Podcast
Questions and Answers
A nurse is reviewing the medical record of a client who is receiving heparin therapy for treatment of DVT. Which of the following interventions should the nurse anticipate taking if the client's aPTT is 96 seconds?
A nurse is reviewing the medical record of a client who is receiving heparin therapy for treatment of DVT. Which of the following interventions should the nurse anticipate taking if the client's aPTT is 96 seconds?
- Stop the heparin infusion (correct)
- Increase the heparin infusion flow rate by 2 mL/hr
- Continue to monitor the heparin infusion as prescribed
- Request a prothrombin timed
A nurse is providing teaching for a client who is 2 days post-op following a heart transplant. Which of the following statements should the nurse include in the teaching?
A nurse is providing teaching for a client who is 2 days post-op following a heart transplant. Which of the following statements should the nurse include in the teaching?
- After 6 months, you will no longer need to restrict your sodium intake.
- You will be able to stop taking immunosuppressants after 12 months.
- Your level of activity tolerance will not change.
- You may no longer be able to feel chest pain. (correct)
Why is a blood draw for a carcinoembryonic antigen (CEA) level being performed for a client with colorectal cancer?
Why is a blood draw for a carcinoembryonic antigen (CEA) level being performed for a client with colorectal cancer?
- The CEA determines if the neutrophil count is below the expected reference range.
- The CEA determines if you are experiencing occult bleeding from the GI tract.
- The CEA determines the efficacy of your chemotherapy. (correct)
- The CEA determines the current stage of your colon cancer.
A nurse is assessing a client who has bradydysrhythmia. Which of the following findings should the nurse expect?
A nurse is assessing a client who has bradydysrhythmia. Which of the following findings should the nurse expect?
Which food selection by a client with chronic cholecystitis indicates effective teaching?
Which food selection by a client with chronic cholecystitis indicates effective teaching?
Which statement indicates effective teaching for a client with gastritis who has a new prescription for famotidine?
Which statement indicates effective teaching for a client with gastritis who has a new prescription for famotidine?
A nurse in the emergency department is caring for a client who had an anterior MI. The client's history reveals she is 1 week post-op open cholecystectomy. The nurse should recognize that which of the following interventions is contraindicated?
A nurse in the emergency department is caring for a client who had an anterior MI. The client's history reveals she is 1 week post-op open cholecystectomy. The nurse should recognize that which of the following interventions is contraindicated?
A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication?
A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication?
What symptom does the nurse expect a client with intussusception to exhibit?
What symptom does the nurse expect a client with intussusception to exhibit?
A nurse is caring for a client who presents to the ER with a BP of 254/138 mmHg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first?
A nurse is caring for a client who presents to the ER with a BP of 254/138 mmHg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first?
Emotional stress is a risk factor for irritable bowel syndrome (IBS).
Emotional stress is a risk factor for irritable bowel syndrome (IBS).
Which ethnic group has a higher incidence of colorectal cancer?
Which ethnic group has a higher incidence of colorectal cancer?
A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. The nurse should plan to monitor for and report which of the following findings to the provider immediately?
A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. The nurse should plan to monitor for and report which of the following findings to the provider immediately?
A nurse is assessing a client who has left-sided heart failure. Which of the following manifestations should the nurse expect to find?
A nurse is assessing a client who has left-sided heart failure. Which of the following manifestations should the nurse expect to find?
Which finding should the nurse expect when assessing a client with peritonitis?
Which finding should the nurse expect when assessing a client with peritonitis?
What findings should a nurse expect when assessing a client with appendicitis?
What findings should a nurse expect when assessing a client with appendicitis?
A nurse is caring for a client who is being treated for heart failure and has prescriptions for digoxin and furosemide. The nurse should plan to monitor for which of the following as an adverse effect of these medications?
A nurse is caring for a client who is being treated for heart failure and has prescriptions for digoxin and furosemide. The nurse should plan to monitor for which of the following as an adverse effect of these medications?
What indicates acute gastric dilation after a gastrectomy?
What indicates acute gastric dilation after a gastrectomy?
A nurse is monitoring a client following coronary artery bypass graft surgery. Which of the following findings can indicate cardiac tamponade?
A nurse is monitoring a client following coronary artery bypass graft surgery. Which of the following findings can indicate cardiac tamponade?
What should a nurse advise a client with hepatic encephalopathy about their dietary protein intake?
What should a nurse advise a client with hepatic encephalopathy about their dietary protein intake?
A nurse is preparing a client for coronary angiography. The nurse should report which of the following findings to the provider prior to the procedure?
A nurse is preparing a client for coronary angiography. The nurse should report which of the following findings to the provider prior to the procedure?
What is immunity developed by vaccination or immunization known as?
What is immunity developed by vaccination or immunization known as?
A nurse is caring for a client following insertion of a permanent pacemaker. Which of the following client statements indicates a potential complication of the insertion procedure?
A nurse is caring for a client following insertion of a permanent pacemaker. Which of the following client statements indicates a potential complication of the insertion procedure?
A nurse is providing discharge teaching for a client who has a prescription for the transdermal nitroglycerin patch. Which of the following instructions should the nurse include in the teaching?
A nurse is providing discharge teaching for a client who has a prescription for the transdermal nitroglycerin patch. Which of the following instructions should the nurse include in the teaching?
A patient with inflammation has a high eosinophil count. What does this finding most likely indicate?
A patient with inflammation has a high eosinophil count. What does this finding most likely indicate?
Which cell types associated with the inflammatory response participate in phagocytosis?
Which cell types associated with the inflammatory response participate in phagocytosis?
