temperature cool • Determine the client's food preferences • Maintain a patent intravenous site • Teach the client relaxation techniques Maintain a patent intravenous site A client uses triamcinolone (Kenalog), a corticosteroid ointment, to manage pruritis caused by a chronic skin rash. The client calls the clinic nurse to report increased erythema with purulent exudate at the site. What action should the nurse implement? • Schedule an appointment for the client to see the healthcare provider • Advise the client to apply plastic wrap over the ointment to promote healing • Explain that the client needs to complete all prescribed doses of the medication • Instruct the client to continue the ointment until all erythema is relieved Schedule an appointment for the client to see the healthcare provider During a paracentesis, two liters of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed, and 50 ml of clear, straw-colored fluid drains within the first hour. What action should the nurse implement? • Palpate for abdominal distention • Clamp drainage tube for 5 minutes • Continue to monitor the fluid output • Send fluid to the lab for analysis Continue to monitor the fluid output The nurse assesses the dressing of a client who has just returned from post-anesthesia and finds that the dressing is wet with a moderate amount of bright red bloody drainage. What action should the nurse take? • Replace dressing with a new sterile dressing, and monitor the wound hourly until bleeding is stopped • Call surgery and request that the surgeon see the wound prior to leaving the hospital • Reinforce the dressing and document that a moderate amount of sanguineous drainage was on the dressing • Document that the dressing was saturated with serious drainage, and do not change the dressing Call surgery and request that the surgeon see the wound prior to leaving the hospital While the home health nurse is making a home visit, a client with a history of seizures demonstrates tonic-clonic seizure activity. What action should the nurse implement first? • Direct a family member to call emergency services • Ascertain the trigger event • Protect the client's head with a pillow • Observe the postictal breathing pattern Protect the client's head with a pillow After a computer tomography (CT) scan with intravenous contrast medium, a client returns to the room complaining of shortness of breath and itching. Which intervention should the nurse implement? A. Send another nurse for an emergency tracheotomy set B. Call respiratory therapy to give a breathing treatment C. Review the client's complete list of allergies D. Prepare a dose of Epinephrine (Adrenalin Prepare a dose of Epinephrine (Adrenalin A client whose history includes IV drug abuse is admitted to the intensive care unit (ICU) with Kaposi's sarcoma associated with Acquired Immune Deficiency Syndrome (AIDS). Which intervention is most important for the nurse to include in the client's plan of care? • Observe for adverse medication reactions • Assess for signs of AIDS dementia • Identify signs of opportunistic infections • Locate local HIV support groups Identify signs of opportunistic infections The charge nurse observes a newly employed nurse gathering equipment to obtain a