…duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer.
Review with the client the need to avoid foods that are rich in milk and cream
antihypertensive …admits that he has not been taking the prescribed medication because the drugs make him "feel bad". ….
Stroke secondary to hemorrhage
(UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along
the side rails.
Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows
major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days.
Describes life without purpose
ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap)
Further evaluation involving surgery may be needed
underwent a tracheostomy is being prepared for discharge to home. Which instructions is most important
Teach tracheal suctioning techniques
,rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration / respiratory rate is 14
breaths / minute.
Document the assessment data
Rational: reservoir bag should not deflate completely during inspiration and the client's respiratory rate is within normal limits.
electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate first?
Respiratory apnea of 30 seconds
elderly client with diabetes slip and fall. What action
Check the client for lacerations or fractures
cesarean section (C-Section), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a
headache.
Inform the anesthesia care provider
S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action
Listen with the bell at the same location
,no longer have a health insurance through her place of employment. Which agency
Medicare
tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline?
Toasted wheat bread and jelly
lumbar puncture, a client voices several complaints. What complaint indicated to the nurse that the client is experiencing a
complication?
"I have a headache that gets worse when I sit up"
Rationale: This complication is usually managed by bedrest, analgesic, and hydration.
An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action
Obtain a clean catch mid-stream specimen
Rationale: This elderly is experiencing symptoms of urinary tract infection.
, child with phenylketonuria (PKU) to select foods that are in keeping with the child's dietary restrictions. Which foods are contraindicated for this
child?
Foods sweetened with aspartame
3 minute surgical hand scrub is adequate preparation for this client.
Direct the nurse to continue the surgical hand scrub for a 5 minute duration
breakfast ….. management of osteoporosis?
Bagel with jelly and skim milk
which client should receive the most care hours by a registered nurse (RN)
An 82-year-old client with Alzheimer's disease newly-fractures femur who has a Foley catheter and soft wrist restrains
applied
…the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first?
Cleanse the foot with soap and water and apply an antibiotic ointment
"My son has athlete's foot, I have been applying triple antibiotic ointment for two days,
Stop using the ointment and encourage complete drying of the feet and wearing clean socks.
Review with the client the need to avoid foods that are rich in milk and cream
antihypertensive …admits that he has not been taking the prescribed medication because the drugs make him "feel bad". ….
Stroke secondary to hemorrhage
(UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along
the side rails.
Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows
major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days.
Describes life without purpose
ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap)
Further evaluation involving surgery may be needed
underwent a tracheostomy is being prepared for discharge to home. Which instructions is most important
Teach tracheal suctioning techniques
,rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration / respiratory rate is 14
breaths / minute.
Document the assessment data
Rational: reservoir bag should not deflate completely during inspiration and the client's respiratory rate is within normal limits.
electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate first?
Respiratory apnea of 30 seconds
elderly client with diabetes slip and fall. What action
Check the client for lacerations or fractures
cesarean section (C-Section), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a
headache.
Inform the anesthesia care provider
S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action
Listen with the bell at the same location
,no longer have a health insurance through her place of employment. Which agency
Medicare
tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline?
Toasted wheat bread and jelly
lumbar puncture, a client voices several complaints. What complaint indicated to the nurse that the client is experiencing a
complication?
"I have a headache that gets worse when I sit up"
Rationale: This complication is usually managed by bedrest, analgesic, and hydration.
An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action
Obtain a clean catch mid-stream specimen
Rationale: This elderly is experiencing symptoms of urinary tract infection.
, child with phenylketonuria (PKU) to select foods that are in keeping with the child's dietary restrictions. Which foods are contraindicated for this
child?
Foods sweetened with aspartame
3 minute surgical hand scrub is adequate preparation for this client.
Direct the nurse to continue the surgical hand scrub for a 5 minute duration
breakfast ….. management of osteoporosis?
Bagel with jelly and skim milk
which client should receive the most care hours by a registered nurse (RN)
An 82-year-old client with Alzheimer's disease newly-fractures femur who has a Foley catheter and soft wrist restrains
applied
…the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first?
Cleanse the foot with soap and water and apply an antibiotic ointment
"My son has athlete's foot, I have been applying triple antibiotic ointment for two days,
Stop using the ointment and encourage complete drying of the feet and wearing clean socks.
