Nursing

What instruction should the nurse include in the discharge teaching plan of a client who had a cataract extraction today?

a. Sexual activities may be resumed upon return home b. Light housekeeping is permitted but avoid heavy lifting

c. Use a metal eye shield on operative eye during the day

d. Administer eye ointment before applying eye drops

A male adult comes to the urgent care clinic 5 days after being diagnose with influenza. He is short of breath, febrile, and coughing green colored sputum. Which intervention should the nurse implement first?

e. Obtain a sputum sample for culture

f. Check his oxygen saturation level

g. Administer an oral antipyretic

h. Auscultate bilateral lung sound

An elder male client tells the nurse that he is loosing sleep because he has to get up several times at night to go to the bathroom that he has trouble starting his urinary stream and that he does not feel like his bladder is ever completely empty. Which intervention should the nurse implement?

a. collect a urine specimen for culture analysis

b. obtain a fingerstick blood glucose level

c. palpate the bladder above the symphysis pubis

d. review the client fluid intake

An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection (UTI) Prescriptions for intravenous antibiotics and insulin infusion are initiated. Which serum laboratory value warrants the most immediate intervention by the nurse?

a. blood ph of 7.30

b. glucose of 350 mg /dl

c. white blood cell count of 15000mm d. potassium of 2.5 meq/l

A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cell. When notifying the healthcare provider what information should the nurse provide first using the SBAR communication process?

a. explain specific reason for urgent notification

b. preface the report by stating the clients name and admitting diagnosis

c. communicate the pre-transfusion temperatures

d. optain prn prescription for acetaminophen for fever 101f

An adult male client is admitted for pneumocystis carinil pneumonia (PCP) secondary to aids. While hospitalize he receives IV pentamidine isethionate therapy. In preparing this client for discharge what important aspect regarding his medication therapy should the nurse explain?

e. AZT therapy must be stopped when IV aerosol pentamine is being used.

f. IV pentamine will be given until oral pentamine can be tolerated

g. It will be necessary to continue prophylactic doses of IV or aerosol pentamine every month

h. Iv pentamine may offer protection to others aids related conditions such as kaposis sarcoma

A client subjective data includes dysuria, urgency, and urinary frequency. What action should the nurse implement next?

a.collect a clean catch specimen b.palpate the suprapubic region c.instruct to wipe from front to back

d.inquire about recent sexual activity

A client tells the nurse that her biopsy results indicate that the cancer cells are well differentiated How should the nurse respond?

a. offer the client reassurance that this information indicates that the clients cancer cells are benign

b. explain that these tissue cells often respond more effectively to radiation than to chemotherapy c. ask the client in the healthcare provider has giving her any information about the

classification of her cancer

d. help the client make plans to begin inmediate treatment since her cancer is likely to spread quickly

A client with a chronic kidney disease is treated on hemodialysis. During the 1 treatment clients blood pressure drops from 150/90 to 80/30 Which action should the nurse take first?

a. monitor bp q45 minutes

b. lower the head of the chair and elevate feet c. stop dialysis treatment

d. administer 5%albumin IV

A client with deep vain thrombosis (DVT) is receiving a continues infusion of heparin sodium 25,000 unit in 5% dextrose injection 250ml. The prescription indicates the dosage should be increase 900 units/hr. The nurse should program the infusion pump to deliver how many ml/hr?

=9

The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this diagnosis?

e. upper mid abdominal gnawing and burning pain

f. severe abdominal cramps and diarrhea after eating spicy foods

g. marked loss of weight and appetite over the last few months

h. use of chewable and liquid antacids for indigestion

The nurse is providing preoperative education for a jewish client schedule to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client?

a.the xenograft is taken from nonhuman sources b.grafting increases the risk for bacterial infection c.as the burn heals the graft permanently attaches d.grafts are later removed by debriding procedure

A client who took a camping vacation two weeks ago in a country with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse to report?

a. jaundice sclera

b. intestinal cramping

c. weakness and fatigue

d. weight loss

During a home visit the nurse assesses the skin of a client with eczema who reports than an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?

a. an old friend with eczema came for visit

b. recently received an influenza immunization

c. corticosteroid cream was applied to eczema d. a grandson and his new dog recently visited

When explaining dietary guidelines to a client with acute glomerulonephritis (AGN) which instruction should the nurse include in the dietary teaching ?

e. select a protein rich food daily f. restrict sodium intake

g. eat high potassium foods

A male client who is 24hr post operative for an exploratory laparoctomy complains that he is starving because he has had no real food since before surgery. Prior to advancing his diet which intervention should the nurse implememt?

h. discontinue intravenous therapy

i. Obtain a prescription for a diet change

j. Auscultate bowel sound in all four quadrants

A client diagnose with stable angina secondary to ischemic heart disease has a prescription for sublingual (SL) nitroglycerin (NTG). The nurse should tell the client to follow which instructions if chest pain is not relieved after taking 3 NTG tables 5 min apart?

