Podcast
Questions and Answers
Which of the following interventions should the nurse include in the plan of care?
Which of the following interventions should the nurse include in the plan of care?
What statement indicates a client understands teaching about chronic kidney disease management?
What statement indicates a client understands teaching about chronic kidney disease management?
I will limit my daily intake of protein.
What instruction should the nurse include in the discharge plan for a client following total hip arthroplasty?
What instruction should the nurse include in the discharge plan for a client following total hip arthroplasty?
Obtain a raised toilet seat.
What action should the nurse take to prepare a client suspected of having a myocardial infarction for an ECG?
What action should the nurse take to prepare a client suspected of having a myocardial infarction for an ECG?
Signup and view all the answers
Which prescription should the nurse verify with the provider before administering medications?
Which prescription should the nurse verify with the provider before administering medications?
Signup and view all the answers
What finding should the nurse anticipate in a client with acute pancreatitis?
What finding should the nurse anticipate in a client with acute pancreatitis?
Signup and view all the answers
Select the findings that require follow-up by the nurse.
Select the findings that require follow-up by the nurse.
Signup and view all the answers
Match the following findings with their potential conditions.
Match the following findings with their potential conditions.
Signup and view all the answers
The nurse should identify that the client is most likely experiencing a ______ and should address the client's ______.
The nurse should identify that the client is most likely experiencing a ______ and should address the client's ______.
Signup and view all the answers
What finding should the nurse report before administering furosemide?
What finding should the nurse report before administering furosemide?
Signup and view all the answers
Withdrawal from which medication precipitated the adrenal crisis?
Withdrawal from which medication precipitated the adrenal crisis?
Signup and view all the answers
What should the nurse do if the client's apical pulse is 58/min while taking digoxin?
What should the nurse do if the client's apical pulse is 58/min while taking digoxin?
Signup and view all the answers
How often should a client with diabetes mellitus have their HbA1c checked?
How often should a client with diabetes mellitus have their HbA1c checked?
Signup and view all the answers
Which instructions should the nurse include about transmission-based precautions for Clostridium difficile? (Select all that apply)
Which instructions should the nurse include about transmission-based precautions for Clostridium difficile? (Select all that apply)
Signup and view all the answers
What should be added to the diet of a client with coronary artery disease?
What should be added to the diet of a client with coronary artery disease?
Signup and view all the answers
What is Mohs surgery?
What is Mohs surgery?
Signup and view all the answers
What change associated with aging should a nurse expect regarding taste?
What change associated with aging should a nurse expect regarding taste?
Signup and view all the answers
What food choice should increase vitamin C intake for better absorption of iron supplements?
What food choice should increase vitamin C intake for better absorption of iron supplements?
Signup and view all the answers
What should the nurse check first in a client who is postoperative after a foot amputation?
What should the nurse check first in a client who is postoperative after a foot amputation?
Signup and view all the answers
For the postoperative client, which actions should the nurse take? (Select all that apply)
For the postoperative client, which actions should the nurse take? (Select all that apply)
Signup and view all the answers
Which nursing interventions should be indicated for a client receiving dialysis? (Select all that apply)
Which nursing interventions should be indicated for a client receiving dialysis? (Select all that apply)
Signup and view all the answers
What is an important reminder for a client using nystatin suspension for oral candidiasis?
What is an important reminder for a client using nystatin suspension for oral candidiasis?
Signup and view all the answers
What precaution should be included for a caregiver of a client with a halo vest?
What precaution should be included for a caregiver of a client with a halo vest?
Signup and view all the answers
How many calories will a client receive in 12 hours with a continuous tube feeding of 60 mL/hr at 1.2 cal/mL?
How many calories will a client receive in 12 hours with a continuous tube feeding of 60 mL/hr at 1.2 cal/mL?
Signup and view all the answers
Which insulin should be withdrawn first when preparing regular and NPH insulin?
Which insulin should be withdrawn first when preparing regular and NPH insulin?
Signup and view all the answers
What should the nurse do first when assisting a client out of bed 4 hours after laparoscopic cholecystectomy?