A nurse is caring for a client in the first hour following an aortic aneurysm repair. Which of the following findings can indicate shock and should be reported to the provider?
A nurse is caring for a client in the first hour following an aortic aneurysm repair. Which of the following findings can indicate shock and should be reported to the provider?
A nurse caring for a client following an abdominal aortic aneurysm resection. Which of the following is the priority assessment for this client?
A nurse caring for a client following an abdominal aortic aneurysm resection. Which of the following is the priority assessment for this client?
What indicates understanding of dietary management in a client with chronic hepatitis C?
What indicates understanding of dietary management in a client with chronic hepatitis C?
A nurse is watching a client's ECG monitor and notes that the client's rhythm has changed from a normal sinus rhythm to supraventricular tachycardia. The client is conscious with a heart rate of 200-210 bpm and has a faint radial pulse. The nurse should anticipate assisting with which of the following interventions?
A nurse is watching a client's ECG monitor and notes that the client's rhythm has changed from a normal sinus rhythm to supraventricular tachycardia. The client is conscious with a heart rate of 200-210 bpm and has a faint radial pulse. The nurse should anticipate assisting with which of the following interventions?
What statement by a client with mild diverticulitis indicates understanding of teaching?
What statement by a client with mild diverticulitis indicates understanding of teaching?
A nurse is providing discharge teaching for a client who has heart failure. The nurse should instruct the client to report which of the following findings immediately to the provider?
A nurse is providing discharge teaching for a client who has heart failure. The nurse should instruct the client to report which of the following findings immediately to the provider?
Which statement indicates effective teaching for a client managing GERD?
Which statement indicates effective teaching for a client managing GERD?
What lab findings should a nurse report for a client with hepatic cirrhosis?
What lab findings should a nurse report for a client with hepatic cirrhosis?
A nurse is admitting a client who has a leg ulcer and a history of diabetes mellitus. The nurse should use which of the following focused assessments to help differentiate between an arterial ulcer and a venous stasis ulcer?
A nurse is admitting a client who has a leg ulcer and a history of diabetes mellitus. The nurse should use which of the following focused assessments to help differentiate between an arterial ulcer and a venous stasis ulcer?
Which medication inhibits gastric acid secretion for treating peptic ulcer disease?
Which medication inhibits gastric acid secretion for treating peptic ulcer disease?
A nurse is reviewing the laboratory results of several clients who have peripheral arterial disease. The nurse should plan to provide dietary teaching for the client who has which laboratory values?
A nurse is reviewing the laboratory results of several clients who have peripheral arterial disease. The nurse should plan to provide dietary teaching for the client who has which laboratory values?
A nurse is providing health teaching for a group of clients. Which of the following clients is at risk for developing peripheral arterial disease?
A nurse is providing health teaching for a group of clients. Which of the following clients is at risk for developing peripheral arterial disease?
What should a client include in their diet to prevent dumping syndrome after gastrectomy?
What should a client include in their diet to prevent dumping syndrome after gastrectomy?
What findings should a client with an ileostomy report to the provider?
What findings should a client with an ileostomy report to the provider?
A nurse is planning a presentation about hypertension for a community women's group. Which of the following lifestyle modifications should the nurse include (select all that apply)?
A nurse is planning a presentation about hypertension for a community women's group. Which of the following lifestyle modifications should the nurse include (select all that apply)?
A nurse is caring for a client in the first 8 hours following coronary artery bypass graft surgery. Which of the following client findings should the nurse report to the provider?
A nurse is caring for a client in the first 8 hours following coronary artery bypass graft surgery. Which of the following client findings should the nurse report to the provider?
What lab findings indicate a client with colorectal cancer?
What lab findings indicate a client with colorectal cancer?
A nurse is caring for a client who has a history of angina and is scheduled for a stress test at 11:00. Which of the following statements by the client requires the nurse to contact the provider for possible rescheduling?
A nurse is caring for a client who has a history of angina and is scheduled for a stress test at 11:00. Which of the following statements by the client requires the nurse to contact the provider for possible rescheduling?
What findings should a nurse expect for a client with acute pancreatitis?
What findings should a nurse expect for a client with acute pancreatitis?
What findings should the nurse expect for a client with a duodenal ulcer?
What findings should the nurse expect for a client with a duodenal ulcer?
A nurse is caring for a client who has dilated cardiomyopathy. The client reports increasing difficulty completing her daily 1-mile walks. The nurse should recognize that this is a finding of which of the following?
A nurse is caring for a client who has dilated cardiomyopathy. The client reports increasing difficulty completing her daily 1-mile walks. The nurse should recognize that this is a finding of which of the following?
A nurse is caring for a client who is scheduled for a coronary artery bypass graft in 2 hours. Which of the following client statements indicates a need for further clarification by the nurse?
A nurse is caring for a client who is scheduled for a coronary artery bypass graft in 2 hours. Which of the following client statements indicates a need for further clarification by the nurse?
What findings should a nurse expect for a client with acute hepatitis B?
What findings should a nurse expect for a client with acute hepatitis B?
A nurse is caring for a client who had an onset of chest pain 24 hours ago. The nurse should recognize that an increase in which of the following is diagnostic of a myocardial infarction?
A nurse is caring for a client who had an onset of chest pain 24 hours ago. The nurse should recognize that an increase in which of the following is diagnostic of a myocardial infarction?
What indicates effective teaching for a client taking lactulose?
What indicates effective teaching for a client taking lactulose?
What action should the nurse take first for a client with acute pancreatitis?
What action should the nurse take first for a client with acute pancreatitis?
A nurse is caring for a client who has a history of DVT and is receiving warfarin. Which of the following client findings provides the nurse with the best evidence regarding the effectiveness of the warfarin therapy?
