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Client has vomiting and diarrhea. ABG analysis results are ph 7.48 paco2 40mmhg, hcos 35, pa02 95, sao2 98%. Which IV solution does nurse anticipate for client? Normal saline 3% Normal saline 0.9%... Dextrose 5% in water Ringer solution Client comes with difficultly breathing, runny nose, pulse of 100, sneezing and coughin. Diagnosis of asthma is made. Which information is most important for nurse to obtain? Select all that apply Any previous attacks like this Exposure to known allergans Family history of allergies Any symptoms while exercising Past history of psychological problems Current list of medications Client reports difficultly moving right arm. Numbness and tingling in arm. Clitn has difficulty speaking and diagnosis of stroke is made. The nurse understands this is what type of stroke? Double hemisphere stroke Hemmorhagic stroke Left brain stroke R right brain stroke Nurse teaches client who had stapedectomy. Teaching is understood when which client request is made. Physical therapy for vertigo Neck brace with padding Diet sheet that lists high protein foods Prescription for stool softener Client diagnoses with pulmonary embolism. Which priority does nurse apply? Give supportive care during healin Cardiac monitoring Prevent further embolism Administer thrombolytic agents Client diagnoses with meniere disease. Client has sudden attack of vertigo, nausea, vomiting, and sweating. Nurse provides which interventions? Select all that apply GLYCEROL TEST D diet high in dosium and caffeine Warm, moist environment Dark quiet environment Lorazepam and meclizine IV lfuids and medications Client has respiratory failure. Client becomes agitate, restless, and disoriented. Client has nasal flaring and RR of 26. Most important client goal for nurse to activate? Will have clear breath sounds in all lyng areas Will have pao2 of 90mmHg Will have heart rate of at least 110 bpm Will cough and deep breath 10 tims an hour Client in middle stage of Parkinson. Client no long able to work at job held for years and gave up hand crafts. Client cries and says” this is to hard I cant do the things I want to do. I never thought I would be like this.” Which is the most important goal for this client? Will indicate reduced feeling of depression Will oibtain new job in preferred field of work Will join Parkinson support group Will maintain independence in activities of daily living Clikent diagnoses with bell palsy. Client is concerned because facial appearance has changed. Feelings of fear and qanxiety are expressed to the nurse. Which is the best goal for this client? Client will take meds as ordered Client will state understanding of disease process Client will share prognosis with spouse Client will express decrease in fear and anxiety Client has hypertension. Client says “I think I can stop taking my medication now. I don’t have those headcahces anymore, so I am over this.” Which is the nurses best response? Remember, you can have hyptertension and not have any symptoms Don’t you remember, I told you the medication would needc to be taken for life We will see what your BP is. Maytbe you can stop. How about your diet? Tell me thwat you remember from our conversation about hypertension Client reports sharpburngin pain in lower gums and jaw. Client diagnoses with trigeminal neuralgia. Eating and brushing teeth often trigger pain. Carbamazepine is prescribed. Nurse knows the medication has the anticipated effects when the client makes which statement? I have to have two new cavities filled in my back molars I have regained the 10 punds lost before the treatment I wish I could use my fan when the house gets hot I miss seeing my friends at my bridge club every week Client receives hearing aid because of decreased hearing in both ears. Nurse speak softly and high-pitched to turn right and go up the stairs. The client turns left and goes down the stairs. Which interpretation does the nurse make? Hearing aid needs volume adjustment Different type of hearing aid is needed Mental changes should be assessed Loud-speaking voice is needed Client who is HIV positive receives a Mantoux test. Nurse identifies a 7mm induration at test site. Which interpretation does nruse make? False positive, previous bacilli Calmette-guerin vaccine Negative reaction, less than 10 mm Negative ractio, less than 15 mm Posititve reaction, greater than 5 mm Client diagnosed with liver cancer has partial hepatectomy. Client has anorexia, nauseam and vomiting with weight loss prior to surgery. The nurse communicates which intervention to the client? Select all Here is a sheet we wily se to track I and O and calories for the day We will ask the dietitian to help you select foods that are low in protein and calories We will help you plan your diet around foods