What should the nurse do first when assisting a client out of bed 4 hours after laparoscopic cholecystectomy?
Signup and view all the answers
What finding should a nurse expect in a client with age-related macular degeneration?
What finding should a nurse expect in a client with age-related macular degeneration?
Signup and view all the answers
What food could improve the taste of bland food on a low-sodium diet?
What food could improve the taste of bland food on a low-sodium diet?
Signup and view all the answers
What tube should the nurse select for a client with peptic ulcer disease needing a gastric sump tube?
What tube should the nurse select for a client with peptic ulcer disease needing a gastric sump tube?
Signup and view all the answers
What intervention should a nurse include in the care plan for a client with tuberculosis (TB)?
What intervention should a nurse include in the care plan for a client with tuberculosis (TB)?
Signup and view all the answers
Which interprofessional team member should the nurse recommend a referral to for a stroke patient before oral intake?
Which interprofessional team member should the nurse recommend a referral to for a stroke patient before oral intake?
Signup and view all the answers
What white blood cell count should a nurse identify as a complication of surgery?
What white blood cell count should a nurse identify as a complication of surgery?
Signup and view all the answers
What indicates understanding of pursed-lip breathing for a client with COPD?
What indicates understanding of pursed-lip breathing for a client with COPD?
Signup and view all the answers
What information about joint protection should be included for a client with rheumatoid arthritis?
What information about joint protection should be included for a client with rheumatoid arthritis?
Signup and view all the answers
What indicates a client understands the process of dealing with mitral valve disease?
What indicates a client understands the process of dealing with mitral valve disease?
Signup and view all the answers
What adverse effect should be mentioned for corticosteroid use in a client with asthma?
What adverse effect should be mentioned for corticosteroid use in a client with asthma?
Signup and view all the answers
What contraindication should be recognized for hormone replacement therapy in a client with a history of blood clots?
What contraindication should be recognized for hormone replacement therapy in a client with a history of blood clots?
Signup and view all the answers
What intervention should be included in the care plan for a COPD client who is dyspneic?
What intervention should be included in the care plan for a COPD client who is dyspneic?
Signup and view all the answers
What birth control method is contraindicated for a client with a history of breast cancer?
What birth control method is contraindicated for a client with a history of breast cancer?
Signup and view all the answers
What statement indicates a client understands about preventing complications of peripheral vascular disease?
What statement indicates a client understands about preventing complications of peripheral vascular disease?
Signup and view all the answers
What outcome should a nurse expect from digoxin in a client with heart failure?
What outcome should a nurse expect from digoxin in a client with heart failure?
Signup and view all the answers
What suggestion should be made to a client on chemotherapy who reports loss of appetite and taste?
What suggestion should be made to a client on chemotherapy who reports loss of appetite and taste?
Signup and view all the answers
Which findings in a newly admitted client require follow-up? (Select the 3 that apply)
Which findings in a newly admitted client require follow-up? (Select the 3 that apply)
Signup and view all the answers
What condition is the client most likely experiencing based on respiratory findings?
What condition is the client most likely experiencing based on respiratory findings?
Signup and view all the answers
What should the nurse attend to first in a client regarding oxygenation?
What should the nurse attend to first in a client regarding oxygenation?
Signup and view all the answers
For each provider prescription, specify if it is anticipated or contraindicated. Which of the following prescriptions are anticipated or contraindicated?
For each provider prescription, specify if it is anticipated or contraindicated. Which of the following prescriptions are anticipated or contraindicated?
Signup and view all the answers
What actions should the nurse take following chest tube placement? (Select all that apply)
What actions should the nurse take following chest tube placement? (Select all that apply)
Signup and view all the answers
What findings indicate that the client's condition is improving after chest tube insertion? (Select all that apply)
What findings indicate that the client's condition is improving after chest tube insertion? (Select all that apply)
Signup and view all the answers
What should the nurse do first when preparing to suction a client with a tracheostomy?
What should the nurse do first when preparing to suction a client with a tracheostomy?
