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Questions and Answers
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?
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?
Obtain a raised toilet seat.
What action should the nurse take to prepare a client suspected of having a myocardial infarction for an ECG?
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Which prescription should the nurse verify with the provider before administering medications?
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What finding should the nurse anticipate in a client with acute pancreatitis?
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Select the findings that require follow-up by the nurse.
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Match the following findings with their potential conditions.
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The nurse should identify that the client is most likely experiencing a ______ and should address the client's ______.
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What finding should the nurse report before administering furosemide?
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Withdrawal from which medication precipitated the adrenal crisis?
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What should the nurse do if the client's apical pulse is 58/min while taking digoxin?
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How often should a client with diabetes mellitus have their HbA1c checked?
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Which instructions should the nurse include about transmission-based precautions for Clostridium difficile? (Select all that apply)
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What should be added to the diet of a client with coronary artery disease?
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What is Mohs surgery?
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What change associated with aging should a nurse expect regarding taste?
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What food choice should increase vitamin C intake for better absorption of iron supplements?
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What should the nurse check first in a client who is postoperative after a foot amputation?
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For the postoperative client, which actions should the nurse take? (Select all that apply)
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Which nursing interventions should be indicated for a client receiving dialysis? (Select all that apply)
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What is an important reminder for a client using nystatin suspension for oral candidiasis?
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What precaution should be included for a caregiver of a client with a halo vest?
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How many calories will a client receive in 12 hours with a continuous tube feeding of 60 mL/hr at 1.2 cal/mL?
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Which insulin should be withdrawn first when preparing regular and NPH insulin?
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What should the nurse do first when assisting a client out of bed 4 hours after laparoscopic cholecystectomy?
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What finding should a nurse expect in a client with age-related macular degeneration?
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What food could improve the taste of bland food on a low-sodium diet?
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What tube should the nurse select for a client with peptic ulcer disease needing a gastric sump tube?
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What intervention should a nurse include in the care plan for a client with tuberculosis (TB)?
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Which interprofessional team member should the nurse recommend a referral to for a stroke patient before oral intake?
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What white blood cell count should a nurse identify as a complication of surgery?
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What indicates understanding of pursed-lip breathing for a client with COPD?
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What information about joint protection should be included for a client with rheumatoid arthritis?
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What indicates a client understands the process of dealing with mitral valve disease?
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What adverse effect should be mentioned for corticosteroid use in a client with asthma?
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What contraindication should be recognized for hormone replacement therapy in a client with a history of blood clots?
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What intervention should be included in the care plan for a COPD client who is dyspneic?
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What birth control method is contraindicated for a client with a history of breast cancer?
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What statement indicates a client understands about preventing complications of peripheral vascular disease?
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What outcome should a nurse expect from digoxin in a client with heart failure?
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What suggestion should be made to a client on chemotherapy who reports loss of appetite and taste?
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Which findings in a newly admitted client require follow-up? (Select the 3 that apply)
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What condition is the client most likely experiencing based on respiratory findings?
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What should the nurse attend to first in a client regarding oxygenation?
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For each provider prescription, specify if it is anticipated or contraindicated. Which of the following prescriptions are anticipated or contraindicated?
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What actions should the nurse take following chest tube placement? (Select all that apply)
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What findings indicate that the client's condition is improving after chest tube insertion? (Select all that apply)
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What should the nurse do first when preparing to suction a client with a tracheostomy?
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What statement indicates an understanding of tuberculosis (TB) transmission risk?
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Which steps should a nurse follow if a client begins to have a seizure? (Place these in the correct order)
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What complication of IV therapy is indicated by a hardened vein and pain at the site?
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Which client should the nurse prioritize seeing first after the change of shift?
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What information should be included in teaching about a continuous passive motion (CPM) machine? (Select all that apply)
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What action should be implemented to prevent aspiration in a client with difficulty swallowing?
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What should the nurse do for a client with Ménière's disease?
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Which of the following interventions should the nurse include in the plan of care?
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What statement indicates the client's understanding of teaching about chronic kidney disease management?
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What should the nurse include in the discharge plan for a postoperative client following a total hip arthroplasty?
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What action should the nurse take to prepare a client suspected of having a myocardial infarction for an ECG?
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Which prescription should the nurse verify with the provider?
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What finding should the nurse anticipate in a client with acute pancreatitis?
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Select the 3 findings that require follow-up by the nurse.
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Match the following findings with their disease processes:
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Following the administration of sumatriptan, the nurse should monitor for ______ due to the risk for ______.
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Which of the following statements by the client indicates understanding of discharge teaching for migraines?
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What action should the nurse take for a postoperative client with a portable wound bulb suction device?
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What statement should the nurse include in teaching for a client with Crohn's disease?
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What action should the nurse take to reduce confusion in a client with dementia due to Alzheimer's disease?
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Which finding should the nurse recognize as priority for a postoperative client with an epidural infusion?
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What instruction should the nurse include in teaching post-surgery regarding wound care?
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What finding should the nurse expect when caring for a client undergoing testing for multiple sclerosis?
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What statement by the client indicates understanding of the teaching regarding leg cast removal?
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What statement indicates understanding of osteoporosis prevention?
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What medication should the nurse expect for a client experiencing heroin withdrawal?
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What manifestation should the nurse anticipate in a client with hypothyroidism?
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What intervention should the nurse include in the plan for a client post-total knee arthroplasty?
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What finding should the nurse report as possible melanoma?
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What statement by the client indicates understanding of GERD teaching?
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What finding indicates therapeutic effectiveness in a client receiving treatment for AIDS-related pneumonia?
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Which of the following client statements indicates understanding of using budesonide and albuterol inhalers? (Select all that apply)
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What information should the nurse include about genital herpes?
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What nursing intervention should be implemented for a client with neutropenia?
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What action should the nurse take to decrease episodes of dumping syndrome post-gastrectomy?
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What should the nurse recommend to promote comfort for a client with osteoarthritis?
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What intervention should be included in the plan of care for a client with pertussis?
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What information should be included in teaching about HbA1c testing for a client with diabetes?
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What action should be included in the plan for a client at risk for increased intracranial pressure due to a head injury?
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What instruction should be included for a client with cirrhosis regarding diet?
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What information should the nurse include regarding tuberculosis (TB) for a client on isoniazid and rifampin?
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What intervention should the nurse take when preparing to remove a client's NG tube to reduce aspiration risk?
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What laboratory result indicates the client is experiencing a myocardial infarction?
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The client is experiencing manifestations of ______ due to the client's ______.
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What should the nurse do if a client reports pain and swelling at the IV site during sodium chloride infusion?
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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.
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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.
