All Clients Need (1001-1200) Flashcards
Which intervention should a nurse try first when caring for a client who exhibits signs of sleep disturbance?
Provide the client with normal sleep aids, such as pillows, back rubs, and snacks.
A client who has cervical cancer is scheduled to undergo internal radiation. In teaching the client about the procedure, the nurse should tell the client that:
a bowel-cleansing procedure will precede radioactive implantation.
A primigravid client at 37 weeks’ gestation has been hospitalized for several days with severe preeclampsia. While caring for the client, the nurse observes that the client is beginning to have a seizure. Which of the following actions should the nurse do first?
Call for immediate assistance in the client’s room.
A client is entering the chemical dependency unit for treatment of alcohol dependency. Which of the client’s possessions should the nurse place in a locked area?
Antiseptic mouthwash.
A client is admitted to the labor and delivery department in preterm labor. To help manage preterm labor, the nurse should expect to administer:
terbutaline (Brethine).
A nurse is planning care for a client with hyperthyroidism. Which nursing interventions are appropriate? Select all that apply.
- Instill isotonic eye drops, as necessary.
- Provide several small, well-balanced meals.
- Provide rest periods.
- Weigh the client daily.
The topic of physiologic changes that occur during pregnancy is to be included in a parenting class for primigravid clients who are in their first half of pregnancy. Which of the following would be important for the nurse to include in the teaching plan?
Increased risk for urinary tract infections.
The membranes of a 26-year-old primigravida at 40 weeks’ gestation admitted for induction of labor rupture spontaneously with evidence of meconium staining. After 1 hour of intravenous oxytocin, the nurse observes late fetal heart rate decelerations. Which of the following should the nurse do next?
Administer oxygen at 8 to 10 liters by mask.
Ibuprofen (Motrin) is prescribed for a client with osteoarthritis. Which of the following instructions about ibuprofen should the nurse include in the client’s teaching plan?
Take with food or antacids.
A nurse is frustrated by her inability to make much progress establishing a therapeutic relationship with a client with bipolar disorder. Her most professional response would be to:
discuss the situation with a more experienced peer.
The nurse teaches a client who had cystoscopy about the urge to void when the procedure is over. What other teaching should be included?
Force fluids.
On her third postpartum day, a client complains of chills and aches. Her chart shows that she has had a temperature of 100.6° F (38.1° C) for the past 2 days. The nurse assesses foul-smelling, yellow lochia. What should the nurse do next?
Anticipate that the physician will order laboratory tests and cultures.
When caring for a client with head trauma, a nurse notes a small amount of clear, watery fluid oozing from the client’s nose. What should the nurse do first?
Test the nasal drainage for glucose.
At what age should a boy be taught how to do a monthly testicular self-examination?
12 years
A client with muscle weakness and an abnormal gait is being evaluated for muscular dystrophy. Which test or finding confirms muscular dystrophy?
Muscle biopsy
A 16-year-old unmarried primigravid client at 37 weeks’ gestation with severe preeclampsia is in early active labor. The client’s blood pressure is 164/110 mm Hg. Which of the following would alert the nurse that the client may be about to experience a seizure?
Epigastric pain.
A nurse is caring for a client with cystic fibrosis. With which members of the health care team is it most appropriate for her to collaborate? Select all that apply.
- Nutritional services
- Physical therapy
- Respiratory therapy
In the process of dealing with the intense feelings about being raped, victims commonly verbalize that they were afraid they would be killed during the rape and wish that they had been. The nurse should decide that further counseling is needed if the client voices which of the following?
I get so angry at times that I have to have a couple of drinks before I sleep.
A client in the second stage of labor is fully dilated. Which nursing action is appropriate for this stage of labor?
Assessing vital signs every 15 minutes
The nurse is taking care of a client with Clostridium difficile. The nurse should do which of the following to prevent the spread of infection? Select all that apply.
- Wear a protective gown when in the client’s room.
- Wash hands with soap and water.
The parents of a neonate with a cleft lip are shocked when they see their child for the first time. Which of the following nursing actions should the nurse include in the neonate’s plan of care to help the parents accept their newborn’s anomaly?
Showing them pictures of babies before and after corrective surgery.
A nurse is caring for four clients on the cardiac unit. Which client has the greatest risk for contracting infective endocarditis?