venous blood sample from a client's implanted port. The nurse has obtained the equipment seen in the photo. What actions should the charge nurse take? (Select all that apply) • Guide the nurse in inserting the needle at a 45 degree angle • Remind the nurse to wear sterile gloves for this procedure • Instruct the nurse to obtain several red-topped tubes • Determine if the nurse has ever performed this skill • Assist in obtaining the correct needle to access the port D, E Shingles Teach the pt about phantom pain The nurse is reviewing blood pressure readings for a group of client's on a medical unit. Which client is at the highest risk for complications related to hypertension? A. Young adult Hispanic female who has a hemoglobin of 11 gm and drinks beer every day B. Middle-aged African-American male who has a serum creatinine level of 2.9 mg/dL C. Older Asian male who eats a diet consisiting of smoked, cured, and pickled foods. D. Post-menopausal Caucasian female who overeats and is 20% above ideal body weight Middle-aged African-American male who has a serum creatinine level of 2.9 mg/dL Shingles Select all the apply - pain - ability - skin integrity PATIENT W/ EZCEMA APPLYING CREAM TTO IS WORKING: HEALING WITH A RETURN SKIN TO NORMAL APPEARANCE. PT WITH OBESITY HIGH GLUCOSE LEVEL IS AT RISK FOR? CARDIOVASCULAR DISEASE PT. W/ RISK OF DVT PERFORM ROM EXERCISES ALSO LEGS EXERCISE CAN BE OTHER WAY TO ANSWER FOR ANEMIA WHAT DOESN'T HAVE IRON, WHICH FOODS ARE NOT RICH IN IRON? NO ORANGE DISCHARGE FOR VENOUS ULCERS SELECT ALL APPLY? - ELEVATE THE FEET WHEN LAYING DOWN - CHECK BROWNISH SKIN AROUND THE ANKLES - VITAMINS PT W/ SIADH HARD CANDY FOR THIRST PT ARRIVE TO PACU POSTOP MOANING WHAT TO DO CHECK PULSE, BP AND RESPIRATIONS Pt. DIAGNOSED RECENTLY W/ DM HAVE NOT BEEN ABLE TO CONTROL GLUCOSE LEVEL DURING 3 MONTH WHAT SHOULD BE DONE - CHECK FOR A1C LEVEL - (OTHER SAY ASSESS FOR WHAT SHE HAVE BEEN EATING 3 DAYS AGO). WHEN BP IS HIGH ADMINISTER (LASIX) PATIENT W/ ESOPHAEGAL VARICES HAVE NOT BE BLEEDING FOR 3 DAYS PROVIDE LUKE WARM BROTH, ICE TEA AND LEMON POPSICLE PT WITH OSTEOMALCIA RISK FOR INJURY SBAR—EXPLAIN SPECIFIC REASON FOR URGENT NOTIFICATON TEMPERATURE INTESTINAL BOWEL OBSTRUCTION PLACE THE PT 90 DEGREES SITTING OSTEOARTHRITIS RISK FOR INJURY RELATED TO JOINT PAIN BONE CANCER TYPE IV GIVE OPIODS- NON OPIODS ANALGESICS HYPOTHYROIDISM RESTRICT SODIUM NA 122 PT ARRIVES TO CLINIC W/ NUCHAL RIGIDITY FEVER FOR 6 HOURS. WHAT TO DO? - PREPARE FOR ISOLATION PRECAUTIONS - ( I PUT THIS ONE AND NO LUMBAR PUNCTURE) INTERMITENT CLAUDICATION TEACHING - BANDAGE ELASTIC WRAPED AROUND LEGS - PAIN TRACTION CAST NOTIFY MD (CAST NO MORE THEN 4HR) PREOPERATIVE NURSING CARE - ASSESS EMOTIONAL PREPAREDNESS - ALSO CAN BE CONCERNS AND ANXIETY FOR SURGERY TRACHESTOMY CARE LEAVE OLD TIES ON UNTIL NEW ONES BE ON PLACE OR SECURE STERNAL TRACTION COMPLAINS OF PAIN ADMINISTER PRN MEDS EXTERNAL FIXATION ADMINISTER PRN MEDS MULTIPLE SCLEROSIS (MS) ADMINISTER ANTIMEDICS/ PRN AS PRESCRIBED FEMALE PATIENT HOW HAVE EPIGASTRIC PAIN FOR 3 DAYS HAVE BEEN TAKIN ANTACIDS AND NO RESOLVE ARRIVE TO HOSPITAL W/HR;128 BPM, BP110/70 WHAT IS THE MOST IMPORTANT INTERVENTION FINDING IN ASSESSMENT ASSESS FOR RADIATING JAW PAIN Pt. W. RADIACTIVE THERAPY WHAT