Signup and view all the answers
What statement indicates an understanding of tuberculosis (TB) transmission risk?
What statement indicates an understanding of tuberculosis (TB) transmission risk?
Signup and view all the answers
Which steps should a nurse follow if a client begins to have a seizure? (Place these in the correct order)
Which steps should a nurse follow if a client begins to have a seizure? (Place these in the correct order)
Signup and view all the answers
What complication of IV therapy is indicated by a hardened vein and pain at the site?
What complication of IV therapy is indicated by a hardened vein and pain at the site?
Signup and view all the answers
Which client should the nurse prioritize seeing first after the change of shift?
Which client should the nurse prioritize seeing first after the change of shift?
Signup and view all the answers
What information should be included in teaching about a continuous passive motion (CPM) machine? (Select all that apply)
What information should be included in teaching about a continuous passive motion (CPM) machine? (Select all that apply)
Signup and view all the answers
What action should be implemented to prevent aspiration in a client with difficulty swallowing?
What action should be implemented to prevent aspiration in a client with difficulty swallowing?
Signup and view all the answers
What should the nurse do for a client with Ménière's disease?
What should the nurse do for a client with Ménière's disease?
Signup and view all the answers
Which of the following interventions should the nurse include in the plan of care?
Which of the following interventions should the nurse include in the plan of care?
Signup and view all the answers
What statement indicates the client's understanding of teaching about chronic kidney disease management?
What statement indicates the client's understanding of teaching about chronic kidney disease management?
Signup and view all the answers
What should the nurse include in the discharge plan for a postoperative client following a total hip arthroplasty?
What should the nurse include in the discharge plan for a postoperative client following a total hip arthroplasty?
Signup and view all the answers
What action should the nurse take to prepare a client suspected of having a myocardial infarction for an ECG?
What action should the nurse take to prepare a client suspected of having a myocardial infarction for an ECG?
Signup and view all the answers
Which prescription should the nurse verify with the provider?
Which prescription should the nurse verify with the provider?
Signup and view all the answers
What finding should the nurse anticipate in a client with acute pancreatitis?
What finding should the nurse anticipate in a client with acute pancreatitis?
Signup and view all the answers
Select the 3 findings that require follow-up by the nurse.
Select the 3 findings that require follow-up by the nurse.
Signup and view all the answers
Match the following findings with their disease processes:
Match the following findings with their disease processes:
Signup and view all the answers
Following the administration of sumatriptan, the nurse should monitor for ______ due to the risk for ______.
Following the administration of sumatriptan, the nurse should monitor for ______ due to the risk for ______.
Signup and view all the answers
Which of the following statements by the client indicates understanding of discharge teaching for migraines?
Which of the following statements by the client indicates understanding of discharge teaching for migraines?
Signup and view all the answers
What action should the nurse take for a postoperative client with a portable wound bulb suction device?
What action should the nurse take for a postoperative client with a portable wound bulb suction device?
Signup and view all the answers
What statement should the nurse include in teaching for a client with Crohn's disease?
What statement should the nurse include in teaching for a client with Crohn's disease?
Signup and view all the answers
What action should the nurse take to reduce confusion in a client with dementia due to Alzheimer's disease?
What action should the nurse take to reduce confusion in a client with dementia due to Alzheimer's disease?
Signup and view all the answers
Which finding should the nurse recognize as priority for a postoperative client with an epidural infusion?
Which finding should the nurse recognize as priority for a postoperative client with an epidural infusion?
Signup and view all the answers
What instruction should the nurse include in teaching post-surgery regarding wound care?
What instruction should the nurse include in teaching post-surgery regarding wound care?
Signup and view all the answers
What finding should the nurse expect when caring for a client undergoing testing for multiple sclerosis?
What finding should the nurse expect when caring for a client undergoing testing for multiple sclerosis?
Signup and view all the answers
What statement by the client indicates understanding of the teaching regarding leg cast removal?
What statement by the client indicates understanding of the teaching regarding leg cast removal?
Signup and view all the answers
What statement indicates understanding of osteoporosis prevention?
