Podcast
Questions and Answers
What should the client practice regularly to maintain their health?
What should the client practice regularly to maintain their health?
Pelvic floor (Kegel) exercises
Which admission assessment findings should the nurse report to the healthcare provider? (Select all that apply)
Which admission assessment findings should the nurse report to the healthcare provider? (Select all that apply)
- Location of the initial IV site
- Core body temperature (correct)
- Swollen lymph nodes in the groin (correct)
- Red blood cell count (RBC)
- White blood cell count (WBC) (correct)
Which action should the nurse implement for a client with cancer experiencing nausea from cooking smells?
Which action should the nurse implement for a client with cancer experiencing nausea from cooking smells?
- Encourage family members to cook meals outdoors and bring the cooked food inside (correct)
- Assess the client's mucous membranes and report the findings to the healthcare provider
- Instruct the client to take an antiemetic before every meal to prevent excessive vomiting
- Advise the client to replace cooked foods with a variety of different nutritional supplements
Which PPE should be removed first when exiting the client's room?
Which PPE should be removed first when exiting the client's room?
What should the nurse's response be to the daughter of a retired chef who is becoming increasingly obsessed with food preparation?
What should the nurse's response be to the daughter of a retired chef who is becoming increasingly obsessed with food preparation?
Which serum laboratory value is most important for the nurse to monitor in a client receiving enoxaparin?
Which serum laboratory value is most important for the nurse to monitor in a client receiving enoxaparin?
Which assessment should the nurse administer for a 24-month-old toddler with sensory sensitivity and social interaction difficulties?
Which assessment should the nurse administer for a 24-month-old toddler with sensory sensitivity and social interaction difficulties?
What is the nurse's legal responsibility regarding obtaining written consent for surgery?
What is the nurse's legal responsibility regarding obtaining written consent for surgery?
Which client's serum laboratory value requires intervention by the nurse after a subtotal thyroidectomy?
Which client's serum laboratory value requires intervention by the nurse after a subtotal thyroidectomy?
What should the nurse explain to a client who feels lumpy places in her breasts during pregnancy?
What should the nurse explain to a client who feels lumpy places in her breasts during pregnancy?
What action should the nurse take for an older client reporting living at home alone and no history of falls?
What action should the nurse take for an older client reporting living at home alone and no history of falls?
Which instruction should the nurse include when teaching a client with recurrent anxiety?
Which instruction should the nurse include when teaching a client with recurrent anxiety?
What should the nurse teach a young woman with multiple sclerosis experiencing fatigue after immunizations?
What should the nurse teach a young woman with multiple sclerosis experiencing fatigue after immunizations?
After administering surfactant to a preterm newborn, which assessment should the nurse monitor?
After administering surfactant to a preterm newborn, which assessment should the nurse monitor?
What should the nurse do after auscultating an S3 heart sound in a client in their third trimester of pregnancy?
What should the nurse do after auscultating an S3 heart sound in a client in their third trimester of pregnancy?
What intervention should the nurse implement for a young male client following a right above-knee amputation who reports an aching sensation?
What intervention should the nurse implement for a young male client following a right above-knee amputation who reports an aching sensation?
What is the most crucial nursing assessment for an asymptomatic HIV-infected client considering a multi-drug therapy?
What is the most crucial nursing assessment for an asymptomatic HIV-infected client considering a multi-drug therapy?
Which actions should the nurse implement for a client experiencing a tonic-clonic seizure? (Select all that apply)
Which actions should the nurse implement for a client experiencing a tonic-clonic seizure? (Select all that apply)
What is the most important information for the nurse to obtain from a client who took a handful of medications?
What is the most important information for the nurse to obtain from a client who took a handful of medications?
Which lunch choice indicates effective teaching regarding a high-protein diet for wound healing?
Which lunch choice indicates effective teaching regarding a high-protein diet for wound healing?
Which resource is most important for designing a health promotion project for African-American women at risk for breast cancer?
Which resource is most important for designing a health promotion project for African-American women at risk for breast cancer?