you like Let ys plan for 6 small meals each day to help with the nausea Lets talk about how to decrease your fluid intake to 1000 ml per day You can help us watch your skin to make sure it is not excoriated or sore Client is diagnosed with glaucoma. Client asks “why do I need to take these eye drops? They hurt my eyes.” Which is the nurses best response? Drops help preserve your vision. Maybe less painful medication can be found. The eye care provider says you need to take them. I am sorry they hurt you Lets talk to your eye care provider to see if there is a medication that is less irritating. You will lose your vision if you don’t use the drops as prescibred. Client diagnosed with stroke. Nurse observes while client eats lunch. Client coughs after many bites, swallows solids very slowly, swallows liquids without difficulty. The client makes stranged movements with tongue during eating. Which action does the nurse take next? Asks client for favorite food choices Encourages client to chew slowly Requests dietary consult Rquests occupational therapy consult Nurse teaches a class about circulatory disease. Which symptom of peripheral arterial disease does te nurse include? Select all Pain in lower extremeties Yellow toe nails Numbness and tngling in toes Thin, shiny, skin on legs Pale foot when leg is elevated Chest pain and dyspnea Client diagnosed with inefetive endocarditis is discharged home on IV antibiotic therapy. The nurse knows the client understands the discharge treatment plan when the client makes which statement? When I get home, I can take off these compression stockings when I am walking I can go back to my job next week and start back traveling I will tell my dentist about this illness before havng my teeth cleaned I can help care for my grandchildren whenthey are sick and stay home from school Client undergoes brachytherapy. Which action is most important for the nurse to take? Werar film badge dosimeter Deliver all client care at one time Place client in neutropenic precautions Provide meals using disposable dishes Dlient is to receive 2 unites of blood. Client has an IV in the right forearm with D5W in normal saline that is used to administer an antibiotic every 4 hours. Which does the nurse do first? Insert a microdrip chamber into IV Start a second IV with isotonic saline Use a filtered tubing to administer the blood Receive the first unit of blood from the blood bank Client experiences a right-brain stroke. Which is the priorty intervention for the nruse when giving care? Assess emotional status Give range of motion exercises Keep client safe Provide communication assistance Client receives low-flow oxygen at 10 L/min at concentration of 50%. Which is the best oxygen administration for the nurse to chose. Partial non rebreathing mask Simple face mask Nasal cannula Oxygen-conserving cannula Client unresponsive after a closed-head injury. Glascow coma scle is 7. Nurse identifies the clients state as which best description? Shows signs of visual and hearing impairment Identified as comatose Has subdural hematoma Is alert with impaired motor function Client receives information priord to having a PET scan done. Nurse recognizes further teaching is needed when the client makes which statement? I will need to drink lots of fluid after the test I am glad I will be asleep during the test I know I must lie still and only move when told to move The IV lines in my arms will give me glucose dye Client is paraplegic because of spinal cord injury. Nurse identities nursing diagnosis “ineffective coping” based on which client statemtn How can I ever get a job now that I am in a wheelchair How long will I need physical therapy before I am discharged When can I start playing wheelchair basketball What are my limitations? I don’t want to be held back A client is discharged to home following a lung wedge resection for stage IIB lung cvancer. The nurse provides information regaridn signs and symptoms to report if they occur. Which nursing statement is best? If you have chest pain, make syre your spouse goes outside to smoke Watch for decreasing pain levels, and let the health care provider know If you have difficulty breating or eating, call the health care providr Please call the health care provider if you have hemoptysis Client diagnosed with myasthenia gravis. Client says “I am tired all the time and don’t want to live anymore. If I stop taking my medicaitons, I can stop breathing.” Which is the nurses best response? Place client on suicide watch Teach client about new medication Give client information about myasthenia gravis group Ask client about feelings of hopelessness Client is diagnoses with immune thrombocytopenia purpura. Client receives corticosteroids. Nurse know the treatment is effections when which observation is made? Bleeding is minimal