What statement indicates understanding of osteoporosis prevention?
Signup and view all the answers
What medication should the nurse expect for a client experiencing heroin withdrawal?
What medication should the nurse expect for a client experiencing heroin withdrawal?
Signup and view all the answers
What manifestation should the nurse anticipate in a client with hypothyroidism?
What manifestation should the nurse anticipate in a client with hypothyroidism?
Signup and view all the answers
What intervention should the nurse include in the plan for a client post-total knee arthroplasty?
What intervention should the nurse include in the plan for a client post-total knee arthroplasty?
Signup and view all the answers
What finding should the nurse report as possible melanoma?
What finding should the nurse report as possible melanoma?
Signup and view all the answers
What statement by the client indicates understanding of GERD teaching?
What statement by the client indicates understanding of GERD teaching?
Signup and view all the answers
What finding indicates therapeutic effectiveness in a client receiving treatment for AIDS-related pneumonia?
What finding indicates therapeutic effectiveness in a client receiving treatment for AIDS-related pneumonia?
Signup and view all the answers
Which of the following client statements indicates understanding of using budesonide and albuterol inhalers? (Select all that apply)
Which of the following client statements indicates understanding of using budesonide and albuterol inhalers? (Select all that apply)
Signup and view all the answers
What information should the nurse include about genital herpes?
What information should the nurse include about genital herpes?
Signup and view all the answers
What nursing intervention should be implemented for a client with neutropenia?
What nursing intervention should be implemented for a client with neutropenia?
Signup and view all the answers
What action should the nurse take to decrease episodes of dumping syndrome post-gastrectomy?
What action should the nurse take to decrease episodes of dumping syndrome post-gastrectomy?
Signup and view all the answers
What should the nurse recommend to promote comfort for a client with osteoarthritis?
What should the nurse recommend to promote comfort for a client with osteoarthritis?
Signup and view all the answers
What intervention should be included in the plan of care for a client with pertussis?
What intervention should be included in the plan of care for a client with pertussis?
Signup and view all the answers
What information should be included in teaching about HbA1c testing for a client with diabetes?
What information should be included in teaching about HbA1c testing for a client with diabetes?
Signup and view all the answers
What action should be included in the plan for a client at risk for increased intracranial pressure due to a head injury?
What action should be included in the plan for a client at risk for increased intracranial pressure due to a head injury?
Signup and view all the answers
What instruction should be included for a client with cirrhosis regarding diet?
What instruction should be included for a client with cirrhosis regarding diet?
Signup and view all the answers
What information should the nurse include regarding tuberculosis (TB) for a client on isoniazid and rifampin?
What information should the nurse include regarding tuberculosis (TB) for a client on isoniazid and rifampin?
Signup and view all the answers
What intervention should the nurse take when preparing to remove a client's NG tube to reduce aspiration risk?
What intervention should the nurse take when preparing to remove a client's NG tube to reduce aspiration risk?
Signup and view all the answers
What laboratory result indicates the client is experiencing a myocardial infarction?
What laboratory result indicates the client is experiencing a myocardial infarction?
Signup and view all the answers
The client is experiencing manifestations of ______ due to the client's ______.
The client is experiencing manifestations of ______ due to the client's ______.
Signup and view all the answers
What should the nurse do if a client reports pain and swelling at the IV site during sodium chloride infusion?
What should the nurse do if a client reports pain and swelling at the IV site during sodium chloride infusion?
Signup and view all the answers
Study Notes
Medication Administration and Monitoring
- Furosemide should not be administered if potassium levels are decreased due to risk of hypokalemia.
- In adrenal crisis, withdrawal from prednisone can precipitate symptoms.
- Digoxin must be withheld if the apical pulse is below 60 beats per minute.
- HbA1c should be checked twice a year for diabetes management.
- Regular and NPH insulin should be prepared by drawing the regular insulin first.
Patient Care and Dietary Considerations
- Clients with Clostridium difficile should use disposable utensils and clean surfaces with bleach; blood pressure cuffs should remain in the client's room.