What action should the charge nurse implement for a new nurse preparing to irrigate an intravenous catheter?
What action should the charge nurse implement for a new nurse preparing to irrigate an intravenous catheter?
Which client should the unlicensed assistive personnel prioritize skin care for based on the Braden Scale?
Which client should the unlicensed assistive personnel prioritize skin care for based on the Braden Scale?
What effect is likely to result from an increased number of elderly persons undergoing glaucoma surgeries?
What effect is likely to result from an increased number of elderly persons undergoing glaucoma surgeries?
What action should the nurse take first for a client afraid of her abusive boyfriend?
What action should the nurse take first for a client afraid of her abusive boyfriend?
What intervention should be included in the plan of care for a client with assessment findings indicating fluid overload?
What intervention should be included in the plan of care for a client with assessment findings indicating fluid overload?
Which finding in the chest tube drainage system requires nurse intervention?
Which finding in the chest tube drainage system requires nurse intervention?
Which laboratory value is most important for the nurse to review for a client demonstrating rapid speech and other manic symptoms?
Which laboratory value is most important for the nurse to review for a client demonstrating rapid speech and other manic symptoms?
What assessment finding indicates a therapeutic response in a client with bacterial meningitis receiving phenytoin?
What assessment finding indicates a therapeutic response in a client with bacterial meningitis receiving phenytoin?
What should the nurse administer for a client with Type 2 DM?
What should the nurse administer for a client with Type 2 DM?
What is the primary action after an abdominal hysterectomy?
What is the primary action after an abdominal hysterectomy?
What should be obtained postoperatively for a client after unilateral knee arthroplasty?
What should be obtained postoperatively for a client after unilateral knee arthroplasty?
Which type of regular activity should the nurse emphasize for osteoporosis?
Which type of regular activity should the nurse emphasize for osteoporosis?
Which information in the client's history requires follow-up prior to a CT scan with contrast?
Which information in the client's history requires follow-up prior to a CT scan with contrast?
What actions should the nurse include in a care plan for a client with Type 2 DM? (Select all that apply)
What actions should the nurse include in a care plan for a client with Type 2 DM? (Select all that apply)
Which client requires the nurse's immediate attention on the adolescent unit?
Which client requires the nurse's immediate attention on the adolescent unit?
What is the most important action for a nurse to implement for a client admitted with hyperemesis gravidarum?
What is the most important action for a nurse to implement for a client admitted with hyperemesis gravidarum?
What sign of overdose should parents report for a child taking propranolol?
What sign of overdose should parents report for a child taking propranolol?
What is the most important client assessment before obtaining a trapeze bar for limited mobility?
What is the most important client assessment before obtaining a trapeze bar for limited mobility?
What should the nurse tell the parents of a toilet-trained child who regresses in behavior after hospitalization?
What should the nurse tell the parents of a toilet-trained child who regresses in behavior after hospitalization?
Which nursing interventions should be delegated to unlicensed assistive personnel (UAP) for a client with Cushing's syndrome?
Which nursing interventions should be delegated to unlicensed assistive personnel (UAP) for a client with Cushing's syndrome?
What historical information should the nurse address for a client with gastritis?
What historical information should the nurse address for a client with gastritis?
After administering a proton pump inhibitor (PPI), what should the nurse do to evaluate its effectiveness?
After administering a proton pump inhibitor (PPI), what should the nurse do to evaluate its effectiveness?
What factor in a multigravida client's history correlates with excessive vaginal bleeding after delivery?
What factor in a multigravida client's history correlates with excessive vaginal bleeding after delivery?
What additional assessment finding requires immediate intervention when a client complains of tenderness at an IV site?
What additional assessment finding requires immediate intervention when a client complains of tenderness at an IV site?
What should the nurse do first for an older adult male with abdominal pain and other concerning symptoms?
What should the nurse do first for an older adult male with abdominal pain and other concerning symptoms?
Which information collected by the nurse is most directly related to chronic peripheral arterial insufficiency?