A nurse is caring for a client who has a history of DVT and is receiving warfarin. Which of the following client findings provides the nurse with the best evidence regarding the effectiveness of the warfarin therapy?
What instruction is important for a client preparing for a colonoscopy?
What instruction is important for a client preparing for a colonoscopy?
A client who has a new diagnosis of hypertension has a prescription for an ACE inhibitor. The nurse instructs the client about adverse effects of the medication. The client demonstrates an understanding of the teaching by stating that he will notify his provider if he experiences which of the following?
A client who has a new diagnosis of hypertension has a prescription for an ACE inhibitor. The nurse instructs the client about adverse effects of the medication. The client demonstrates an understanding of the teaching by stating that he will notify his provider if he experiences which of the following?
A client is being evaluated in the ED for a possible brain attack (stroke). Assessment findings consistent with a brain attack include which of the following? (select all that apply)
A client is being evaluated in the ED for a possible brain attack (stroke). Assessment findings consistent with a brain attack include which of the following? (select all that apply)
What intervention should be included for a client with cirrhosis and ascites?
What intervention should be included for a client with cirrhosis and ascites?
What findings should a nurse expect for a client with upper GI bleeding?
What findings should a nurse expect for a client with upper GI bleeding?
A client is admitted with a diagnosis of acute stroke. The provider orders 'diet as tolerated.' Before feeding this client, which nursing action is priority?
A client is admitted with a diagnosis of acute stroke. The provider orders 'diet as tolerated.' Before feeding this client, which nursing action is priority?
Which of the following recommendations is best for the nurse to suggest to a client as a way to keep blood pressure under control?
Which of the following recommendations is best for the nurse to suggest to a client as a way to keep blood pressure under control?
What instructions should be included in the care plan for a client with ulcerative colitis to minimize exacerbation?
What instructions should be included in the care plan for a client with ulcerative colitis to minimize exacerbation?
What indicates the effectiveness of a paracentesis for ascites?
What indicates the effectiveness of a paracentesis for ascites?
Which of the following assessment findings indicate to the nurse the client is experiencing left-sided heart failure?
Which of the following assessment findings indicate to the nurse the client is experiencing left-sided heart failure?
What food should be recommended to minimize odor and flatus for a client with a new colostomy?
What food should be recommended to minimize odor and flatus for a client with a new colostomy?
The nurse is teaching a group of adult clients about risk for coronary artery disease, especially myocardial infarction. This nurse should instruct this group of clients about which of the following as ways to decrease incidence of CAD and MI? (select all that apply)
The nurse is teaching a group of adult clients about risk for coronary artery disease, especially myocardial infarction. This nurse should instruct this group of clients about which of the following as ways to decrease incidence of CAD and MI? (select all that apply)
Which client response requires a focused GI assessment?
Which client response requires a focused GI assessment?
What priority finding should the nurse report for a client with cirrhosis?
What priority finding should the nurse report for a client with cirrhosis?
What clinical manifestation suggests anemia is a possibility?
What clinical manifestation suggests anemia is a possibility?
After abdominal surgery, what is the most reliable assessment that suggests return of peristaltic movement?
After abdominal surgery, what is the most reliable assessment that suggests return of peristaltic movement?
When administering a new medication to an older client, the nurse understands that:
When administering a new medication to an older client, the nurse understands that:
What finding should be monitored for a client receiving clindamycin for acute pelvic inflammatory disease?
What finding should be monitored for a client receiving clindamycin for acute pelvic inflammatory disease?
What is an appropriate action for a nurse providing preoperative teaching for a client who is anxious about an upcoming gastrectomy?
What is an appropriate action for a nurse providing preoperative teaching for a client who is anxious about an upcoming gastrectomy?
A 59-year-old man was admitted to the hospital with dysphagia, stating that he has been having more difficulty swallowing food, even when he has chewed it thoroughly and drinks plenty of water. A CT scan shows an area for a possible esophageal tumor. The client undergoes a biopsy and is awaiting results. The client asks, 'What am I going to do if this is cancer?' What is the most appropriate nursing response?
A 59-year-old man was admitted to the hospital with dysphagia, stating that he has been having more difficulty swallowing food, even when he has chewed it thoroughly and drinks plenty of water. A CT scan shows an area for a possible esophageal tumor. The client undergoes a biopsy and is awaiting results. The client asks, 'What am I going to do if this is cancer?' What is the most appropriate nursing response?
What medication should the nurse instruct a client to discontinue 48 hours prior to surgery?
What medication should the nurse instruct a client to discontinue 48 hours prior to surgery?
The client with a long history of osteoarthritis is at risk for developing GERD if he or she:
The client with a long history of osteoarthritis is at risk for developing GERD if he or she:
What finding should be reported for a client undergoing general anesthesia for surgery?
What finding should be reported for a client undergoing general anesthesia for surgery?
A priority nursing intervention in the care of a client with a hiatal hernia is:
A priority nursing intervention in the care of a client with a hiatal hernia is:
What intervention should the nurse use to ensure proper functioning of a Jackson-Pratt drain post-surgery?
What intervention should the nurse use to ensure proper functioning of a Jackson-Pratt drain post-surgery?
Which assessment variable requires immediate intervention post-esophagectomy?
Which assessment variable requires immediate intervention post-esophagectomy?
What statement indicates understanding of preoperative teaching for a client scheduled for moderate sedation?
What statement indicates understanding of preoperative teaching for a client scheduled for moderate sedation?
