Untitled Quiz

Questions and Answers

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)

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?

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?

Gloves Signup and view all the answers

What should the nurse's response be to the daughter of a retired chef who is becoming increasingly obsessed with food preparation?

If the client was compulsive about food when he was younger, the aging process can magnify this Signup and view all the answers

Which serum laboratory value is most important for the nurse to monitor in a client receiving enoxaparin?

Platelet count Signup and view all the answers

Which assessment should the nurse administer for a 24-month-old toddler with sensory sensitivity and social interaction difficulties?

The Modified Checklist for Autism in Toddlers (M-CHAT) Signup and view all the answers

What is the nurse's legal responsibility regarding obtaining written consent for surgery?

Determine that the surgical consent form has been signed and is included in the client's record Signup and view all the answers

Which client's serum laboratory value requires intervention by the nurse after a subtotal thyroidectomy?

Total calcium 5.0 mg/dL Signup and view all the answers

What should the nurse explain to a client who feels lumpy places in her breasts during pregnancy?

Explain that this normal secretion can be assessed at the next visit. Signup and view all the answers

What action should the nurse take for an older client reporting living at home alone and no history of falls?

Continue to obtain client data needed to complete the fall risk survey Signup and view all the answers

Which instruction should the nurse include when teaching a client with recurrent anxiety?

Practice using muscle relaxation techniques Signup and view all the answers

What should the nurse teach a young woman with multiple sclerosis experiencing fatigue after immunizations?

Immunizations can trigger a relapse of the disease, so get plenty of extra rest Signup and view all the answers

After administering surfactant to a preterm newborn, which assessment should the nurse monitor?

Arterial blood gases Signup and view all the answers

What should the nurse do after auscultating an S3 heart sound in a client in their third trimester of pregnancy?

Document in the client's record Signup and view all the answers

What intervention should the nurse implement for a young male client following a right above-knee amputation who reports an aching sensation?

Encourage discussion of feelings about the loss of his limb Signup and view all the answers

What is the most crucial nursing assessment for an asymptomatic HIV-infected client considering a multi-drug therapy?

Willing to comply with complex drug schedules Signup and view all the answers

Which actions should the nurse implement for a client experiencing a tonic-clonic seizure? (Select all that apply)

Ease the client to the floor Signup and view all the answers

What is the most important information for the nurse to obtain from a client who took a handful of medications?

When the client last took drugs for bipolar disorder Signup and view all the answers

Which lunch choice indicates effective teaching regarding a high-protein diet for wound healing?

A tuna fish sandwich with chips and ice cream Signup and view all the answers

Which resource is most important for designing a health promotion project for African-American women at risk for breast cancer?

Participation of community leaders in planning the program Signup and view all the answers

What action should the charge nurse implement for a new nurse preparing to irrigate an intravenous catheter?

Suggest the nurse use a 20-gauge needle Signup and view all the answers

Which client should the unlicensed assistive personnel prioritize skin care for based on the Braden Scale?

An older man whose sheets are damp each time he is turned Signup and view all the answers

What effect is likely to result from an increased number of elderly persons undergoing glaucoma surgeries?

Decreased prevalence of glaucoma in the population Signup and view all the answers

What action should the nurse take first for a client afraid of her abusive boyfriend?

Explore the client's readiness to discuss the situation Signup and view all the answers

What intervention should be included in the plan of care for a client with assessment findings indicating fluid overload?

Administer prescribed diuretic Signup and view all the answers

Which finding in the chest tube drainage system requires nurse intervention?

Continuous bubbling in the water-seal chamber Signup and view all the answers

Which laboratory value is most important for the nurse to review for a client demonstrating rapid speech and other manic symptoms?

Divalproex Signup and view all the answers

What assessment finding indicates a therapeutic response in a client with bacterial meningitis receiving phenytoin?

Normal electroencephalogram after drug administration Signup and view all the answers

What should the nurse administer for a client with Type 2 DM?

insulin per sliding scale Signup and view all the answers

What is the primary action after an abdominal hysterectomy?

perform daily surgical dressing change Signup and view all the answers

What should be obtained postoperatively for a client after unilateral knee arthroplasty?

vital signs Signup and view all the answers

Which type of regular activity should the nurse emphasize for osteoporosis?

Weight-bearing exercise Signup and view all the answers

Which information in the client's history requires follow-up prior to a CT scan with contrast?

Takes metformin for type 2 diabetes mellitus Signup and view all the answers

What actions should the nurse include in a care plan for a client with Type 2 DM? (Select all that apply)

Fingerstick glucose assessments every 6h with meals Signup and view all the answers

Which client requires the nurse's immediate attention on the adolescent unit?

