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Final 2

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jennraq2u's version from 2016-10-17 21:20

Section

Question Answer
A client has undergone a lumbar laminectomy with spinal fusion 12 hours earlier. What assessment finding should indicate to a nurse that the client has a leakage of cerebrospinal fluid?Clear fluid drainage noted on the surgical dressing
The nurse is conducting a focused neurologic assessment. When assessing the client's cranial nerve function, the nurse would include which of the following assessments?Assessment of gag reflex
The nursing students are learning how to assess function of cranial nerve VIII. To assess the function of cranial nerve VIII the student would be correct in completing which of the following techniques?Test for air and bone conduction - equilibrium
When planning to move a person with a possible spinal cord injury, the nurse should direct the team toImmobilize the head and neck to prevent further injury
The nurse observes red urine and several large clots in the tubing of the normal saline continuous irrigation catheter for the client who is one (1) day postoperative Transurethral Resection of the Prostate (TURP). A nurse wouldTitrate the infusion rate of the NS irrigation
The nurse emptied 2,000 ml from the drainage bag of a continuous irrigation of a client. The amount of irrigation in the hanging was 3,000 ml at the beginning of the shift. There was 1,800 left in the bag hours later. What is the correct urine at the end of the 8 hour shift?800 ml
A statement that indicates discharge teaching has been effective for the client who is postoperative transurethral resection of prostate (TURP)?I will call the urologist if I experience any difficulty urinating
Teaching participants about the risk factor for hypertension. The nurse notes what nonmodifiable risk factors for hypertension?A family history of hypertension
The nurse is caring for an adult client who has gone into ventricular fibrillation. When assisting with defibrillating the client, what must the nurse do?Maintain firm contact between paddles and client skin
The nurse is unable to read the telemetry monitor at the nurse's station. What intervention should the nurse implement first?Contact the client on the client care system
The nurse is assessing heart sounds. What location would the nurse place the stethoscope to listen to the pulmonic valve?2nd ICS left of the sternal boarder
The nurse is preparing to perform a client's abdominal assessment. What examination sequence should the nurse follow?Inspection, ausculation, percussion, and palpation
A nurse student has ausculated a client's abdomen and note one or two bowel sounds in a 2-minute period of time. How would you tell the student to document the client's bowel sounds?Hypoactive
What would the nurse do to prevent reflux gastric contents from coming through the blue gastric sump tube?Keep the vent lumen above the client's waist
Feeding tubes and endotracheal tubes, the educator emphasized the need to check for tube placement in the stomach as well as revolume. What is the main purpose of this nursing action?Prevent aspiration
The nurse is caring for a client with impaired renal function. A creatinine clearance measurement has been ordered. The nurse should facilitate collection of what samples?A 24-hour urine specimen and a serum creatinine level midway through the urine collection process
A client with renal failure secondary to diabetic nephropathy has been admitted to the medical unit. What is the most life-threatening effect of renal failure which the nurse should monitor the clientRetention of Potassium
4 clients. What client does the nurse know is at the greatest risk of developing ESKD (end-stage kidney disease)?A client with diabetes and poorly controlled hypertenstion
A patient with cancer of the bladder. The nurse is monitoring the client's urine output hourly and notifies the physician when the hourly output is less than what?30ml
A client with kidney stones is scheduled for extracorporeal shock wave lithotripsy (ESWL). What should the nurse include in the patient's post-procedure care?Strain the client's urine following the procedure
The patient in hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid-base imbalance?Respiratory alkalosis
You are performing assessment on an older adult client newly admitted for end-stage liver disease. What principle should guide your assessment of the patient's skin turgor?Inelastic skin turgor is a normal part of aging
Assessing a patient diagnosed with cholecystitis experiencing localized abdominal pain. When assessing the characteristics f the patient's pain, the nurse should anticipate that it may radiate to what region?Right shoulder
A client's abdominal ultrasound indicates cholelithiasis. When the nurse is reviewing the patient's laboratory studies, what finding is most closely associated with the diagnosis?Decreased serum alkaline phosphatase leve
A client has been scheduled for an ultrasound of the gallbladder the following morning. What should the nurse do in preparation for this diagnostic study?Have the client refrain from food and fluids after midnight
A client with primary hypertension complaining of gradual onset of blurry vision and decreased visual acuity of the past several weeks. The nurse is aware that these symptoms could be indicative of what?Retinal blood vessel damage
