Untitled Quiz

Questions and Answers

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.

brittle

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?

Determine the client's knowledge regarding gestational diabetes. Signup and view all the answers

What dietary instruction should be given to a client with atherosclerosis?

Increase fiber intake to at least 30 g per day. Signup and view all the answers

What instruction should a nurse give to a client with a short-arm plaster cast?

Elevate the wrist above heart level. Signup and view all the answers

Which symptom indicates severe dehydration in an infant?

Absence of tears Signup and view all the answers

What finding should a nurse report in a 2-year-old regarding eye health?

Presence of strabismus Signup and view all the answers

What medication is a risk factor for developing cholecystitis?

Atorvastatin Signup and view all the answers

What precautions should a nurse initiate for a preschooler with pertussis?

Droplet precautions Signup and view all the answers

What medication might be prescribed for a heparin overdose?

Protamine Signup and view all the answers

What instruction should a client with benign prostatic hyperplasia follow?

Void as soon as you feel the urge. Signup and view all the answers

What finding should a nurse expect in a client with primary open-angle glaucoma?

Progressive loss of peripheral vision Signup and view all the answers

Which of the following findings should be expected in left-sided heart failure? (Select all that apply)

Hacking cough Signup and view all the answers

What might a 10-year-old sibling expect after a sibling's death?

Curiosity about what will happen to the client's body Signup and view all the answers

What pain characteristic indicates cholecystitis?

Abdominal pain that radiates to the right shoulder Signup and view all the answers

What medication should be expected for a client with social phobia?

Paroxetine Signup and view all the answers

What should a nurse do for a client with generalized anxiety disorder?

Reframe situations in a positive manner for the client. Signup and view all the answers

What actions should be taken for a client with cellulitis? (Select all that apply)

Administer cefazolin intermittent IV bolus. Signup and view all the answers

What finding indicates a possible small-bowel obstruction?

Visible peristaltic waves in the upper abdomen Signup and view all the answers

What symptom corresponds with hypocalcemia?

Circumoral tingling Signup and view all the answers

What action should a client with hypoglycemia take?

Drink 120 mL (4 oz) of fruit juice. Signup and view all the answers

What indicates understanding of using a peak flow meter?

I will base my peak flow meter score on the best of three attempts. Signup and view all the answers

What instructions should be included for preventing osteoporosis? (Select all that apply)

Reduce excessive caffeine intake. Signup and view all the answers

What should a nurse encourage when teaching a client with a hearing impairment?

Encourage the client to repeat what the nurse has said. Signup and view all the answers

The nurse should rely on the client's nonverbal communications to ensure the client understands the information.

False Signup and view all the answers

What should the nurse do first for a client diagnosed with active tuberculosis and a weight loss of 5.9 kg (13 lb)?

Initiate airborne precautions. Signup and view all the answers

Which instruction should the nurse include for a client postoperative from TURP?

Perform Kegel exercises several times throughout the day. Signup and view all the answers

Which statement indicates a client with COPD understands the teaching?

I should make my abdomen rise with each inhalation. Signup and view all the answers

What reactions to death should a nurse expect from a preschooler?

Believes that their own thoughts can cause death. Signup and view all the answers

What manifestation should the nurse expect in a school-age child with erythema infectiosum?

Facial eruption. Signup and view all the answers

What information should the nurse teach an obese female client about disease management?

Morbid obesity is measured as a BMI over 40. Signup and view all the answers

What is the proper way to care for toenails in older adults with type 1 diabetes?

Trim toenails straight across to prevent ingrown toenails. Signup and view all the answers

What finding should the nurse expect in a client with hyponatremia?

Decreased level of consciousness. Signup and view all the answers

What acid-base imbalance is a client with Cushing's disease at risk for?

Metabolic alkalosis. Signup and view all the answers

What finding indicates a client has diabetic ketoacidosis?

Blood glucose 396 mg/dL. Signup and view all the answers

What should a nurse expect from a client with mild anxiety?

Follows directions. Signup and view all the answers

What should the nurse instruct a client taking finasteride?

You might need to take the medication for several months before seeing any relief. Signup and view all the answers

What finding should the nurse expect in a client with pernicious anemia?

Numbness of hands. Signup and view all the answers

What is an important instruction for a client taking rifampin?

Do not drink alcohol while taking this medication. Signup and view all the answers

What should the nurse expect in a newborn with hypothermia?

Hypoglycemia. Signup and view all the answers

What should the nurse teach a client with hypothyroidism about levothyroxine?

This medication causes adverse effects if the dosage is too high or too low. Signup and view all the answers

What is an adverse effect of warfarin that a nurse should recognize?

Increased menstrual flow. Signup and view all the answers

Which intervention should the nurse include to promote elimination of renal calculi?

Encourage intake of at least 3 L of fluid each day Signup and view all the answers

Which client statement indicates an understanding of postoperative education after a laparoscopic cholecystectomy?

The adhesive bandages on my incision will fall off as the incision heals. Signup and view all the answers

Which intervention should the nurse include to prevent MRSA infection for an immunocompromised client?

Bathe the client with chlorhexidine wipes. Signup and view all the answers

What is a common manifestation of type 1 herpes simplex virus?

Cold sore Signup and view all the answers

Which finding should the nurse expect in a client with Graves' disease?

Exophthalmos Signup and view all the answers

What indicates that the client understands teaching about duloxetine?

It might take several weeks to notice an improvement in my symptoms. Signup and view all the answers

Which client statement shows understanding of treatment with lindane lotion for scabies?

I will wash the lotion off 12 hours after I apply it. Signup and view all the answers

Which finding should the nurse report immediately for a client with appendicitis?

