Podcast
Questions and Answers
Oxygen saturation
Oxygen saturation
Oxygen saturation levels indicate how well oxygen is being carried in the blood.
Temperature
Temperature
Temperature can indicate the presence of infection or other health issues.
For each potential provider's prescription, what is the status of 'Cough and deep breathe every 2 hr'?
For each potential provider's prescription, what is the status of 'Cough and deep breathe every 2 hr'?
anticipated
For each potential provider's prescription, what is the status of 'Perform neurological checks every 2 hr'?
For each potential provider's prescription, what is the status of 'Perform neurological checks every 2 hr'?
For each potential provider's prescription, what is the status of 'Limit the client's fluid intake to 1,500 mL per day'?
For each potential provider's prescription, what is the status of 'Limit the client's fluid intake to 1,500 mL per day'?
In a medical record review, which findings require nursing intervention?
In a medical record review, which findings require nursing intervention?
Which findings indicate the client is improving?
Which findings indicate the client is improving?
What information should a nurse provide after an upper gastrointestinal series with barium contrast?
What information should a nurse provide after an upper gastrointestinal series with barium contrast?
Which image indicates that the client has exophthalmos?
Which image indicates that the client has exophthalmos?
What should the nurse include in teaching for an older adult client prescribed an opioid analgesic for pain management?
What should the nurse include in teaching for an older adult client prescribed an opioid analgesic for pain management?
What instructions should a nurse provide to a client after a gastrectomy?
What instructions should a nurse provide to a client after a gastrectomy?
After hospitalization for heart failure, which finding should the nurse report to the provider?
After hospitalization for heart failure, which finding should the nurse report to the provider?
Which statement by a client with stress incontinence indicates understanding of teaching?
Which statement by a client with stress incontinence indicates understanding of teaching?
What should a nurse expect in a client who sustained a rattlesnake bite?
What should a nurse expect in a client who sustained a rattlesnake bite?
When performing a dressing change for a client recovering from a hemicolectomy and noticing protruding bowel, what should the nurse do first?
When performing a dressing change for a client recovering from a hemicolectomy and noticing protruding bowel, what should the nurse do first?
If a client with portal hypertension is vomiting blood mixed with food, what action should the nurse take first?
If a client with portal hypertension is vomiting blood mixed with food, what action should the nurse take first?
To mitigate the risk of colorectal cancer, what dietary alteration should the client make?
To mitigate the risk of colorectal cancer, what dietary alteration should the client make?
What should a client with type 2 diabetes mellitus and a new prescription for metformin understand?
What should a client with type 2 diabetes mellitus and a new prescription for metformin understand?
What actions should the nurse take for a postoperative client? Select all that apply.
What actions should the nurse take for a postoperative client? Select all that apply.
Which assessment finding should the nurse expect for a client with a potassium level of 3 mEq/L?
Which assessment finding should the nurse expect for a client with a potassium level of 3 mEq/L?
Where should a nurse palpate to verify a client has an inguinal hernia?
Where should a nurse palpate to verify a client has an inguinal hernia?
What finding contributes to delayed wound healing in a client with a stage III pressure injury?
What finding contributes to delayed wound healing in a client with a stage III pressure injury?
What action should the nurse take for a client experiencing a tonic-clonic seizure?
What action should the nurse take for a client experiencing a tonic-clonic seizure?
What should a client with chronic kidney disease understand about erythropoietin?
What should a client with chronic kidney disease understand about erythropoietin?
What instruction should the nurse provide regarding a cutaneous diversion procedure for a client with bladder cancer?
What instruction should the nurse provide regarding a cutaneous diversion procedure for a client with bladder cancer?
What intervention should the nurse include to decrease psychosocial health issues in a client starting dialysis treatments?
What intervention should the nurse include to decrease psychosocial health issues in a client starting dialysis treatments?
In a client with hyperthyroidism, what is the priority assessment finding to report?
In a client with hyperthyroidism, what is the priority assessment finding to report?