An 18yo client with antisocial behavior who is being yelled at by other clients Signup and view all the answers

What is the most important action for a nurse to implement for a client admitted with hyperemesis gravidarum?

Initiate prescribed intravenous fluids Signup and view all the answers

What sign of overdose should parents report for a child taking propranolol?

Bradycardia Signup and view all the answers

What is the most important client assessment before obtaining a trapeze bar for limited mobility?

Upper body muscle strength Signup and view all the answers

What should the nurse tell the parents of a toilet-trained child who regresses in behavior after hospitalization?

Children usually resume their toileting behaviors when they leave the hospital. Signup and view all the answers

Which nursing interventions should be delegated to unlicensed assistive personnel (UAP) for a client with Cushing's syndrome?

Note and report the client's food and liquid intake during meals and snacks Signup and view all the answers

What historical information should the nurse address for a client with gastritis?

Consumes 10 or more drinks of alcohol every weekend Signup and view all the answers

After administering a proton pump inhibitor (PPI), what should the nurse do to evaluate its effectiveness?

Ask the client about gastrointestinal pain Signup and view all the answers

What factor in a multigravida client's history correlates with excessive vaginal bleeding after delivery?

She is a gravida 6, para 5 Signup and view all the answers

What additional assessment finding requires immediate intervention when a client complains of tenderness at an IV site?

Red streaks tracking the vein Signup and view all the answers

What should the nurse do first for an older adult male with abdominal pain and other concerning symptoms?

send emesis sample to the lab Signup and view all the answers

Which information collected by the nurse is most directly related to chronic peripheral arterial insufficiency?

History of intermittent claudication Signup and view all the answers

What is the most important information for parents of a child recovering from an atrial septal defect repair?

Brush the child's teeth every day and ensure the child receives regular dental follow-up Signup and view all the answers

What action should a nurse take when a UAP requests reassignment due to lack of N95 fit testing?

Instruct the UAP that a standard face mask is sufficient for the provision of care for the assigned client Signup and view all the answers

Which outcome indicates the effectiveness of a tertiary prevention program for type 2 diabetes?

Clients who developed disease complications promptly received rehabilitation Signup and view all the answers

What is the highest priority problem for a client who is immobile and has been experiencing fecal incontinence?

Bowel incontinence Signup and view all the answers

What intervention should the nurse implement for an older adult with aspiration pneumonia drinking through a straw?

Teach coughing and deep breathing exercises Signup and view all the answers

What is the next step when a client requests stronger medication after taking acetaminophen for headache?

Explain the reason for using only non-narcotics Signup and view all the answers

What nursing intervention requires the greatest caution for a client with COPD?

Administering narcotics for pain relief Signup and view all the answers

What should the nurse implement for a client receiving haloperidol decanoate who develops facial grimacing?

Complete abnormal involuntary movement scale (AIMS) Signup and view all the answers

Prolonged exposure to high concentrations of supplemental oxygen can cause which effect?

Disrupted surfactant production Signup and view all the answers

Which side effect of ramelteon should a nurse report?

Somnambulism Signup and view all the answers

What should the nurse instruct a client using an incentive spirometer after a return demonstration?

Remind the client to cough after using the spirometer Signup and view all the answers

What action should a nurse take for a client who's working out with a personal trainer but still has sleep issues?

Ask the client for a description of the exercise schedule that is being followed Signup and view all the answers

What should educational materials for older clients include?

Uses common words with few syllables Signup and view all the answers

What action should the nurse take for a client with severe PAD who experiences rest ischemia?

Offer cold packs when the pain occurs Signup and view all the answers

Which assessments should a nurse include when evaluating treatment effectiveness for a client with Herpes zoster?

Pain scale Signup and view all the answers

How many mL/hour should a nurse program the infusion pump for a client receiving a heparin infusion?

18 Signup and view all the answers

When gathering evidence for clinical decision-making, which consideration is most important?

Relevance to the situation Signup and view all the answers

Which medication should the nurse bring to the healthcare provider's attention for a client with calcium kidney stones and gout?

Allopurinol Signup and view all the answers

What should be included in the care plan for a client with urge incontinence who is now experiencing urinary retention?

Teach the client techniques for performing intermittent catheterization Signup and view all the answers

Which assessment finding is evidence that the child is experiencing increased intracranial pressure (ICP)?

Sluggish and unequal pupillary responses Signup and view all the answers

Which additional information is the client most likely to report to the nurse with acute pancreatitis?

Abdominal pain decreases when lying supine Signup and view all the answers

Which information is most important for the nurse to provide the parents prior to discharging a child newly diagnosed with sickle cell anemia (SCA)?

Instructions about how much fluid the child should drink daily Signup and view all the answers

To auscultate for a carotid bruit, the nurse places the stethoscope at what location?