An older client diagnosed with bacterial gastroenteritis reports abdominal cramping, diarrhea, nausea, and vomiting, and fatigue for the past 24 hours. The nurse should monitor the client for what priority assessment?
An older client diagnosed with bacterial gastroenteritis reports abdominal cramping, diarrhea, nausea, and vomiting, and fatigue for the past 24 hours. The nurse should monitor the client for what priority assessment?
What statement by a client indicates a need for further teaching about post-operative care after a mastectomy?
What statement by a client indicates a need for further teaching about post-operative care after a mastectomy?
A client has recently been placed on corticosteroids as treatment for ulcerative colitis. The nurse should monitor the client's laboratory results for evidence of which condition?
A client has recently been placed on corticosteroids as treatment for ulcerative colitis. The nurse should monitor the client's laboratory results for evidence of which condition?
What instruction is important for a client in the immediate post-op period with a PCA pump?
What instruction is important for a client in the immediate post-op period with a PCA pump?
What priority laboratory analysis should the nurse review when caring for a client with Crohn's disease?
What priority laboratory analysis should the nurse review when caring for a client with Crohn's disease?
A client is admitted to the acute medical client care unit. The nurse reviews her admission lab results. Which result supports a diagnosis of malnutrition?
A client is admitted to the acute medical client care unit. The nurse reviews her admission lab results. Which result supports a diagnosis of malnutrition?
Which assessment finding indicates that a client in the PACU is ready for discharge?
Which assessment finding indicates that a client in the PACU is ready for discharge?
Upon assessment, the client is noted to have conjunctival xerosis, dry skin, follicular hyperkeratosis, and a bright magenta (purple) tongue. Which vitamin deficiency does the nurse suspect?
Upon assessment, the client is noted to have conjunctival xerosis, dry skin, follicular hyperkeratosis, and a bright magenta (purple) tongue. Which vitamin deficiency does the nurse suspect?
Which client should be assessed first by the nurse during the afternoon report?
Which client should be assessed first by the nurse during the afternoon report?
What is a potential outcome when administering total parenteral nutrition (TPN)?
What is a potential outcome when administering total parenteral nutrition (TPN)?
An older adult with anemia requests help with his menu choices. What type of food should the client be encouraged to eat?
An older adult with anemia requests help with his menu choices. What type of food should the client be encouraged to eat?
What percentage of adults in the US are obese (BMI > 30)?
What percentage of adults in the US are obese (BMI > 30)?
A client receiving chemotherapy for treatment of cancer is at greatest risk for developing:
A client receiving chemotherapy for treatment of cancer is at greatest risk for developing:
A 26-year-old female client informs the nurse that she has had red, raised lesions at the base of the tongue and on the inside of her mouth for the past 2 weeks. What question should the nurse ask the client?
A 26-year-old female client informs the nurse that she has had red, raised lesions at the base of the tongue and on the inside of her mouth for the past 2 weeks. What question should the nurse ask the client?
An older client with poor oral hygiene was admitted after a fall in which he sustained a fractured hip. What is the priority nursing intervention?
An older client with poor oral hygiene was admitted after a fall in which he sustained a fractured hip. What is the priority nursing intervention?
A nurse is reviewing the prescriptions for a client who has Campylobacter enteritis. Which of the following prescriptions should the nurse clarify with the provider?
A nurse is reviewing the prescriptions for a client who has Campylobacter enteritis. Which of the following prescriptions should the nurse clarify with the provider?
A nurse is caring for a client who has GERD and a new prescription for metoclopramide. The nurse should plan to monitor for which of the following adverse effects?
A nurse is caring for a client who has GERD and a new prescription for metoclopramide. The nurse should plan to monitor for which of the following adverse effects?
Flashcards
Heparin Therapy and DVT Management: Stopping Infusion
Heparin Therapy and DVT Management: Stopping Infusion
A prolonged clotting time, indicated by an aPTT of 96 seconds, may necessitate stopping the heparin infusion.
Heart Transplant: Chest Pain Absent
Heart Transplant: Chest Pain Absent
Patients with heart transplants may not experience chest pain due to nerve damage caused by the procedure.
Bradydysrhythmia: Confusion
Bradydysrhythmia: Confusion
A common sign of bradydysrhythmia, confusion arises from the reduced blood flow to the brain.
Anterior MI: Thrombolytic Therapy Contraindication
Anterior MI: Thrombolytic Therapy Contraindication
Thrombolytic therapy should be avoided for post-op patients from unrelated surgeries, as it poses a risk of significant bleeding.
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Endocarditis: Valvular Disease
Endocarditis: Valvular Disease
Valvular disease can be a complication of endocarditis, affecting heart valve function.
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Hypertensive Crisis: Priority Action
Hypertensive Crisis: Priority Action
Immediate IV therapy initiation is the priority for patients with critically high BP (254/138 mmHg), indicating hypertensive crisis.
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Heart Failure: Slurred Speech
Heart Failure: Slurred Speech
Monitor for slurred speech in clients with congestive heart failure, as it may indicate a stroke or neurological compromise.
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Left-Sided Heart Failure: Clinical Manifestations
Left-Sided Heart Failure: Clinical Manifestations
Jugular vein distension and weakened peripheral pulses are typical findings in left-sided heart failure.
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Heart Failure Medications: Lightheadedness
Heart Failure Medications: Lightheadedness
Clients on digoxin and furosemide may experience lightheadedness due to possible hypotension; monitor carefully.
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Cardiac Tamponade: Sternal Instability
Cardiac Tamponade: Sternal Instability
Sternal instability following surgery may indicate cardiac tamponade, a serious complication.