Which findings indicate increased intracranial pressure (ICP)? (Select all that apply.)
Which findings indicate increased intracranial pressure (ICP)? (Select all that apply.)
What action should the nurse take when administering enoxaparin subcutaneously?
What action should the nurse take when administering enoxaparin subcutaneously?
What should a nurse check for a client who has had a plaster cast applied to their left leg 2 hours ago?
What should a nurse check for a client who has had a plaster cast applied to their left leg 2 hours ago?
What statement indicates a client with esophageal cancer understands the teaching about radiation therapy?
What statement indicates a client with esophageal cancer understands the teaching about radiation therapy?
What instruction should a nurse include in discharge teaching for a client with hemianopsia at risk for falls?
What instruction should a nurse include in discharge teaching for a client with hemianopsia at risk for falls?
Which client should a nurse assess first after receiving a change-of-shift report?
Which client should a nurse assess first after receiving a change-of-shift report?
What laboratory value should a nurse report for a postoperative client following total hip arthroplasty?
What laboratory value should a nurse report for a postoperative client following total hip arthroplasty?
Which client medication interacts with feverfew?
Which client medication interacts with feverfew?
What assessment finding should a nurse suspect indicates hypertonic dehydration in an older adult client?
What assessment finding should a nurse suspect indicates hypertonic dehydration in an older adult client?
What should a nurse place at the bedside of a client with dysphagia?
What should a nurse place at the bedside of a client with dysphagia?
What finding indicates an adverse reaction to propranolol in a client with hypertension?
What finding indicates an adverse reaction to propranolol in a client with hypertension?
If a client is to receive 2,000 kcal per day via TPN with 500 kcal/L, what should the IV pump be set at in mL/hr?
If a client is to receive 2,000 kcal per day via TPN with 500 kcal/L, what should the IV pump be set at in mL/hr?
What is the priority intervention for a nurse caring for a client having a seizure?
What is the priority intervention for a nurse caring for a client having a seizure?
What intervention should be included in the plan of care for a client with neutropenia from chemotherapy?
What intervention should be included in the plan of care for a client with neutropenia from chemotherapy?
What action should a nurse include in the plan of care for a client undergoing brachytherapy?
What action should a nurse include in the plan of care for a client undergoing brachytherapy?
What is the appropriate action for a nurse preparing to administer packed RBCs?
What is the appropriate action for a nurse preparing to administer packed RBCs?
Which medication should a client with supraventricular tachycardia withhold prior to elective cardioversion?
Which medication should a client with supraventricular tachycardia withhold prior to elective cardioversion?
What is the first action for a nurse caring for a client with anorexia, fever, night sweats, and a productive cough?
What is the first action for a nurse caring for a client with anorexia, fever, night sweats, and a productive cough?
What food should a nurse recommend a client avoid to reduce the risk of migraine headaches?
What food should a nurse recommend a client avoid to reduce the risk of migraine headaches?
What adverse effect should a nurse monitor for a client taking lactulose for hepatic encephalopathy?
What adverse effect should a nurse monitor for a client taking lactulose for hepatic encephalopathy?
What feeling should a nurse expect to find in a client who had extracorporeal shock wave lithotripsy?
What feeling should a nurse expect to find in a client who had extracorporeal shock wave lithotripsy?
What should a nurse tell a client who requests sildenafil for erectile dysfunction?
What should a nurse tell a client who requests sildenafil for erectile dysfunction?
What should a nurse demonstrate during preoperative teaching for a client scheduled for an open cholecystectomy?
What should a nurse demonstrate during preoperative teaching for a client scheduled for an open cholecystectomy?
What should a nurse administer for a client with cholecystitis?
What should a nurse administer for a client with cholecystitis?
What statement explains how omeprazole relieves symptoms of a gastric ulcer?
What statement explains how omeprazole relieves symptoms of a gastric ulcer?
What laboratory result is expected in a client with pancreatitis?
What laboratory result is expected in a client with pancreatitis?
What precaution should a nurse implement for a client at risk for seizures?
