Questions and Answers
Which actions should the nurse take for a client experiencing a postpartum hemorrhage? (Select all that apply)
Which data collection findings should the nurse report to the provider prior to surgery? (Select all that apply)
To which interprofessional team member should the nurse refer a client who is experiencing difficulty using eating utensils?
Occupational therapist
Which client condition should be reported to a regulatory agency?
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What should the nurse include with the discharge report for a client recovering from a cerebrovascular accident?
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What statement by the parent indicates an understanding of teaching about lactose intolerance?
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What indicates that a client understands the teaching about managing type 1 diabetes?
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What finding should the nurse expect in a client with iron deficiency anemia?
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Which immunization is contraindicated for an immunocompromised client?
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What method should the nurse use when communicating with a client who has expressive aphasia?
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What action should the nurse take after accidentally brushing the needle on the counter's surface?
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Which technique should the nurse use to elicit the Babinski reflex in a newborn?
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What should the nurse do first when a client questions an unfamiliar medication?
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What therapeutic response should the nurse make to a client accusing them of stealing?
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What instruction should the nurse give about safe lifting technique?
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What infection control precautions should be instructed for a client with hepatitis A?
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What finding should the nurse expect in a client who has multiple sclerosis?
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What response should the nurse provide to a client stressed about a tumor diagnosis?
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What factor should the nurse consider when using the FLACC scale for an infant's pain level?
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What manifestation indicates increased intracranial pressure in a school-age child?
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What position should the nurse place a client undergoing thoracentesis?
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What statement indicates understanding of the DASH diet?
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What action should the nurse take for a client in labor with spontaneous rupture of membranes?
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What information should the nurse share about puberty with prepubescent female clients?
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What priority action should the nurse take for a client experiencing a situational crisis?
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When bottle feeding a newborn with formula, how often should the newborn be fed?
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Which food contains the highest amount of protein that the nurse should recommend for a client with HIV?
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What statement indicates effective coping by a family of a client with terminal cancer?
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What action should the nurse take for a terminally ill client practicing Orthodox Judaism?
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Which strategies should be included for managing pediculosis capitis? (Select all that apply)
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What adverse effect should the nurse monitor in a client postoperative following a cholecystectomy after receiving morphine?
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What laboratory result should the nurse report before administering gentamicin?
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What snack should the nurse offer to an older adult client experiencing difficulty sleeping?
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What instruction should the nurse give a client about self-administering epoetin alfa?
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Which client should the LPN ask to have reassigned to an RN?
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What communication technique lets the client know that their concerns and feelings are heard?
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What should the nurse maintain to keep the urine diluted to a reddish-pink color after a transurethral resection of the prostate (TURP)?
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Which action by a newly licensed nurse demonstrates sterile technique when applying sterile gloves?
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What is a recommended choice for reducing solid fat consumption?
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What task should the charge nurse delegate to the LPN regarding a stroke patient?
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What statement indicates possible financial maltreatment?
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What diagnostic test should a nurse expect for a client with symptoms of bacterial meningitis?
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What are advance directives?
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What should be done when washing hands with soap and water?
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What statement by a client indicates a delusion?
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What position should a nurse keep a client in after a tonic-clonic seizure?
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What is the first action a nurse should take for a client after a bronchoscopy?
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What position should a client be assisted into for a lumbar puncture?
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What type of precautions should a nurse initiate for a client with rubeola?
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What finding indicates digoxin has been effective in a client with heart failure?
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What urine specific gravity should a nurse expect from a client with diabetes insipidus?
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What should a nurse instruct a client to do during a 12-lead ECG?
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What is the appropriate method for inserting a rectal suppository in a school-age child?
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What heart rate finding should the nurse report to the provider for a preschooler?
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What statement indicates a client understands the use of an ipratropium inhaler?
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What finding should a nurse report when inspecting a newborn's skin?
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What equipment should be placed in a client's room who has a history of seizures?
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What position should a chest tube drainage system be in relative to the client's chest?
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What factor increases a person's risk of experiencing partner violence?
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What is a recommended strategy for managing anxiety?
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What is a common adverse effect following a lumbar puncture?
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What question should a nurse ask first when a client is in severe pain?
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What medication should be readily available for a postpartum client with a deep-vein thrombosis?
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What is an example of assault in a healthcare setting?
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What priority finding should be reported for a school-age child with cystic fibrosis?
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When transferring a client with right-sided weakness to a wheelchair, where should the nurse place the wheelchair?
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What therapeutic effect should a nurse teach about low-dose aspirin in a client with coronary artery disease?
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Which raw food contains the highest amount of water per 1 cup serving?
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What statement should the nurse make regarding fat intake for weight loss?
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What type of client should a nurse recommend for discharge during a natural disaster situation?
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What should a nurse provide to a client scheduled for a nonstress test (NST)?
