Questions and Answers
Which information is most helpful for the nurse to provide about treatment options?
Which intervention should the nurse implement first for a client post-abdominal surgery?
Which statement by the client demonstrates an understanding of using allopurinol to treat gout?
Which statement by a client with schizophrenia confirms that the nurse's assessment of delusion is correct?
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What intervention should the nurse implement when changing the dressing for a client with a Penrose drain?
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Which physiologic parameter should the nurse use to evaluate a therapeutic response to dopamine in a client in septic shock?
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Which assessment finding indicates progress toward the desired effect of treatment in a client with cirrhosis of the liver?
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Which assessment finding places a client at risk for problems associated with impaired skin integrity?
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What is the reason for the nurse's silence when the client expresses, 'I don't know how I will go on'?
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Which activity should the nurse suggest a depressed client perform when asked how he feels?
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Which intravenous solution is best for a client admitted with right lower quadrant abdominal pain and possible ectopic pregnancy?
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What action should the nurse take for a client who had a pneumonectomy and a call system alarm is initiated by another client?
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What interpretation should the nurse make about an elevated serum rheumatoid factor in a client with rheumatoid arthritis?
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Which dietary instruction should the nurse include for reducing episodes of Raynaud's syndrome?
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Which assessment finding requires immediate intervention for a post-operative client with right pneumonectomy?
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When is the best time for the nurse to assess a client for residual urine?
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What action should the nurse implement based on identifying a specific gravity of 1.035 in a client's urinalysis?
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In a client with heart failure who reports increased shortness of breath, which action is most important after administering furosemide?
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Which additional finding is the nurse likely to obtain while assessing a client newly diagnosed with left ventricular dysfunction?
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Which client is the most likely candidate for total parenteral nutrition (TPN)?
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What action should the nurse take first when a 3-year-old child with an upper respiratory infection has a rectal temperature of 102°F?
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Which intervention should the nurse implement for an adolescent female with an eating disorder?
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Which interventions should the nurse suggest for an older client with fears of falling at home? (Select all that apply)
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Which priority intervention should the nurse implement for a client with a deep, full-thickness burn over both upper legs?
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Which assessment finding is most critical in a client with persistent epigastric pain who has been taking oral antacids without relief?
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Which client assignment is best for the new graduate nurse in the Intensive Care Department?
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How should the nurse respond to a mother concerned about the cost of prepared toddler foods?
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Following a traumatic delivery, an infant receives an initial Apgar score of 3. Which intervention is most important for the nurse to implement?
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A client tells the nurse that he is 'very nervous' about the surgery he is scheduled to have in the morning. Which action should the nurse implement first?
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The nurse notes that a client's legs become dusky-red whenever the client is sitting with both feet dangling. Which follow-up assessment should the nurse complete?
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The nurse who is working on a post-surgical intensive care unit receives report regarding the assigned clients for the upcoming shift. Which client should the nurse assess first?
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A 4-year-old girl returns to the pediatrician's office for a postoperative visit following hospitalization for minor surgery. When observing the child in the waiting area, which behavior should the nurse consider normal for this age child?
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A client who is an avid hiker expresses concern about losing too much potassium while hiking. In teaching the client to prepare a potassium-rich snack mix, which items should the nurse encourage the client to include? (Select all that apply)
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The nurse notes that the influenza immunization rates are much lower for certain demographic groups than for others. Which intervention is likely to be most useful in increasing the rates of immunization in these underserved groups?
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While inserting an indwelling urinary catheter into a client, the nurse observes urine flow in the tubing. Which action should be taken next?
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A client who takes nonsteroidal anti-inflammatory drugs (NSAIDs) every day for rheumatoid arthritis is being treated for anemia. Which intervention is most important for the nurse to include in the plan of care?
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Which long-term outcome is most important for the nurse to include in the plan of care for an older adult client with chronic pyelonephritis?