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Coronary Angiography: Shellfish Allergy
Coronary Angiography: Shellfish Allergy
Reporting previous allergic reactions to shellfish (potential cross-reactivity) is crucial before coronary angiography.
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Pacemaker Insertion: Hiccups
Pacemaker Insertion: Hiccups
Hiccups following pacemaker insertion may signify phrenic nerve irritation; monitor for this potential complication.
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Transdermal Nitroglycerin: Patch Application
Transdermal Nitroglycerin: Patch Application
Apply transdermal nitroglycerin patches to areas away from folds and joints to maximize medication absorption and prevent overlap.
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Aortic Aneurysm Repair: Low Urine Output
Aortic Aneurysm Repair: Low Urine Output
Urine output of 20 mL/hr is a potential sign of shock post-aortic aneurysm repair, requiring prompt intervention.
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Abdominal Aneurysm Resection: Priority Assessment
Abdominal Aneurysm Resection: Priority Assessment
Urine output is the priority assessment after abdominal aortic aneurysm resection due to the risk of renal impairment post-surgery.
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Supraventricular Tachycardia: Vagal Maneuvers
Supraventricular Tachycardia: Vagal Maneuvers
Assist with vagal maneuvers for stable clients exhibiting signs of supraventricular tachycardia, as this may help slow the heart rate.
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Heart Failure: Weight Gain Reporting
Heart Failure: Weight Gain Reporting
A weight gain of 2 lbs in 24 hours should be reported immediately to a healthcare provider, as it may indicate fluid retention in heart failure.
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Ulcer Differentiation: Pain Assessment
Ulcer Differentiation: Pain Assessment
Assess the presence or absence of pain around the ulcer site to distinguish between arterial and venous ulcers.
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Peripheral Arterial Disease: Dietary Teaching
Peripheral Arterial Disease: Dietary Teaching
Educate clients to understand the significant correlation between high cholesterol levels and low HDL and the risk of CAD.
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Peripheral Arterial Disease: Diabetes Risk
Peripheral Arterial Disease: Diabetes Risk
Clients with diabetes have a heightened risk of developing peripheral arterial disease due to vascular changes.
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Hypertension: Lifestyle Modifications
Hypertension: Lifestyle Modifications
Encourage limited alcohol intake, regular exercise, and smoking cessation for effective hypertension management.
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Post-CABG PACU Monitoring: High Drainage
Post-CABG PACU Monitoring: High Drainage
A mediastinal drainage of 100 mL/hr after coronary artery bypass surgery should be reported, as it may indicate complications.
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Stress Test Rescheduling: Smoking
Stress Test Rescheduling: Smoking
Smoking within 24 hours of a stress test requires notification of the provider, as it can pose risks to the client.
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Dilated Cardiomyopathy: Worsening Symptoms
Dilated Cardiomyopathy: Worsening Symptoms
Increasing difficulty in performing daily activities, such as walking, may signal worsening heart failure in dilated cardiomyopathy.
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Preoperative Medication: Anticoagulants
Preoperative Medication: Anticoagulants
Clarify anticoagulant usage, such as warfarin, pre-surgery to minimize bleeding risks. Patients should be aware of their medications.
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Myocardial Infarction: CK-MB Elevation
Myocardial Infarction: CK-MB Elevation
An increase in Creatine Kinase-MB (CK-MB) is diagnostic for myocardial infarction, indicating heart muscle damage.
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Warfarin Effectiveness: INR Value
Warfarin Effectiveness: INR Value
An INR of 2.5 reliably indicates that warfarin therapy is effective, preventing clot formation.
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ACE Inhibitors: Persistent Cough
ACE Inhibitors: Persistent Cough
Persistent cough is a common side effect of ACE inhibitors; monitor clients for this possibility.
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Acute Stroke: Classic Signs
Acute Stroke: Classic Signs
Facial droop, slurred speech, and weakness of extremities are classic signs of acute stroke, indicating a brain injury.
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Head Elevation: Aspiration Prevention
Head Elevation: Aspiration Prevention
Elevate the head of the bed to 30 degrees before feeding clients at risk for aspiration to enhance swallowing safety.
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Blood Pressure Control: Exercise
Blood Pressure Control: Exercise
Regular exercise is the most effective way to manage hypertension by improving cardiovascular health.
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Left-Sided Heart Failure: Fatigue & Dyspnea
Left-Sided Heart Failure: Fatigue & Dyspnea
Fatigue and dyspnea are key indicators of left-sided heart failure, reflecting the heart's inability to pump effectively.
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Reducing CAD & MI Risks: Client Education
Reducing CAD & MI Risks: Client Education
Encourage smoking cessation, regular physical activity, and frequent BP monitoring to help reduce the risks of CAD and MI.
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Focused GI Assessment: NSAID Use
Focused GI Assessment: NSAID Use
Frequent use of NSAIDs may merit a focused GI assessment due to the potential for ulceration and gastrointestinal complications.
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Post-Abdominal Surgery: Peristalsis Return
Post-Abdominal Surgery: Peristalsis Return
A client's report of passing flatus is the most reliable indication that bowel function is returning after abdominal surgery.
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Older Adults: Medication Toxicity
Older Adults: Medication Toxicity
Older adults may experience a rapid onset of medication toxicity, requiring close monitoring to adjust dosages appropriately.
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Esophageal Tumor: Treatment Discussions
Esophageal Tumor: Treatment Discussions
Engage clients in discussions about treatment options for an esophageal tumor without making assumptions; a biopsy is needed for confirmation.
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Osteoarthritis and GERD: Increased Risk
Osteoarthritis and GERD: Increased Risk
Frequent use of NSAIDs, particularly in conjunction with obesity, increases the risk for GERD, reflecting acid reflux.