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An LPN is allowed to reinforce teaching once the plan has been established.
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What should a nurse tell a client with type 2 diabetes about weight gain during pregnancy?
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What action should a nurse take with a client who has Alzheimer's disease?
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What information should be included in a weekly nursing care summary for an older adult client?
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What indicates a client's understanding of taking ferrous sulfate elixir?
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What should the charge nurse do regarding an assistive personnel's repeated failure to provide oral care?
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What is the first step a nurse should take for a child with a minor burn?
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What intervention should be included in the care plan for a client following a TURP?
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What should the nurse advise regarding a newborn's crib placement?
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What should a client with tuberculosis understand about the people they live with?
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Which client should the nurse recommend for treatment first?
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What should a nurse do when performing postmortem care for a client?
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What should a nurse do for a client with viral meningitis?
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What instruction should be given to a client with severe left-sided heart failure?
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Which over-the-counter medication should a client taking captopril avoid?
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What ECG finding should the nurse report for telemetry monitoring?
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What finding indicates a urinary tract infection?
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Which urinalysis results indicate follow-up for a urinary tract infection?
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What is a leading cause of urosepsis in a client with a history of catheterization?
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What advice should a nurse give to prevent urinary tract infections?
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What prescriptions should the nurse anticipate for a client with a urinary tract infection?
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What findings indicate treatment has been effective for a urinary tract infection?
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What should a nurse document if a patient doesn't meet critical pathway goals?
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What adventitious lung sound should a nurse document when hearing a high-pitched, crowing sound?
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Where should a nurse look to find information about a client's personal health insurance?
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What should a nurse say to prepare a preschooler for an IM immunization?
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Which client should a nurse see first?
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The nurse will administer _____ mL of amoxicillin for each dose if the prescription is 875 mg PO every 12 hr.
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What component of a Tourette syndrome prescription should the nurse question?
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What action indicates a client understands how to use an incentive spirometer?
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What is the nurse's response to a client doubting surgery will help?
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Study Notes
Postpartum Care and Hemorrhage
- Large amounts of lochia rubra and a boggy fundus indicate possible postpartum hemorrhage.
- Actions for nurse: massage the uterine fundus, administer methylergonovine, weigh perineal pads, provide emotional support, insert urinary catheter, and administer oxygen at 12 L/min via nonrebreather mask.
- Immediate intervention is crucial to prevent hemorrhagic shock.
Preoperative Considerations
- Important data to report prior to surgery includes hemoglobin level, any allergies (especially latex), and family history of malignant hyperthermia.
- Hemoglobin levels below normal might necessitate blood products during surgery.
- All latex products must be removed if the client has a latex allergy.
Interprofessional Referrals
- Clients with difficulty using eating utensils post-stroke require a referral to an occupational therapist for adaptive strategies.
Reportable Conditions
- Tuberculosis is a communicable disease that must be reported to local health authorities.
Discharge Instructions
- Include a list of potential complications in discharge instructions for safe home care post-cerebrovascular accident.
Lactose Intolerance
- Probiotic-rich yogurt is beneficial for children with lactose intolerance, aiding in lactose digestion.
Diabetes Management
- Clients with type 1 diabetes must check blood sugar levels during decreased appetite to prevent hyperglycemia.
Anemia Symptoms
- Difficulty concentrating is a common finding in clients with iron deficiency anemia due to impaired oxygen delivery caused by low hemoglobin levels.
Immunization Guidelines
- The MMR vaccine is contraindicated for immunocompromised clients due to the live virus.
Communication Techniques
- For clients with expressive aphasia, using a picture board aids communication by providing a non-verbal means to express needs.
Medication Preparation
- If a needle touches an unsterile surface, a new dose of insulin must be prepared to ensure sterility.
Reflex Testing in Infants
- Elicit the Babinski reflex by stroking the sole of the newborn's foot upward towards the great toe.
Medication Queries
- Always verify medication prescriptions in the client's medical record when there is uncertainty about a drug's identification.
Therapeutic Communication
- Encourage the client to discuss their feelings and perceptions regarding accusations, validating their concerns.
Safe Lifting Techniques
- Advise clients to hold objects close to their body to prevent injury while lifting.
Infection Control
- Use contact precautions for clients with hepatitis A who are incontinent of stool.
Multiple Sclerosis Expectations
- Expect ataxia in clients with multiple sclerosis, alongside other symptoms like fatigue and memory issues.
Coping with Grief
- Reminiscing about positive past experiences can aid family members in coping with terminal illness.
Orthodox Jewish Practices
- Ensure that a family member will remain with the deceased until burial, respecting cultural and religious practices.
Pediculosis Capitis Management
- Effective strategies include storing clothing separately at school, boiling combs for sanitation, and drying linens at high temperatures.