Which information collected by the nurse is most directly related to chronic peripheral arterial insufficiency?
What is the most important information for parents of a child recovering from an atrial septal defect repair?
What is the most important information for parents of a child recovering from an atrial septal defect repair?
What action should a nurse take when a UAP requests reassignment due to lack of N95 fit testing?
What action should a nurse take when a UAP requests reassignment due to lack of N95 fit testing?
Which outcome indicates the effectiveness of a tertiary prevention program for type 2 diabetes?
Which outcome indicates the effectiveness of a tertiary prevention program for type 2 diabetes?
What is the highest priority problem for a client who is immobile and has been experiencing fecal incontinence?
What is the highest priority problem for a client who is immobile and has been experiencing fecal incontinence?
What intervention should the nurse implement for an older adult with aspiration pneumonia drinking through a straw?
What intervention should the nurse implement for an older adult with aspiration pneumonia drinking through a straw?
What is the next step when a client requests stronger medication after taking acetaminophen for headache?
What is the next step when a client requests stronger medication after taking acetaminophen for headache?
What nursing intervention requires the greatest caution for a client with COPD?
What nursing intervention requires the greatest caution for a client with COPD?
What should the nurse implement for a client receiving haloperidol decanoate who develops facial grimacing?
What should the nurse implement for a client receiving haloperidol decanoate who develops facial grimacing?
Prolonged exposure to high concentrations of supplemental oxygen can cause which effect?
Prolonged exposure to high concentrations of supplemental oxygen can cause which effect?
Which side effect of ramelteon should a nurse report?
Which side effect of ramelteon should a nurse report?
What should the nurse instruct a client using an incentive spirometer after a return demonstration?
What should the nurse instruct a client using an incentive spirometer after a return demonstration?
What action should a nurse take for a client who's working out with a personal trainer but still has sleep issues?
What action should a nurse take for a client who's working out with a personal trainer but still has sleep issues?
What should educational materials for older clients include?
What should educational materials for older clients include?
What action should the nurse take for a client with severe PAD who experiences rest ischemia?
What action should the nurse take for a client with severe PAD who experiences rest ischemia?
Which assessments should a nurse include when evaluating treatment effectiveness for a client with Herpes zoster?
Which assessments should a nurse include when evaluating treatment effectiveness for a client with Herpes zoster?
How many mL/hour should a nurse program the infusion pump for a client receiving a heparin infusion?
How many mL/hour should a nurse program the infusion pump for a client receiving a heparin infusion?
When gathering evidence for clinical decision-making, which consideration is most important?
When gathering evidence for clinical decision-making, which consideration is most important?
Which medication should the nurse bring to the healthcare provider's attention for a client with calcium kidney stones and gout?
Which medication should the nurse bring to the healthcare provider's attention for a client with calcium kidney stones and gout?
What should be included in the care plan for a client with urge incontinence who is now experiencing urinary retention?
What should be included in the care plan for a client with urge incontinence who is now experiencing urinary retention?
Which assessment finding is evidence that the child is experiencing increased intracranial pressure (ICP)?
Which assessment finding is evidence that the child is experiencing increased intracranial pressure (ICP)?
Which additional information is the client most likely to report to the nurse with acute pancreatitis?
Which additional information is the client most likely to report to the nurse with acute pancreatitis?
Which information is most important for the nurse to provide the parents prior to discharging a child newly diagnosed with sickle cell anemia (SCA)?
Which information is most important for the nurse to provide the parents prior to discharging a child newly diagnosed with sickle cell anemia (SCA)?
To auscultate for a carotid bruit, the nurse places the stethoscope at what location?
To auscultate for a carotid bruit, the nurse places the stethoscope at what location?
After receiving report on an inpatient acute care unit, which client should the nurse assess first?
After receiving report on an inpatient acute care unit, which client should the nurse assess first?
The client presenting to the emergency department with palpitations after vaping is likely to develop which acid-base imbalance?
The client presenting to the emergency department with palpitations after vaping is likely to develop which acid-base imbalance?