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Hiatal Hernia: Strangulation Signs
Hiatal Hernia: Strangulation Signs
Instruct clients to recognize signs of intestinal strangulation, including sudden, severe pain, after hiatal hernia repair.
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Post-Esophagectomy Monitoring: Elevated Respiratory Rate
Post-Esophagectomy Monitoring: Elevated Respiratory Rate
An elevated respiratory rate of 28 post-esophagectomy surgery may require immediate nursing intervention to address potential complications.
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Gastroenteritis: Dehydration Monitoring
Gastroenteritis: Dehydration Monitoring
Monitor for dehydration in clients with gastrointestinal distress, as it can be a serious complication of gastroenteritis.
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Corticosteroid Monitoring: Hyperglycemia
Corticosteroid Monitoring: Hyperglycemia
Assess glucose levels for hyperglycemia in clients receiving corticosteroids for ulcerative colitis, as corticosteroids can affect blood sugar.
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Crohn's Disease: Hemoglobin Monitoring
Crohn's Disease: Hemoglobin Monitoring
Review hemoglobin levels as a priority assessment for clients with Crohn's disease, as anemia is a common complication.
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Malnutrition Diagnosis: Prealbumin
Malnutrition Diagnosis: Prealbumin
Prealbumin levels can indicate malnutrition severity and the effectiveness of treatment in clients with various conditions.
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Vitamin A Deficiency: Symptoms
Vitamin A Deficiency: Symptoms
Conjunctival xerosis and hyperkeratosis are symptoms that may indicate a vitamin A deficiency, affecting vision and skin health.
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TPN Administration: Potential Risks
TPN Administration: Potential Risks
Total parenteral nutrition (TPN) carries risks such as infection and potential for hyperglycemia, requiring careful monitoring.
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Anemia: Dietary Recommendations
Anemia: Dietary Recommendations
Encourage foods rich in iron, such as prunes, to help manage anemia through dietary means.
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Obesity Prevalence in Adults
Obesity Prevalence in Adults
Approximately 34% of adults in the US are classified as obese (BMI over 30), highlighting the prevalence of this condition.
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Cancer Treatment: Increased Infection Risk
Cancer Treatment: Increased Infection Risk
Clients receiving chemotherapy are at greater risk for conditions such as stomatitis and oral infections, requiring careful oral care.
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Oral Lesions: HIV Risk Assessment
Oral Lesions: HIV Risk Assessment
Consult on past history of HIV when clients present with persistent oral lesions, as this could indicate a potential risk factor.
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Oral Hygiene: Aspiration Prevention
Oral Hygiene: Aspiration Prevention
Prioritize oral care, particularly for older clients, to prevent aspiration pneumonia following injury or illness.
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Campylobacter Enteritis: IV Fluid Clarification
Campylobacter Enteritis: IV Fluid Clarification
Clarify IV fluid prescriptions for clients with campylobacter enteritis to ensure appropriate treatment measures are in place.
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Metoclopramide: Monitoring Ataxia
Metoclopramide: Monitoring Ataxia
Be vigilant for signs of ataxia in clients receiving metoclopramide for GERD, as it is a potential side effect.
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Abdominal Assessment: Board-Like Abdomen
Abdominal Assessment: Board-Like Abdomen
A board-like abdomen may indicate peritoneal irritation or acute abdominal conditions, requiring prompt medical evaluation.
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Abdominal Assessment: Periumbilical Cyanosis
Abdominal Assessment: Periumbilical Cyanosis
Periumbilical cyanosis is a potential sign of serious underlying issues, such as acute pancreatitis or bowel necrosis.
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Abdominal Assessment: Increased Bowel Sounds
Abdominal Assessment: Increased Bowel Sounds
Increased bowel sounds often suggest intestinal obstruction or increased gastrointestinal activity, necessitating further assessment.
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Appendicitis: Temperature and Pain
Appendicitis: Temperature and Pain
An elevated oral temperature (e.g., 38.4°C), along with possible right lower quadrant pain, suggests appendicitis.
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Appendicitis: WBC Count May Be Normal
Appendicitis: WBC Count May Be Normal
While elevated temperature is a critical indicator in appendicitis, the WBC count may be normal. This emphasizes the importance of a comprehensive assessment.
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Appendicitis: Uncommon Symptoms
Appendicitis: Uncommon Symptoms
Bloody diarrhea and severe nausea/vomiting are generally not expected findings in appendicitis; other sources for these symptoms may exist.
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Post-Gastrectomy: Acute Gastric Dilation
Post-Gastrectomy: Acute Gastric Dilation
Acute gastric dilation may present as hiccups after surgery, requiring prompt intervention to prevent complications.
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Hepatic Encephalopathy: Dietary Management
Hepatic Encephalopathy: Dietary Management
Clients with hepatic encephalopathy should limit animal protein intake due to ammonia production; veggie burgers are a good alternative.
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Hepatic Encephalopathy: High-Fat Food Avoidance
Hepatic Encephalopathy: High-Fat Food Avoidance
High-fat foods, such as beef, should be avoided in clients with hepatic encephalopathy, as fats can worsen liver function.
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Heparin Therapy and DVT Management
- Anticipate stopping heparin infusion if aPTT is 96 seconds, indicating a prolonged clotting time.
- Request prothrombin time if necessary, but increase flow rate is inappropriate.
Heart Transplant Post-Operative Care
- Patients may not feel chest pain post-transplant due to nerve damage.
- Sodium intake restrictions typically continue beyond 6 months; never stop immunosuppressants prematurely.
Bradydysrhythmia Assessment
- Expect confusion as a common finding associated with bradydysrhythmia.