Board-like abdomen Signup and view all the answers

What should the nurse include in teaching for gastrointestinal reflux disease?

Plan to finish eating at least 3 hr before bedtime. Signup and view all the answers

Which statement shows understanding of warfarin teaching?

I should contact my provider if I notice a pink-tinged color to my urine. Signup and view all the answers

Which urinalysis result indicates a continuing infection after treatment with ciprofloxacin?

Positive leukocyte esterase Signup and view all the answers

Which finding indicates a client has accepted loss after a colostomy?

Touches the colostomy stoma when the bag is changed Signup and view all the answers

Which finding in a school-age child suggests peritonitis?

Abdominal distention Signup and view all the answers

Which finding is a priority to report for a client with a peptic ulcer?

Hemoglobin 7.6 mg/dL Signup and view all the answers

Which finding indicates heat exhaustion?

Vomiting Signup and view all the answers

Which food is the best nondairy source of calcium?

Collard greens Signup and view all the answers

Which intervention should be included in the care plan for a postoperative DVT client?

Make sure the client's legs are elevated while in bed. Signup and view all the answers

What is the priority finding to report after an ileostomy placement?

The stoma is purple in color. Signup and view all the answers

Which intervention should be included in the care plan for a preschooler with heart failure?

Offer small, frequent meals based on the child's endurance level. Signup and view all the answers

Which action should the nurse take to treat heat stroke?

Apply ice packs to the client's axillae, neck, groin, and chest. Signup and view all the answers

Which medication should be included in asthma attack teaching?

Albuterol Signup and view all the answers

Where should the ileostomy be located after surgery for ulcerative colitis?

Right side of the abdomen, lateral to, and slightly above the umbilicus. Signup and view all the answers

Which finding should the nurse expect in a child with a blood glucose level of 250 mg/dL?

Fruity breath odor Signup and view all the answers

Which statement shows understanding of metformin teaching?

I will call the doctor if I have muscle pain in my back. Signup and view all the answers

What should the nurse teach a client about atenolol?

You should contact your provider if your pulse rate drops below 60 per minute. Signup and view all the answers

Which action can help prevent pneumonia in older adults?

Wash your hands when you return home from running errands. Signup and view all the answers

Which lactose-free food should the nurse recommend?

Soy milk Signup and view all the answers

What dietary recommendation should the nurse make for a client with hyperlipidemia due to nephrotic syndrome?

Less than 30% of daily calories should come from fat. Signup and view all the answers

What is the pH of the ABG result indicating the client is experiencing?

Alkalosis Signup and view all the answers

What is paresthesia?

Numbness and tingling due to a decrease in calcium ionization. Signup and view all the answers

Which instructions should the nurse include for treating pediculosis capitis? (Select all that apply)

Seal items that are not machine washable in plastic bags for 1 week. Signup and view all the answers

What instruction should the nurse provide to prevent the spread of methicillin-resistant Staphylococcus aureus?

Do not return to football practice until the infection has healed. Signup and view all the answers

What acid-base imbalance does a patient with a pH of 7.28 and HCO3- of 14 mEq/L have?

Metabolic acidosis. Signup and view all the answers

Which herbal supplement can help treat hyperlipidemia?

Garlic. Signup and view all the answers

What should the nurse say to the parent struggling to cope with a terminally ill child?

Let's talk about a few ways you have dealt with stress in the past. Signup and view all the answers

Which finding should the nurse instruct a client who had lithotripsy to report?

Painful urination. Signup and view all the answers

What action should the nurse take for a client with left hemiparesis?

Encourage the client to use wide-grip utensils when eating with the right hand. Signup and view all the answers

Adolescents cope with death better than children of other ages.

False Signup and view all the answers

Which symptom indicates mild hypothermia?

Slurred speech. Signup and view all the answers

It is okay for a client who had cataract surgery to lift a 2-year-old child.

False Signup and view all the answers

What is the priority action for a client experiencing panic-level anxiety?

Protect the client from harm. Signup and view all the answers

What indicates a venous ulcer rather than an arterial ulcer?

Discoloration and edema of the right ankle. Signup and view all the answers

What should a nurse do when a client begins a panic attack?

Remain with the client until manifestations subside. Signup and view all the answers

What acid-base imbalance is indicated by a pH of 7.28 and a PaCO2 of 49 mm Hg?

Respiratory acidosis. Signup and view all the answers

What should be the first action for a traumatic amputation?

Call 911 and examine the amputation site. Signup and view all the answers

What electrolyte imbalance should be suspected in a client taking antacids frequently?

Hypermagnesemia. Signup and view all the answers

What finding requires intervention during preoperative screening for knee arthroplasty?

Coagulation time. Signup and view all the answers

What should the nurse prioritize for a client with respiratory acidosis?

Apply oxygen therapy. Signup and view all the answers

What clinical name should be documented for a client with a fear of open spaces?

Agoraphobia. Signup and view all the answers

What is the best way to maintain bone health for osteoporosis?

Maintain bone health by eating fruits, vegetables, and protein. Signup and view all the answers

What statement indicates understanding of home care for gastroesophageal reflux?

I should add 1 teaspoon of rice cereal to my infant's formula. Signup and view all the answers

What action should a nurse take for a client receiving total parenteral nutrition?

Administer the prescribed regular insulin. Signup and view all the answers

What acid-base imbalance is indicated by a pH of 7.48 and HCO3- of 30 mEq/L?

Metabolic alkalosis. Signup and view all the answers

What finding indicates effective treatment after isotonic IV fluids in severe dehydration?

Brisk skin turgor. Signup and view all the answers

What lab result indicates an adverse reaction to exenatide?

Lipase 185 units/L. Signup and view all the answers

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.

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.

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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