To best prepare for a client with dyspnea's arrival, the nurse should ensure that the client's bed is in which position?
To best prepare for a client with dyspnea's arrival, the nurse should ensure that the client's bed is in which position?
Which information in the client's admission assessment is relevant to the nurse's plan for taking the blood pressure reading in a client with Parkinson's disease?
Which information in the client's admission assessment is relevant to the nurse's plan for taking the blood pressure reading in a client with Parkinson's disease?
Before reporting the finding of purulent drainage at a wound to the healthcare provider, which laboratory values should the nurse review?
Before reporting the finding of purulent drainage at a wound to the healthcare provider, which laboratory values should the nurse review?
Which action should the nurse take for the older brother of a child who was resuscitated after near-drowning?
Which action should the nurse take for the older brother of a child who was resuscitated after near-drowning?
Which action should the nurse take for a client with cirrhosis experiencing jaundice and pruritus?
Which action should the nurse take for a client with cirrhosis experiencing jaundice and pruritus?
What therapeutic response to furosemide should the nurse expect in a client with acute heart failure?
What therapeutic response to furosemide should the nurse expect in a client with acute heart failure?
Which intervention should the nurse include in the plan of care for a child with tetanus?
Which intervention should the nurse include in the plan of care for a child with tetanus?
Which occurrence is the most likely cause of diabetic ketoacidosis in an adolescent diagnosed with diabetes mellitus Type 1?
Which occurrence is the most likely cause of diabetic ketoacidosis in an adolescent diagnosed with diabetes mellitus Type 1?
After notifying the family of a client's impending death, what priority action should the nurse implement?
After notifying the family of a client's impending death, what priority action should the nurse implement?
Which self-care measure is most important for a client recently diagnosed with type 2 diabetes mellitus?
Which self-care measure is most important for a client recently diagnosed with type 2 diabetes mellitus?
What instruction should the nurse provide to a client who has decided to bottle feed after giving birth?
What instruction should the nurse provide to a client who has decided to bottle feed after giving birth?
Which recommendations should the nurse provide a client after a below-the-knee amputation?
Which recommendations should the nurse provide a client after a below-the-knee amputation?
Which type of testing should the nurse provide education about for a toddler with a milk allergy?
Which type of testing should the nurse provide education about for a toddler with a milk allergy?
Which intervention has the highest priority when preparing a client for a bronchoscopy?
Which intervention has the highest priority when preparing a client for a bronchoscopy?
What instruction should the nurse provide the UAP after beginning a blood transfusion with no indications of a reaction?
What instruction should the nurse provide the UAP after beginning a blood transfusion with no indications of a reaction?
Which intervention is most important for a client with multi-organ failure caused by a ruptured appendix?
Which intervention is most important for a client with multi-organ failure caused by a ruptured appendix?
To assess the quality of a client's pain for a headache, which approach should the nurse use?
To assess the quality of a client's pain for a headache, which approach should the nurse use?
Which action should the nurse take first for a client with leaking fluid and greenish-brown vaginal discharge?
Which action should the nurse take first for a client with leaking fluid and greenish-brown vaginal discharge?
What information should the nurse provide to a client asking about reducing risk factors for benign prostatic hyperplasia (BPH)?
What information should the nurse provide to a client asking about reducing risk factors for benign prostatic hyperplasia (BPH)?
The healthcare provider prescribes a fluid challenge of 0.9% sodium chloride 1,000 mL to be infused intravenously over 4 hours. The IV administration set delivers 10 gtt/mL. How many gtt/minute should the nurse regulate the infusion?
The healthcare provider prescribes a fluid challenge of 0.9% sodium chloride 1,000 mL to be infused intravenously over 4 hours. The IV administration set delivers 10 gtt/mL. How many gtt/minute should the nurse regulate the infusion?
Which assessment is most important for monitoring adverse effects from prasugrel in a client after cardiac catheterization?
Which assessment is most important for monitoring adverse effects from prasugrel in a client after cardiac catheterization?