- Oily fish should be included in the diet for those with coronary artery disease to improve health.
- Vitamin C-rich foods, like boiled broccoli, enhance absorption of oral iron supplements.
- For clients on a low-sodium diet, introduce lemon juice to improve food flavor.
Surgical and Postoperative Care
- Monitor incisional dressings and report any unusual findings postoperatively.
- In the case of a hemothorax, follow-up necessary findings include oxygen saturation levels and pain intensity.
- Chest tubes require secure connections and proper position of the client for optimal drainage.
Respiratory and Cardiac Considerations
- Pursed-lip breathing is beneficial in COPD management, especially during physical activities.
- Orthostatic hypotension can occur as an adverse effect of corticosteroids in asthma patients.
- Chest x-rays are not indicated when the patient has hypotension and is stable on other management strategies.
Nursing Interventions and Education
- Proper protocols should be followed for clients experiencing seizure activity, including protecting the patient's head and timing the seizure.
- Use of a continuous passive motion (CPM) machine includes ensuring the knee is moved as prescribed.
- Instruct clients with difficulty swallowing to consume thicker liquids to prevent choking.
Health Promotion and Safety Measures
- Clients with rheumatoid arthritis should apply cold packs to inflamed joints for pain relief.
- Regular monitoring is essential for clients with heart failure and those receiving anticoagulants following surgical procedures.
- Families of clients with halo vests need to be educated on hygiene practices like changing liners.
Recognizing Complications and Disease Management
- High white blood cell counts post-surgery could indicate infection.
- Understanding and managing chronic kidney disease includes dietary protein restrictions.
- Birth control methods that contain estrogen, like combination oral contraceptives, are contraindicated in clients with a history of breast cancer.
Home Health and Discharge Planning
- Clients should be advised against crossing their legs to prevent complications from peripheral vascular disease.
- Safe discharge post-hip arthroplasty involves ensuring mobility aids like raised toilet seats are available for client use.
Clinical Scenario Management
- When caring for a client after a penetrating chest wound, monitor vital signs carefully for changes indicating complications like hemothorax.
- Always prioritize oxygenation followed by blood pressure stabilization in emergency situations.
- Ensure that hand hygiene and infection control practices are enforced when managing clients with tuberculosis.### Elevated Serum Amylase Level
- Elevated amylase levels may indicate conditions such as pancreatitis, pancreatic duct obstruction, or perforated peptic ulcer.
Client Assessment Findings
- Visual disturbances, particularly flashing lights, may suggest migraines or neurologic issues.
- Throbbing pain behind the left eye, rated a 7/10, may relate to migraines; photophobia and nausea are common migraine symptoms.
- Vital signs reflect mild tachycardia (112 bpm) and elevated respiratory rates (22/min), alongside normal blood pressure (138/80 mm Hg) and stable oxygen saturation (98% on room air).
Neurological Condition Follow-up
- Follow-up required for visual disturbances, headache, and nausea as potential indicators of migraine, stroke, or meningitis.
Diagnosis Consistency
- Nausea can indicate a migraine or meningitis.
- Visual changes are associated with migraine, stroke, or meningitis.
- Headache is common in all three conditions: migraine, stroke, and meningitis.
Migraine Management
- The likely diagnosis for the client experiencing headache and symptoms is migraine.
- Pain management is essential in addressing a client's migraine.
Nursing Interventions for Migraine
- Anticipated interventions include administering sumatriptan and dimming lights in the client's room for comfort.
Monitoring Post-Sumatriptan
- Chest pain should be monitored after sumatriptan administration due to the risk of myocardial ischemia.
Discharge Instructions Post-Migraine
- Clients should be educated on dietary triggers, tracking food and headache occurrences, and using cool compresses during migraine attacks to manage symptoms effectively.
Postoperative Care with Wound Suction
- To care for a client with a portable wound bulb suction device, compress the bulb reservoir and close the drainage valve effectively.
Dietary Teaching for Crohn's Disease
- A low-residue diet is recommended for managing Crohn's disease and minimizing gastrointestinal irritations.