Registered nurse in the cardiac step-down unit must prioritize assignments. The nurse has an ancillary staff member available to help care for the clients in the unit. Which client should the RN assess first?The client with heart failure who is having some difficulty breathing or constipation
A client experiences orthostatic hypotension while receiving furosemide (Lasix) to treat hypertension. hat should the nurse do?Instruct the client to sit for several minutes before standing up or rise up slowly
Caring for a client with acute heart failure who is ordered to receive 40 mg. furosmide (Lasix) IV push. What laboratory value is most important for the nurse to check before administering the medication?Potassium
The client has undergone an abdominal aortic aneurism resection. What complication does the nurse monitor for?Hemorrhage and shock LOC
the health care provider orders aspirin, 325 mg. P.O. daily for a client who has experienced a transient ischemic attack (TIA). The nurse should tell the client that the physician has ordered this medication for what reason?To reduce the chance of blood clot formation
A client is admitted with right- sided heart failure. What position should the nurse place the head of the bed in to obtain the best reading of juglar vein distension?Semi fowler's
A nurse is reviewing self-care measures for a client with peripheral vascular disease. What statement indicates proper self-care measures?I have my wife help me inspect the soles of my feet every day.
The nurse notes edema to the right leg with skin color changes to the right lower extremity. The client reports pain at the incision site at 4 on a scale of 1-10 and pain to the right calf of 7 on a 1-10 scale. The notifies the health care provided because he suspects the client may have what complication?Deep vein thrombosis
What is the most important information for the nurse to document as an indication of the progress of a client with heart failure?Record of daily weights
Information about a 65-year old client. When developing a plan to decrease stroke risk, what risk factor is most important for the nurse to address?The client's blood pressure (BP) is consistently between 150/80 to 170/90 mm
A client with right-sided weakness that started 1 hour ago is admitted to the emergency department and all these diagnostic test are ordered. Which order should the nurse act on first?Noncontrast computed tomography (CT) scan
A client with a stroke has progressive development of neurologic deficits with increasing weakness and decreased level of consciousness (LOC). What is the priority nursing diagnosis for this client?Impaired physical mobility related to weakness
A 32-year-old client has a stroke resulting from a ruptured aneurysm and subarachnoid hemorhage. What intervention will be included in the care plan?Inserting an oropharyngeal airway to prevent airway obstruction
A client with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?Check the respiratory rate
A client with a severe head injury has been maintained on IV fluids of 5% dextrose in water D5W) at 50 ml/hr for 3 days. The nurse will anticipate the need to do what?Continue the D5W to provide the needed glucose for brain function
An unconscious client has a nursing diagnosis of ineffective tissue perfusion (cerebral) related to cerebral tissue swelling. What is an appropriate nursing intervention for this client?Maintain the client in a head-up position
The nurse observes the client in a tonic-clonic, generalized seizure. What is the priority nursing action?Remain with the client until it is over and try to prevent injury
The client has has an acute MI and the nurse is providing discharge teaching. The client's spouse is embarrassed to ask, but when can he resume regular sexual activity? How should the nurse respond?When he can climb a flight of stairs without getting short of breath or experiencing any chest pain
Performing triage at the scene of a terrorist attack using five-level triage system categories. What order?1-resuscitation 2-emergent 3-urgent 4-minor 5-non-urgent
The nurse is teaching a class on disaster preparedness. Which are components of an Emergency Operations Plan (EOP)?a plan for practice drills, a deactivation response, a security plan
The female client is diagnosed with hypothyroidism. The nurse should assess the client for what?Constipation, Decreased energy and fatigue, Weight gain of 10 pounds and Menorrhagia*Hair Loss
The client has been admitted with new onset status epilepticus. To be placed on seizure precautions. What does the nurse know to place?Siderails up, suction equipment at the bedside and IV access
The client newly diagnosed with a seizure disorder is placed on P.O. phyenytoin (Dilantin) 200mg. What should the nurse include when teaching about the medication?Do not skip doses of this medication or abruptly stop taking it
The student nurse is preparing a teaching plan for a patient being discharged status post myocardial infarction (MI). What should the student include in the teaching plan?Need for careful monitoring for cardiac symptoms, Need for carefully regulated exercise, Need for dietary modifications
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