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A client experiencing shock has had a urinary output of 250 mL in the last 10
hours. What is the nurse's most appropriate response?
Notify the physician.
Which client is most likely to be experiencing hypovolemic shock?
A client who had surgery 24 hours ago and who also has a nasogastric tube
The physician has ordered arterial blood gases for a client experiencing
shock. The nurse knows that which value indicates shock?
pH 7.32
A 63-year-old Arab American male states his left leg is "hot." What is the
nurse's best first response?
Assess for pain
The client is complaining of excruciating pain in a foot that has been
amputated. The family tells the nurse that the client is just addicted to pain
medications. What is the nurse's best response?
"He is experiencing phantom limb pain."
,A client has had abdominal surgery and has orders to be ambulated three
times a
day. Oral pain medication has been ordered for the client. What should the
nurse do to facilitate ambulation?
Mediate 1 hour prior to ambulating the client.
The client reports frequent use of acetaminophen. How should the nurse
best respond?
"Do you drink alcohol?"
A client with chronic pain has been admitted with a fever. The nursing
assessment reveals that the client has a decreased level of consciousness.
What should the nurse ask the family about?
What medications the client has taken
The practical nurse is reviewing the social history from a client diagnosed
with small cell carcinoma of the lung. Which information is significant for
this disease?
The client has smoked two (2) packs of cigarettes a day for 20 years
The practical nurse and an unlicensed assistive personnel (UAP) are caring for
a
group of clients on a medical unit. Which information provided by the UAP
warrants immediate intervention by the practical nurse?
The client receiving Procrit (epoetin alfa) has a T 99.2˚F, P 68, R 24, and BP of
198/102
,The client diagnosed with lung cancer has been told the cancer has
metastasized to the brain. Which intervention should the practical nurse
expect to implement?
Discuss implementing an advance directive
The client diagnosed with lung cancer is being discharged. Which
statement made by the client indicates a reiteration of information is
required?
"It doesn't matter if I smoke now. I already have cancer."
The practical nurse is interviewing clients at the clinic. Which information
provided by a client warrants further investigation?
The client has been coughing up blood in the mornings
The male client had abdominal surgery and the practical nurse suspects the
client has peritonitis. Which information support the diagnosis of
peritonitis?
Hard, rigid abdomen and white blood cell count 22,000/mm3
The client who had abdominal surgery tells the practical nurse, "I felt
something give way in my stomach." Which intervention should the practical
nurse implement first?
Inspect the abdominal wound incision
The client is one (1) day postoperative major abdominal surgery. Which
client problem is a priority?
Fluid and electrolyte imbalance
, The client has an eviscerated abdominal wound. Which intervention should
the practical nurse implement?
Apply sterile normal saline dressing
The client is diagnosed with peritonitis. Which information indicates to the
practical nurse the client's condition is improving?
The client has a decrease in temperature and a soft abdomen
A patient is being released from the hospital with a prescription for
tetracycline. What should the nurse include in patient teaching?
Select all that apply.
Advise limiting exposure to the sun.
Inform patient of the possibility of gastrointestinal upset.
Suggest eating crackers and some juice when taking this medicine.
The nurse wants to determine if a patient not fully awake from anesthesia for a
surgical procedure is experiencing pain. What findings should the nurse use to
make this determination?
Select all that apply.
Moaning
Restlessne
ss
Pulling at a body area
Elevated blood pressure