BSN HESI 266-- consolidated
Terms in this set (68)
A client experiences an AOB a. low back pain and hypotension
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
We have an expert-written solution to this problem!
,When conducting discharge c. Eat a high-fiber diet and increase fluid intake.
teaching for a
client diagnosed with diverticulosis,
which diet instruction should the
nurse include?
a. Have small frequent meals and
sit up for at least two hours
after meals.
b. Eat a bland diet and avoid spicy
foods.
c. Eat a high-fiber diet and increase
fluid intake.
d. Eat a soft diet with increased
intake of milk and milk
products
The nurse observes an c. Increase the flow of the bladder irrigation
increased 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?
a. Provide additional oral fluid intake
b. Measure the client's intake and
output.
c. Increase the flow of the bladder
irrigation
,d. Administer
a PRN dose of an
antispasmodic agent
We have an expert-written solution to this problem!
A client with lung cancer who wears B. Administer a narcotic antagonist
subcutaneous morphine sulfate
patch for pain is short of breath
and is difficult to arouse.
When performing a head to toe
assessment, the nurse
discovers four analgesic patches
on the client's body. Which
intervention should the nurse
implement first?
A. Remove all of the morphine
patches
B. Administer a narcotic antagonist
C. Apply oxygen per face mask
D. Measure the client's blood
pressure
, c. Right foot pale with sluggish capillary refill
After falling down the basement
The answer indicates a potential problem with the blood circulation
steps, a client is brought to the
in the client's right foot. When a leg cast is applied, it should not
emergency room. X-ray
interfere with the blood flow to the foot. However, if the foot
confirms that the client's right leg
becomes pale and the capillary refill is sluggish, it suggests
is fractured.
that the blood flow might be compromised. Capillary refill is the
Following application of a leg cast,
time taken for color to return to an external
which assessment finding capillary bed after pressure is applied to cause blanching. Normal capillary
warrants immediate refill time is
intervention by the nurse? usually less than 2 seconds. Sluggish or delayed capillary refill
a. Circumferential edema of right can be a sign of peripheral vascular disease, shock, or
foot. hypothermia. In this case, it could be due to the cast being too
b. Complaint of throbbing right leg tight, causing a reduction in blood flow to the foot. This is a
pain.
serious condition that requires
c. Right foot pale with sluggish
capillary refill. immediate intervention by the nurse to prevent further complications
d. Increased temperature to lower such as tissue necrosis due to lack of oxygen and nutrients. The
extremity nurse may need to adjust or remove the cast to restore proper
blood flow.
An overweight, young adult who A. Check finger stick glucose
was recently diagnosed with type B. Assess
skin temperature and moisture
2 diabetes mellitus is C. Measure pulse and
admitted for a hernia repair. He
tells the nurse that he is feeling blood pressure ANSWER:
very weak and jittery. Which
actions should the nurse (CAM)
implement?
(Select all that apply.)
A. Check his fingerstick glucose level
B. Assess his skin temperature and
moisture
Terms in this set (68)
A client experiences an AOB a. low back pain and hypotension
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
We have an expert-written solution to this problem!
,When conducting discharge c. Eat a high-fiber diet and increase fluid intake.
teaching for a
client diagnosed with diverticulosis,
which diet instruction should the
nurse include?
a. Have small frequent meals and
sit up for at least two hours
after meals.
b. Eat a bland diet and avoid spicy
foods.
c. Eat a high-fiber diet and increase
fluid intake.
d. Eat a soft diet with increased
intake of milk and milk
products
The nurse observes an c. Increase the flow of the bladder irrigation
increased 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?
a. Provide additional oral fluid intake
b. Measure the client's intake and
output.
c. Increase the flow of the bladder
irrigation
,d. Administer
a PRN dose of an
antispasmodic agent
We have an expert-written solution to this problem!
A client with lung cancer who wears B. Administer a narcotic antagonist
subcutaneous morphine sulfate
patch for pain is short of breath
and is difficult to arouse.
When performing a head to toe
assessment, the nurse
discovers four analgesic patches
on the client's body. Which
intervention should the nurse
implement first?
A. Remove all of the morphine
patches
B. Administer a narcotic antagonist
C. Apply oxygen per face mask
D. Measure the client's blood
pressure
, c. Right foot pale with sluggish capillary refill
After falling down the basement
The answer indicates a potential problem with the blood circulation
steps, a client is brought to the
in the client's right foot. When a leg cast is applied, it should not
emergency room. X-ray
interfere with the blood flow to the foot. However, if the foot
confirms that the client's right leg
becomes pale and the capillary refill is sluggish, it suggests
is fractured.
that the blood flow might be compromised. Capillary refill is the
Following application of a leg cast,
time taken for color to return to an external
which assessment finding capillary bed after pressure is applied to cause blanching. Normal capillary
warrants immediate refill time is
intervention by the nurse? usually less than 2 seconds. Sluggish or delayed capillary refill
a. Circumferential edema of right can be a sign of peripheral vascular disease, shock, or
foot. hypothermia. In this case, it could be due to the cast being too
b. Complaint of throbbing right leg tight, causing a reduction in blood flow to the foot. This is a
pain.
serious condition that requires
c. Right foot pale with sluggish
capillary refill. immediate intervention by the nurse to prevent further complications
d. Increased temperature to lower such as tissue necrosis due to lack of oxygen and nutrients. The
extremity nurse may need to adjust or remove the cast to restore proper
blood flow.
An overweight, young adult who A. Check finger stick glucose
was recently diagnosed with type B. Assess
skin temperature and moisture
2 diabetes mellitus is C. Measure pulse and
admitted for a hernia repair. He
tells the nurse that he is feeling blood pressure ANSWER:
very weak and jittery. Which
actions should the nurse (CAM)
implement?
(Select all that apply.)
A. Check his fingerstick glucose level
B. Assess his skin temperature and
moisture
