Nursing Assessment and Patient Care

Questions and Answers

What type of care should be initiated for a client whose caregiver requests adult day care services?

PACE

Which of the following findings should the nurse identify as an adverse effect of captopril to report to the provider?

Blurred vision

Polyuria

Tinnitus

Cough (correct)

Which instruction should the nurse include for a client with a fracture of the right fibula?

Use a three-point gait. (correct)

Adjust the crutches for comfort as needed.

Wear leather-soled shoes.

Advance the affected leg first when walking upstairs.

What is the priority action for a nurse caring for a client who had abdominal surgery 24 hours ago?

Assist with deep breathing and coughing. Signup and view all the answers

Which prescription for a postoperative client is contraindicated?

Ondansetron 4 mg PO for nausea. Signup and view all the answers

What indicates a client's understanding of advance directives?

I can designate my partner as my health care surrogate. Signup and view all the answers

What should the nurse assess first for a client who is 48 hours postoperative following a laryngectomy?

Determine the client's reading skills. Signup and view all the answers

The client is at highest risk for developing _ as evidenced by the _ following a total thyroidectomy.

hypocalcemia; report of numbness around lips Signup and view all the answers

What statement indicates altruism by a client in therapy?

I told my doctor that I would like to start a support group for other women who are sick in my community. Signup and view all the answers

Which child should the nurse assess first?

10-year-old child awaiting appendectomy surgery with sudden pain relief. Signup and view all the answers

What should the nurse do when suspecting physical abuse in a child with scald burns?

Contact Child Protective Services. Signup and view all the answers

Which action should the nurse plan when administering an IM injection to an obese client?

Use the ventrogluteal site. Signup and view all the answers

Select the 4 client findings that indicate a thyroid storm.

Temperature Signup and view all the answers

Which newly licensed nurse action requires intervention?

Starts a task then determines what supplies are needed. Signup and view all the answers

Which finding should the nurse identify as an adverse effect of amitriptyline?

Blurred vision Signup and view all the answers

What indicates understanding of asthma management in a parent?

I will make sure my child receives a yearly influenza immunization. Signup and view all the answers

What behavior should the nurse expect in a child with autism spectrum disorder?

Strict adherence to routines. Signup and view all the answers

What action should the nurse take for a client with active pulmonary tuberculosis?

Assign the client to a private room with negative air pressure. Signup and view all the answers

The client is at risk for experiencing _ due to the client’s _ during pregnancy.

metabolic acidosis; weight loss Signup and view all the answers

Health care personnel can proceed with necessary life-saving care when a client is unable to give informed consent in an emergency due to implied consent.

True Signup and view all the answers

What is the nurse's priority activity for a client with a new diagnosis of type 1 diabetes mellitus?

Ensure that the client understands the medication regimen. Signup and view all the answers

Select the 3 findings that require immediate follow-up for a client in a mental health clinic.

Speech Signup and view all the answers

What is the priority step of the time management process that should be included when teaching newly licensed nurses?

Making a list of activities to complete. Signup and view all the answers

What action should the nurse take before performing a paracentesis?

Instruct the client to void. Signup and view all the answers

Which of the following statements by the client indicates an understanding of the teaching regarding common discomforts associated with pregnancy?

I will wear a supportive bra overnight. Signup and view all the answers

What action should the nurse take for a client recently started on risperidone?

Implement fall precautions for the client. Signup and view all the answers

What condition is the client most likely experiencing based on the symptoms?

Intestinal obstruction Signup and view all the answers

Which action should the nurse take for a client receiving chemotherapy and has neutropenia?

Avoid including raw fruits in the client's diet. Signup and view all the answers

Select the statements that indicate understanding of newborn care.

I will use the bulb syringe first in her mouth and then in her nose. Signup and view all the answers

What should a nurse do when preparing to administer insulin via a pen device?

Hold the insulin pen device perpendicular to the client's skin to inject the medication. Signup and view all the answers

Which question should the nurse ask to assess for an adverse effect of ibuprofen in an adolescent with juvenile idiopathic arthritis?

Have you had any stomach pain or bloody stools? Signup and view all the answers

What intervention should a nurse plan for a client with a magnesium level of 2.7 mEq/L?

Initiate continuous cardiac monitoring. Signup and view all the answers

The client is at greatest risk for developing ________ as evidenced by electrolyte imbalance.

dysrhythmias Signup and view all the answers

Which finding indicates that the use of ginger tea is effective for a pregnant client?