A client 4 days postoperative after mitral valve replacement
A child, age 5, is hospitalized for treatment of Kawasaki disease. Which nursing action best identifies potential complications of this disease?
Instituting cardiac monitoring
A nurse is talking with a delusional client when the fire alarm sounds and a staff member closes the door to the client’s room. The client becomes very agitated and declares, “The aliens have arrived!” Which actions are appropriate for the nurse to take? Select all that apply.
- Staying with the client until she receives further instructions
- Continuing to speak to the client in a reassuring tone
After a dose-response test, the client with an overdose of barbiturates receives pentobarbital sodium (Nembutal) at a nonintoxicating maintenance level for 2 days and at decreasing dosages thereafter. This regimen is effective in the client does not develop:
Seizures.
Which measurement should a nurse use to monitor the respiratory status of a client with pulmonary edema?
Arterial blood gas (ABG) analysis
An adolescent is admitted for treatment of bulimia nervosa. When developing the care plan, the nurse anticipates including interventions that address which metabolic disorder?
Metabolic alkalosis
A nurse is obtaining the history of a child, age 4. Which question best evaluates the child’s developmental status?
Can you ride a tricycle?
A client commonly jumps when spoken to and reports feeling uneasy. The client says, “It’s as though something bad is going to happen.” In which order from first to last should the following nursing actions be done?
- Reduce environmental stimuli.
- Ask the client to deep breathe for 2 minutes.
- Discuss the client’s feelings in more depth.
- Teach problem solving strategies.
A client in the manic phase of bipolar disorder is admitted to the facility. Which agents are appropriate for this client?
Lithium (Lithobid) and valproic acid (Depakote)
A nurse is caring for a family whose infant has anencephaly. The most appropriate nursing intervention is to:
help the family prepare for the infant’s imminent death.
Which of the following measures should be implemented promptly after a client’s nasogastric (NG) tube has been removed?
Provide the client with oral hygiene.
Which of the following factors contribute to a risk for amputation in a client with peripheral vascular disease? Select all that apply.
- Uncontrolled diabetes mellitus for 15 year.
- A 20-pack-year history of cigarette smoking.
- A serum cholesterol concentration of 275 mg/dL.
A nurse is palpating a client’s pulse on the inner aspect of his ankle, below the medial malleolus. Which pulse is the nurse assessing?
Posterior tibial
The emergency department nurse has admitted an infant with bulging fontanels, “setting sun” eyes, and lethargy. Which of the following diagnostic procedures would be contraindicated in this infant?
Lumbar puncture.
The nurse is changing the subclavian dressing of a client who is receiving total parenteral nutrition. When assessing the catheter insertion site, the nurse notes the presence of yellow drainage from around the sutures that are anchoring the catheter. Which action should the nurse take first?
Obtain a culture specimen of the drainage.
Which of the following statements by a primigravid client about the amniotic fluid and sac indicates the need for further teaching?
Fetal nutrients are provided by the amniotic fluid.
Which of the following would be true regarding medication reconciliation? Select all that apply.
- Medication reconciliation is a Joint Commission National Patient Safety Goal.
- Medication reconciliation is designed to obtain and communicate an accurate list of a client’s home medications across the continuum of care.
- Medications are considered reconciled if a medication order exists that is therapeutically equivalent to the one prior to admission.
A nurse is caring for a 10 month old who weighs 8.0 kg and has been admitted for dehydration. The infant has vomited five times in the last 3 hours and has had no wet diapers in the last 8 hours. The nurse informs the primary healthcare provider. Which of the following orders should the nurse question?
Begin an IV line and administer a fluid bolus of Dextrose 35%.
When caring for a client in the first stage of labor, the nurse documents cervical dilation of 9 cm and intense contractions lasting 45 to 60 seconds and occurring about every 2 minutes. Based on these findings, the nurse should recognize that the client is in which phase of labor?
Transitional phase
A male neonate with a 3 X 5 cm sac in the lumbar region of his back is diagnosed with myelomeningocele. What should the nurse expect to find when inspecting this sac?
Spinal fluid, nerve tissue, and spinal bony defect.
