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1 of 128
Term
NGN: The client has returned to work at in accounting firm and has
started going to a grief support group. She reports she is seeking
care from a healthcare professional because her father is worried
about her. The client says she only gets 2 to 3 hours of sleep due to
nightmares about the crash. She informed that exercising right after
work helps her get better sleep and to relax. She feels that she is
"jumpy" after the accident, especially when she is in the car. She also
stated, "I feel so sad that I can't seem to feel anything at all". In
addition to her father, the client has a large family and friend support
system. She denies alcohol or drug use.
(highlight areas in the above paragraph that the nurse should...)
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, C) Evaluate the clients asthma medication's that can elevate the blood glucose.
D) Have the client describe a typical day at work, home, and social activities.
E) Have the client demonstrate technique used to monitor blood glucose levels.
-Provide mouth care. (UAP)
-Document changes in respiratory status. (RN/RT)
-Set up the oxygen administration system. (RN/RT)
-Change the gauze under the nasal cannula. (UAP)
-she only gets 2 to 3 hours of sleep due to nightmares about the crash.
-She feels that she is "jumpy" after the accident, especially when she is in
the car.
- "I feel so sad that I can't seem to feel anything at all"
-The tubing should be tucked under the chin and secured with the sliding
adjustment piece. (UNDERSTANDING)
-Humidification of oxygen is not needed for administration under 4 L per minute.
(UNDERSTANDING)
-The nasal cannula can deliver up to 10 L per minute of oxygen. (NOT
UNDERSTANDING)
-A nasal cannula delivers 100% oxygen to the client. (NOT UNDERSTANDING)
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2 of 128
Term
NGN: For newborn baby.
Which six orders take priority?
A) Transfer to neonatal intensive care unit.
B) Blood glucose level.
,C) Feed immediately.
D) Bolus of 2 mL per kilogram glucose 10% IV.
E) Monitor for respiratory distress.
F) Echocardiogram.
G) Contact respiratory therapy for ABG and oxygen therapy.
H) Monitor temperature every 30 minutes.
I) Keep in warmer with bilirubin lights.
J) Apply dextrose gel inside the babies cheek.
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-Vitals have remained stable
-Oxygen 98% on 0.25 L per minute oxygen via nasal cannula
-Able to tolerate breastmilk.
-Glucose after feeding was 60, temp 97.8 F axillary
-Calcium and magnesium within normal limits.
-Direct bilirubin five
B) Respiratory rate.
C) Blood pressure.
D) Pain.
E)Temperature.
G) Oxygen saturation.
A) Transfer to neonatal intensive care unit.
B) Blood glucose level.
C) Feed immediately.
D) Bolus of 2 mL per kilogram glucose 10% IV.
E) Monitor for respiratory distress.
J) Apply dextrose gel inside the babies cheek.
A) Assess the clients blood pressures every 15 minutes.
This likely dysreflexia but the BP needs to be monitored first. Dysreflexia is an
, abnormal overreaction of the involuntary her nervous system. EXP, change in
heart rate, blood pressure, diaphoretic, skin flushing, throbbing HA,
confusion/anxiety
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3 of 128
Term
In evaluating the effectiveness of a postoperative client intermittent
pneumatic compression devices, which assessment is most
important for the nurse to complete?
A) Observe both lower extremities for redness and swelling.
B) Monitor the amount of drainage from the clients incision.
C) Palpate all peripheral pulse points for volume and strength.
D) Evaluate the clients ability to use an incentive spirometer.
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C) Evaluate the clients asthma medication's that can elevate the blood glucose.
D) Have the client describe a typical day at work, home, and social activities.
E) Have the client demonstrate technique used to monitor blood glucose levels.
A) Place a bedside commode next to bed.
E) Encourage family to participate in the clients care.
C) Palpate all peripheral pulse points for volume and strength.
Puzzler absent all week I can enter key compromise circulation, due to
clock formation.