The client reports a decrease in episodes of nausea. Signup and view all the answers

Which finding should the nurse report for a newborn after delivery?

Nasal flaring. Signup and view all the answers

What finding indicates the therapy of packed RBCs has been effective?

Hemoglobin 14.9 g/dL Signup and view all the answers

Which nutrient should a nurse instruct a client with Crohn's disease to decrease?

Fiber. Signup and view all the answers

Which variable should the nurse include as a risk factor for osteoporosis in older adults?

Sedentary lifestyle Signup and view all the answers

According to Nägele's rule, what is the estimated date of birth for a client with the LMP of May 8?

February 15. Signup and view all the answers

Which alteration in speech indicates the client with bipolar disorder is using?

Flight of ideas Signup and view all the answers

What task should a nurse delegate to an assistive personnel (AP)?

Arrange the lunch tray for a client who has a hip fracture. Signup and view all the answers

What action should a nurse take when transferring a stroke patient to a rehabilitation facility?

Facilitate an interdisciplinary conference at the new facility for the family. Signup and view all the answers

Which actions should the nurse take when caring for a postpartum client who indicates signs of hemorrhage?

Firmly massage the uterine fundus. Signup and view all the answers

The client is at risk for developing due to .

spinal shock, autonomic dysreflexia. Signup and view all the answers

Which statement indicates that the family understands home hospice care?

We can expect the hospice nurse to provide support for us after our mother's death. Signup and view all the answers

Which action should the nurse take regarding the continuous passive motion (CPM) machine?

Turn off the CPM machine during mealtime. Signup and view all the answers

What finding should prompt a referral for occupational therapy for a stroke patient?

Difficulty performing ADLs. Signup and view all the answers

In which situation should the RN intervene when observing an LPN and AP moving a client?

The LPN and AP grasp the client under his arms to lift him up in bed. Signup and view all the answers

The nurse should first address the client's followed by the client's .

oxygen saturation, urinary output. Signup and view all the answers

What should a nurse identify as an adverse effect of epinephrine?

Report of chest pain. Signup and view all the answers

Which task should the nurse assign to the member of the group functioning as the orienteer?

Noting the progress of the group toward assigned goals. Signup and view all the answers

What intervention should the nurse include in the care plan for a client with left-sided weakness after a stroke?

Support the client's left arm on a pillow while sitting. Signup and view all the answers

What action should the nurse take for a client with immunosuppression and a continuous IV infusion?

Monitor the client's mouth every 8 hr. Signup and view all the answers

Which client should the nurse assess first?

A client who is postoperative with abdominal distention and no bowel sounds Signup and view all the answers

Match the assessment findings with the appropriate disorder:

Intellectual impairment = Intellectual disability (ID) Interrupting others = Attention Deficit Hyperactivity Disorder (ADHD) Impaired language skills = ADHD Hyperreactivity to sensory input = ADHD Losing necessary things = ADHD Signup and view all the answers

Which statement indicates an understanding of isolation precautions?

A client who requires airborne precautions should be placed in a negative-pressure airflow room. Signup and view all the answers

What isolation precautions should be initiated for a client with pneumonia?

Droplet Signup and view all the answers

Which manifestation of ovarian cancer should the nurse include in teaching?

Abdominal bloating Signup and view all the answers

Identify the acid-base imbalance for a client with pH 7.2, PaCO2 60 mm Hg, and HCO3- 25 mEq/L.

Respiratory acidosis Signup and view all the answers

Which prescription should the nurse clarify for a client with type 1 diabetes and ankle pain?

Apply a cold pack to the client's ankle for 30 min every hour. Signup and view all the answers

What action should the nurse take to prevent TB transmission?

Have the client wear a surgical mask while being transported outside the room. Signup and view all the answers

Informed consent promotes which ethical principle?

Autonomy Signup and view all the answers

Which adverse effect should the nurse monitor for in a client taking valproic acid?

Jaundice Signup and view all the answers

Which potential provider prescription is anticipated for a client post-stroke?

Oxygen therapy to keep oxygen saturation above 95%. Signup and view all the answers

Calculate the manual IV infusion gtt/min for 1,500 mL at 50 mL/hr using 15 gtt/mL.