Which information should the nurse include in a client's health record after a fall?
Which information should the nurse include in a client's health record after a fall?
Which subjective findings support the diagnosis of tuberculosis in a client with a positive skin test?
Which subjective findings support the diagnosis of tuberculosis in a client with a positive skin test?
What assessment data should the nurse obtain next for a client with type 1 diabetes mellitus who is lethargic and has rapid respirations?
What assessment data should the nurse obtain next for a client with type 1 diabetes mellitus who is lethargic and has rapid respirations?
What action should the nurse take first for a post-total abdominal hysterectomy client with a saturated pad and decreased urinary output?
What action should the nurse take first for a post-total abdominal hysterectomy client with a saturated pad and decreased urinary output?
Which action is most important for a nurse on a palliative care unit when facilitating continuity of care for a client who has requested no heroic measures?
Which action is most important for a nurse on a palliative care unit when facilitating continuity of care for a client who has requested no heroic measures?
Which intervention should the nurse implement for a client with heart failure and pulmonary edema who exhibits dependent peripheral edema?
Which intervention should the nurse implement for a client with heart failure and pulmonary edema who exhibits dependent peripheral edema?
In assessing a client with type 1 diabetes mellitus, sequence the actions the nurse should complete:
In assessing a client with type 1 diabetes mellitus, sequence the actions the nurse should complete:
Which finding may indicate an emerging situation for a client with type 2 diabetes mellitus?
Which finding may indicate an emerging situation for a client with type 2 diabetes mellitus?
What information should the nurse provide first to a healthcare provider when reporting a client who suddenly became confused after a fall?
What information should the nurse provide first to a healthcare provider when reporting a client who suddenly became confused after a fall?
Which intervention should the nurse implement for a client with an electrolyte imbalance and weight gain after burns?
Which intervention should the nurse implement for a client with an electrolyte imbalance and weight gain after burns?
Which nursing actions should the nurse assign to the PN?
Which nursing actions should the nurse assign to the PN?
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Study Notes
Assessment of Increased Intracranial Pressure
- Sluggish and unequal pupillary responses indicate heightened intracranial pressure in a child with bacterial meningitis.
Management of Acute Pancreatitis
- A client with acute pancreatitis often reports right upper quadrant pain radiating to the right scapula, typically worsened by certain positions.
Patient Education in Sickle Cell Anemia
- Essential instruction for parents includes the importance of adequate fluid intake for a child with sickle cell anemia.
Carotid Bruit Auscultation
- Auscultate for carotid bruit at the base of the neck on the right side.
Prioritizing Client Assessment
- In cases of suspected bowel obstruction due to volvulus, assess clients experiencing abdominal rigidity first.
Acid-Base Imbalance from Vaping
- A teenager presenting with anxiety and hyperventilation after vaping is likely to develop respiratory alkalosis.
Positioning for Dyspnea
- Position clients with dyspnea in a Fowler's position to facilitate easier breathing.
Blood Pressure Measurement in Parkinson's Disease
- Relevant factors include frequent syncope, flat affect, and blurred vision when measuring blood pressure in clients with Parkinson's disease.
Postoperative Care Considerations
- Before reporting purulent drainage from a wound, review the client’s culture for sensitive organisms to identify possible infections.
Addressing Trauma in Caregivers
- Engage the preadolescent brother of a near-drowning victim by asking how he felt during the incident, fostering emotional support.
Managing Jaundice in Cirrhosis
- Recommend cooler baths and the application of calamine lotion for clients with cirrhosis experiencing jaundice and pruritus.
Furosemide Effect in Heart Failure
- Expected therapeutic response to furosemide in acute heart failure includes reduced preload.
Care Plan for Tetanus
- Minimize stimuli in the environment of a child with tetanus to prevent exacerbating symptoms.
Diabetic Ketoacidosis Triggers
- Recent illnesses, such as cold and ear infections, can precipitate diabetic ketoacidosis in youths with Type 1 diabetes.
