Complete Verified & Updated Solutions
A nurse is providing teaching to a client who is perimenopausal and has a prescription
for hormone replacement therapy. For which of the following adverse effects should the
nurse instruct the client to notify the provider? - ✓✓Calf pain
Numbness in the arms
Intense headache
A nurse is planning care for a client who is postoperative following a laparotomy and
has a closed-suction drain. Which of the following actions should the nurse take to
manage the drain? - ✓✓Compress the drain reservoir after emptying.
A nurse is caring for a client who has DKA. Which of the following findings should
indicate to the nurse that the client's condition is improving? - ✓✓Glucose 272 mg/dL
A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr
ago. The nurse should identify which of the following findings as an indication of a
myocardial infarction (MI)? - ✓✓Troponin I 8 ng/mL
A nurse is planning a health promotional presentation for a group of African American
clients at a community center. Which of the following disorders presents the greatest
risk to this group of clients? - ✓✓hypertension
,A nurse is providing education to a client who is at risk for osteoporosis. Which of the
following instructions should the nurse include? - ✓✓Walk for 30 min four times per
week.
A nurse is caring for a client who has an arterial line. Which of the following actions
should the nurse take? - ✓✓Place a pressure bag around the flush solution.
A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the
following results should the nurse expect? - ✓✓PaCO2 56
A nurse is providing postoperative teaching for a client who had a total knee
arthroplasty. Which of the following instructions should the nurse include? - ✓✓Flex the
foot every hour when awake.
A nurse is planning care for a client who is postoperative following a parathyroidectomy.
Which of the following actions should the nurse identify as the priority? - ✓✓Place a
tracheostomy tray at the bedside.
A nurse is evaluating the plan of care for four clients after 2 days of hospitalization. The
nurse should identify the need to revise the plan for which of the following clients? -
✓✓A client who is postoperative following abdominal surgery and reports feeling that
something "popped" when they coughed
A nurse is checking the ECG rhythm strip for a client who has a temporary pacemaker.
The nurse notes a pacemaker artifact followed by a QRS complex. Which of the
following actions should the nurse take? - ✓✓Document that depolarization has
occurred.
,A nurse is providing discharge instructions to a client who has active tuberculosis (TB).
Which of the following information should the nurse include in the instructions? -
✓✓Sputum specimens are necessary every 2 to 4 weeks until there are three negative
cultures.
A nurse is caring for a client who is receiving a blood transfusion. The client becomes
restless, dyspneic, and has crackles noted to the lung bases. Which of the following
actions should the nurse anticipate taking? - ✓✓Slow the infusion rate
A nurse is assessing a client who is postoperative following a thyroidectomy. Which of
the following findings is the nurse's priority? - ✓✓Temperature 38.9° C (102° F)
A nurse is caring for a client who has homonymous hemianopsia as a result of a stroke.
To reduce the risk of falls when ambulating, the nurse should provide which of the
following instructions to the client? - ✓✓Scan the environment by turning your head
from side to side.
A PACU nurse is assessing a client who is postoperative following a right nephrectomy.
The client's initial vital signs were heart rate 80/min, blood pressure 130/70 mm Hg,
respiratory rate 16/min, and temperature 36° C (96.80 F). Which of the following vital
sign changes should alert the nurse that the client might be hemorrhaging? - ✓✓Heart
rate 110/min
A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty.
The client is unable to void on the bedpan. Which of the following actions should the
nurse take first? - ✓✓Scan the bladder with a portable ultrasound.
, A nurse is assessing a client who has advanced lung cancer and is receiving palliative
care. The client has just undergone thoracentesis. The nurse should expect a reduction
in which of the following common manifestations of advanced cancer? - ✓✓Dyspnea
A nurse is caring for a client who is postoperative. - ✓✓Nurses' Notes
Client admitted to medical-surgical unit from PACU. Client reports incisional pain as 2
on a scale of 0 to 10. Client appears restless and frequently asks for water. Bilateral
lower extremities cool with +1 pedal pulses. Urine output is 40 mL for the past 2 hr.
Moderate amount of bright red drainage noted on surgical incision dressing.
Vital Signs
Temperature 37.6° C (99.7° F)
Heart rate 114/min
Respiratory rate 22/min
Blood pressure 88/54 mm Hg
Oxygen saturation 93% on room air
Diagnostic Results
Hgb 18 g/dL (12 to 16 g/dL)
Hct 54% (37% to 47 %)
Total WBC count 11,000/mm3 (5,000 to 10,000/mm3)
Troponin T 0.04 ng/mL (less than 0.1 ng/mL)
Medical History.