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|The nurse is providing instructions to a 68 year old client who is at high risk for development of coronary heart disease (CHD). Which intervention should the nurse include?||
Increase intake of soluble fiber to 10 to 25 grams per day.
|An Adult client is admitted to the hospital burn unit with second and third degree burns over 40% of the body surface area. In assessing the potential for skin regeneration, what should the nurse remember about thrid degree burns?||
Regenerative function of the skin is absent because the dermal layer has bbeen destroyed.
|Which description of symptoms is charcteristic of a client diagnosed with trigeminal neuralgia (Tic dououreux)?||
Sudden, stabbing, severe pain over the lip and chin.
|Prior to a cardiac catherization, which activity should the nurse have the client practice?||
Valsalva's manuever and coughing.
|A client is placed on respirator following a cerebral hemmorhage, and vecuronium bromide (Norcuron) .04mg/kg q 12h IV is prescribed. Which nursing diagnosis is the priority?||
Impaired communication related to paralysis of skeletal muscles.
|Which client should the nurse recognize as most likely to experience sleep apnea?||
Obese older male client with a short, thick neck.
|A client receiving cholestyramine (Questran) for hyperlipidemia should be evaluated for what vitamin deficency?||
Vit K (Thse drugs reduce the absorption of the fat soluble vitamins ADEK.
|The nurse identifies bright red drainage, about 6 cm in diameter, on the dresssing of a client who is one day post abdominal surgery. Which action should the nurse take next?||
Mark the drainage on the dressing and take vital signs.
|A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which assessment finding should the nurse expect this client ot exhibit?||
Lower left quadrant pain an da low-grade fever. (sigmoid most common site)
|The nurse is assessing the lab results for a client who is admitted with renal failure and osteodystrophy. Which findings are consistent with this client's clinical picture?||
Serum Potassium of 5.5 mEq and total calcium of 6mg/dl.
Renal failure (hyperKalemia and Hypocalcemia)
|The nurse is assessing a client lab values following administration of chemotherapy. Which lab values leads the nurse to suspect that the client is experiencing tumor lysis syndrome?||
Serum calcium 5.0mg/dl.
TLS results in hyperkalemia, hypocalcemia, and hyperuricemia.
|A client who is HIV positive ask the nurse, "How will I know when I have Aids"? Which response is best for the nurse to provide?||
Aids is diagnosed when a specifc oppurtunistic infection is found in an other wise healthy individual.
|A splint is prescribed for nightitme use by a client with rhuematoid arthritis. Which statement by the nurse provides the most accurate explanation for use of the splints.||
Prevention of deformities.
|Then nurse is planning care for a client who has a right hemispheric stroke. Which nursing diagnosis should the nurse include in the plan of care?||
Risk for injury related to denial of deficits and impulsiveness. Right brain damage= difficulty in judgement and spatial perception. Left=speech issues and language deficits
|Then nurse knows that lab values sometimes vary for the older client. Which data should the nurse expect to find when reveiwing lab values of an 80 year old male?||
Increased protein in the urine, slightly increased serum glucose levels.
|The nurse is planning care to prevent complication for a client with multiple myeloma. Which intervention is most important for the nurse to include?||
Maintain a Fluid fo 3 to 4 l per day.
Malignant plasma cells that infiltrate bone casue demineralization>>>promote excretion of calcium
|The nurse is assessing a client with bacterial meningitis. Which assessment finding indicates the client may have developed septic emboli?||
Cyanosis of fingertips
Emboli lodge in small arterioles of extermities
|A client who is sexually active with several partners requests an IUD as a contraceptive method. Which information should the nurse provide?||
Using an IUD offers no protection against sexually transmitted diseases (STD), which increae the risk of pelvic inflammatory disease.
|In preparing a discharge plan for a 22 year old male client diagnosed with Buerger's disease (thromboangitis oblitrans), which referral is most important?||
Smoking cessation program.
|An 81 year old male client has emphysema. He lives at home with his cat and manages self care with no difficulty. When making a home visit, the nurse notices that his tongue is somewhat cracked and his eyeballs are sunken into his head. What nursing inter||
Help the client to determine ways to increase his fluid intake.
|Based on the analysis of the client's atrial fibrillation, the nurse should prepare for which treament protocol.||
THe nurse should prepare for anticoag therapy which is prescribed before rhythmn control.