12.5 Signup and view all the answers

Which statement about basal body temperature method of birth control is true?

Your body temperature might decrease slightly just prior to ovulation. Signup and view all the answers

What action should be included in the care plan for a child with cystic fibrosis?

Administer high-dose antibiotic therapy. Signup and view all the answers

What finding is expected in a client with pulmonary edema?

Pink, frothy sputum Signup and view all the answers

How should the nurse maintain sterile technique during a dressing change?

Maintain sterile objects within the line of vision. Signup and view all the answers

What action should the nurse take for a client with rheumatoid arthritis?

Allow for frequent rest periods throughout the day. Signup and view all the answers

In caring for a client with sickle cell disease, which interventions should be implemented? (Select all that apply)

Administer IV fluids. Signup and view all the answers

Which client should the nurse attend to first?

An older adult client who is anxious and attempting to pull out an IV line Signup and view all the answers

For which client should the home health nurse initiate a referral to PACE?

An older adult client with complex care needs. Signup and view all the answers

Why should the nurse turn off the CPM machine during meals?

To promote client comfort and dietary intake Signup and view all the answers

Which client should the nurse recommend for discharge?

A client who has cellulitis and is receiving oral antibiotics every 8 hr Signup and view all the answers

Which instructions should the nurse include in the teaching for a child's medication?

Report diarrhea to the provider immediately. Signup and view all the answers

What is an indication of potential violence in a client?

Pacing around the chair Signup and view all the answers

Which client should the nurse recommend for treatment first?

A middle adult client who has unstable vital signs Signup and view all the answers

When should the nurse initiate a request for a high-frequency chest compression vest?

When the client has only a small amount of mucus after percussion therapy Signup and view all the answers

Which client should the nurse intervene to prevent a potential food and medication interaction?

A client who is receiving an MAOI and is requesting a cheeseburger for dinner Signup and view all the answers

What is a potential adverse effect of PEEP?

Tension pneumothorax Signup and view all the answers

Why should the nurse assess the amount of vaginal bleeding in a client in the fourth stage of labor?

To identify potential hemorrhage Signup and view all the answers

Which discharge instructions are recommended for a client with hyperemesis gravidarum?

Alternate eating solid foods and liquids Signup and view all the answers

What food recommendations should the nurse make for a client taking phenelzine?

Yogurt Signup and view all the answers

What information should the nurse include in the change-of-shift report?

The time of the client's last dose of pain medication Signup and view all the answers

What is the first action the nurse should take in an emergency situation?

Survey the scene for potential hazards Signup and view all the answers

What task should the nurse delegate to an assistive personnel (AP)?

Measure the client's daily weight Signup and view all the answers

What is the priority intervention for a client with a fever and fluid-filled vesicles?

Initiate transmission-based precautions Signup and view all the answers

What is the risk for the client with a history of seizure activity?

Seizures Signup and view all the answers

What is the characteristic of a client with borderline personality disorder?

Emotional instability and self-harming behaviors Signup and view all the answers

What is the amount of mannitol the nurse should administer?

18g Signup and view all the answers

Which site should the nurse select for IV access in an older adult client?

Radial vein of the inner arm Signup and view all the answers

What is the nurse's response to the client's statement about their family?

How does this make you feel? Signup and view all the answers

What is the indication that the medication is effective?

Decreased hallucinations Signup and view all the answers

What information should the nurse include in the teaching for a client with total parenteral nutrition?

I will need to measure your weight daily Signup and view all the answers

What should the nurse do in an emergency situation when unable to locate the client's family?

Proceed with provision of medical care Signup and view all the answers

Study Notes

Change-of-Shift Report

Prioritize assessment of postoperative clients with abdominal distention and absent bowel sounds, indicating potential paralytic ileus.
Stable clients, like those with blood glucose levels of 105 mg/dL, may be assessed later.

ADHD vs Intellectual Disability

Key indicators for ADHD include hyperreactivity, disorganization (losing items), and interrupting others.
Intellectual disability may encompass similar deficits, particularly in cognitive function and language skills.

Infection Control Education

Understanding that airborne precautions must be followed for clients with conditions like tuberculosis requires a negative-pressure room.
Droplet precautions are necessary for clients with measles or pneumonia, using surgical masks as needed.

Ovarian Cancer Signs

Abdominal bloating is an early sign of ovarian cancer; other signs include changes in bowel habits and urinary symptoms.