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A primigravida client being treated for preeclampsia with magnesium sulfate delivered a 7-pound infant four hours ago by cesarean delivery. Which nursing problem has the highest priority?
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A client is hospitalized with an inflammatory bowel disease (IBD) exacerbation and is being treated with a corticosteroid. The client develops a rigid abdomen with rebound tenderness. Which action should the nurse take?
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When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)?
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When preparing a client who is to undergo a resection of a leiomyosarcoma of the uterus, the nurse notices that apixaban is listed on the medication reconciliation list. Which assessment finding requires immediate nursing intervention?
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In conducting a pain assessment of a client with osteoarthritis, which action should the nurse include?
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When teaching a client with Parkinson's disease, which rationale for the prescription of carbidopa-levodopa should the nurse include?
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A middle-aged male client, admitted to a critical care unit several weeks ago because of serious injuries sustained in a motor vehicle accident, is currently in stable condition. Based on this client's age and recent life-threatening crisis, which intervention should the nurse implement?
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The nurse provides dietary instructions about iron-rich foods to a client with iron deficiency anemia. Which food selection made by the client indicates a need for additional instructions?
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The healthcare provider prescribes oral vancomycin for a female client who has Clostridium difficile in the stool. Which action should the nurse take before administering the first dose?
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An older client with a history of Type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. The client is lethargic, moderately confused, and cannot remember when taking the last dose of insulin or eating. Which action should the nurse implement first?
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While interviewing an elderly client, the nurse observes that the client's hands tremble uncontrollably while reaching for a glass of water. How should the nurse document this finding?
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A client diagnosed with dementia is disoriented, wandering, has a decreased appetite, and is having trouble sleeping. Which is the priority nursing problem for this client?
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The charge nurse is making assignments on an inpatient psychiatric unit. The staff consists of two psychiatric technicians and one practical nurse (PN). Which team assignment is best to assign to the PN?
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A client who has small cell carcinoma of the lung is admitted with symptoms of syndrome of inappropriate antidiuretic hormone (SIADH). As the client responds to treatment, the client's serum sodium level increases from 120 to 125 mEq/L or mmol/L (SI). Based on this finding, which intervention should the nurse implement?
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Prior to obtaining an axillary temperature, the nurse should perform which action?
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A 17-year-old client gave birth 12 hours ago. She states that she doesn't know how to care for her baby. To promote parent-infant attachment behaviors, which intervention should the nurse implement?
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A client with uremia is experiencing uremic frost. Which action should the nurse implement?
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After placing a 36-week-gestation newborn in an isolette and drying the infant with several blankets, what should the nurse implement next?
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Which intervention should the nurse implement for a client in the third trimester of pregnancy experiencing nasal stiffness and nosebleeds?
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Which action should the hospice nurse implement for a terminally ill male patient showing decreased awareness and poor appetite?
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When coffee ground material is observed in the drainage from the nasogastric tube, which intervention should the nurse implement?
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Which laboratory test should the nurse review to evaluate recovery in a client with acute pancreatitis?
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Which action should the nurse take first when 300 ml of dark red fluids have drained from the nasogastric tube?
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Which health care measure is most important for clients with asthma, chronic bronchitis, and emphysema?
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How should the nurse respond to a mother who reports her one-month-old infant has a flat head?
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Which action should the nurse perform first after a woman delivers a term infant and the placenta in the hospital parking lot?
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Which laboratory finding should be reported before administering the maximum recommended dosage of piperacillin/tazobactam?
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Which assessment finding in a client with diabetic ketoacidosis warrants immediate intervention by the nurse?
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When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which approach should the nurse use?
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What action should the nurse take regarding a client with testicular cancer who has a living will refusing resuscitation?
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Which assessment finding observed in a client requires immediate intervention by the nurse?
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What should be done in response to a positive Babinski reflex in a client with cirrhosis?