After a retropubic prostatectomy, a client needs continuous bladder irrigation. The client has an I.V. of dextrose 5% in water infusing at 40 ml/hour, and a triple-lumen urinary catheter with normal saline solution infusing at 200 ml/hour. The nurse empties the urinary catheter drainage bag three times during an 8-hour period for a total of 2,780 ml. How many milliliters does the nurse calculate as urine? Record your answer using a whole number. Do not use any commas.
1180
Which of the following diet instructions are appropriate when teaching a client in the early stages of cirrhosis about nutritional needs? Select all that apply.
- “I encourage you to eat small, frequent meals.”
- “An adequate intake of protein is important to your health.”
What is the approximate time that the blastocyst spends traveling to the uterus for implantation?
7 days
A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which finding suggests that the client has developed hyperglycemia?
Increased urine output
A client with advanced stomach cancer is scheduled for chemotherapy. As part of the chemotherapy regimen, the nurse expects the physician to order:
fluorouracil (5-fluorouracil, 5 FU [Fluoroplex]).
A 4-week-old infant admitted with the diagnosis of hypertrophic pyloric stenosis presents with a history of vomiting. The nurse should anticipate that the infant’s vomitus would contain gastric contents and which of the following?
Mucus and streaks of blood.
The client with rheumatoid arthritis tells the nurse, “I have a friend who took gold shots and had a wonderful response. Why didn’t my physician let me try that?” Which of the following responses by the nurse would be most appropriate?
Every person is different. What works for one client may not always be effective for another.
Clonidine (Catapres) can be used to treat hypertension as well as:
opioid withdrawal.
The nurse finds it difficult to relieve a client’s pain satisfactorily. Which of the following measures should the nurse take next when continuing efforts to promote comfort?
Improve the nurse-client relationship.
A home health nurse visits a client who’s taking pilocarpine (Pilocar), a miotic agent, to treat glaucoma. The nurse notes that the client’s pilocarpine solution is cloudy. What should the nurse do first?
Advise the client to discard the drug because it may have undergone chemical changes or become contaminated.
A client who has asthma is taking albuterol (Ventolin) to treat bronchospasms. The nurse should assess the client for which of the following adverse effects that can occur as a result of taking this drug? Select all that apply.
- Headache.
- Nervousness.
- Nausea.
The nurse assesses a 6-month-old for vaccination readiness. Which finding would most likely indicate the need to delay administering the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine?
An acute bilateral ear infection.
A parent asks the nurse about the major causes of brain injury in children. What should the nurse include in the response as the most common causes? Select all that apply.
- Falls.
- Motor vehicle accidents.
- Bicycle accidents.
A nurse is preparing to discharge a child who has rheumatic fever. The nurse plans to teach the parents about which medication that will be used to prevent a recurrence of the disease?
Antibiotics
Following a boating accident, a client with multiple fractures is admitted to a semiprivate room in a progressive care unit. The client, who was piloting the boat, is unaware that his girlfriend’s 9-year-old son was killed in the accident. The client’s parents instruct the nurse to prohibit phone calls and to withhold information about the accident. During an assessment of the client, the nurse notices that the television is on and the news is starting. What should the nurse do?
Allow the client to view the television and deal with any questions as they come.
A client with a history of polysubstance abuse is admitted to the facility. He complains of nausea and vomiting 24 hours after admission. The nurse who assesses the client notes piloerection, pupillary dilation, and lacrimation. The nurse suspects that the client is going through withdrawal from which substance?
Opioids
A nurse and newly hired nursing assistant are caring for a group of clients. The nurse is administering medications and needs to know the fingerstick glucose results before administering a medication. The nurse asks the nursing assistant if she’s been validated on obtaining fingerstick glucose readings. The nursing assistant says she didn’t have the skill validated, but she’s seen it done many times and knows she can do it. What should the nurse do?
Go with the nursing assistant into the client’s room, and validate her ability to perform the procedure.
A client with osteoarthritis will undergo an arthrocentesis on a painful edematous knee. What should be included in the nursing plan of care? Select all that apply.
- Explain the procedure.
- Assess the site for bleeding.
- Offer pain medication.
The nurse is to wear personal protective equipment (PPE) to administer a chemotherapeutic agent to the client. The nurse should use which of the following guidelines for PPE use and care? Select all that apply.
- Understand the proper use and limitations of PPE.
- Use care in removing all items to reduce contamination.
- Discard the PPE in containers for contaminated waste.