Acid-Base Imbalances

A pH of 7.2, PaCO2 of 60 mm Hg indicates respiratory acidosis, necessitating recognition of these abnormalities in acid-base balance.

Type 1 Diabetes Management Post-Injury

Cold therapy is contraindicated in clients with diabetes due to impaired circulation risks.
Regular neurovascular checks and blood glucose monitoring are critical after injuries.

Tuberculosis Precautions

Clients with active TB should wear masks when outside their rooms to minimize transmission risks to others.

Informed consent promotes client autonomy, giving them the right to make informed decisions regarding their treatment plans.

Valproic Acid Adverse Effects

Monitor for signs of jaundice as a potential indicator of liver damage in clients taking valproic acid for seizures.

Neurological Assessment and Care

Anticipate monitoring oxygen saturation and blood glucose levels in patients exhibiting signs of increased intracranial pressure.
Cluster nursing care is contraindicated due to risks of exacerbating increased ICP.

IV Infusion Calculations

Calculate and set IV drip rates accurately, ensuring proper adjustments for patient needs.

Basal Body Temperature Method

Educate clients that body temperature may drop slightly before ovulation, assisting them in tracking fertility cycles.

Cystic Fibrosis Care

High-dose antibiotics are essential due to the metabolic needs of children with cystic fibrosis facing infections.

Recognizing Pulmonary Edema

Expect pink, frothy sputum in clients with pulmonary edema due to fluid accumulation in the lungs.

Maintaining Sterile Technique

Keep sterile items within the direct line of vision to uphold aseptic conditions during procedures.

Rheumatoid Arthritis Pain Management

Encourage rest periods interspersed with activity to manage joint pain effectively in rheumatoid arthritis clients.

Sickle Cell Crisis Management

Administer IV fluids rapidly to alleviate crisis symptoms and utilize humidification with oxygen therapy to ensure comfort.

Client Prioritization in Nursing

Address safety concerns first, prioritizing clients who are anxious and attempting to remove IV lines.

Referral to PACE Program

Initiate PACE referrals for older adults needing adult day care services, which align with comprehensive elder care objectives.

Captopril Adverse Effects

A persistent cough is a significant side effect of captopril that requires communication to the healthcare provider.

Crutch Training for Fracture Management

Instruct clients to use a three-point crutch gait to ensure mobility without pressure on the injured limb.

Postoperative Care Priorities

Encourage deep breathing exercises post-abdominal surgery to prevent complications such as pneumonia and promote lung expansion.### Postoperative Care
Deep breathing and coughing exercises reduce the risk of postoperative pneumonia.
Key assessments post laparoscopic cholecystectomy include alertness, incision site status, and auscultation of lung sounds.
Dressings should be clean, dry, and intact; change when soiled.
Educate on symptoms to report: swelling, redness, drainage, or warmth at the incision site.

Provider Prescriptions

Apply heat for abdominal pain related to carbon dioxide retention.
Encourage deep breathing exercises hourly to aid recovery.
Ondansetron for nausea should be provided as needed, not on a scheduled basis.

Advance Directives Education

Client can designate a partner as their health care surrogate, showcasing understanding of advance directives.
Younger clients may underestimate the importance of planning for future health care.

Postoperative Laryngectomy Care

Assess reading skills first to tailor communication methods for a patient unable to speak after a laryngectomy.

Risk Assessment Post Thyroidectomy

Watch for hypocalcemia indicated by muscle cramps and numbness around the lips following thyroid surgery.
Immediate treatment with calcium gluconate required to prevent complications.

Altruism in Cancer Care

Proactive behavior, such as starting a community support group, illustrates altruism in patients coping with breast cancer.

Pediatric Assessment Prioritization

Sudden relief of pain in a child awaiting appendectomy can signal a serious condition like peritonitis; assess this patient first.

Suspected Child Abuse Protocol

Legally required to report suspected physical abuse to Child Protective Services—do not confront the parents directly.

Intramuscular Injection Guidelines

Opt for the ventrogluteal site for IM injections in obese clients, as it avoids large nerves and vessels.

Indicators of Thyroid Storm

Monitor for increased temperature, heart rate, blood pressure changes, and alterations in mental status after thyroid surgery.

New Nurse Performance Evaluation

Interventions needed when a new nurse starts a task without adequate preparation, compromising time management.