What precaution should a nurse implement for a client at risk for seizures?
What instruction should a nurse include in discharge teaching for a client with a partial-thickness burn on the hand?
What instruction should a nurse include in discharge teaching for a client with a partial-thickness burn on the hand?
What finding should a nurse prioritize when assessing a client suspected of having a stroke?
What finding should a nurse prioritize when assessing a client suspected of having a stroke?
What medication should a nurse plan to administer for a client experiencing muscle cramps and tingling during hemodialysis?
What medication should a nurse plan to administer for a client experiencing muscle cramps and tingling during hemodialysis?
What vital sign finding in an ICU client with a traumatic brain injury indicates Cushing's triad?
What vital sign finding in an ICU client with a traumatic brain injury indicates Cushing's triad?
What conditions should a nurse be aware of regarding a client just admitted from the emergency department?
What conditions should a nurse be aware of regarding a client just admitted from the emergency department?
What instruction should be included for a female client at risk for urinary tract infections?
What instruction should be included for a female client at risk for urinary tract infections?
What finding in a client undergoing a CT scan with IV contrast requires further assessment?
What finding in a client undergoing a CT scan with IV contrast requires further assessment?
What heart rate finding indicates fluid volume deficit in a client with vomiting and diarrhea?
What heart rate finding indicates fluid volume deficit in a client with vomiting and diarrhea?
What adverse effect should a nurse monitor for a client taking enalapril?
What adverse effect should a nurse monitor for a client taking enalapril?
What adverse effect should a nurse observe after administering magnesium sulfate IV?
What adverse effect should a nurse observe after administering magnesium sulfate IV?
What syringe size should a nurse use to irrigate and dress a clean, granulating wound?
What syringe size should a nurse use to irrigate and dress a clean, granulating wound?
Select the four findings that require follow-up by the nurse.
Select the four findings that require follow-up by the nurse.
Identify the abnormal findings that can indicate a problem.
Identify the abnormal findings that can indicate a problem.
What is the nurse's first priority when addressing a client's urgent issue?
What is the nurse's first priority when addressing a client's urgent issue?
What laboratory value should a nurse expect in a client with cirrhosis?
What laboratory value should a nurse expect in a client with cirrhosis?
What method should a nurse teach a young adult client for testicular self-examination?
What method should a nurse teach a young adult client for testicular self-examination?
What client statement indicates understanding of the effects of epoetin alfa?
What client statement indicates understanding of the effects of epoetin alfa?
Which client is at risk for experiencing a role change?
Which client is at risk for experiencing a role change?
What finding indicates chronic glomerulonephritis with oliguria?
What finding indicates chronic glomerulonephritis with oliguria?
What vital sign finding should a nurse prioritize for a client with acute cholecystitis?
What vital sign finding should a nurse prioritize for a client with acute cholecystitis?
What finding can indicate peritonitis in a client?
What finding can indicate peritonitis in a client?
What BUN level should a nurse expect in a client with diabetic ketoacidosis (DKA)?
What BUN level should a nurse expect in a client with diabetic ketoacidosis (DKA)?
What is the priority intervention for a nurse caring for a client after cardiac catheterization with a hematoma?
What is the priority intervention for a nurse caring for a client after cardiac catheterization with a hematoma?
What supplement can interfere with levothyroxine effectiveness?
What supplement can interfere with levothyroxine effectiveness?
For which client should a nurse refer to physical therapy?
For which client should a nurse refer to physical therapy?
Which of the following findings requires follow-up?
Which of the following findings requires follow-up?
Flashcards
Limb Cast Tightness Assessment
Limb Cast Tightness Assessment
Check if one finger fits under a cast; should fit when loosened by swelling.
Client Awareness in Radiation Therapy
Client Awareness in Radiation Therapy
Client should use hands for cleansing treated skin areas, not cloths.
Visual Scanning with Hemianopsia
Visual Scanning with Hemianopsia
Instruct clients to scan visually when walking to prevent falls.