|A client with cirrhosis develops increasing pedal edema and ascites. What dietary modification is most important for the nurse to teach this client?||
Restrict salt and fluid intake.
|Which reaction should the nurse identify in a client who is responding to stimulatiion of the sympathetic nervous system?||
Increased Heart rate
|Thenurse is preparing a teaching plan for a client who is newly diagnosed with Type 1 diabetes mellitus. Which signs and symptoms should the nurse describe when teaching the client about hypoglycemia?||
Sweating, trembling, tachycardia
Hyper: Poly uria, dipsia, phagia, fruity breath tachypnea
|A client who is receiving chemotherapy asks the nurse, "Why is so much of my hair falling out each day"? WHich response by the nurse best explains the reason for alopecia?||
Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant.
|Which finding should the nurse identify as most significant for a client diagnosed with polycystic disease?||
3+ bacteria in urine
|A female client receiving IV vasopressin (Pitressin) for esophageal varice rupture reports to the nurse that she feels substernal tightness and pressure across her chest. Which PRN protocol should the nurse initiate?||
Start an IV nitro infusion
|The nurse is assessing a client with Chronic Renal Failre. Which finding is most important for the nurse to respond to first?||
Potassium 6.0 mEQ>
|A male client receives a local anesthetic during surgery. During the post-operative assessment, the nurse notices the client is slurring his speech. Which action should the nurse take?||
Evaluate his blood pressure, pulse, and respiratory status.
|Which assessment finding by the nurse during a client's clinical breast exam requires follow-up?||
A newly retracted nipple.
|A client is being admitted to the medical unit from teh emergency dept after having a chest tube inserted. What equipment should be brought to his client's room?||
Rubber tipped clamp (assesses air leaks)
|Which information should thenurse give a client with chronic renal failure (CRF)?||
Avoid salt subsitutes
|A client who is one week postoperative after an aortic valve replacemnt suddenly develops severe pain in the left leg. On assessment, the nurse determines that the client's leg is pale and cool, and no pulses are palpable in the left leg. After notifying||
Keep client in bed in the supine position (anti-coagulan therapy & rest)
|After the fourth dose of gentamicin sulfate (Garamycin) IV, the nurse plans to draw blood samples to determine peak and trough levels. When are the best times to draw these samples?||
5 m,inutes before and 30 minutes after the next dose.
|When teaching diaphragmatic breathing to a client with chronic obstructive pulmonary (COPD), which information should the nurse provide?||
Place a small book or magazine on the abdomen and make it rise while inhaling deeply
|A client taking a thiazide diuretic for the past six months has a serum potassium level of 3. The nurse anticipates which change in prescription for the client?||
A potassiium supplement will be prescribed.
|A 20 year old female client calls the nurse to report alump she found in her breast. Which response is the best for the nurse to provide?||
Most lumps are benign, but it is always best to come in for an examination.
|Which intervention should the nurse implement for a female client diagnosed with pelvic relaxation disorder?||
Encourage the client to perform Kegel exercises 10 times daily.
|During a health fair, a 72 year odl male client tells the nurse that he is experiencing shortness of breath. Auscultation reveals crackles and wheezing in both lungs. Suspecting that the client might have chronic bronchitis, which classic symptom should t||
productive cough with grayish-white sputum.
|A client has taken steroids for 12 years to help manage chronic obstructive pulmonary (COPD). When making a home visit, which nursing function is of greatest importnace to this client? Assess the client's||
C Temperature over skin color and turgor
steroids and infection
|A client has undergone insertion of a permanent pacemaker. When developing a discharge teaching plan, the nurse writes a goal of, "The client will verbalize symptoms of pacemaker failure. "Which symptom are the most important to teach the client||
Feelings of dizziness
|In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the lab test results to indicate a decreased serum level of which substance?||
|The healthcare provider prescribes aluminum and magnesium hydroxde (maalox, 1 tablet PO PRN, for a client with chronic renal failure who is complaining of indigestion. What intrevention should the nurse implement?||
Question the healthcare provider prescription.
(it can casue hypermagnesium)
|An elderly client is admitted with a diagnosis of bacterial pnuemonia. The nurse's assessment of the client is most likely to reveal which sign and symptom?||
Confusion and tachcardia
|A 67 year old woman who lives alone is admitted after tripping on a rug in her home and fractures her hip. WHic predisposing factor probably led to the fracture in the proximal end of her femur?||