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What should the nurse ensure after obtaining a urine specimen for culture and sensitivity from an indwelling urinary catheter?
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What should the nurse do to assist an older client with unilateral weakness using a walker?
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Which nursing intervention helps reduce flu-like symptoms in a client with cancer after administering colony-stimulating factor?
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Which laboratory value should be reviewed before administering the initial dose of a statin medication?
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Which concern voiced by a client after a lumbar puncture indicates a complication of the procedure?
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What should the nurse monitor for in a client withdrawing from a fentanyl citrate addiction?
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Which recent illness is most significant in obtaining a health history for a child with acute rheumatic fever?
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What should the nurse's follow-up action be with a client who plans to eat dairy products to help protect their duodenal ulcer?
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Which mechanism contributes to edema and ascites in clients with cirrhosis?
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Which pathophysiological mechanism supports a client's clinical presentation of severe, colicky abdominal pain and distention in intestinal obstruction?
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What nursing instruction is most important for a client recently diagnosed with glaucoma expressing fear of going blind?
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Which client should be assigned to a new graduate nurse learning on a cardiac unit?
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How many mL should be administered for Penicillin G procaine 240,000 units, if the vial is labeled 1,200,000 units/2 mL?
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What should the nurse do first if a client in labor states, 'I think my water just broke!' and the umbilical cord is on the perineum?
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What nursing intervention is most important for a client with anorexia nervosa who collapses at an outpatient clinic?
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Which physical therapy regimen should be encouraged for a 16-year-old with juvenile idiopathic arthritis (JIA)?
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What information should be included about a daily diet for a client in end-stage kidney failure requiring dialysis?
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Which neurovascular assessment of a client with right hemisphere stroke requires immediate intervention?
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What pathological process should the nurse base withholding oral fluids in a client diagnosed with acute pancreatitis?
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What should the nurse advise a male client with testicular cancer and a decreased alpha fetoprotein level?
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How many units of Heparin should be administered to a client weighing 198 pounds, prescribed at 100 units/kg?
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What action should the nurse take to assist a client reporting sleeplessness and anxiety over financial status?
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Which client will the nurse care for in the outpatient psychiatric clinic?
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Study Notes
Neonatal Care
- For a 36-week-gestation newborn, remove wet blankets from the isolette after drying.
Respiratory Assessment
- In third-trimester pregnant clients with nasal stiffness, normal respiratory findings can be documented.
Hospice Care
- Instruct family to offer soft, bland foods for a terminally ill client with poor appetite and decreased awareness.
Postoperative Care
- Verify the placement of a nasogastric tube if coffee ground material is observed in the drainage.
Laboratory Values in Pancreatitis
- Lipase levels should be monitored to evaluate recovery in clients with acute pancreatitis.
Post-surgical Assessment
- Determine vital signs first if 300 ml of dark red fluid drains from a nasogastric tube.
Asthma and COPD Prevention
- Advise clients with respiratory conditions to avoid crowded areas in colder months to prevent exposure.
Infant Care for Flat Head
- Position the infant on the stomach when awake to prevent flatness on the back of the head.
Post-delivery Care
- The first action after a delivery in an unusual setting is to massage the fundus and administer oxytocin.
Medication Administration
- Report decreased creatinine clearance before administering high doses of piperacillin/tazobactam.
Diabetic Ketoacidosis Assessment
- A fruity breath indicates the need for immediate intervention in a client with DKA.
COPD Management
- Explain the various positions for postural drainage to the client with COPD.
Ethical Considerations in Patient Care
- Initiate an ethics committee review if a client with terminal illness refuses DNR despite a good prognosis.
Urgent Assessment Findings
- Cyanotic oral mucosa indicates a critical need for immediate intervention.
Neurological Assessment
- A positive Babinski reflex in cirrhosis requires a comprehensive neurologic assessment.
Urine Specimen Collection
- Ensure sterility of the specimen container immediately after obtaining a urine specimen.
