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Questions and Answers
What type of breathing should be used when feeling short of breath?
What type of breathing should be used when feeling short of breath?
Pursed-lip breathing
The nurse should expect a client who is experiencing malnutrition to have _____ hair.
The nurse should expect a client who is experiencing malnutrition to have _____ hair.
brittle
Which statement indicates understanding of how to handle a hearing aid?
Which statement indicates understanding of how to handle a hearing aid?
I will make sure the hearing aid is off before inserting it in my ear.
What is the priority intervention when planning discharge for a client with gestational diabetes?
What is the priority intervention when planning discharge for a client with gestational diabetes?
What dietary instruction should be given to a client with atherosclerosis?
What dietary instruction should be given to a client with atherosclerosis?
What instruction should a nurse give to a client with a short-arm plaster cast?
What instruction should a nurse give to a client with a short-arm plaster cast?
Which symptom indicates severe dehydration in an infant?
Which symptom indicates severe dehydration in an infant?
What finding should a nurse report in a 2-year-old regarding eye health?
What finding should a nurse report in a 2-year-old regarding eye health?
What medication is a risk factor for developing cholecystitis?
What medication is a risk factor for developing cholecystitis?
What precautions should a nurse initiate for a preschooler with pertussis?
What precautions should a nurse initiate for a preschooler with pertussis?
What medication might be prescribed for a heparin overdose?
What medication might be prescribed for a heparin overdose?
What instruction should a client with benign prostatic hyperplasia follow?
What instruction should a client with benign prostatic hyperplasia follow?
What finding should a nurse expect in a client with primary open-angle glaucoma?
What finding should a nurse expect in a client with primary open-angle glaucoma?
Which of the following findings should be expected in left-sided heart failure? (Select all that apply)
Which of the following findings should be expected in left-sided heart failure? (Select all that apply)
What might a 10-year-old sibling expect after a sibling's death?
What might a 10-year-old sibling expect after a sibling's death?
What pain characteristic indicates cholecystitis?
What pain characteristic indicates cholecystitis?
What medication should be expected for a client with social phobia?
What medication should be expected for a client with social phobia?
What should a nurse do for a client with generalized anxiety disorder?
What should a nurse do for a client with generalized anxiety disorder?
What actions should be taken for a client with cellulitis? (Select all that apply)
What actions should be taken for a client with cellulitis? (Select all that apply)
What finding indicates a possible small-bowel obstruction?
What finding indicates a possible small-bowel obstruction?
What symptom corresponds with hypocalcemia?
What symptom corresponds with hypocalcemia?
What action should a client with hypoglycemia take?
What action should a client with hypoglycemia take?
What indicates understanding of using a peak flow meter?
What indicates understanding of using a peak flow meter?
What instructions should be included for preventing osteoporosis? (Select all that apply)
What instructions should be included for preventing osteoporosis? (Select all that apply)
What should a nurse encourage when teaching a client with a hearing impairment?
What should a nurse encourage when teaching a client with a hearing impairment?
The nurse should rely on the client's nonverbal communications to ensure the client understands the information.
The nurse should rely on the client's nonverbal communications to ensure the client understands the information.
What should the nurse do first for a client diagnosed with active tuberculosis and a weight loss of 5.9 kg (13 lb)?
What should the nurse do first for a client diagnosed with active tuberculosis and a weight loss of 5.9 kg (13 lb)?
Which instruction should the nurse include for a client postoperative from TURP?
Which instruction should the nurse include for a client postoperative from TURP?
Which statement indicates a client with COPD understands the teaching?
Which statement indicates a client with COPD understands the teaching?
What reactions to death should a nurse expect from a preschooler?
What reactions to death should a nurse expect from a preschooler?
What manifestation should the nurse expect in a school-age child with erythema infectiosum?
What manifestation should the nurse expect in a school-age child with erythema infectiosum?
What information should the nurse teach an obese female client about disease management?
What information should the nurse teach an obese female client about disease management?
