Nursing Milestone Review

Questions and Answers

Which intervention should be implemented to help prevent osteoporosis in a client who had bariatric surgery?

Identify foods high in vitamin D. (correct)

Discuss importance for vitamin A.

Encourage increased intake of milk. (correct)

Administer supplemental iron.

What should be the nurse's first intervention for an older client with a change in mental status?

Check accuracy of medication list.

Insert an indwelling Foley catheter.

Establish mental status baseline.

Obtain a capillary blood glucose level. (correct)

What is the most important factor influencing the frequency of vital sign assessment in the immediate postoperative period?

Staffing considerations.

Unit policy and procedures.

Client’s condition. (correct)

Healthcare provider's prescription.

In the case of an older client who fell and presents with symptoms of an altered extremity, what action is paramount?

Use a Doppler to assess bilateral pedal pulses. Signup and view all the answers

When assessing a newly admitted client with Parkinson’s disease who has a mask-like facial appearance, which assessment should be prioritized?

Swallowing ability. Signup and view all the answers

What recent history should the nurse anticipate in a child suspected of having bacterial meningitis?

Earache Signup and view all the answers

Which instruction should the nurse provide to a menopausal client to lower her risk of developing osteoporosis?

Increase calcium intake Signup and view all the answers

What is the best initial nursing action when observing an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation after TURP?

Increase the flow of the bladder irrigation Signup and view all the answers

Which information should be included in the teaching plan for a client recently diagnosed with gout?

Fluid intake should increase to at least 3 liters per day Signup and view all the answers

During the first hemodialysis treatment, if a client's blood pressure drops significantly, what should the nurse do?

Lower the head of the chair and elevate feet Signup and view all the answers

Which laboratory test should the nurse review to monitor the recovery of a client with acute pancreatitis?

Lipase Signup and view all the answers

After administering hydromorphone to a post-operative client, which assessment should be completed next given the client’s low blood pressure?

Level of consciousness Signup and view all the answers

What should the charge nurse do first for a postpartum client reporting a severe headache?

Determine if the client received anesthesia during delivery Signup and view all the answers

What should the nurse initiate first after clamping a nasogastric tube and the client begins to vomit?

Reconnect the tube to low suction Signup and view all the answers

How should the nurse respond to a family's concern about an older client with difficulty in visual perception eating only half of the meal provided?

Suggest that the family bring foods from home that the client enjoys eating Signup and view all the answers

What is the most appropriate action for a nurse caring for a client with schizophrenia who is using tangential speech?

Provide supportive silence while the client speaks Signup and view all the answers

What intervention should the nurse prioritize for a client experiencing a significant blood pressure drop during dialysis?

Assess for other symptoms like dizziness or palpitations Signup and view all the answers

Which action is most appropriate for a nurse when a post-operative client shows signs of respiratory depression after receiving pain medication?

Administer oxygen as prescribed Signup and view all the answers

What is a critical nursing intervention when a client receiving continuous bladder irrigation reports abdominal pain?

Palpate the bladder for fullness Signup and view all the answers

In managing a client with suspected meningitis, which complication would be most concerning to the nurse if an earache is reported?

Increased intracranial pressure Signup and view all the answers

What should a nurse monitor closely for a patient diagnosed with gout who is prescribed a high-protein diet?

Uric acid levels Signup and view all the answers

When caring for a client with a nasogastric tube who is experiencing nausea, what should the nurse assess before taking further action?

Presence of bowel sounds Signup and view all the answers

In which scenario is it most appropriate for the nurse to educate a client about increasing fluid intake?

A client with a urinary tract infection Signup and view all the answers

What is the first intervention the nurse should implement for a client with Guillain-Barre syndrome who is experiencing anxiety and weakness?

Administer an IV PRN anti-anxiety medication. Signup and view all the answers

What action is the nurse's priority after obtaining a negative COVID-19 test result and a client presents with new symptoms eight days later?

Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus. Signup and view all the answers

For an older client with a change in mental status after nausea and vomiting, what should the nurse implement first?

Obtain a capillary blood glucose level. Signup and view all the answers

What information during the preoperative checklist would require the nurse to take immediate action?

Preoperative serum potassium level is 2.8 mEq/L. Signup and view all the answers

How should the nurse prioritize care for a client with COVID-19 symptoms after a previous negative test?

Promptly collect another COVID-19 test sample. Signup and view all the answers

When caring for a client with Guillain-Barre syndrome, which action should be avoided until further evaluation?

