- After several hours of non-productive coughing, a client presents to the emergency room complainingof chest tightness and shortness of breath. History includes end stage chronic obstructive pulmonary disease(COPD) and diabetes mellitus. While completing the pulmonary assessment, the nurse hears wheezing andpoor air movement bilaterally. Which actions should the nurse implement? (Select all that apply.)
- An older male comes to the clinic with a family member. When the nurse attempts to take the client'shealth history, he does not respond to questions in a clear manner. Which action should the nurseimplement first?
- . An unlicensed assistive personnel UAP leaves the unit without notifying the staff. Inwhat order should the unit manager implement this intervention to address the UAPs behavior? (Placethe action in order from first on top to last on bottom.)
- At the end of a preoperative teaching session on pain management techniques, aclient starts to cry and states, "I just know I can't handle all the pain." What is the priority nursing diagnosisfor this client?
- During the admission assessment, the nurse auscultates heart shounds for clientwith no history ofcardiovascular disease. Where should the nurse listen when assessing the client's point of maximalimpulse
- A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives aprescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse includein this client's teaching plan? (Select all that apply.)
- Several months after a foot injury, and adult woman is diagnosed with neuropathic pain. The clientdescribes the pain as severe and burning and is unable to put weight on her foot. She asks the nurse when thepain will "finally go away." How should the nurse respond?
- The nurse is developing an educational program for older clients who are being discharged with newantihypertensive medications. The nurse should ensure that the educational materials include whichcharacteristics? Select all that apply
- Which location should the nurse choose as the best for beginning a screening program forhypothyroidism?
- An older male resident of LTC facility is hospitalized for a cardiac catheterization that occurredyesterday. Since the procedure was conducted, the client has become increasingly disoriented. The nightshift nurse reports that he attempted to remove the sandbag from his femoral artery multiple times duringthe night. What actions should the nurse take? (Select all that apply.)
- An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the Unna boot isremoved during a follow-up appointment, the nurse observes that the ulcer site contains bright red tissue.What action should the nurse take in response to this finding?
- A new mother tells the nurse that she is unsure if she will be able to transition into parenthood. Whataction should the nurse take?
- The nurse enters a client's room and observes the client's wrist restraint secured as seen in the picture.What action should the nurse take?
- The healthcare provider prescribes the antibiotic cephradine 500mg PO every 6 hours for a client with apostoperative wound infection. Which foods should the nurse encourage this client to eat?
- The nurse should teach the client to observe which precaution while taking dronedarone?
- A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the clientto perform a series of movements that require use of the facial muscles. What symptoms suggest that the clienthas most likely experience a Bell's palsy rather than a stroke?
- A client with intestinal obstructions has a nasogastric tube to low intermittent suctionand is receiving an IV of lactated ringer's at 100 ml/H. which finding is most importantfor the nurse to report to the healthcare provider?
- A client is admitted with an epidural hematoma that resulted from a skateboarding accident. Todifferentiate the vascular source of the intracranial bleeding, which finding should the nurse monitor?
- The nurse is caring for a client receiving continuous IV fluids through a single lumen central venouscatheter (CVC). Based on the CVC care bundle, which action should be completed daily to reduce the risk forinfection?
- When preparing a client for discharge from the hospital following a cystectomy and a urinary diversion totreat bladder cancer, which instruction is most important for the nurse to include in the client's dischargeteaching plan?