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Terms in this set (91)
A nurse is caring for a client who has Thinning of the skin.
atopic dermatitis and a prescription for
triamcinolone ointment. The nurse Only apply the ointment to dry patches of the skin to avoid atrophy.
should assess the client to monitor for
which of the following adverse effects?
A nurse is assessing a client who has left- Frothy sputum
sided heart failure. Which of the following
findings should the nurse identify as a Pink-tinged frothy sputum can be an early indication of pulmonary edema and can
manifestation of left-sided heart failure? be life-threatening. Therefore, the nurse should notify the provider immediately.
A nurse is caring for a client who is Respiratory alkalosis
experiencing anxiety as well as
numbness and tingling of the lips and - The pH is alkaline (increased)
fingers. The client's ABGs are: pH 7.48, - PCO2 is decreased representing alveolar hyperventilation & resultant
PCO2 30 mm Hg, HCO3- 24 mEq/L, PaO2 respiratory alkalosis
85 mm Hg. Which of thefollowing acid-
base imbalances should the nurse
identify that the client is experiencing?
A nurse is assessing a client who has Osteoporosis
Cushing's syndrome. Which of the
following findings should the nurse Bone become thinner as a result of mineral loss & nitrogen depletion.
expect?
, A pearly, waxy nodule.
- Basal cell carcinoma has a nodular lesion with well defined borders & pearly or
A nurse is inspecting the skin of a client waxy appearance resulting from overexposure to the sun. especially on the
who has basal cell carcinoma. The nurse face, head, and neck.
should identify which of the following -A client who has melanoma has a lesion with irregular borders and variegated
lesion characteristics on the client's skin? colors of red, white, and blue, most often on the upper back or lower legs.
-A client who has squamous cell carcinoma has a firm, nodular, and crusty lesion
with a ulcerated center, resulting from sun exposure, chronic irritation, burns, or
irradiation to the skin.
A nurse in an emergency department is LOW URINE SPECFIC GRAVITY.
assessing a client who is overusing -A client who has hyponatremia as a result of diuretic overuse has a low urine
prescribed diuretics and has a sodium level specific gravity. The increased excretion of water alters the ratio of particulate matter,
of 127 mEq/L. Which of the following which affects the specific gravity.
laboratory findings should the nurse
expect?
A home health nurse is assisting a client Remove clutter from rooms and hallways
with planning care for a family member
who has Alzheimer's disease. Which of - This allows the client is able to walk without the risk of falling or tripping
the following instructions should the over objects. Later in the disease, the client can experience seizures, so
nurse include? cluttered areas could be a risk to the client
A nurse is caring for a client who has REFRACTORY HYPOXEMIA
developed acute respiratory distress
syndrome (ARDS). Which of the following - A client who has ARDS has refractory hypoxemia, which is hypoxemia that does
findings should the nurse identify as a not improve with oxygen therapy. Extensive pulmonary edema evident on a chest x-
manifestation of this syndrome? ray is a manifestation of ARDS.
USE OF ASSCESSORY MUSCLES.
An emergency room nurse is assessing
a client who has asthma and difficulty
- A client who has status asthmaticus uses accessory muscles to help facilitate
breathing. Which of the following findings
breathing, which is a manifestation of a severe airflow obstruction. The situation is
should indicate to the nurse that the
life- threatening and the nurse should intervene immediately with strong systemic
client is experiencing status
bronchodilators, epinephrine, corticosteroids, and oxygen.
asthmaticus?
A nurse is teaching a client who has a SKIN RASH.
new prescription for PHENYTOIN to
treat a seizure disorder. Which of the - the nurse should determine that the priority finding is a rash, which can have a
following adverse effects should the measles-like appearance and progress to exfoliative dermatitis or Stevens-Johnson
nurse instruct the client to report syndrome. The client should report this finding to the provider immediately.
IMMEDIATELY to the provider?
A nurse is monitoring a client following CLEAR DRAINAGE OF DRESSINGS
a LUMBAR LAMINECTOMY. The client
has a drain and indwelling urinary - This is an indication of a cerebral spinal leak
catheter. The nurse should identify which
of the following findings as an indication
of a COMPLICATION of the surgery?
A nurse is assessing a client who has INCREASED ABDOMINAL GIRTH
RIGHT-SIDED HEART FAILURE. Which of
the following findings should the nurse
identify as a manifestation of RIGHT- SIDED
HEART FAILURE?