Nursing 1234 Test Questions and Correct Solutions| Verified | Graded to Pass

Neurologic deficits that should be expected in right-hemispheric stroke - 1. Visual Spatial Deficits 2. Left Hemianopsia 3. One sided neglect The nurse should postpone the allergy testing and report to the provider which of the following findings? - Current Medications "Clients should avoid corticosteroids and avoid antihistamines from 48hr to 2 weeks to prep for testing according to how long they last." The nurse should plan to make a referral to physical therapy for which type of client? - Client receiving prep teaching for a r-knee arthroplasty "Client will need to be taught how to ambulate safely" What is the nurses priority for a patient having a seizure? - Turn the client to the side. "The patient should be side-lying to prevent them from aspirating. This also allows oral secretions to come out that may obstruct the airway." *Other actions - loosen clothing around neck, check pupils, and move furniture away from pt. *Look for safety risks first. Follow ABC! Assess which risk is greater before acting. Nursing actions for a patient 12 hr postoperative following a total hip arthroplasty? - Place a pillow between the client's legs "This action will allow the patient to avoid dislocation" pg. 437 Caring for a client with dysphagia. (Difficulty swallowing) Bedside item? - Suction machine "This item should be in place to readily suction the patient if the airway starts to become obstructed." Nursing teaching for a patient that will undergo a cutaneous diversion procedure to establish a ureterostomy. *Cutaneous diversion - occurs when a patient has bladder cancer. The provider creates a reservoir from a section in the bowel that will allow the urine to flow to another area via the ureters instead of the bladder. - Cut the opening of the skin barrier 1/8 inch wider than the stoma. pg. 241 Nursing findings to indicate fluid volume deficit - Heart rate 110/min *In hypovolemia the HR will elevate and the BP will lower." *The higher ( 1.030) the urine specific gravity the more dehydrated the patient. Nursing actions to include in the clients plan of care for a patient receiving brachytherapy. (Internal radiation placed in a closed area of the body to target cancerous tissue) - Wear a lead apron while providing care to the client. "Protects the nurse from the radiation, must wear a dosimeter to measure exposure." D/C Teaching "The clients urine and feces can contain radioactive substances which can be harmful to other if disposed of improperly, will need to place urine and feces in a bio bag." pg. 606 Older client who has hemianopsia; at risk for falls. Nursing teaching? - Remind client to scan their complete range of vision during ambulation "Hemianopsia cause a patient to experience vertical midline blindness in 1/2 of their visual field, usually caused by a stroke." Interventions the nurse should include in the plan of care for a patient starting dialysis treatments for chronic kidney disease. - Tell the client that it is possible to return to similar previous levels of activity. "Other options are not therapeutic or medically correct. This statement can be true if patient has positive outcomes from the treatment which may be causing negative side effects." Manifestations of ICP in a patient with a closed head injury - 1. Sleepiness exhibited by the client. 2. Widening pulse pressure - late finding of Cushings triad w/severe HTN and bradycardia 3. Decereberate posturing - due to deteriorating motor function pg. 81 Assessment for a patient suspected of hypertonic dehydration - Urine specific gravity 1.045 *Patients may also have Na level 145, and blood osmolality 295. pg. 278 Adverse effect of enlapril - Orthostatic hypotension "Calcium channel blocker" Client teaching for a patient receiving sildenafil to treat erectile dysfunction. - You will not be able to use sildenafil if you are taking nitroglycerin. "This combination can cause severe hypotension and/or death." Precautions for a patient who is immunocompromised to prevent a pseudomonas aeruginosa infection. - Avoid placing plants or flowers in the client's room. "These items can have harmful bacteria on them that can increase the r/4 infection." Teaching about client rights. Instructions the nurse should include. - A client should sign an informed consent before receiving a placebo during a research trial. "The client should be informed although it is a placebo because they are being part of a clinical trial in which those who may not receive the placebo may experience side effects. Patients are not told they have the placebo for the trial to work so everyone is given the same info." Pain management for a patient needing a dressing change. Patient is worried about getting addicted to morphine. What should the nurse say? - Instruct the client on alternative therapies for pain reduction. "This statement acknowledges the patient's concern and provides therapeutic options." Medication to withhold for 48hr period to a cardio version for a patient with supra ventricular tachycardia ? - Digoxin "This helps bring the heart back to a normal rhythm for the critical first few hours after cardioversion. This will allow the physician to fix the original problem."