Care for Anterior MI Patients
- Avoid administering thrombolytic therapy in patients who are post-op from unrelated surgeries.
Endocarditis Complications
- Recognize valvular disease as a potential complication in endocarditis cases.
Hypertensive Crisis Management
- Priority action includes initiating IV therapy for patients with critically high BP (254/138 mmHg).
Congestive Heart Failure Monitoring
- Monitor for slurred speech, indicating potential stroke or compromised neurological status.
Left-Sided Heart Failure Signs
- Expect symptoms like jugular vein distension and weak peripheral pulses.
Heart Failure Medication Side Effects
- Monitor clients for lightheadedness when on digoxin and furosemide due to possible hypotension.
Cardiac Tamponade Indicators
- Sternal instability may be indicative of cardiac tamponade post-surgery.
Pre-Coronary Angiography Assessment
- Report previous allergic reactions to shellfish before the procedure for allergy considerations.
Pacemaker Insertion Complications
- Hiccups may indicate phrenic nerve irritation; monitor for this complication after pacemaker insertion.
Transdermal Nitroglycerin Patch Teaching
- Apply patches in areas away from folds and joints to ensure effective medication absorption and avoid overlap.
Post-Aortic Aneurysm Repair Observations
- Report urine output of 20 mL/hr as a potential sign of shock.
Abdominal Aortic Aneurysm Resection Priority
- Urine output is the priority assessment due to risk of renal impairment after surgery.
Supraventricular Tachycardia Management
- Anticipate assisting with vagal maneuvers for clients showing signs of stable tachycardia.
Heart Failure Client Reporting
- A weight gain of 2 lbs in 24 hours should be reported immediately as it may indicate fluid retention.
Differentiating Ulcer Types
- Assess presence/absence of pain around the ulcer site to distinguish between arterial and venous ulcers.
Dietary Teaching in Peripheral Arterial Disease
- Educate clients with significant cholesterol levels and low HDL significantly correlating with CAD risk.
Risk Factors for Peripheral Arterial Disease
- Clients with diabetes are particularly at risk for developing peripheral arterial disease.
Hypertension Lifestyle Modifications
- Encourage limited alcohol intake, regular exercise, and smoking cessation for hypertension management.
PACU Monitoring Post-Coronary Artery Bypass
- Report mediastinal drainage of 100 mL/hr as it may indicate complications.
Stress Test Rescheduling Indicators
- Any smoking within 24 hours of the test should prompt provider notification for client safety.
Dilated Cardiomyopathy Symptom Recognition
- Increasing difficulty in performing physical activity like walking indicates potential worsening heart failure.
Preoperative Medication Clarity
- Clarify usage of anticoagulants like warfarin pre-surgery; patients should have a clear understanding of their medication regimen.
Diagnosing Myocardial Infarction
- An increase in Creatine Kinase-MB is diagnostic for myocardial infarction.
Effectiveness of Warfarin Therapy
- INR of 2.5 is a reliable indicator that warfarin therapy is effective in preventing clot formation.
ACE Inhibitor Education
- Monitor for persistent cough as a common side effect of ACE inhibitors.
Indicators of Acute Stroke
- Signs include facial droop, slurred speech, and weakness of extremities.
Head Elevation for Swallowing Safety
- Elevate the head of the bed to 30 degrees before feeding clients at risk for aspiration.
Blood Pressure Control Recommendations
- Promote regular exercise as the best way to manage hypertension.
Left-Sided Heart Failure Symptoms
- Fatigue and dyspnea are key indicators of left-sided heart failure.
Reducing CAD and MI Risks
- Encourage smoking cessation, regular physical activity, and frequent BP monitoring among clients.
Focused GI Assessment Requirements
- Regular use of NSAIDs may necessitate focused GI assessment due to potential for ulceration.
Post-Abdominal Surgery Return of Peristalsis
- Client report of passing flatus is the most reliable indicator of returning bowel function.
Older Adults and Medication Administration
- Close monitoring is crucial as older clients may experience rapid onset of medication toxicity.
Esophageal Tumor Management Discussion
- Engage clients in discussions about treatment options without providing assumptions prior to biopsy results.
Osteoarthritis and GERD Risk
- Frequent use of NSAIDs in conjunction with obesity heightens the risk for developing GERD.
Hiatal Hernia Nursing Interventions
- Instruct clients to recognize signs of intestinal strangulation for early complications.
Post-Esophagectomy Monitoring
- Elevated respiratory rate (28) post-surgery may require immediate nursing intervention.
Gastroenteritis Client Monitoring
- Monitor for dehydration in clients with gastrointestinal distress.
Corticosteroid Monitoring
- Assess glucose levels for hyperglycemia when clients are on corticosteroids for ulcerative colitis.
Crohn's Disease Laboratory Review
- Review hemoglobin levels as a priority assessment for Crohn's disease clients.
Malnutrition Diagnosis Support
- Prealbumin levels can indicate malnutrition severity and treatment effectiveness.
Vitamin A Deficiency Symptoms
- Symptoms like conjunctival xerosis and hyperkeratosis suggest potential vitamin A deficiency.
TPN Administration Risks
- Total parenteral nutrition is associated with risks such as infection and potential for hyperglycemia.
Anemia Dietary Recommendations
- Encourage food rich in iron such as prunes to improve anemia management.
Obesity Prevalence in Adults
- Approximately 34% of adults in the US are classified as obese (BMI > 30).
Cancer Treatment Risks
- Clients receiving chemotherapy face greater risks for conditions such as stomatitis and oral infections.
