Nursing Milestone Review
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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?

    <p>Use a Doppler to assess bilateral pedal pulses.</p> 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?

    <p>Swallowing ability.</p> Signup and view all the answers

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

    <p>Earache</p> Signup and view all the answers

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

    <p>Increase calcium intake</p> 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?

    <p>Increase the flow of the bladder irrigation</p> Signup and view all the answers

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

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

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

    <p>Lower the head of the chair and elevate feet</p> Signup and view all the answers

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

    <p>Lipase</p> 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?

    <p>Level of consciousness</p> Signup and view all the answers

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

    <p>Determine if the client received anesthesia during delivery</p> Signup and view all the answers

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

    <p>Reconnect the tube to low suction</p> 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?

    <p>Suggest that the family bring foods from home that the client enjoys eating</p> 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?

    <p>Provide supportive silence while the client speaks</p> Signup and view all the answers

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

    <p>Assess for other symptoms like dizziness or palpitations</p> 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?

    <p>Administer oxygen as prescribed</p> Signup and view all the answers

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

    <p>Palpate the bladder for fullness</p> 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?

    <p>Increased intracranial pressure</p> 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?

    <p>Uric acid levels</p> 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?

    <p>Presence of bowel sounds</p> Signup and view all the answers

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

    <p>A client with a urinary tract infection</p> 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?

    <p>Administer an IV PRN anti-anxiety medication.</p> 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?

    <p>Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus.</p> 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?

    <p>Obtain a capillary blood glucose level.</p> Signup and view all the answers

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

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

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

    <p>Promptly collect another COVID-19 test sample.</p> Signup and view all the answers

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

    <p>Administering sedatives for anxiety relief.</p> 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?

    <p>Obtain the client's signature before surgery.</p> Signup and view all the answers

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

    <p>Evaluate the need for adjustment of antihypertensive medication.</p> 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?

    <p>Ensure the client is isolated in their room.</p> 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?

    <p>Performing neurological checks.</p> Signup and view all the answers

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

    <p>Low protein, high carbohydrate, low sodium, low potassium</p> Signup and view all the answers

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

    <p>Elevate and immobilize right knee in a flexed position</p> Signup and view all the answers

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

    <p>Was physically abused by his mother</p> 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?

    <p>Review eye pressure measurements</p> Signup and view all the answers

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

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

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

    <p>Apply cold compresses to reduce swelling</p> Signup and view all the answers

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

    <p>Visual fields testing results</p> Signup and view all the answers

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

    <p>Increase potassium in the diet</p> Signup and view all the answers

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

    <p>Providing individual counseling support</p> Signup and view all the answers

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

    <p>Decreased intraocular pressure</p> 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.

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