Client Safety with Weakness
- Hold the walker securely to assist a client with unilateral weakness in rising from a chair.
Management of Chemotherapy Symptoms
- Administer acetaminophen every four hours to alleviate flu-like symptoms following colony-stimulating factors.
Statin Medication Review
- Check serum liver enzymes before starting statin medication to prevent complications.
Complications Post-Lumbar Puncture
- Headaches worsening in an upright position suggest potential complications from the procedure.
Withdrawal Management
- Advise clients withdrawing from fentanyl to rise slowly from a reclining position to prevent dizziness.
Pediatric History for Rheumatic Fever
- Recent sore throat is significant in assessing the risk for acute rheumatic fever in children.
Nutritional Guidance for Ulcers
- Educate clients with duodenal ulcers to avoid rich dairy products that may worsen their condition.
Cirrhosis and Edema
- Hypoalbuminemia is a key mechanism leading to edema and ascites in cirrhosis patients.
Intestinal Obstruction Pathophysiology
- Weakened diaphragm and high abdominal pressure contribute to symptoms in intestinal obstruction cases.
Glaucoma Management
- Stress the importance of maintaining prescribed eye drop regimens to manage glaucoma effectively.
Assignment for New Graduates
- Assign stable clients with atrial fibrillation whose saline lock is infiltrated to new graduates for orientation.
Dosage Calculations
- For a child needing Penicillin G procaine, administer 0.4 mL from a vial labeled 1,200,000 units/2 mL.
Emergency Obstetric Care
- In labor, place the client in Trendelenburg position if the umbilical cord is on the perineum.
Acute Care for Anorexia Nervosa
- Position a client with signs of hypoglycemia with the head flat and feet elevated for safety.
Activities for Juvenile Idiopathic Arthritis
- Encourage aquatic exercises to strengthen joints and muscles for adolescents with arthritis.
Dietary Management in Kidney Failure
- Advise clients with kidney failure to decrease protein intake to prevent buildup of nitrogenous waste.
Stroke Assessment
- Immediate intervention is required for unequal hand grip strengths in clients with suspected strokes.
Management of Acute Pancreatitis
- Withholding oral fluids helps decrease pancreatic enzyme secretion in acute pancreatitis patients.
Chemotherapy and Tumor Markers
- Advise clients with decreased alpha fetoprotein levels that treatment is likely effective.
Heparin Administration Calculation
- For a client weighing 198 pounds, administer a Heparin bolus dose of 9000 units.
Anxiety Management Techniques
- Teach clients to limit sugar and caffeine intake to help reduce anxiety levels.
ADHD Treatment Education
- Provide time management strategies as a key component in managing ADHD effectively.
Postoperative IV Fluid Management
- Decrease IV fluids to maintain an open vein in a post-abdominal surgery client showing signs of fluid overload.
Gout Management Education
- Reinforce the importance of daily allopurinol intake to prevent gout flare-ups.
Assessment of Schizophrenia Symptoms
- Statements indicating belief in delusions, such as harm from fire, can confirm delusional thinking in schizophrenia.### Nursing Interventions and Patient Care
- A client with a Penrose drain and serosanguineous drainage requires sterile gloves before dressing changes.
- Administering dopamine to a client in septic shock should be evaluated by monitoring urinary output.
- In a client with cirrhosis, decreased abdominal girth indicates effective treatment with a low sodium diet and albumin infusions.
- A capillary refill time of 5 seconds signals a risk for impaired skin integrity.
- Silence from the nurse during discussions of loss allows the client to reflect on their feelings.
Client Assessments
- Encouraging a depressed client to complete a written self-esteem assessment can help assess their mood.
- For a female client post-ectopic pregnancy, initiate Normal Saline IV at 20 mL/hour if vital signs are unstable.
- Absence of lung sounds post-pneumonectomy is critical and requires immediate intervention.
- Measure residual urine immediately after a client voids for accurate assessment.