Postoperative Monitoring
- A respiratory rate of 10/min indicates respiratory depression, a potential adverse effect of morphine administration.
Renal Function Monitoring
- Report a creatinine level of 2.5 mg/dL prior to gentamicin administration due to nephrotoxicity risks.
Sleep Disturbances in Older Adults
- Offer carbohydrate-rich snacks like whole grain crackers before bedtime to promote better sleep.
Epoetin Alfa Administration
- Reinforce that epoetin alfa should be self-administered via the subcutaneous route.
Scope of Practice for Nursing Staff
- LPNs should not develop teaching plans, such actions should be reassigned to registered nurses.
Weight Gain during Pregnancy
- Advise clients with diabetes that recommended weight gain during pregnancy remains the same as for clients without diabetes.
Alzheimer's Disease Care
- Facilitating reminiscence about the past can help clients with Alzheimer's cope with memory loss.
Weekly Nursing Care Summary
- Hydration status should be closely monitored and documented in older adults to prevent dehydration.
Iron Supplement Instructions
- Patients taking ferrous sulfate should be instructed to rinse their mouth after dosage to prevent staining.### Charge Nurse Responsibilities
- Discuss inappropriate actions with the assistive personnel (AP) and clarify care expectations.
- Evaluate AP performance as part of the nurse's delegation responsibilities.
- Teaching and counseling are crucial in nursing leadership.
Pediatric Burn Care
- First step: clean the burn with mild soap and tepid water to eliminate possible infectious material.
- Remove embedded debris to prevent infection and promote healing.
- Apply antimicrobial ointment to minimize infection risk.
- Cover with a gauze dressing to keep the area protected.
- Educate parents about the dressing change schedule post-discharge.
TURP Care
- Irrigate the bladder with sterile technique to lower infection risk post-transurethral resection of the prostate (TURP).
Newborn Safety Instructions
- Place the baby’s crib away from heat sources to prevent risks like fire and strangulation.
Tuberculosis Understanding
- Family members should be tested for tuberculosis due to its contagious nature.
Prioritizing Treatments in Urgent Care
- Immediate treatment is required for clients experiencing shortness of breath, potentially indicating anaphylaxis after amoxicillin intake.
Postmortem Care
- Ensure the client’s eyelids are gently closed for proper presentation to family members.
Isolation for Viral Meningitis
- Place clients with viral meningitis in private rooms to limit viral transmission.
Heart Failure Patient Education
- Advise clients with severe heart failure to rest for 15 minutes between activities to manage fatigue.
Hypertension Medication Guidance
- Instruct clients on captopril to avoid ibuprofen as it diminishes the medication's effectiveness.
ECG Interpretation
- A PR interval of 0.24 seconds indicates a heart block and should be reported to the provider.
Urinary Tract Infection Indicators
- Symptoms indicating a UTI include frequency, dysuria, and urgency.
Urinalysis Follow-Up
- Positive nitrites, leukocyte esterase, WBC, and RBC in urinalysis results suggest a UTI and require follow-up.
Urosepsis Risk Factors
- Prior catheterization increases the risk of developing urosepsis.
Preventing Future UTIs
- Advise clients to avoid irritants like coffee and alcohol and suggest showering instead of bathing to limit bacteria exposure.
- Emphasize proper perineal hygiene and regular voiding to prevent bladder distention.
Expected Prescriptions for UTI Treatment
- Anticipate prescriptions for phenazopyridine and sulfamethoxazole, along with a urine culture and sensitivity test.
Signs of Effective UTI Treatment
- Effective treatment indicated by reports of discomfort-free urination and clear urine.
Postoperative Monitoring
- Document any variances in vital signs and patient status that deviate from the critical pathway guidelines.
Stridor Identification
- High-pitched crowing sound during inhalation should be noted as stridor in lung assessments.
Health Insurance Information Location
- The client's admission sheet contains details about personal health insurance.
Pediatric Injection Preparation
- Use play therapy when preparing preschoolers for procedures to reduce anxiety.
Client Prioritization in Care Settings
- Attend to clients with pneumonia showing confusion first due to the potential decrease in oxygenation.
Medication Dosage Calculation
- For amoxicillin 875 mg, the administration amount is 11 mL based on provided concentrations.
Medication Dosage Confirmation
- Query the dosage strength and amount prescribed for haloperidol to ensure accurate medication reconciliation.
Incentive Spirometer Use
- Correct use involves inhaling deeply to elevate the cylinder of the spirometer.
Addressing Client Concerns
- Reflecting doubt about surgical benefits acknowledges client feelings and promotes therapeutic communication.
Continuous Bladder Irrigation Protocol
- Maintain the irrigation flow rate to ensure urine remains a diluted reddish-pink color to monitor for bleeding/clots.
Sterile Technique in Gloving
- Donning the glove on the dominant hand first is essential for maintaining sterile technique during procedures.