During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following would be most appropriate to institute?
Keeping extraneous noise to a minimum.
As a client is being admitted to the facility, her husband asks the nurse why she must sign a statement confirming that she has been told of her rights to communicate her wishes about life support and resuscitation. How should the nurse respond?
We make sure our clients know they have the right to specify advance directives and appoint someone to speak for them.
Nursing preparations for a client undergoing electroconvulsive therapy (ECT) resemble those used for:
general anesthesia.
A very elderly, drowsy client with fragile skin is being transferred from the surgery cart to the bed. How should the nurse plan to direct the transfer to prevent skin shearing?
With two people, one at each side using a drawsheet, one person at the head, and one person at the feet.
A nurse is asked to develop an in-service to explain documents guiding professional nursing practice on the obstetrical unit. One of the documents included is the American Nursing Association Code of Ethics. The nurse correctly explains that the code asks nurses to demonstrate which of the following? (Select all that apply.)
- Be responsible and accountable for individual practice.
- Maintain integrity and shape social policy.
- Develop, maintain, and improve health care environments.
- Increase professional competence and personal growth.
The definition of a nihilistic delusion is:
false belief that one is dead or that a calamity is about to occur.
Umbilical cord prolapse necessitated cesarean birth of a preterm, low-birth-weight neonate. Immediately after birth, the neonate is limp, gasping for air, unresponsive to stimulation, and has blue discoloration of the face, lips, and torso. Which intervention should the nursery nurse perform first?
Determine unresponsiveness and assess the need for resuscitation.
A physician has ordered hydrochlorothiazide (HydroDIURIL) for a client diagnosed with Ménière’s disease. Which instruction should the nurse include in the teaching session?
Increase your intake of bananas, tomatoes, and oranges.
The client is to be discharged from the hospital after a safe, medically supervised withdrawal from alcohol. Which of the following outcomes indicate client readiness for an outpatient alcohol treatment program? Select all that apply.
- The client verbalizes the damaging effects of alcohol on his body.
- The client plans to attend Alcoholics Anonymous meetings.
- The client takes naltrexone (ReVia) daily.
The nurse discusses the eating habits of school-age children with their parents, explaining that these habits are most influenced by:
Examples provided by parents at mealtimes.
The client is scheduled to have a kidney, ureter, and bladder (KUB) radiograph. To prepare the client for this procedure, the nurse should explain to the client that:
No special preparation is required for the examination.
The nurse reviews an arterial blood gas report for a client with chronic obstructive pulmonary disease (COPD): pH 7.35; PC02 62; PO2 70; HCO3– 34. The nurse should:
Assess the vital signs.
A client is to have a transsphenoidal hypophysectomy to remove a large, invasive pituitary tumor. The nurse should instruct the client that the surgery will be performed through an incision in the:
Upper gingival mucosa in the space between the upper gums and lip.
A nurse is caring for a terminally ill client. Place the five stages of death and dying described by Elisabeth Kubler-Ross in the order in which they occur. Use all options.
- Denial and isolation
- Anger
- Bargaining
- Depression
- Acceptance
The nurse is suctioning a client who had a laryngectomy. What is the maximum amount of time the nurse should suction the client?
10 seconds.
A 4-month-old infant has been carried into the emergency department after falling off his parents’ bed and hitting his head on the floor. What should the nurse do next?
Move the family to an area where an assessment can be completed and call for a physician.
A client with acute respiratory distress syndrome (ARDS) is on a ventilator. The client’s peak inspiratory pressures and spontaneous respiratory rate are increasing, and the PO2 is not improving. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the physician with the recommendation for:
Initiating IV sedation.
Thirty people are injured in a train derailment. Which client should be transported to the hospital first?
A 25-year-old with a sucking chest wound.
When teaching a client about levodopa-carbidopa (Sinemet) therapy for Parkinson’s disease, a nurse should include which instruction?
Be aware that your urine may appear darker than usual.
A staff member says she’s really busy and asks the charge nurse to double-check a dose of insulin she has drawn up. The nurse holds up a bottle of Lente insulin, but the charge nurse notices a bottle of Lantus insulin on the medication cart. This nurse has made multiple medication errors and the charge nurse is concerned that she isn’t safe. What should the charge nurse do?
Tell the nurse that she’d like to start at the beginning to be on the safe side.