Prioritize Chest Pain Assessment
Prioritize Chest Pain Assessment
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Significant Laboratory Findings
Significant Laboratory Findings
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Medication Interaction Awareness
Medication Interaction Awareness
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Hypertension Drug Symptoms
Hypertension Drug Symptoms
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Magnesium Sulfate Adverse Effects
Magnesium Sulfate Adverse Effects
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Foot Inspection for Diabetics
Foot Inspection for Diabetics
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Avoiding Migraine Triggers
Avoiding Migraine Triggers
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Blood Pressure Monitoring with Epoetin Alfa
Blood Pressure Monitoring with Epoetin Alfa
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IV Access for Postoperative Clients
IV Access for Postoperative Clients
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Emergencies and Vital Signs
Emergencies and Vital Signs
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Airborne Precautions for Respiratory Symptoms
Airborne Precautions for Respiratory Symptoms
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Cross-Contamination Prevention
Cross-Contamination Prevention
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Liver Dysfunction Laboratory Evaluation
Liver Dysfunction Laboratory Evaluation
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Monitoring for Dehydration
Monitoring for Dehydration
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Managing Acute Chest Syndrome
Managing Acute Chest Syndrome
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Cancer Care Education
Cancer Care Education
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TPN Caloric Intake Instructions
TPN Caloric Intake Instructions
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Diabetes Medication Instruction
Diabetes Medication Instruction
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Postoperative Voiding Instruction
Postoperative Voiding Instruction
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Signs of Hypokalemia
Signs of Hypokalemia
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Inguinal Hernia Assessment
Inguinal Hernia Assessment
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Urine Output and Pressure Injury Healing
Urine Output and Pressure Injury Healing
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Tonic-Clonic Seizure Management
Tonic-Clonic Seizure Management
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Erythropoietin Purpose
Erythropoietin Purpose
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Ureterostomy Skin Barrier Advice
Ureterostomy Skin Barrier Advice
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Psychosocial Care in Dialysis
Psychosocial Care in Dialysis
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Hyperthyroidism Blood Pressure Concerns
Hyperthyroidism Blood Pressure Concerns
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Symptoms of Increased ICP
Symptoms of Increased ICP
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Enoxaparin Injection Site
Enoxaparin Injection Site
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Study Notes
Nursing Assessment and Care
- Assess limb casts for tightness by checking if one finger can fit underneath; normal for molds to loosen with swelling.
- Identify client awareness in radiation therapy by their willingness to use hands, not cloths, for cleansing treated skin areas.
- Instruct clients with hemianopsia to perform visual scanning during ambulation to minimize fall risks.
Priority Client Assessment
- Prioritize the assessment of clients who are experiencing chest pain or have had myocardial infarctions.
- Report significant laboratory findings promptly, such as hemoglobin levels at 8 g/dL after hip arthroplasty.
Medication Interactions and Adverse Effects
- Be aware of medication interactions, such as feverfew with naproxen.
- Recognize symptoms of hypertension drugs like propranolol, particularly night cough.
- Monitor for adverse effects of magnesium sulfate, including respiratory paralysis, and follow-up on complications following drug administration.
Patient Education and Discharge Instructions
- Teach clients about safe practices, such as inspecting feet daily for diabetic patients and avoiding aged cheese to reduce migraine triggers.
- Instruct clients to monitor blood pressure when taking epoetin alfa, and ensure understanding of condition and treatment for hypothyroidism.
Emergency and Postoperative Care
- Implement immediate interventions for postoperative clients, including the establishment of IV access in seizure-prone patients.
- During emergencies, the priority action could include managing vital signs like tachycardia and changes in mental status in clients with neurological conditions.
Infection Control and Precautions
- Follow airborne precautions for clients with respiratory symptoms, especially in cases of suspected infectious processes.
- Prevent cross-contamination in immunocompromised clients by prohibiting plants or flowers in their rooms.
Laboratory Monitoring and Evaluation
- Evaluate laboratory results for clients with liver dysfunction (elevated bilirubin in cirrhosis) and monitor electrolyte levels in conditions like pancreatitis (low calcium).