What is the proper way to care for toenails in older adults with type 1 diabetes?
What is the proper way to care for toenails in older adults with type 1 diabetes?
What finding should the nurse expect in a client with hyponatremia?
What finding should the nurse expect in a client with hyponatremia?
What acid-base imbalance is a client with Cushing's disease at risk for?
What acid-base imbalance is a client with Cushing's disease at risk for?
What finding indicates a client has diabetic ketoacidosis?
What finding indicates a client has diabetic ketoacidosis?
What should a nurse expect from a client with mild anxiety?
What should a nurse expect from a client with mild anxiety?
What should the nurse instruct a client taking finasteride?
What should the nurse instruct a client taking finasteride?
What finding should the nurse expect in a client with pernicious anemia?
What finding should the nurse expect in a client with pernicious anemia?
What is an important instruction for a client taking rifampin?
What is an important instruction for a client taking rifampin?
What should the nurse expect in a newborn with hypothermia?
What should the nurse expect in a newborn with hypothermia?
What should the nurse teach a client with hypothyroidism about levothyroxine?
What should the nurse teach a client with hypothyroidism about levothyroxine?
What is an adverse effect of warfarin that a nurse should recognize?
What is an adverse effect of warfarin that a nurse should recognize?
Which intervention should the nurse include to promote elimination of renal calculi?
Which intervention should the nurse include to promote elimination of renal calculi?
Which client statement indicates an understanding of postoperative education after a laparoscopic cholecystectomy?
Which client statement indicates an understanding of postoperative education after a laparoscopic cholecystectomy?
Which intervention should the nurse include to prevent MRSA infection for an immunocompromised client?
Which intervention should the nurse include to prevent MRSA infection for an immunocompromised client?
What is a common manifestation of type 1 herpes simplex virus?
What is a common manifestation of type 1 herpes simplex virus?
Which finding should the nurse expect in a client with Graves' disease?
Which finding should the nurse expect in a client with Graves' disease?
What indicates that the client understands teaching about duloxetine?
What indicates that the client understands teaching about duloxetine?
Which client statement shows understanding of treatment with lindane lotion for scabies?
Which client statement shows understanding of treatment with lindane lotion for scabies?
Which finding should the nurse report immediately for a client with appendicitis?
Which finding should the nurse report immediately for a client with appendicitis?
What should the nurse include in teaching for gastrointestinal reflux disease?
What should the nurse include in teaching for gastrointestinal reflux disease?
Which statement shows understanding of warfarin teaching?
Which statement shows understanding of warfarin teaching?
Which urinalysis result indicates a continuing infection after treatment with ciprofloxacin?
Which urinalysis result indicates a continuing infection after treatment with ciprofloxacin?
Which finding indicates a client has accepted loss after a colostomy?
Which finding indicates a client has accepted loss after a colostomy?
Which finding in a school-age child suggests peritonitis?
Which finding in a school-age child suggests peritonitis?
Which finding is a priority to report for a client with a peptic ulcer?
Which finding is a priority to report for a client with a peptic ulcer?
Which finding indicates heat exhaustion?
Which finding indicates heat exhaustion?
Which food is the best nondairy source of calcium?
Which food is the best nondairy source of calcium?
Which intervention should be included in the care plan for a postoperative DVT client?
Which intervention should be included in the care plan for a postoperative DVT client?
What is the priority finding to report after an ileostomy placement?
What is the priority finding to report after an ileostomy placement?
Which intervention should be included in the care plan for a preschooler with heart failure?
Which intervention should be included in the care plan for a preschooler with heart failure?
Which action should the nurse take to treat heat stroke?
Which action should the nurse take to treat heat stroke?
Which medication should be included in asthma attack teaching?
Which medication should be included in asthma attack teaching?
Where should the ileostomy be located after surgery for ulcerative colitis?
Where should the ileostomy be located after surgery for ulcerative colitis?