after injection Purpuric lesions fade to white Platelet count is 175,000 Erythrocyte count is 5.1 million A client with heart failure is to be weighed daily. Client asks why this is necessary. Which is the best information for the nurse to give? Determines the number of calories for the diet Indication of the fluid status in the body Shows activity affects activity tolerance Helps determine if the medication is working Client diagnoses with flaccid neurogenic bladder due to spinal cord injury. Client has had severl urinary tract infections. Bladder traiing program ahs been establish. Which documentation indicates the clients bladder function is currently satisfactory? Client has had no UTI in 3 days Client verbalizes when to empty bladder Client empties baldder completely every 2-3 hours Client correctly demonstrates bladder emptying technique Client diagnosed with COPD. Client has had asthma for 10 years, has smoked for 40 years, and has frequent episodes of bronchitis. Nurse identiing a nursing diagnosis based on which most important client problem? Life-style that exacerbates COPD Problems with oxygen intake causing confusion Low self esteem because of health status changes Interest in seeking behavior changes Nurse teaches client diagnoses with venous thromboembolism in the right calf. The nurse knows the cleitn understands the teaching when the client makes which statement? I need to exorcise vigorously for at least 15 minutes twice a day I may continue to take my fish oil and saw palmetto I may stop taking my anticoagulants when I no longer have pain I need to limit the amount of ginger and garlic I eat Nurse plans care for the client with tuberculosis. Cloient says it is difficult to remember to take ehe medications every day since they are not helping with the cough. The nurse adds which nursing diagnosis to the clients care plan? Activity intolerance related to cough and fatigue from disease Ineffective breathing patterns related to disease process and coughing Noncomplienace related to lack of understanding of management regime Ineffective self-health management related to lack of motivation Nruse suctions a clienets tracheostomy. Which nechnigue does the nurse use? Select all that apply Suctions client every hour Use sterile technique when suctioning Uses intermittent suctioning Routintely instills sterile normal saline before suctioning Rotates the catheter when withdrawing Applies suction when inserting catheter Client diagnoses with epilpsey. Client talks to the nurse about difficulties of managing the disorder. Which is the most important goal for this client? Will maintin seizure free status for 1 year Will demonstrate methods of managing self during a seizure Will describe ways to effectively manage the disease Will meet requirements to get driving license again Client with pancreatic cancer receives radiation as palliative care. The nurse knows the treatment is effective when they notice which observation? Client requests less pain medication Famiy says patient looks less ill Client requests special meal Client sleeps 4 hours in afternoon Client has sustaintedinjurty from industrial accident. Client says large metal beam cause the contusions to the chest, arms, and legs. The client is heaving chest pain and dyspnea. Which addition symptom does the nurse anticipate? Select all that ap-ply Elevated temperature Increasing hypotention Frothy sputum Tracheal deviation Flushed face and arms Cough with hemoptysis Client with viral pneumonia is palce on 4 L of oxygen. The nruseenteres which nursing diagnosis in the clients plan of care. Ineffective breathing pattern related to inflammatory process Excess fluid volume related to edema in lungs Chromic pain related to inflammatory process and congestion Disturbed sleep pattern related to oxygen therapy Client sustained spinal cord injury at c6 level. Client wear halo vest to stabilize the vertebrae folliwngsurrgey. Which is most important nursing action for client Maintina adequate fluid volume Maintina adequate respirations Faciliatating bladder management Facilitating adequate bowel function Client diagnosed with sickle cell disease. The nurse teaches information for which most common complication? Pneumonia Kidney damage Leg ulcers Osteoporosis Client on chemotherapy has an absolute neutrophil count of 900 cells. Neutropenic precautions are instituted. The client asks why the family needs to wear gowns, masks, and gloves when they visit. Which is the nruses best response? This is to keep you from getting an infection I know you want to touch and to be close to them but that is not possible You are very likely to become infefcted, and this keeps you away from their germs You seem upset. Tell me what you know about your condition. [Show More]

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