k. drive to the nearest emergency department

l. take another NTG SL tablet and lie down until angina subsides

m.call primary healthcare provider

n. call 911 pain is unrelieved and chew a tablet of aspirin 325mg

After taking orlistat (Xenical) for one week a femela client tells the home health nurse that she is experiencing increasingly frequent oily stools and flatus. What action should the nurse take?

a. obtain stool specimen to evaluate for occult blood and fat content

b. instruct the client to increase her intake of saturated fats over the next week c. ask the client to describe her dietary intake history for the last several days

d. advice the client to stop taking the drug and contact the healthcare provider

Two days after an abscess of the chin was drained the client returns to the clinic with fever chills and a maculopapular rash with pruritis. The client has taken an oral antibiotic and cleansed the wound today with provide iodine (Betadine) solution. Which intervention should the nurse implement first?

o. determine if the client has a history of diabetes p. assess airway patency and oxygen saturation

q. review recent medication history and allergies

r. obtain samples for complete blood count and cultures

A client experiences an ABO 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

A young adult male who has had type 2 diabetes mellitus (DM) is admitted to the intensive care unit with hyperglycemic nonketotic symdrome (HHNS). A sliding scale protocol for an isotonic IV solution with regular insulin is prescribed based on the results of a continuous blood glucose monitoring device that is attached to the clients central venous catheter. When the clients respirations become labored and his lungs sound indicate crackles what action should the nurse take?

e. collect a specimen for a white blood cell count and cultures

f. determine the clients glycosylated hemoglobin (A1C) (POSSIBLE ANSWER)

g. administer insulin IV push until the clients fluid volume is adjusted h. decrease infusion rate to address fluid overload

When preparing to apply a fentanyl (Duragesic) transdermal patch the nurse notes that the previously applied patch is intact on the clients upper back and the client denies pain. What action should the nurse take?

a. Remove the patch and consult with the healthcare provider about the client pain resolution

b. Place the patch on the clients shoulder and leave both patches in place for 12 hours

c. Administer an oral analgesic and evaluate its effectiveness before applying a new patch d. Apply a new patch in a different location after removing the original patch

A client who had a myocardial infarction is admitted to the coronary critical care unit (CCU) with a nitroglycerin drip infusing. The clients last blood pressure measurements was 78/36.What action should the nurse implement?

a. obtain blood pressure q5 minutes using duranap machine

b. change the dilution of the nytroglycerin infusion c. reduce the rate of the nitroglycerin infusion

d. begin dopamine infusion at 5mcg/kg per minute

An adolescent is admitted to the hospital because of a suicide attempt with an overdose of acetaminophen (Tylenol). Which blood values are most important for the nurse to monitor during the first 72 hours following ingestion of this overdose?

e. BUN creatinine specific gravity

f. White blood count, hemoglobin hematocrit

g. PH,PCO2, HC03

h. LDH OR LD, SGOT OR ALT, SGPT OR AST.

An elderly post operative female client is receiving morphine sulfate via a PCA pump. Which assessment finding should prompt a nurse to administer the prescribed PRN medication naloxone?

i. her respiratory rate is 7 breath/minute

j. she indicates that she feels as if she cannot get enough air to breath

k. she has intercostal retractions and bilateral wheezing is auscultated

l. her pulse oximeter is 89% on room air

Which assessment finding indicates to the nurse that the muscarinic agent bethanechol (Urecholine) is effective for a client diagnose with urinary retention?

a. urinary output equal to intake

b. no terminal urinary dribbling

c. denies stress incontinence

d. absence of xerostomia

Following involvement in a motor vehicle collision, a middle aged adult client is admitted to the hospital with multiple facial fractures. The clients blood alcohol level is high on admission. Which PRN prescription should be administer if the clients begins to exhibit signs and symptoms of delirium tremens (DT s)?

a. Lorazepam (Ativan) 2mg IM

b. Chlorpromazine (thorazine) 50 mg IM

c. Prochlorperazine (Compazine) 5 mg IM

d. Hydromorphone (Dilaudid) 2 mg IM

Which instructions should the nurse include in the teaching plan of a client who is taking the diuretic spironolactone (Aldactone)?

a. call the healthcare provider f you develop gynecomastia b. Take the medication in the morning

c. Avoid caffeine and smoking

d. Increase your consumption of bananas and oranges

A glucagon emergency kit is prescribed for a client with type 1 diabetes mellitus. When should the nurse instruct the client to take the glucagon?

a. after meals to increase endogenous insulin secretion

b. after insulin administration to prevent hypoglycemia c. when recognized signs of severe hypoglycemia occur

d. when unable to eat during sick days

A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included in preparing this client for this treatment?

e. describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider

f. explain the need for using lead shields for 2 to 3 weeks after the treatment

g. describe the signs of goiter because this is a common side effects of radioactive iodine

h. explain that relief of the signs/ symptoms of hyperthyroidism will occur immediately

A female client is being treated for tuberculosis with rifampin (rifadin) Which statement indicates that futher teaching is needed?