The base of the neck on the right side. Signup and view all the answers

After receiving report on an inpatient acute care unit, which client should the nurse assess first?

The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity Signup and view all the answers

The client presenting to the emergency department with palpitations after vaping is likely to develop which acid-base imbalance?

Respiratory alkalosis Signup and view all the answers

To best prepare for a client with dyspnea's arrival, the nurse should ensure that the client's bed is in which position?

Fowlers Signup and view all the answers

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?

Flat affect Signup and view all the answers

Before reporting the finding of purulent drainage at a wound to the healthcare provider, which laboratory values should the nurse review?

Culture for sensitive organisms Signup and view all the answers

Which action should the nurse take for the older brother of a child who was resuscitated after near-drowning?

Ask the older brother how he felt during the incident Signup and view all the answers

Which action should the nurse take for a client with cirrhosis experiencing jaundice and pruritus?

Encourage the client to use cooler water and apply calamine lotion after soaking Signup and view all the answers

What therapeutic response to furosemide should the nurse expect in a client with acute heart failure?

Reduced preload Signup and view all the answers

Which intervention should the nurse include in the plan of care for a child with tetanus?

Minimize the amount of stimuli in the room Signup and view all the answers

Which occurrence is the most likely cause of diabetic ketoacidosis in an adolescent diagnosed with diabetes mellitus Type 1?

Had a cold and ear infection for the past two days Signup and view all the answers

After notifying the family of a client's impending death, what priority action should the nurse implement?

The client's need for pain medication should be determined Signup and view all the answers

Which self-care measure is most important for a client recently diagnosed with type 2 diabetes mellitus?

Blood glucose monitoring Signup and view all the answers

What instruction should the nurse provide to a client who has decided to bottle feed after giving birth?

Apply ice to the breasts for comfort Signup and view all the answers

Which recommendations should the nurse provide a client after a below-the-knee amputation?

Inspect skin for redness Signup and view all the answers

Which type of testing should the nurse provide education about for a toddler with a milk allergy?

Serum immunoglobulin E (IgE) Signup and view all the answers

Which intervention has the highest priority when preparing a client for a bronchoscopy?

Instruct client to write down the questions Signup and view all the answers

What instruction should the nurse provide the UAP after beginning a blood transfusion with no indications of a reaction?

Continue to measure the client's vital signs every thirty minutes until the transfusion is complete Signup and view all the answers

Which intervention is most important for a client with multi-organ failure caused by a ruptured appendix?

Maintain strict intake and output Signup and view all the answers

To assess the quality of a client's pain for a headache, which approach should the nurse use?

Ask the client to describe the pain Signup and view all the answers

Which action should the nurse take first for a client with leaking fluid and greenish-brown vaginal discharge?

Begin continuous fetal monitoring Signup and view all the answers

What information should the nurse provide to a client asking about reducing risk factors for benign prostatic hyperplasia (BPH)?

Increase physical activity Signup and view all the answers

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?

42 gtt/min Signup and view all the answers

Which assessment is most important for monitoring adverse effects from prasugrel in a client after cardiac catheterization?

Observe color of urine Signup and view all the answers

Which information should the nurse include in a client's health record after a fall?

The client fell sustaining a fracture to the left hip Signup and view all the answers

Which subjective findings support the diagnosis of tuberculosis in a client with a positive skin test?

Mucopurulent cough and night sweats Signup and view all the answers

What assessment data should the nurse obtain next for a client with type 1 diabetes mellitus who is lethargic and has rapid respirations?

Blood glucose Signup and view all the answers

What action should the nurse take first for a post-total abdominal hysterectomy client with a saturated pad and decreased urinary output?

Assess for weakness or dizziness Signup and view all the answers

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?

Obtain a detailed report from the nurse transferring the client Signup and view all the answers

Which intervention should the nurse implement for a client with heart failure and pulmonary edema who exhibits dependent peripheral edema?

Obtain sputum sample Signup and view all the answers

In assessing a client with type 1 diabetes mellitus, sequence the actions the nurse should complete:

Observe breathing patterns = 1 Assess blood pressure = 2 Measure body temperature = 3 Palpate for pedal edema = 4 Signup and view all the answers

Which finding may indicate an emerging situation for a client with type 2 diabetes mellitus?

Fingertips feel numb Signup and view all the answers

What information should the nurse provide first to a healthcare provider when reporting a client who suddenly became confused after a fall?

Increasing confusion of the client Signup and view all the answers

Which intervention should the nurse implement for a client with an electrolyte imbalance and weight gain after burns?

Auscultate for irregular heart rate Signup and view all the answers

Which nursing actions should the nurse assign to the PN?

Perform daily surgical dressing change for a client who had an abdominal hysterectomy Signup and view all the answers

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.

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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