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A nurse is caring for a client with pneumonia.Which of the following assessment findings would require immediate intervention? a) Crackles in the lungs b) Productive cough with green sputum c) Oxygen saturation of 89% d) Fever of 100.4°F A patient is receiving a bronchodilator for an acute asthma attack. Which side effect should the nurse monitor for? a) Bradycardia b) Hypoglycemia c) Tachycardia d) Respiratory depression A nurse is assessing a client with tuberculosis (TB). Which of...

ANS: D All of the factors contribute to the patient's risk, but only the hypertension can potentially be modified to decrease the patient's risk for further expansion of the aneurysm. When discussing risk factor modification for a 60-year-old patient who has a 4-cm abdominal aortic aneurysm, the nurse will focus patient teaching on which of these patient risk factors? a. Male gender b.Marfan syndrome c.Abdominal trauma history d.Uncontrolled hypertension

A nurse is caring for a patient with urinary retention due to an enlarged prostate. What would the nurse expect to find upon assessment? a. Increased urinary output b. Difficulty starting urination c. Clear, pale yellow urine d. Strong urge to urinate with no ability to void When assessing a patient's urine for possible infection, which of the following would be a concerning finding? a. Pale yellow color b. Clear consistency c. Cloudy appearance d. Slight odor Which condition is ...

A patient has been receiving chemotherapy and radiation for a diagnosis of non-Hodgkin's lymphoma. In your morning as- sessment, you notice the patient has new onset facial edema, distention of head and neck veins, and dyspnea. Which oncologic emergency would be suspected? a. Hypercalcemia b. Spinal Cord Compression c. Superior Vena Cava Syndrome (SVCS) d. Tumor Lysis Syndrome (TLS) When providing education to a patient newly diagnosed with cir- C. Superior Vena Cava Syn...

The nurse is listing consequences of malignant hyperthermia. Which consequences should be included? (select all that apply) A. Disseminated intravascular coagulation B. Renal failure C. Cardiac dysrhythmias D.Gastroenteritis E. Pulmonary edema Which type of body temperature changes in response to the environment? A. core B. metabolic C. surface D.physiologic

Dizziness and weakness in IV fluids Check the client's blood pressure and heart rate Shakiness and sweating in diabetes Give the client orange juice or glucose tablets Pulse oximetry reading of 88%

Nurse's best initial action for a client rocking back and forth Action that promotes client's autonomy in therapeutic relationship Nurse's response demonstrating empathy to a client feeling misunderstood Client behavior requiring pause in discharge planning Finding indicating disturbance in sensorium and cognition Nurse's priority action for a client expressing worthlessness Behavior indicating progress in recovery from a psychotic episode

When assessing a patient with a partial-thickness burn, the nurse would expect to find (SATA): a. blisters b. exposed fascia c. exposed muscles d. intact nerve endings e. red, shiny, wet appearance Pain management for the burn patient is most effective when (SATA): a. a pain rating tool is used to monitor the patient's level of pain b. painful dressing changes are delayed until the patient's pain is completely relieved c. the patient is informed about and has some control over ...

First-line treatment for major depressive disorder due to their effectiveness and favorable side effect profile. Claiming exclusive understanding of a client by disregarding other Blurred boundaries staff input, which can lead to countertransference and ethical violations. The highest priority nursing intervention for a client in severe cognitive decline, as physiological needs are life-sustaining. An observation that may indicate unresolved distress, anxiety, or Fearful affect continuin

Intervention for bathing assistance Encourage the patient to wash as much Important action for oral care Assess the patient's level of consciousUnderstanding adaptive equipment use I will use a button hook to fasten my Finding to report immediately Pulse oximetry 88% on room air. Next action for elevated temperature Offer acetaminophen as prescribed. Next assessment for irregular radial pulse Obtain an apical pulse for 1 full minute. Drip rate calculation for Heparin IV