Which finding should the nurse expect in a child with a blood glucose level of 250 mg/dL?
Which finding should the nurse expect in a child with a blood glucose level of 250 mg/dL?
Which statement shows understanding of metformin teaching?
Which statement shows understanding of metformin teaching?
What should the nurse teach a client about atenolol?
What should the nurse teach a client about atenolol?
Which action can help prevent pneumonia in older adults?
Which action can help prevent pneumonia in older adults?
Which lactose-free food should the nurse recommend?
Which lactose-free food should the nurse recommend?
What dietary recommendation should the nurse make for a client with hyperlipidemia due to nephrotic syndrome?
What dietary recommendation should the nurse make for a client with hyperlipidemia due to nephrotic syndrome?
What is the pH of the ABG result indicating the client is experiencing?
What is the pH of the ABG result indicating the client is experiencing?
What is paresthesia?
What is paresthesia?
Which instructions should the nurse include for treating pediculosis capitis? (Select all that apply)
Which instructions should the nurse include for treating pediculosis capitis? (Select all that apply)
What instruction should the nurse provide to prevent the spread of methicillin-resistant Staphylococcus aureus?
What instruction should the nurse provide to prevent the spread of methicillin-resistant Staphylococcus aureus?
What acid-base imbalance does a patient with a pH of 7.28 and HCO3- of 14 mEq/L have?
What acid-base imbalance does a patient with a pH of 7.28 and HCO3- of 14 mEq/L have?
Which herbal supplement can help treat hyperlipidemia?
Which herbal supplement can help treat hyperlipidemia?
What should the nurse say to the parent struggling to cope with a terminally ill child?
What should the nurse say to the parent struggling to cope with a terminally ill child?
Which finding should the nurse instruct a client who had lithotripsy to report?
Which finding should the nurse instruct a client who had lithotripsy to report?
What action should the nurse take for a client with left hemiparesis?
What action should the nurse take for a client with left hemiparesis?
Adolescents cope with death better than children of other ages.
Adolescents cope with death better than children of other ages.
Which symptom indicates mild hypothermia?
Which symptom indicates mild hypothermia?
It is okay for a client who had cataract surgery to lift a 2-year-old child.
It is okay for a client who had cataract surgery to lift a 2-year-old child.
What is the priority action for a client experiencing panic-level anxiety?
What is the priority action for a client experiencing panic-level anxiety?
What indicates a venous ulcer rather than an arterial ulcer?
What indicates a venous ulcer rather than an arterial ulcer?
What should a nurse do when a client begins a panic attack?
What should a nurse do when a client begins a panic attack?
What acid-base imbalance is indicated by a pH of 7.28 and a PaCO2 of 49 mm Hg?
What acid-base imbalance is indicated by a pH of 7.28 and a PaCO2 of 49 mm Hg?
What should be the first action for a traumatic amputation?
What should be the first action for a traumatic amputation?
What electrolyte imbalance should be suspected in a client taking antacids frequently?
What electrolyte imbalance should be suspected in a client taking antacids frequently?
What finding requires intervention during preoperative screening for knee arthroplasty?
What finding requires intervention during preoperative screening for knee arthroplasty?
What should the nurse prioritize for a client with respiratory acidosis?
What should the nurse prioritize for a client with respiratory acidosis?
What clinical name should be documented for a client with a fear of open spaces?
What clinical name should be documented for a client with a fear of open spaces?
What is the best way to maintain bone health for osteoporosis?
What is the best way to maintain bone health for osteoporosis?
What statement indicates understanding of home care for gastroesophageal reflux?
What statement indicates understanding of home care for gastroesophageal reflux?
What action should a nurse take for a client receiving total parenteral nutrition?
What action should a nurse take for a client receiving total parenteral nutrition?
What acid-base imbalance is indicated by a pH of 7.48 and HCO3- of 30 mEq/L?
What acid-base imbalance is indicated by a pH of 7.48 and HCO3- of 30 mEq/L?