End-of-Life Care for DNR Patients
- Determine the client's need for pain medication as a priority when signs of impending death manifest.
Self-Care After Diabetes Diagnosis
- Blood glucose monitoring is critical for clients newly diagnosed with type 2 diabetes.
Breast Care for Postpartum Clients
- Advise applying ice to swollen breasts of a postpartum client choosing to bottle-feed to alleviate discomfort.
Recommendations for BKA Clients
- Use a residual limb shrinker, inspect skin for redness, and wash the stump with soap and water for clients post-below-the-knee amputation.
Allergy Testing Education
- Educate families on serum immunoglobulin E (IgE) testing for toddlers with suspected milk allergies.
Preparing for Bronchoscopy
- Prioritize instructing the client to document questions when preparing for bronchoscopy.
Monitoring Post-Transfusion Clients
- Ensure ongoing measurement of vital signs every thirty minutes during the transfusion to promptly detect reactions.
Sepsis Protocol for Multi-Organ Failure
- Maintain strict intake and output as a crucial intervention in a client with sepsis.
Pain Assessment Techniques
- Ask clients to describe the qualities of their pain for a thorough assessment.
Labor and Delivery Protocol
- Begin continuous fetal monitoring for clients leaking greenish-brown fluid to assess fetal well-being.
Reducing BPH Risk Factors
- Encourage increased physical activity as a strategy to mitigate risk factors for benign prostatic hyperplasia.
IV Infusion Rate Calculation
- For a 1,000 mL IV fluid challenge over four hours using a 10 gtt/mL set, the infusion rate is 42 gtt/min.
Monitoring for Medication Adverse Effects
- Observe urine color to identify potential adverse effects from prasugrel in clients post-cardiac catheterization.
Incident Documentation
- Document accurately that a client fell and sustained a fracture during unattended time to maintain care records.
Tuberculosis Diagnosis Indicators
- Mucopurulent cough and night sweats support the diagnosis of tuberculosis.
Blood Glucose Testing Priority
- If respiratory patterns change in a diabetic client, measure blood glucose levels next for immediate insight.
Post-Surgical Monitoring
- Assess for weakness or dizziness first in a client who has had a hysterectomy and shows signs of saturation in post-operative pads.
Continuity of Care in Palliative Settings
- Obtain a detailed report regarding a client transitioning to the palliative care unit to ensure accurate and ongoing care.
Interventions for Heart Failure
- An appropriate action after initiating telemetry and positioning in a client with heart failure is to obtain a sputum sample for analysis.
Sequencing Assessments in Myxedema Coma
- Prioritize observing breathing patterns, assessing blood pressure, measuring temperature, and palpating for edema in suspected myxedema coma.
Alert Symptoms for Diabetic Clients
- Numbness in fingertips may indicate an emerging critical situation in clients with diabetes.
Information Reporting Using SBAR
- Report the increasing confusion of a client immediately following a fall to ensure effective communication of critical health changes.
Monitoring for Electrolyte Imbalance
- Auscultate for irregular heart rates in clients showing weight gain and elevated CVP related to electrolyte imbalances from severe burns.
Delegating Tasks to Practical Nurses
- Appropriate tasks for practical nurses include administering sliding scale insulin, changing surgical dressings, and obtaining postoperative vital signs.
Exercise Recommendations for Osteoporosis
- Emphasize the importance of weight-bearing exercise in a routine aimed at preventing osteoporosis.
Evaluating CT Scan Concerns
- Follow up on a client's metformin use prior to contrast CT scans, as it may require specific pre-procedure protocols.
Diabetes Management Plan
- Include education on foot care, injection technique, and carbohydrate-controlled meal coordination in the care plan for a client with diabetes.### Nursing Care and Assessments
- Carbohydrate-controlled meals should be coordinated at consistent times to maintain stable blood glucose levels.
- Fingerstick glucose assessments should occur every 6 hours and correlate with meal timings.
Psychiatric Nursing Prioritization
- The most critical client needing immediate attention is an 18-year-old with antisocial behavior facing peer hostility.