Oral Lesions and HIV Risk Assessment
- Consult on past history of HIV when clients present with persistent oral lesions.
Oral Hygiene Priorities
- Prioritize oral care for older clients to prevent aspiration pneumonia post-injury.
Clarification on Campylobacter Enteritis
- Clarify IV fluid prescriptions to ensure appropriate treatment measures are in place.
Monitoring Adverse Effects of Metoclopramide
- Be vigilant for signs of ataxia in clients receiving metoclopramide for GERD.### Abdominal Assessment and Findings
- Board-like abdomen may indicate peritoneal irritation or acute abdominal conditions.
- Periumbilical cyanosis can be a sign of serious underlying issues such as acute pancreatitis or bowel necrosis.
- Increased bowel sounds often suggest intestinal obstruction or increased gastrointestinal activity.
Appendicitis Assessment
- Typical findings: elevated oral temperature (e.g., 38.4°C), possible right lower quadrant pain.
- WBC count in appendicitis may be normal, making elevated temperature a more critical indicator.
- Presence of bloody diarrhea or severe nausea/vomiting are generally not expected findings in appendicitis.
Postoperative Care After Gastrectomy
- Acute gastric dilation can manifest as hiccups following surgery.
- Elevated blood pressure, bradycardia, and localized pain in left lower quadrant typically do not indicate gastric dilation.
Dietary Management in Hepatic Encephalopathy
- Clients should limit animal protein intake due to ammonia production concerns; alternatives like veggie burgers encouraged.
- High-fat foods, such as beef, should be avoided.
Types of Immunity
- Immunity developed through vaccination is classified as artificial active immunity.
Inflammation and Eosinophil Count
- High eosinophil count often suggests tissue damage from an allergen-antibody reaction.
- Indicates that the inflammatory response may be chronic due to sustained irritation or damage.
Understanding Chronic Hepatitis C
- Key teaching points: avoidance of alcohol and acetaminophen is crucial for liver health.
- Clients should be informed that treatment duration may vary and should not assume a set term like three months.
Diverticulitis Management
- Clients should avoid high-fiber diets during acute episodes; low fiber intake recommended for symptom management.
Gastroesophageal Reflux Disease (GERD) Management
- Recommendations include decreasing carbonated beverage intake and avoiding snacks before bedtime to mitigate symptoms.
Laboratory Findings in Hepatic Cirrhosis
- Elevated ammonia levels (e.g., 180 mcg/dL) should be reported as they indicate potential complications; INR and bilirubin levels are also significant.
Pharmacology for Peptic Ulcer Disease
- Famotidine is a medication that inhibits gastric acid secretion; it is essential for managing peptic ulcers.
Dietary Strategies to Prevent Dumping Syndrome
- Recommended foods include egg and lactose-reduced milk, while high-sugar foods should be avoided.
Ileostomy Care Instruction
- Clients should report excessive liquid output, burning sensations, or inability to tolerate certain foods.
Colorectal Cancer Expectations
- Expect low hemoglobin levels (such as 9.1 g/dL), indicating potential anemia related to cancer.
Acute Pancreatitis Laboratory Markers
- Increased serum amylase is a common finding during episodes of acute pancreatitis.
Duodenal Ulcer Symptomatology
- Pain from duodenal ulcers typically occurs 1.5-3 hours after meals, distinguishing it from other abdominal pain patterns.
Hepatitis B Assessment
- Expect findings such as joint pain and periumbilical discoloration during the evaluation.
Crohn's Disease Symptoms
- Fatty, diarrheal stools often indicate malabsorption associated with Crohn's disease flare-ups.
Lactulose for Hepatic Encephalopathy
- Educate clients to expect soft stools and to monitor for symptoms like bloating.
Patient Education on Colonoscopy Preparation
- Clear liquid diet is necessary 24 hours before the procedure; patients should be NPO for 6 hours prior.
Ascites Management in Cirrhosis
- Daily measurement of abdominal girth is critical for monitoring ascites.
Upper GI Bleeding Assessment
- Expect indicators such as hypotension and epigastric pain during assessment of a bleeding episode.
Ulcerative Colitis Management Plan
- Recommendations include relaxation techniques and minimizing carbonated beverage consumption to reduce exacerbations.
Paracentesis Effectiveness Indicators
- Post-procedure decreased shortness of breath signifies effectiveness; other measures might not show immediate results.
Colostomy and Odor Management
- Recommend yogurt to assist in managing flatus and odor in clients with new colostomies.
Prioritizing Findings in Cirrhosis
- Bloody stools represent a critical finding that must be promptly reported.
Recognizing Anemia Symptoms
- Shortness of breath is a clinical manifestation that may indicate anemia.
Clindamycin Use in Pelvic Inflammatory Disease
- Monitor clients for signs of antibiotic-related complications like watery diarrhea.
Preoperative Teaching for Gastrectomy
- Providing factual information is essential to alleviate client anxiety regarding surgery.
Medication Management Prior to Surgery
- Discontinue warfarin 48 hours before surgery to minimize bleeding risks.
Anesthesia Awareness
- Report low potassium levels indicating potential complications related to anesthesia.
Jackson-Pratt Drain Care
- Compressing and emptying the drain reservoir as needed ensures proper function.
Post-Moderate Sedation Understanding
- Clients should expect to feel sleepy post-procedure due to the nature of sedation.
Preoperative Medication History
- Note medications such as captopril that can negatively interact with anesthetic agents.
Preventing Respiratory Complications After Surgery
- Advise the client to splint their incision when coughing or deep breathing to mitigate respiratory issues.
Mastectomy Recovery Instructions
- Avoiding blood draws from the affected arm is essential for preventing complications.
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