What finding indicates effective treatment after isotonic IV fluids in severe dehydration?
What finding indicates effective treatment after isotonic IV fluids in severe dehydration?
What lab result indicates an adverse reaction to exenatide?
What lab result indicates an adverse reaction to exenatide?
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Study Notes
Renal Calculi Care
- Encourage the intake of at least 3 liters of fluid daily to promote urine production and facilitate calculi elimination.
Postoperative Cholecystectomy Education
- Inform clients that adhesive bandages will typically fall off in 7 to 10 days as the incision heals.
MRSA Prevention for Immunocompromised Clients
- Implement bathing with chlorhexidine wipes to reduce the risk of hospital-acquired MRSA infection.
Herpes Simplex Virus Identification
- Recognize cold sores on the lips as a manifestation of type 1 herpes simplex virus infection.
Graves' Disease Symptoms
- Expect exophthalmos (protruding eyeballs) as a key symptom associated with Graves' disease, an autoimmune disorder.
Duloxetine for Peripheral Neuropathy
- Inform clients it may take several weeks to notice symptom improvement with duloxetine.
Scabies Treatment with Lindane Lotion
- Instruct clients to wash off the lindane lotion after 8 to 12 hours to effectively treat scabies.
Appendicitis Assessment
- A board-like abdomen is an urgent finding indicating possible peritonitis in appendicitis that requires immediate reporting to the provider.
Gastroesophageal Reflux Disease Management
- Advise to finish eating at least 3 hours before bedtime to help prevent reflux episodes.
Warfarin Education for Deep-Vein Thrombosis
- Monitor for signs of blood in urine; contact a provider if pink-tinged urine is noticed while on warfarin.
Urinalysis for Pyelonephritis
- Positive leukocyte esterase indicates a continuing infection post-treatment of pyelonephritis.
Grief Acceptance Post-Colostomy
- Touching the colostomy stoma during care indicates acceptance of the body image change related to grief.
Peritonitis in School-Age Children
- Abdominal distention is a key indicator of peritonitis, requiring timely assessment.
Peptic Ulcer Complications
- A hemoglobin level of 7.6 mg/dL is a priority finding indicating potential chronic bleeding from a peptic ulcer.
Heat Exhaustion Indicators
- Recognize vomiting as a common sign of heat exhaustion due to dehydration from excessive sweating.
Calcium Sources for Lactose Intolerance
- Recommend collard greens as a high-calcium, nondairy food alternative.
Deep-Vein Thrombosis Postoperative Care
- Elevate legs in bed and use antiembolic stockings to prevent venous insufficiency.
Ileostomy Postoperative Assessment
- Report a purple-colored stoma immediately as it indicates inadequate blood supply, necessitating urgent intervention.
Pediatric Heart Failure Nutrition
- Offer small, frequent high-calorie meals based on the child's comfort and endurance levels.
Heat Stroke Treatment
- Use ice packs on the axillae, neck, groin, and chest to cool a client with heat stroke effectively.
Asthma Management
- Albuterol, a short-acting beta agonist, should be used during asthma attacks for bronchodilation.
Ileostomy Location
- Expect an ileostomy to be positioned on the right side of the abdomen, above the umbilicus.
Diabetes Mellitus Signs
- A blood glucose level of 250 mg/dL may result in fruity breath odor, signaling possible ketoacidosis.
Metformin Side Effects Awareness
- Instruct clients to contact their provider for muscle pain, which may indicate lactic acidosis, a serious condition.
Atenolol Monitoring
- Advise clients to contact their provider if their pulse drops below 60 beats per minute while taking atenolol.
Pneumonia Prevention for Older Adults
- Stress the importance of hand hygiene, particularly washing hands after public exposure to reduce pneumonia risk.
Lactose-Free Dietary Options
- Soy milk is a beneficial lactose-free alternative for clients with lactose intolerance.
Nephrotic Syndrome Dietary Recommendations
- Instruct clients to limit fat intake to less than 30% of daily calories to manage hyperlipidemia associated with nephrotic syndrome.