Antepartum Care
- For a client with hyperemesis gravidarum, initiating prescribed intravenous fluids is crucial for managing dehydration and nourishment.
Pediatric Medication Education
- Parents should be advised to recognize bradycardia as a sign of propranolol overdose.
Mobility Assessment
- Upper body muscle strength is essential for determining the need for a trapeze bar in clients with mobility limitations.
Toilet Training Concerns
- It’s common for children to revert to earlier toileting behaviors during hospital stays; they typically resume normal habits post-discharge.
Delegation to Unlicensed Assistive Personnel
- UAP can report client complaints of pain, monitor weight gain, and note fluid intake during meals for clients with Cushing's syndrome.
Health History Focus
- A history of excessive alcohol consumption is significant for understanding a young adult's gastritis symptoms.
Evaluation of PPI Effectiveness
- After administering a proton pump inhibitor, inquiring about gastrointestinal pain is vital for evaluating effectiveness.
Postpartum Assessment
- A gravida 6, para 5 client experiencing more than expected vaginal bleeding warrants closer observation.
IV Site Assessment
- Immediate intervention is required for a client with red streaks tracking the vein above an IV site.
Emergency Scenario Prioritization
- For a client with abdominal pain and bowel obstruction, collect the emesis sample first, then elevate the head of the bed.
Peripheral Arterial Insufficiency History
- A history of intermittent claudication correlates directly with chronic peripheral arterial insufficiency.
Respiratory Postoperative Care
- Regular dental hygiene is essential for a child recovering from atrial septal defect repair to prevent infective endocarditis.
Staff Assignment in Infection Control
- A standard face mask suffices for a UAP caring for a client with droplet precautions related to influenza.
Tertiary Prevention Effectiveness
- Effective tertiary prevention programs for diabetes are indicated by timely rehabilitation for clients who develop complications.
Caregiver Support
- The highest priority nursing problem for an immobile client with fecal incontinence is addressing bowel incontinence.
Aspiration Precautions
- For a weak client with aspiration pneumonia, teaching deep breathing exercises is crucial when they cough while drinking.
Pain Management in Trauma
- Explain to clients requiring pain relief post-trauma that only non-narcotics can be administered before CT scans.
Caution with COPD Patients
- Administering narcotics for pain relief in clients with COPD requires heightened caution due to respiratory depression risks.
Monitoring for Extrapyramidal Symptoms
- Monitor for abnormal involuntary movements when a client receives haloperidol decanoate.
Risks of Long-term Oxygen Therapy
- Prolonged oxygen therapy can disrupt surfactant production, increasing the risk of respiratory complications.
Reporting Medication Side Effects
- Somnambulism as a side effect of ramelteon must be reported to the healthcare provider.
Incentive Spirometer Usage
- Clients should be reminded to cough after using an incentive spirometer to enhance lung clearance.
Exercise and Sleep Intervention
- Identify the client's specific exercise routine when discussing persistent sleep difficulties, as routines may affect sleep patterns.
Educational Material for Older Clients
- Education for older adults on antihypertensives should use simple language, illustrative pictures, and definitions of complex terms.
Pain Management in Peripheral Arterial Disease
- Cold packs should be suggested to relieve leg pain associated with rest ischemia in PAD.
Effectiveness of Herpes Zoster Treatment
- Evaluate skin integrity and functional ability when assessing treatment outcomes for clients with shingles.
Heparin Infusion Calculation
- The proper infusion rate for a heparin solution should be programmed according to the prescribed units per kg.
Importance of Evidence-Based Practice
- The most critical factor when gathering evidence for clinical decision-making is its relevance to the specific patient situation.
Attention to Gout and Medication Interactions
- Allopurinol should be flagged for clients with calcium kidney stones to prevent potential complications.
Management of Urinary Retention
- Encourage pelvic floor exercises regularly for clients experiencing urinary retention after receiving Botox injections for urge incontinence.