- Assess for dehydration in clients with fluid loss, such as elevated heart rate or concentrating urine.
Specific Interventions for Compromised Conditions
- Manage complications like acute chest syndrome in sickle cell crisis effectively by monitoring oxygen saturation and vital signs.
- Anticipate the need for specific interventions concerning managing chronic conditions, such as implementing a physical therapy referral for clients needing mobility assistance.
Cancer Care Considerations
- Provide teaching on managing symptoms and side effects from cancer treatments, including the proper methods for self-examination and understanding chemotherapy's effects on the body.
- Monitor pain management in clients receiving opioids, considering alternatives, and educating on addiction fears.
Treatment and Symptom Management
- Instruct clients undergoing TPN about caloric intake calculations, and manage nutrient solutions accordingly.
- Promote appropriate dietary changes and lifestyle modifications to help manage chronic conditions and prevent exacerbations.
Communication and Understanding Client Needs
- Encourage effective communication about patient rights and informed consent, especially during clinical trials involving placebo treatment.
- Ensure clients understand their health conditions and the importance of following treatment regimens and appointment schedules.### Postoperative Care
- Encourage clients to void every 4 hours to reduce the risk of urinary retention.
- For clients two weeks postoperative from a gastrectomy, advise avoiding drinking fluids with meals, eating several small meals daily, consuming high-protein snacks, and avoiding highly seasoned foods.
Heart Failure Management
- Report significant findings such as a heart rate of 55/min for clients on a follow-up after hospitalization for heart failure.
Managing Incontinence
- An indication of understanding for a client with stress incontinence and a BMI of 32 is the statement, "I am dieting to lose weight."
Emergency Response
- Administer opioid analgesics for clients who suffer a rattlesnake bite.
Wound Care Protocol
- On discovering bowel protrusion during a dressing change post-hemicolectomy, the first action should be to call for help.
Managing Portal Hypertension
- If a client with portal hypertension is vomiting blood mixed with food, the first step is to obtain vital signs.
Cancer Risk Reduction
- For clients with family histories of colorectal cancer, recommend incorporating cabbage into their diet.
Diabetes Medication Instruction
- Clients prescribed metformin should understand to take the medication with a meal.
Postoperative Procedures
- In postoperative care, instruct clients to splint the abdomen with a pillow when coughing, plan for early ambulation, report urinary output, and assess pain on a 0 to 10 scale.
Potassium Level Implications
- A potassium level of 3 mEq/L can lead to hypoactive bowel sounds.
Inguinal Hernia Assessment
- To assess for an inguinal hernia, palpate the inguinal area.
Pressure Injury Healing
- A urine output of 25 mL/hr in clients with a stage III pressure injury can contribute to delayed wound healing.
Seizure Management
- During a tonic-clonic seizure, the nurse should loosen restrictive clothing.
Chronic Kidney Disease Treatment
- Clients on erythropoietin should recognize it aims to increase energy levels.
Ureterostomy Teaching
- For clients undergoing a ureterostomy, advise they should keep the skin barrier opening one-eighth inch wider than the stoma.
Psychosocial Care in Dialysis
- Stress the possibility of a return to previous activity levels can help mitigate psychosocial health issues in clients starting dialysis.
Hyperthyroidism Concerns
- The priority finding for a client with a new diagnosis of hyperthyroidism to report is a blood pressure of 170/80 mm Hg.
Increased Intracranial Pressure Indicators
- In closed head injury clients with intraventricular catheters, report signs of increased intracranial pressure (ICP) like sleepiness, widening pulse pressure, and decerebrate posturing.
Enoxaparin Administration
- For clients on bed rest receiving enoxaparin, inject into the anterolateral abdominal wall.
Studying That Suits You
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Description
Test your knowledge on nursing assessments with this quiz focused on adult medical-surgical nursing. It includes scenarios such as monitoring casts and recognizing complications. Perfect for preparation for the NGN exam format.