TO TEACH/ RECOMMEND TO PROTECT THAT PART OF THE SKIN SPECIALLY FROM THE SUN Pt WITH ALS WHAT TO DO TO PREVENT RESPIRATORY COMPLICATIONS: TEACH BREATHING TECNIQUES, USES SPIROMETER, AUSCULTATE FOR BREATH OR LUNG SOUNDS. PT WITH LEFT LEF ULCER KEEP LEG ELEVATED AS MUCH AS HE CAN PT WITH AN EXTERNAL DEVICE COMPLAINING OF PAIN ASSESS FOR PHERIPHERAL PULSES EXAMPLES OF DASH DIET PEEL FRUITS AND VEGETABLES CHEST TUBE W/ A DRAINAGE CHANGING FROM CLEAR TO GREEN KEEP IV FLUIDS PT W/ OPEN ANGLE GLAUCOMA SELECT ALL THAT APPLY - FREQUENT EYE EXAM TO ASSES FOR VISSION, - USE DROPS TO DIMINSH IOP, - AVOID EXTRENOUS EXERCICES LIKE JOGGING OR RUNNING PT W/ HYPERTHYROIDISM DEVELOPING EXOSPHTALMUS: PRESCRIBE TEAR EYE DROPS. PT VOMITING BLOOD LIKE THE PICTURE SAME AS HEMATENSIS - CHECK VITAL SIGNS - AUSCULTATE LUNGS SOUNDS PATIENT W/ ML FELL AND WHEN RECEIVING THE NURSE HE HAVE 2 PROJECTILE VOMITS WHAT SHE DO PROVIDE ANTIEMETICS PRN PATIENT THAT HAVE THE K= 6.7 WHAT MEDICATION PROVIDE KAYELAXATE (TREATS HYPERKALEMIA PT W/ RAYNAUD SYNDROME WHICH WORK AS A DATA ENTRY CLERK - PROVIDE A SPACE TO WARM THE ENVIROMENT NEXT TO HER - KEEP MONITORING COLON CANCER PT KAYELAXATE Med RENAL INJURY KAYELAXATE MED PT WITH A BRONCHOSCOPY AND DRINK A GLASS OF JUICE DELAY THE PROCEDURE 6 HOURS NEW PATIENT DIAGNOSES WITH DM TYPE IS RECEIVING TEACHING IN WHICH GLUCOMETER WILL BE THE BEST ASSESS FOR VISUAL ACUITY AND ABILITY TO READ OR SOMETHING LIKE THAT ABG (PH 7.25 PCO2 50 SODIUM 60 TACHY AND CONFUSION/ RESPIRATORY ACUTE AGN DIET RESTRICT NA INTAKE PT W/ A EXPRESSIVE APHASIA IS ANGER WHAT SHOULD DO THE NURSE CVA- COMMUNICATE W/ PICTURE BOARDS NURSE IS TEACHING THE WIFE IF A PATIENT DIAGNOSED W/ SEIZURE WHAT TO DO TEACH HER HOW TO POSITION HIM PT AFTER TTO OF SOMETHING AND WANTS TO EAT NURSE ASSESS FOR BOWEL MOVEMENTS SLE (lupus) ASSESS FOR HEMATURIA PATIENT ALLERGIC TO BANANA (LATEX CALL TO MD AND OR STAFF TO BE CHANGE EVERYTHING FOR SYNTHETIC MATERIALS SUBCUT EMPHYSEMA- TORACOTOMY WAS A SELECT ALL THAT APPLY ASSESS FOR LUNG SOUNDS RESTLESS LEG SYNDROME ASSESS FOR IRON AND FERRITIN BNP ADMINISTRATIVE FUROSEMIDE LASIX IV PARKINSON PT WALKING REASURE THAT STEPPING ON CRACKLES IS NOT HARMFUL ADDISON DISEASE TAKE CORTICOSTEROID MEDS CARPO TONIC SYNDROME WEAR BRACE IN BOTH WRIST PARKINSON AND ALZHEIMER PT TACHYCARDIA AND CONFUSION MID ABDOMEN BURNING PAIN PEPTIC ULCER ANTIBIOTICS CLEAR DRAINAGE IMPROVE ALLOPURINOL FOR GOUT TAKE MEDS ALWAYS CENTRAL FALL RISK CARDIOVASCULAR DISEASE RIGHT HIP FRACTURE O2 SAT LEVEL DESCRIBE PAIN NEUROPATHY NERVOUS SYSTEM ACUTE ABDOMINAL PAIN, NAUSEA, PROJECTILE VOMITING SEVERE HEADACHE AND PHOTO Sensitivity UROLITHISIS O LITHOTRIPSY PROCEDURE RESTRICT PHYSICAL ACTION UAP: ABD PAIN LARGE TARRY STOOL TEST STOOL FOR OCCULT BLOOD Insulin for a glucose level of 255 Obtain capillary glucose NGT proper tube procedure Elevate dead 60 to 90 degree RA Impaired peripheral mobility relate to join pain BMI: COLON CANCER Large waist circumference with central fat Finger stick glucose finding 50 LOC--Level of conscious RN needs to go 4 patients and which one needs to see first: A. The patient discharge yesterday and dehydrated B. The patient start a new medication and is incontinence C. The patient that doesn't want to take a