Reducing Solid Fat in Diet
- Instruct clients to choose loin cuts of beef to minimize saturated fats in their diet.
Assigning Tasks to LPN
- Administering initial NG tube feeding is within the LPN’s scope and should be reassigned from assistive personnel.
Identifying Possible Financial Maltreatment
- Recognizing control over a client's finances indicates potential financial abuse and warrants further investigation.
Diagnostic Tests for Meningitis
- Expect cerebrospinal fluid analysis for clients exhibiting signs of bacterial meningitis.
Advance Directives Explanation
- Advance directives serve as written instructions for end-of-life care when the client can no longer make decisions.
Hand Hygiene Guidelines
- Emphasize the importance of removing rings during handwashing for effective hygiene practices.### Schizophrenia
- Delusion of persecution: Belief that harm is intended by others using unrealistic means, exemplified by the statement about lasers in glasses.
Seizure Management
- Post-ictal care: After a tonic-clonic seizure, keep the client in a side-lying position to allow secretions to drain and prevent aspiration.
Bronchoscopy Aftercare
- First priority: Check for the client's gag reflex to minimize the risk of aspiration post-bronchoscopy.
Lumbar Puncture Positioning
- Positioning: Assist the client into the lateral recumbent position for optimal needle placement during lumbar puncture.
Rubeola Precautions
- Airborne transmission: Implement airborne precautions, including a private room with negative-pressure airflow and N95 respirators for healthcare workers.
Heart Failure Treatment
- Effectiveness of digoxin: A decrease in cardiac workload signifies the medication's effectiveness by improving heart conduction and reducing oxygen demand.
Diabetes Insipidus
- Expected urinary findings: Anticipate urine specific gravity of 1.002 or lower, with a typical presentation of colorless urine.
ECG Procedure
- Client instructions: Advise the client to remain still during a 12-lead ECG to avoid inaccuracies due to motion artifacts.
Pediatric Suppository Administration
- Technique for insertion: Use a single finger to insert the rectal suppository past the anal sphincters for proper administration.
Pediatric Heart Rate Monitoring
- Reporting vital signs: A heart rate of 146/min in preschoolers exceeds normal limits and requires reporting to the provider.
Asthma Inhaler Use
- Ipratropium inhaler instructions: Instruct the client to wait 1 minute between puffs to allow for better medication absorption.
Newborn Skin Assessment
- Petechiae significance: Generalized petechiae on a newborn can indicate serious conditions like infection or low platelet count, warranting provider notification.
Seizure Preparedness
- Equipment necessity: Ensure suction catheters are available in the room for a client with a history of seizures to manage oral secretions and maintain airway patency.
Chest Tube Care
- Drainage system maintenance: Keep the closed drainage system below the client's chest level to prevent backflow of secretions.
Partner Violence Education
- Risk factors: Threats to leave a relationship may increase the risk of experiencing partner violence, as it undermines the perpetrator's control.
Anxiety Management
- Behavioral technique: Teach clients with generalized anxiety disorder about 'thought stopping' to manage anxiety during distressing thoughts.
Lumbar Puncture Monitoring
- Adverse effect observations: Monitor for headaches after a lumbar puncture, and address with prescribed pain medication and hydration.
Pain Assessment
- First question for pain management: Ask "Where is your pain located?" to prioritize effective assessment and pain relief measures.
Postpartum Care and DVT
- Antidote availability: Have protamine sulfate readily available to reverse heparin's effects in a postpartum client with a deep vein thrombosis.
Legal Issues in Nursing
- Assault example: Threatening to administer an injection against a client's refusal constitutes assault and violates patient rights.
Cystic Fibrosis Assessment
- Appetite as a concern: A lack of appetite in children with cystic fibrosis signals potential risk for pulmonary infection and requires provider notification.
Patient Transfer Techniques
- Transfer safety: Position the wheelchair on the client's stronger side during transfer to minimize falling risks.
Coronary Artery Disease Medication
- Aspirin’s action: Low-dose aspirin acts as an antiplatelet agent, inhibiting platelet aggregation to reduce thrombotic events in CAD patients.
Nutritional Guidance
- Water-rich foods: Suggest cherry tomatoes as they contain 141 g of water per cup, making them excellent for hydration in fluid volume deficit.
Weight Management Advice
- Dietary fat limit: Recommend keeping fat intake below 30% of daily caloric intake to aid in weight loss efforts due to the higher calorie density of fats.
Disaster Response in Healthcare
- Discharge recommendations: A client with pneumonia on oral antibiotics may be safely discharged during a natural disaster, freeing up resources for new admissions.
Nonstress Test Procedure
- Client involvement: Provide a handheld event marker for the client to document fetal movements during a nonstress test, facilitating better fetal monitoring.
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