Dementia Care Strategies
- Encouraging reminiscence of past experiences can help reduce confusion in clients with dementia due to Alzheimer's disease.
Postoperative Priority Findings
- Dyspnea is a priority finding in clients with an epidural infusion due to the risk for respiratory complications.
Wound Care Education
- Report any purulent drainage from surgical sites to healthcare providers during discharge education.
Multiple Sclerosis Anticipations
- Muscle spasticity is commonly expected in clients testing for multiple sclerosis.
Cast Removal Understanding
- Clients should be aware they may feel vibrations from the cast cutter during removal.
Osteoporosis Prevention Teaching
- Limiting coffee intake is advised to aid in osteoporosis prevention understanding.
Substance Withdrawal Management
- Methadone is typically prescribed for clients undergoing withdrawal from heroin.
Hypothyroidism Manifestations
- Bradycardia is a common symptom to anticipate in clients with hypothyroidism.
Postoperative Mobility Interventions
- Encourage clients to change positions at least every 2 hours post knee arthroplasty surgery to prevent complications.
Skin Lesions Evaluation
- Irregular borders of skin lesions should be reported as potential melanoma indicators.
GERD Education
- Waiting at least 2 hours after eating before lying down is a recommended practice for GERD management.
Effectiveness of Pneumonia Therapy
- A decrease in exertional dyspnea indicates the effectiveness of intervention for clients with AIDS-related pneumonia.
Asthma Inhaler Education
- Clients should rinse their mouths post-budesonide inhaler use, keep records on albuterol inhaler usage, utilize albuterol before swimming, and understand inhalation order.
Genital Herpes Awareness
- The herpes virus can be transmitted even when lesions are not present, highlighting the importance of safe practices.
Neutropenia Care Protocols
- To protect a neutropenic client, limit visitors to healthy adults.
Post-Gastrectomy Measures
- Keeping clients in a supine position after meals can help minimize episodes of dumping syndrome.
Osteoarthritis Comfort Strategies
- Sleeping on a firm mattress can enhance comfort for clients with osteoarthritis.
Droplet Precautions for Pertussis
- Apply a mask to clients suspected of having pertussis during transport to prevent transmission.
HbA1c Testing for Diabetes Management
- HbA1c results reflect glucose control over the previous three months, essential for managing diabetes.
Managing Increased Intracranial Pressure
- Using a turn sheet is advised to reposition clients at risk for increased ICP post head injury.
Cirrhosis Dietary Guidelines
- Low-sodium food consumption is critical for clients with cirrhosis to manage fluid retention and complications.
Tuberculosis Education
- Household members of clients with tuberculosis should undergo testing to prevent further spread.
NG Tube Removal Protocol
- Pinching the NG tube is essential to minimize aspiration risks prior to removal.
Myocardial Infarction Indicators
- Elevated troponin levels are a key indicator of myocardial infarction.
Peritonitis Signs and Symptoms
- Cloudy dialysate, abdominal pain, fever, and red/warm dialysis access site indicate peritonitis in clients undergoing peritoneal dialysis.
Burn Injury Risks
- Clients with burn injuries face risks of hypovolemia and respiratory failure during the emergent phase of care.
Prostate Cancer Symptoms
- Tumor obstruction of the urethra is a common cause of urinary difficulties in clients with prostate cancer.
Cholecystitis Management
- Actions for cholecystitis include administering morphine IV, ensuring the client remains NPO, while monitoring for jaundice and increasing temperature.
IV Site Complications Management
- Steps for managing pain and swelling at the IV site: check the IV site, stop the infusion, withdraw the catheter, elevate the arm, and notify the charge nurse.
Respiratory Disease Findings
- Symptoms like elevated temperature, specific breath sounds, respiratory rate of 26/min, and cough may indicate pneumonia, asthma, or emphysema.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Description
Test your knowledge with this set of flashcards designed for PN Adult Medical Surgical practice in 2023. Cover key concepts such as medication administration and critical patient conditions. Perfect for nursing students preparing for their exams.