shower The patient start a new medication and is incontinence The school nurse is implementing standards to manage students and provide a safe and healthy school setting. Which action is most important for the nurse to implement? A- Maintain student immunization records B- Develop an emergency plan for the school C- Ensure that medical supplies are available D- Conduct annual student health assessments Maintain student immunization records Diabetic,renal no function,decrease urine or not urine, septic shock, check urine specific Gravity and osmolarity urine. Acute Renal Failure: Low Protein Chronic Renal Failure: NOT Protein at all Urine claude and check input and output The nurse is reinforcing home care instructions with a client who is being discharged following transurethral resection of the prostate (TURP). Which intervention is most important for the nurse to include in the clients discharge instructions? A- Avoid strenuous activity for 6 weeks B- Report fresh blood in the urine C- Take acetaminophen for fever 101 D- Consume 6 to 8 glasses of water daily Report fresh blood in the urine A pt with possible pneumonia come to the hospital and the nurse need to do an assessment but the family don't want to leave the room, what the nurse need to do first? A -Call the security B- Put the family out of the room C- Put a pneumonia droplet sign in the door D - Continue with the assessment and put mask to the family Put a pneumonia droplet sign in the door A public health nurse receives funding to initiate a primary prevention program in the community. Which program best fits the nurse's proposal? A. Case management and screening for clients with HIV. B. Regional relocation center for earthquake victims. C. Vitamin supplements for high-risk pregnant women. D. Lead screening for children in low-income housing Vitamin supplements for high-risk pregnant women. The Multiple Organ Dysfunction Syndrome (MODS) can be defined as the development of potentially reversible physiologic derangement involving two or more organ systems not involved in the disorder that resulted in ICU admission, and arising in the wake of a potentially life-threatening physiologic insult. shock Lower abdominal pain (Order): 1. Ask for last food that eat 2. AUSCULTATE 4 QUADRANTS 3. DETERMINE BOWEL MOVEMENT 4. POSITION BENT KNEES 5. INSPECT ABDOMINAL 4, 1, 3, 5, 2 After receiving IV fluids in the emergency department, an elderly client is admitted to the acute care unit with a medical diagnosis of dehydration. The client is receiving 0.9% normal saline at 125ml/hr. via a saline lock and has a bounding pulse, tachycardia, and pedal edema. When contacting the healthcare provider, the nurse anticipates a prescription for what intervention? a. Decrease the rate of the normal saline infusion b. Increase the rate of the normal saline solution c. Change the IV solution to 0.45 saline solution d. Remove the saline lock from the client's arm Decrease the rate of the normal saline infusion A patient with chemicals in the eyes and is in the hospital. What the nurse tells to the UAP to do to help the patient with the food? A- Give food to the patient in the mouth B- Indicate to the patient where is the tray ( reorient ) C- Look how the patient eat D- Fin