Post-Infection Assessment Reporting
- Swollen lymph nodes, elevated WBC, and core body temperature must be communicated to the healthcare provider for clients with infections.
Managing Food Aversions in Cancer Patients
- Encourage outdoor meal preparation to mitigate nausea triggered by cooking smells for cancer patients.
Proper Removal of PPE
- Gloves should be the first piece of personal protective equipment removed after patient care to prevent contamination.
Aging and Dietary Habits
- Compulsive food behaviors in older adults may intensify if they were prevalent in younger years, necessitating careful observation and support.
Monitoring Enoxaparin Effects
- Regular monitoring of the platelet count is essential for clients receiving enoxaparin to identify potential adverse effects.
Developmental Screening for Toddlers
- Administer the Modified Checklist for Autism in Toddlers (M-CHAT) for a 24-month-old exhibiting social and communicative challenges.
Legal Responsibility in Consent
- The nurse is responsible for confirming the surgical consent form is signed and recorded in the client's medical file.
Postoperative Complications of Hyperthyroidism
- A total calcium level of 5.0 mg/dL in a postoperative hyperthyroidism patient requires immediate nurse intervention.### Calcium Levels
- Total calcium level of 5.0 mg/dL indicates possible hypocalcemia, which requires further assessment and intervention.
Third Trimester Pregnancy
- Breast changes, including "lumpy places" and yellowish nipple discharge, may be normal.
- Normal secretions can be assessed at the next healthcare visit, no immediate intervention required.
Fall Risk Assessment in Older Adults
- Client living at home alone reports no falls, which may indicate a low risk but data collection should continue for accuracy in fall risk survey.
Anxiety Management
- Teaching should emphasize practicing muscle relaxation techniques alongside medication information.
Multiple Sclerosis and Immunizations
- Post-immunization symptoms like fatigue and visual issues can occur; it's important to advise rest as immunizations may trigger disease relapse.
Preterm Newborn Care
- Following surfactant administration, monitoring arterial blood gases is crucial to assess respiratory function.
Heart Sounds in Pregnancy
- Auscultation of an S3 heart sound should be documented; this may be a normal finding associated with increased blood volume.
Post-Amputation Client Support
- Encourage the young male client to discuss feelings regarding limb loss to support emotional health.
HIV Treatment Considerations
- Client's willingness to adhere to complex medication schedules is key in determining the initiation of a multi-drug cocktail for HIV therapy.
Seizure Management
- During a tonic-clonic seizure, loosen clothing, ease the client to the floor, and document seizure duration; do not restrain the client.
Suicidal Client Assessment
- Understand the last time the client took bipolar medication is crucial for patient safety and treatment planning.
Diet and Nutrition for Wound Healing
- A lunch choice that includes high protein (e.g., tuna fish sandwich) indicates effective dietary teaching for wound recovery.
Breast Cancer Awareness Program
- Involving community leaders in program planning is essential for the success of health promotion initiatives for at-risk populations.
IV Catheter Irrigation Preparation
- Suggest using a larger gauge needle (20-gauge) for intravenous catheter procedures to enhance infusion efficacy.
Skin Care Priority in Elderly Clients
- Focus on clients with damp sheets due to incontinence for prioritized skin care to prevent pressure injuries.
Glaucoma Surgery Impact
- Increased surgical procedures for glaucoma lead to a decreased prevalence of the condition in the population.
Domestic Abuse Intervention
- Explore the client's readiness to discuss the abusive situation first to gauge emotional safety and readiness for intervention.
Fluid Management for Edema
- Administering prescribed diuretics is essential for managing weight gain, pitting edema, and crackles in the lungs.
Chest Tube Monitoring
- Continuous bubbling in the water-seal chamber indicates a possible air leak and requires immediate nursing intervention.
Lab Value Monitoring in Psychiatry
- Rapid speech and decreased sleep point to a possible manic episode; review lab values for Divalproex for therapeutic response.
Meningitis Treatment Monitoring
- A normal electroencephalogram after administering phenytoin indicates a therapeutic effect for the client with bacterial meningitis.
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