d- I will take my usual contraceptive for birth control

A client is discharged with a prescription for warfarin ( Coumadin). What discharge instructions should the nurse emphasize to the client?

a. take a multi vitamin supplement daily

b. use an astringent for superficial bleeding c. avoid going barefoot especially outside

d. include large amounts of spinach in the diet

In caring for a client with diabetes insipidus who is receiving an antidiuretic hormone intranasally which serum lab test is most important for the nurse to monitor?

e. osmolality

f. calcium

g. platelets

h. glucose

After administering dihydroergotamine (Migranal) 1 mg subcutaneously to a client with a severe migraine headache the nurse should explain that relief can be expected within what time frame?

a. 2 hours

b. 5 minutes

c. 1 hour

d. 15 minutes

A client with hypertension who has been taking labetalol for two weeks, reports a five pound (2.2 kg) weight gain. Which follow up assessment is most important for the nurse to obtain?

a. capillary refill

b. body temperature

c. muscle strength d. breath sounds

A male client is receiving pilocarpine hydrochloride (Isopto Carpine) ophthalmic drops for glaucoma. He calls the clinic and ask the nurse why he has difficulty seeing at night. What explanation should the nurse provide?

a. The eye drops slow pupil response to accommodate for darkness

b. The drops increase the fluid in the eyes and cloud the visual field

c. The drug can cause lens to become more opaque

d. The medication causes pupils to dilate which reduces night vision

A client who is taking and oral dose of tetracycline complains of gastrointestinal upset.

What snack should the nurse instruct the client to take with the tetracycline?

a. toasted wheat bread and jelly

b. cheese and crakers

c. cold cereal with skim milk

d. fruit flavored yogurt

The therapeutic effect of insulin in treating type 1 diabetes mellitus is based on which physiologic action?

e. Facilitates transport of glucose into the cell

f. Increases intracellular receptor site sensitivity

g. Stimulates function of beta cells in the pancreas

h. Delays carbohydrates digestion and absorption

The health care provider prescribe a medication for an older adult client who is complaining of insomnia. And instructs the client to return in 2 weeks. The nurse should question which prescription?

i. Eszoplicone (Lunesta)10 mg orally at bed time

j. Zolpidem 10 mg orally at bed time

k. Temazepan orally at bed time

l. Ramelteon orally at bedtime

A male client reports to the nurse that he is experiencing GI distress from high dose of a corticosteroid and is planning to stop taking the medication. In response to the clients statement what nursing action is most important for the nurse to take?

m. Encourage the client to take medication with food to decrease GI distress

n. Advice the client that the medication should be stopped gradually rather than abruptly.

o. Review the clients dosing schedule to ensure he is taking the prescribed amount

p. Assess the client for other indication of adverse effects of corticosteroid

Fifteen minutes after receiving sulfa athenozole . A male client report a burning sensation over his abdomen chest and groin. Which intervention is most important for the nurse to implement?

q. Auscultate lung sounds for wheezing

r. Review the clients list if drugs allergies

s. Add sulfamethinozole to clients allergies

t. Check neurological vital signs

Antibiotic resistant organism are a major infection control problems. To help minimize the emergence of resistant bacteria what instruction should the nurse provide to the clients?

u. stop taking prescribed antibiotics when symptoms decrease v. avoid using antibiotics when suffering from colds or the flu

w. ask the healthcare provider to prescribe the newest antibiotic when needed

x. request a prescription for first time vancomysin for a sore throat

A client with symptoms of influenza that started the previous day ask the clinic nurse about taking oseltamivir (Tamiflu) to treat the infection. Which response should the nurse provide?

y. Advise the client once symptoms occur is too late to receive an influenza vaccination

z. Refer the client to the healthcare provider at the clinic to obtain a medication prescription

aa. Explain to the client that antibiotics are not useful in treating viral infections such as influenza

bb. Instruct the client that over the counter medications are sufficient to manage influenza

symptoms

Twenty minutes after the nurse starts a secondary IV infusion of cafepime (maxipime) 2 grams using an infusion pump to deliver the dose in one hour, the client reports feeling nauseated. What action should the nurse implement?

cc. stop medication infusion and notify the healthcare provider of the adverse effect dd. increase the rate of the infusion to complete the dose of the medication more

rapidly

ee. continue the infusion and administer a prn antiemetic prescription ff. reasurre the client that the nausea is not related to the iv infusion

The nurse administer donepezil hydrochloride (Aricept) to a client with Alzheimers disease as an intervention for which client problem?

gg. fluid volume excess hh. disturbed though processes

ii. chronic pain

jj. altered breathing patterns

To prevent deep vein thrombosis following knee replacement surgery, an adult male client is receiving enoxaparin (Lovenox) subcutaneously daily. Which laboratory finding requires immediate action by the nurse?

kk. blood urea nitrogen (BUN) 20mg/dl or 7.1 mmol/L (SI) ll. Hematocrit 45%

mm. Serum creatinine 1.0 mg/dl or 88.4 mol/L (SI) nn. Platelet count of 100,000/mm3 or 100×10??/ L (SI)