Respiratory Alkalosis Symptoms
- Expect paresthesias (numbness and tingling) as a common symptom of respiratory alkalosis.
Pediculosis Capitis Treatment
- Recommend washing all bedding and clothes in hot water to eliminate lice contamination effectively.
MRSA Infection Management for Adolescents
- Advise against returning to contact sports until the methicillin-resistant Staphylococcus aureus infection has fully healed.
ABG Interpretation for Dehydrated Client
- Assess renal function and hydration status based on arterial blood gas results indicating acidosis.### Acid-Base Imbalances
- Metabolic acidosis is indicated by a pH below the expected range, normal or low PaCO2, and low HCO3-. Common cause: diabetic ketoacidosis.
- Respiratory acidosis occurs with a pH below normal, PaCO2 above normal, and normal or slightly elevated HCO3-. Common causes include opioid use and airway obstruction.
- Metabolic alkalosis is characterized by a pH above normal, HCO3- above normal, and normal or above normal PaCO2. Common causes: prolonged vomiting, NG suctioning, and excessive antacid use.
Herbal Supplements for Hyperlipidemia
- Garlic is effective in improving cholesterol levels and reducing plaque buildup in arteries; can also lower blood pressure.
Support for Grieving Parents
- Encourage parents coping with their child's terminal illness to discuss past stress management techniques, fostering a supportive environment.
Post-Lithotripsy Care
- Instruct clients to report painful urination immediately, as it may indicate infection or stone recurrence.
Stroke Rehabilitation
- Encourage the use of wide-grip utensils for clients with hemiparesis to promote independence in eating.
Adolescent Reactions to Death
- Adolescents may isolate themselves when grieving due to difficulty in communication.
Mild Hypothermia Assessment
- Slurred speech is a common manifestation of mild hypothermia, along with shivering and decreased coordination.
Cataract Surgery Recovery
- Clients should be informed that full vision improvement may take 4 to 6 weeks post-surgery, despite immediate visual gains.
Anxiety Management
- The priority for a client with panic-level anxiety is to protect them from harm. This may involve reducing environmental stressors.
Peripheral Ulcer Assessment
- Discoloration and edema of the ankle characterize venous ulcers, as opposed to diminished pulses or atrophy which suggest arterial ulcers.
Panic Attack Management
- Remain with the client during a panic attack to ensure safety and assist with anxiety management techniques.
Opioid-Induced Respiratory Depression
- Identify respiratory acidosis when ABG shows a low pH and elevated PaCO2. Common causes include opioid administration.
Traumatic Amputation First Aid
- Call emergency services, control bleeding, keep the extremity elevated, and prepare the amputated part for possible reattachment.
Antacid-Related Electrolyte Imbalance
- Frequent antacid use, especially those containing magnesium, can lead to hypermagnesemia, which presents with hypotension and lethargy.
Preoperative Screening in Clinics
- Report elevated coagulation times (INR) before procedures to prevent intraoperative bleeding risks.
Effective IV Fluid Therapy in Children
- Brisk skin turgor after administering isotonic IV fluids indicates successful treatment for severe dehydration.
Monitoring for Diabetic Treatments
- Elevated lipase levels can indicate pancreatitis, a potential adverse effect of exenatide treatment for type 2 diabetes.
COPD Self-Care Techniques
- Instruct clients to use pursed-lip breathing to manage dyspnea effectively.
Recognizing Malnutrition
- Look for brittle hair, indicative of malnutrition, along with other signs such as poor wound healing.
Hearing Aid Use and Care
- Ensure the hearing aid is turned off before use to prevent loud noises and discomfort during insertion.
Gestational Diabetes Education
- Assess the client’s knowledge of gestational diabetes as part of the educational process to tailor further teaching effectively.
Atherosclerosis Self-Care
- Advise increasing daily fiber intake to at least 30 g to assist in lipid elimination and reduce atherosclerosis risk.