Administering sedatives for anxiety relief. Signup and view all the answers

What should the nurse do after completing a surgical checklist and finding that a client's surgical consent form is unsigned?

Obtain the client's signature before surgery. Signup and view all the answers

If a client with a history of hypertension vomits for two days, what is the most relevant intervention?

Evaluate the need for adjustment of antihypertensive medication. Signup and view all the answers

In response to a client with COVID-19 symptoms showing up after a negative test, which precaution should the nurse prioritize?

Ensure the client is isolated in their room. Signup and view all the answers

What is the priority assessment for a client who has just developed a severe headache along with a change in mental status?

Performing neurological checks. Signup and view all the answers

What type of diet should be instructed for a client experiencing acute renal failure?

Low protein, high carbohydrate, low sodium, low potassium Signup and view all the answers

What is the best initial intervention for a 12-year-old boy with hemophilia experiencing hemarthrosis?

Elevate and immobilize right knee in a flexed position Signup and view all the answers

Which factor in the pushed employee's history is most related to his aggressive reaction?

Was physically abused by his mother Signup and view all the answers

What is the most appropriate action to evaluate the effectiveness of pilocarpine ophthalmic solution in a client with open-angle glaucoma?

Review eye pressure measurements Signup and view all the answers

What assessment technique should a nurse perform if unable to palpate the testicles in a newborn scrotum?

Use a fingertip to palpate the inguinal canal for a weakening or indentation Signup and view all the answers

What is the priority nursing intervention for a child with hemophilia during an episode of hemarthrosis?

Apply cold compresses to reduce swelling Signup and view all the answers

In the management of open-angle glaucoma, what should be considered when evaluating the effectiveness of treatment?

Visual fields testing results Signup and view all the answers

Which intervention is inappropriate for a client with acute renal failure?

Increase potassium in the diet Signup and view all the answers

What is a recommended strategy to reduce aggression in an employee following a stressful incident?

Providing individual counseling support Signup and view all the answers

What clinical finding would indicate successful administration of pilocarpine for glaucoma?

Decreased intraocular pressure Signup and view all the answers

Study Notes

Pediatric Considerations

Suspected bacterial meningitis typically presents with a recent history of earache.
A 12-year-old boy with hemophilia may experience severe knee pain due to hemarthrosis; intervention includes elevating and immobilizing the knee.

Menopause and Osteoporosis

Menopausal clients who are lactose intolerant should increase calcium intake to lower the risk of osteoporosis.

Dialysis Management

In hemodialysis, if a client's blood pressure drops significantly, the nurse should lower the head of the chair and elevate the feet to stabilize BP.

Acute Pancreatitis Recovery

In patients with acute pancreatitis, lipase levels should be monitored to assess clinical recovery following reduced abdominal pain.

Post-Delivery Monitoring

A new mother reporting severe headache post-delivery requires immediate assessment to determine if she received anesthesia during delivery.

Dietary Management in Mental Health

Clients with schizophrenia on acute renal failure may benefit from a low protein, high carbohydrate, and low sodium diet.

Visual and Nutritional Issues

In older clients with visual perception issues post-CVA, engaging with familiar food options may help improve eating habits.

Gout Management

Important advice for gout management includes increasing fluid intake to at least 3 liters daily and avoiding certain foods high in purines.

Postoperative Care

In post-operative clients, especially those receiving opioids, first assess the level of consciousness if hypotension and decreased respiratory rate are noted.

COVID-19 Protocols

For clients with negative COVID-19 test results but symptomatic later, it is essential to maintain distance, wear a mask, and follow exposure reporting guidelines.

Medication and Mental Status

In older clients with changes in mental status after nausea and vomiting, first obtain a capillary blood glucose level to rule out hypoglycemia.

Preoperative Assessments

Immediate interventions prior to surgery include ensuring all consent forms are signed and addressing abnormal laboratory values, such as low potassium levels.

Fall Risk and Assessment

In older clients with signs of a possible hip fracture, prioritizing assessment of blood flow and pedal pulses in the affected limb is crucial for timely intervention.

Parkinson’s Disease Management

For clients with Parkinson’s disease exhibiting a mask-like facial appearance, assessing swallowing ability is important to prevent aspiration risks.

Infection in Diabetic Patients

Diabetic patients admitted with respiratory infections require careful monitoring of their symptoms and management of underlying conditions.

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Description

This quiz assesses nursing knowledge regarding common conditions such as bacterial meningitis and menopause-related osteoporosis risk. Participants will answer questions related to clinical symptoms and lifestyle recommendations for clients. Prepare to test your understanding of essential nursing practices.