Laboratory and Diagnostic Findings
- A specific gravity of 1.035 in urinalysis suggests the need for increased fluid intake of at least 2,400 mL/day.
- ST elevation in ECG leads post-epigastric pain is a critical finding that requires immediate attention.
Safety and Risk Management
- A charge nurse should assign lower acuity clients to a new graduate nurse to ensure safety.
- Install grab bars and assess fall risks with older clients concerned about falls.
- In case of a deep burn, prioritize giving an IV bolus of normal saline for fluid resuscitation.
Patient Education and Dietary Considerations
- For Raynaud's syndrome, dietary instruction should eliminate caffeine intake.
- Monitoring potassium levels with a potassium-rich snack mix can include dried apricots, seedless raisins, and dried bananas.
- Teach a mother to incorporate table foods alongside prepared toddler foods to enhance her child's nutrition.
Special Situations and Precautions
- Autonomic dysreflexia in spinal cord injury patients should first be assessed for an acutely distended bladder.
- Document a client's agnostic views in their spiritual assessment during the admission process.
- Post-surgical clients need immediate ongoing assessment for any signs of distress or complications.
Communication and Support
- A client expressing anxiety about surgery should have their concerns escalated to the healthcare provider.
- During postoperative visits, normal behavior for a 4-year-old could include ignoring peers.
Community Health and Access to Services
- Increasing influenza vaccination rates in underserved populations can be effectively addressed by establishing clinics in target neighborhoods.### Urinary Catheterization and Other Procedures
- Inflate the balloon of the catheter with 5 ml of sterile water.
- Document urine color and clarity post-procedure.
- Instruct the client to breathe deeply and exhale slowly.
- Insert the catheter an additional inch if needed for proper placement.
Important Nursing Interventions
- For clients on NSAIDs with anemia, monitor for gastrointestinal bleeding.
- For older adults with chronic pyelonephritis, emphasize independent management of daily living activities.
- In post-cesarean clients with preeclampsia, prioritize assessing for uterine atony to prevent risk of injury.
- Monitor for bloody stools in clients with inflammatory bowel disease being treated with corticosteroids.
Assessment and Monitoring
- Assess deep tendon reflexes (DTRs) in pregnant clients with elevated blood pressure.
- Immediate intervention required for clients on apixaban showing signs of bleeding gums.
- Observe movements of joints in clients with osteoarthritis during pain assessments.
- In a diabetic client showing symptoms of confusion and cramping, initiate an IV infusion of normal saline first.
Client Education and Dietary Recommendations
- Educate clients with iron deficiency anemia on iron-rich food selections, clarifying that kidney beans are not optimal choices.
- Explain the mechanism of carbidope-levodopa in increasing dopamine for muscle function in Parkinson's disease.
Psychological Support and Recovery
- In critical care settings, encourage clients to reflect on personal goals and priorities to promote psychological recovery.
- Stress safety measures for clients with dementia, prioritizing risk for injury as a nursing problem.
Team Assignments and Responsibilities
- In a psychiatric setting, assign one-on-one observation of suicidal clients to practical nurses for enhanced safety.
Lab and Vital Sign Monitoring
- Maintain prescribed fluid restrictions for clients with SIADH as serum sodium levels improve.
- Before obtaining an axillary temperature, ensure a protective sheath is used on the thermometer.
Promotion of Parent-Infant Bonding
- Encourage rooming-in for young mothers post-delivery to facilitate attachment behaviors.
Managing Complications in Uremia
- In cases of uremic frost, explain the necessity for hemodialysis as a critical intervention.
These notes synthesize vital nursing actions, preventative measures, and client education within clinical scenarios.
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Test your knowledge with these HESI iNet flashcards focused on nursing care for newborns and maternal health. Each card presents a clinical scenario requiring critical thinking and application of nursing principles. Perfect for nursing students preparing for the HESI exam.