Post-Cast Care Instructions
- Clients should elevate the wrist above the heart level to minimize pain and swelling after applying a plaster cast.
Managing Contact Dermatitis in Children
- Provide personalized guidance based on the specifics of the child’s condition, focusing on effective disease management strategies.### Pediatric Care Notes
- Wash child’s exposed clothing in cold water with powder detergent to remove potential irritants.
- Keep child away from others for 10 days after lesions appear to prevent transmission.
- Clean affected areas with antibacterial soap every other day to maintain hygiene.
- Place child in a tepid oatmeal bath for 15 minutes to alleviate itching.
COPD Management
- Effective treatment with nebulized acetylcysteine is indicated by thin, white mucus, signifying effective mucus thinning and absence of infection.
Gastroenteritis in Infants
- Expect infant with severe dehydration to show absence of tears, flat anterior fontanel, and a capillary refill time of 2 seconds.
Pediatric Eye Assessment
- Strabismus, or eye crossing, should be reported if present past 4 months of age to prevent amblyopia.
Gallstones Risk Factors
- Atorvastatin use raises the risk of gallstones due to increased serum cholesterol levels.
Infectious Disease Precautions
- For a child with pertussis, initiate droplet precautions to mitigate transmission risk; use surgical masks within close proximity.
Heparin Therapy Monitoring
- Anticipate prescribing protamine if a client shows signs of heparin overdose, particularly when aPTT levels are elevated.
Benign Prostatic Hyperplasia (BPH) Management
- Instruct BPH clients to void as soon as they feel the urge to reduce urinary retention risks.
Primary Open-Angle Glaucoma (POAG) Signs
- Clients with POAG typically experience progressive loss of peripheral vision, indicating the need for visual field testing.
Left-Sided Heart Failure Symptoms
- Expect symptoms such as nocturia, dyspnea, and a hacking cough, which are common in left-sided heart failure.
Child’s Reaction to Sibling’s Death
- A 10-year-old sibling may display curiosity about the deceased's body and the funeral process, normalizing their grief experience.
Cholecystitis Presentation
- Clients with cholecystitis often have abdominal pain that may radiate to the right shoulder, typically triggered by fatty foods.
Social Anxiety Disorder Treatment
- Paroxetine, an SSRI, is commonly prescribed for managing social anxiety disorder.
Generalized Anxiety Disorder Interventions
- Reframe situations positively to help clients with generalized anxiety disorder adjust their thought patterns.
Cellulitis Management
- Elevate the affected area and administer cefazolin IV as part of treatment for lower extremity cellulitis.
Small-Bowel Obstruction Indicators
- Visible peristaltic waves in the upper abdomen signal a potential small-bowel obstruction.
Hyponatremia Symptoms
- With hyponatremia, expect decreased level of consciousness as a reaction to cerebral edema.
Hypoglycemia Management for Diabetics
- Instruct clients experiencing hypoglycemia to consume 120 mL of fruit juice, providing quick relief with carbohydrates.
Peak Flow Meter Use in Asthma
- Peak flow rates should be recorded based on the best of three attempts for accurate asthma monitoring.
Osteoporosis Prevention
- Encourage increased dairy intake, weight-bearing exercises, and reduced caffeine use for osteoporosis prevention.
Postoperative TURP Care
- Observe for multiple red clots in the catheter tubing post-TURP as a sign of potential bleeding, necessitating provider notification.
Osteoarthritis Symptoms
- Joint pain in osteoarthritis typically improves with rest, particularly early in the disease.
Communication with Hearing Impairments
- Engage clients with hearing impairments by encouraging them to repeat back information shared to ensure understanding.
Tuberculosis Precautions
- Initiate airborne precautions immediately for clients diagnosed with active tuberculosis to prevent airborne transmission.
Diabetes Foot Care
- Instruct diabetic clients to trim toenails straight across to avoid ingrown toenails, reducing infection risks.
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