Nursing Assessment and Care Quiz

<p>Monitoring infant's temperature to prevent hyperthermia. (A), Keeping the infant's head covered with a cap to prevent heat loss. (B), Covering the infant's eyes to protect them from the light. (D)</p> Signup and view all the answers

<p>The client's report of right upper abdominal pain. (D)</p> Signup and view all the answers

<p>Instruct the parents to ensure the child's hair is clean and free of conditioner before the procedure. (D)</p> Signup and view all the answers

<p>Use a syringe to allow the medications to flow by gravity. (A)</p> Signup and view all the answers

<p>Raised facial rash (B)</p> Signup and view all the answers

<p>Instruct the client to empty her bladder prior to the procedure. (D)</p> Signup and view all the answers

<p>I will need to keep my hand elevated above my heart for several days. (B)</p> Signup and view all the answers

<p>Obtain vital signs including blood pressure and temperature. (A)</p> Signup and view all the answers

<p>Wear a splint as prescribed. (D)</p> Signup and view all the answers

<p>Offer to take pictures of the newborn for the client. (C)</p> Signup and view all the answers

<p>Plan to take this medication with food. (B)</p> Signup and view all the answers

<p>Prealbumin (D)</p> Signup and view all the answers

<p>A client who has a hip fracture and a new onset of tachypnea. (D)</p> Signup and view all the answers

<p>A client who has a new onset of atrial fibrillation and a heart rate of 160/min (B)</p> Signup and view all the answers

<p>Monitor the client's partial thromboplastin time (PTT) every 6 hours. (C)</p> Signup and view all the answers

<p>Monitor blood glucose levels before each meal and at bedtime. (C)</p> Signup and view all the answers

<p>Respiratory rate (C)</p> Signup and view all the answers

<p>The client reports pain in the lower abdomen and has a temperature of 101.2°F (38.4°C). (A)</p> Signup and view all the answers

<p>The client reports a headache and body aches. (D)</p> Signup and view all the answers

<p>Notify the provider of the client's fever. (B)</p> Signup and view all the answers

<p>The client's breast and abdominal pain. (A)</p> Signup and view all the answers

<p>Acute myocardial infarction (AMI). (A)</p> Signup and view all the answers

<p>FHR baseline 170/min (D)</p> Signup and view all the answers

<p>Determine if the client's health care surrogate is aware of the risks and benefits of the procedure. (C)</p> Signup and view all the answers

<p>Request a female interpreter through the facility. (A)</p> Signup and view all the answers

<p>Deep tendon reflex 3+ bilaterally (A), Right upper abdominal pain (B), 1+ dependent edema noted bilaterally (D), 0.68 kg (1.5 lb) weight gain in one week (F)</p> Signup and view all the answers

<p>Monitor blood pressure (C), Prepare for delivery (G)</p> Signup and view all the answers

<p>Platelet count 98,000/mm3 (B)</p> Signup and view all the answers

<p>Place the client in Trendelenburg position. (A)</p> Signup and view all the answers

<p>Consume foods high in potassium. (A)</p> Signup and view all the answers

<p>Placental abruption (A), Fetal growth restriction (B), Premature delivery (C), Eclampsia (D), Fetal demise (F)</p> Signup and view all the answers

<p>The child usually has an aura prior to onset. (B)</p> Signup and view all the answers

<p>Contact the healthcare provider for a prescription for a more potent medication (A), Elevate the head of the bed (C), Apply a cold compress to the forehead (E)</p> Signup and view all the answers

<p>I should wash my hands for 10 seconds with hot water after working in the garden. (B)</p> Signup and view all the answers

<p>Administer an antiemetic (A), Avoid spicy and fatty foods (C), Encourage frequent small meals (D)</p> Signup and view all the answers

<p>Using an electronic messaging system to remind clients when to take medications. (D)</p> Signup and view all the answers

<p>Increase fetal heart rate monitoring (A)</p> Signup and view all the answers

<p>Obesity (B), Hypertension (D), Diabetes (E)</p> Signup and view all the answers

<p>Limit the time your infant feeds to 10 minutes on each breast. (D)</p> Signup and view all the answers

<p>ICP is often associated with a decrease in heart rate. (D)</p> Signup and view all the answers

<p>Feed on demand, noting cues like rooting, sucking, and crying. (C)</p> Signup and view all the answers

Offer to take pictures of the newborn for the client during grieving.

Instruct clients to take phenytoin with food to reduce gastrointestinal upset.

A nursing finding indicating concentrated urine, report if above normal range.

Plan to assess the client with new onset tachypnea first.

Identify factors that may contribute to increased infections.

Assess clients with weakness post-epidural, as it may cause complications.

Review key client conditions before taking over care.

Assess clients for symptoms and complications linked to C. diff infections.

Before an EEG, ensure the child's hair is clean and free of conditioner.

Flush the NG tube with 15-30 mL water between medications to avoid reactions.

Expected finding includes a raised facial rash in clients with lupus.

Clients should empty their bladder before a paracentesis procedure.

Client should keep their hand elevated above the heart for several days post-surgery.

The affected hand should not be used for 4 to 6 weeks after surgery.

Headache, nausea, vomiting, and right upper abdominal pain are signs needing follow-up.

A restless state in a pregnant client could indicate distress and should be monitored.

Indicates possible cardiac issues; can suggest myocardial infarction.

A drop in blood pressure upon standing, causing dizziness.

Nurse's priority is to assess pain and patterns before intervention.

A baseline FHR of 170/min indicates potential distress in labor.

Use professional interpreters to ensure understanding and safety.

Ensure client's health care surrogate understands risks and benefits.

Client's right to refuse treatment must be documented.

Assess symptoms like body aches and chills to differentiate infections.

A woman who is pregnant for the first time and has not yet delivered.

Swelling of the face often linked to fluid retention or high blood pressure during pregnancy.

An exaggerated reflex reaction indicating possible neurological or metabolic issues.

Elevated blood pressure that may indicate hypertension, particularly in pregnancy.

A person giving a kidney to a recipient while still alive; must meet health criteria.

Testing performed on newborns to detect genetic disorders early.

Measurement of protein in urine, where elevated levels may indicate kidney issues in pregnancy.

A procedure to obtain amniotic fluid for testing, often performed when fetal abnormalities are suspected.

Interventions aimed at reducing the impact of an already established disease.

Start breastfeeding when the infant shows signs of hunger.

Recognizing which activities are safe during pregnancy related to infections.

Type of seizure that may appear as daydreaming, often lasting 30-60 seconds.

Dietary instruction for clients to manage kidney health, including protein intake.

Positioning to relieve cord compression in labor.

Understanding limitations on potassium intake in chronic kidney disease.

Steps to take following open gastric bypass surgery for recovery and health.

Temperature 37° C, HR 92/min, RR 24/min, BP 156/96 mm Hg, O2 sat 94%.

WBC count at 1100 was 12,500 mm3, within normal limits (5,000 to 15,000 mm3).

Platelet count was low at 98,000/mm3 (Normal: 150,000 to 400,000/mm3).

The nurse should ensure the newborn wears a diaper during phototherapy.

Characteristics include impulsive behavior and possible self-harm.

For older adults, assess skin turgor on the neck.

Advise to consume foods high in bran fiber for irritable bowel syndrome.

Nurses can assign basic tasks like monitoring vital signs to AP.