Adverse Effects of Amitriptyline

Blurred vision should be monitored as an adverse effect of amitriptyline.

Asthma Management Education

Ensure annual influenza vaccination to reduce infection risk in children with asthma.

Autism Spectrum Disorder Characteristics

Expect strict adherence to routines and rituals in children on the autism spectrum.

Tuberculosis Infection Control

Assign clients with active pulmonary tuberculosis to a private room with negative air pressure to prevent disease transmission.

Monitor for metabolic acidosis in pregnant clients experiencing significant weight loss and inadequate nutritional intake.

Common Pregnancy Discomforts

Wearing a supportive bra overnight can alleviate discomfort associated with breast changes during pregnancy.

Intestinal Obstruction Identification

Signs include abdominal distension, hypoactive bowel sounds, and prolonged absence of bowel movements; requires IV fluids and semi-Fowler's positioning for relief.### Bowel Sounds and Urine Output Monitoring
Assess bowel sounds a minimum of twice daily to check for peristalsis return.
Monitor urine output closely in clients receiving IV fluids.
Dehydration is a key manifestation of intestinal obstruction.

Hip Joint Abduction

Hip joint abduction occurs when the leg moves away from the body's midline during assessment.

Chemotherapy and Neutropenia Care

Exclude raw fruits and vegetables from the client's diet to minimize bacterial infection risk.
Limit visits from young children to reduce exposure risk.
Measure client’s temperature per shift.

Ibuprofen Adverse Effects

Assess for stomach pain or bloody stools to identify potential gastrointestinal bleeding caused by ibuprofen.

Postoperative Risk Assessment

Client post CABG at risk for dysrhythmias due to hypokalemia evidenced by lab results showing low potassium levels and muscle cramping.
Monitor electrolyte levels closely following CABG surgery.

Ginger Tea Effectiveness

A decrease in episodes of nausea indicates the effectiveness of ginger tea in pregnant clients.

Effectiveness of Packed RBC Therapy

A hemoglobin level of 14.9 g/dL indicates that packed RBC therapy was successful in elevating low hemoglobin.

Osteoporosis Risk Factors

Sedentary lifestyle recognized as a significant risk factor for osteoporosis; encourage weight-bearing exercises in older adults.

Alterations in Speech in Bipolar Disorder

Flight of ideas is characterized by continuous speech with rapid and frequent topic switching.

Neuroleptic Malignant Syndrome Management

Conditions likely indicating neuroleptic malignant syndrome include muscle rigidity, diaphoresis, and altered vital signs.
Hold antipsychotic medications and provide cooling interventions; monitor hydration status and temperature.

Intracranial Pressure Mitigation

Keeping the client's environment quiet helps reduce the risk of increased intracranial pressure.

Hospice Care Understanding

Expect ongoing support from hospice services post-death; importance of bereavement care.

Advocacy in Nursing

Advocacy empowers clients to self-actualize; view it as a leadership role encouraging personal growth.

Postpartum Hemorrhage Interventions

Immediate actions include massaging the uterine fundus, administering methylergonovine, weighing perineal pads, providing emotional support, and administering oxygen.

Continuous Passive Motion Machine Use

The CPM machine should be switched off during meal times to enhance comfort while eating.

Client Discharge Decisions

Clients receiving oral antibiotics for cellulitis can be safely discharged, whereas others may need continued hospital care.

Discharge Instructions for Amoxicillin/Clavulanate

Shake the medication well before administering, store it in the refrigerator, and report diarrhea to the provider.

Monitoring for Violence in Mental Health

Pacing around a partner during a visit can indicate potential for violent behavior; closer assessment and de-escalation are needed.

Triage Prioritization in Emergency

Clients with unstable vital signs require immediate treatment due to the risk of severe complications or death.

Cystic Fibrosis and Airway Clearance

Recommend a high-frequency chest compression vest for children who achieve inadequate results with standard therapies.

Preventing Food and Medication Interactions

Clients on MAOIs should avoid tyramine-rich foods like cheeseburgers to prevent hypertensive crises.

Adverse Effects of PEEP

Tension pneumothorax is a potential adverse effect of positive end-expiratory pressure (PEEP); monitoring lung sounds for warning signs is crucial.

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Description

This quiz assesses nursing knowledge on postoperative care, ADHD and intellectual disability, infection control, ovarian cancer signs, and acid-base imbalances.