ECON 351 ATI ADULT MEDICAL SURGICAL PROCTOR COMPLETE SOLUTION

ECON 351 ATI ADULT MEDICAL SURGICAL PROCTOR COMPLETE SOLUTION Seizures and Epilepsy: Seizure precautions During a seizure: Position client on the floor and provide a patent airway, turn client to side and loosen restrictive clothing Cancer treatment options: Protective Isolation (999) If WBC drops below 1,000, place the client in a private room and initiate neutropenic precautions. - Have client remain in his room unless be needs to leave for a diagnostic procedure, in case of transport place a mask on him - Protect from possible sources of infection (plants, change water in equipment daily) - Have client, staff and visitors perform frequent hand hygiene, restrict ill visitors - Avoid invasive procedures (rectal temps, injections) - Administer (neupogen, neulasta) to stimulate WBC production Infection control: Appropriate room assignment Standard Precautions: 1. applies to all patients 2. Hand washing a. alcohol based preferred unless hands visually soiled 3. Gloves - when touching anything that has the potential to contaminate. 4. Masks, eye protection & face shields when care may cause splashing or spraying of body fluids Droplet: 1. private room or with someone with same illness 2. masks Airborne: 1. private room 2. masks or respiratory protection devices a. use an N95 respirator for tuberculosis 3. Negative pressure airflow 4. full face protection if splashing or spraying is possible Contact: 1. private room or room with same illness 2. gloves & gowns 3. disposal of infections dressing materials into a single, nonporous bag without touching the outside of the bag TB: Priority action for a client in the emergency department (249) Wear an N95 or HEPA respirator -Place client in negative airflow room and implement airborne precautions -use barrier protection when the risk of hand or clothing contamination exists Immunizations: Recommended vaccinations for older adult clients (943) Adults age 50 or older: -Pneumococcal Vaccine (PPSV) - Influenza vaccine - Herpes Zoster Vaccine -Hepatitis A - Hepatitis B - Meningococcal Vaccine Pulmonary Embolism: Risk factors for DVT (258) Long term immobility - Oral contraceptives - Pregnancy - Tobacco use - Hypercoagulabilty - Obesity - Surgery - Heart failure or chronic A-Fib - Autoimmune hemolytic anemia (sickle cell) -Long bone fractures -Advanced age Disorders of the male reproductive system: Complications of continuous irrigation following Trans-urethral Resection (743) Urethral trauma -Urinary retention - Bleeding - Infection Stroke: Caring for a client who has left sided hemiplegia (155) Observe extremities for injury - Apply an arm sling if client is unable to care for the affected extremity - Ensure foot rest is on wheel chair and ankle brace is on the affected foot - Instruct client to dress the affected side first Fractures and immobilization devices: Prevent complications (787) Assess neurovascular status of the affected body part for every hour for 24 hours and Q4 hours after that - Maintain body alignment - avoid lifting or removing weights -Monitor pain level - Monitor for signs of infection - Support nutrition Pain Management: use of non pharmacological methods of pain relief Cutaneous (skin) stimulation- TENS, heat, cold, therapeutic touch and massage - Distraction (deep breathing, ambulation, visitors, TV and music) - Relaxation (meditation, yoga and progressive muscle relaxation -Imagery (focus on pleasant thoughts) - Elevation of extremities to promote venous return Acute Kidney injury and chronic kidney disease: Evaluating teaching about nutrition Restrict dietary intake of potassium, phosphate and magnesium during oliguric phase -K and Na is regulated according to stage of kidney injury - high protein diet to replace the high rate of protein breakdown due to the stress from the illness. Possible TPN Heart failure and pulmonary edema: Dietary teaching about sodium restriction Maintain fluid and sodium restriction Increase dietary intake of potassium Pulmonary Embolism: Planning care for a client who is receiving enoxaparin Assess for contraindications (active bleeding, peptic ulcer disease, history of stroke, recent trauma) -Monitor bleeding times (PT, aPTT and INR) -Monitor for side effects such as thrombocytopenia, anemia and hemmorhage Rheumatoid Arthritis: Reviewing Laboratory Values Positive Anti- cyclic citrullinated peptide -RF Antibody (Diagnostic level for RA is 1:40-1:60) expected reference range 1:20 - Elevated ESR 20-40 mild inflammation 40-70 moderate 70-150 severe - Positive C-reactive protein - Positive ANA titier - Elevated WBC's Medications affecting coagulation: Heparin Contraindications Avoid NSAIDS while on heparin Antibiotics affecting protein synthesis: Adverse effects of gentamicin Ototoxicity: cochlear damage (hearing loss) and vestibular damage (loss of balance). -Nephrotoxicity (proteinuria, elevated BUN, creatinine levels). -Hypersensitivity ( rash, pruritis, parathesia of hands and feet, and urticaria). Electrolyte imbalance: manifestations of hypokalemia Weak, irregular pulse, hypotension, respiratory distress Premature ventricular contractions, bradycardia, inverted T waves, ST depression Decreased GI motility, abdominal distension, constipation, n/v, anorexia, polyuria Decreased K (3.5) ABG: Metabolic alkalosis (pH 7.45) Electrolyte imbalance: Priority assessment for hypokalemia Assessing for a patent and open airway Blood and blood product transfusions: Administering Fresh Frozen Plasma Initiate a large bore IV access: 20 gauge needle Complete transfusion withing 2-4 hours time frame If reaction occurs: -Stop transfusion immediately - Initiate 0.9% NaCl in a separate line - Save blood bag and blood tubing Cardiovascular Diagnostic and Therapeutic Procedures: Caring for a client who has a PICC ----- Assessing site every 8 hours. Note redness, swelling, drainage, tenderness and condition of dressing -Change tube and positive pressure cap per facility protocol -Using 10mL or larger syringe to flush the line -Cleanse with alcohol for 3 seconds before accessing it -Use transparent dressing Cardiovascular Diagnostic and Therapeutic Procedures: Teaching about a PICC Advise client not to immerse arm in water, to cover dressing site to avoid water exposure -Avoid BP in the arm with PICC Cardiovascular Diagnostic and Therapeutic Procedures: PICC care Apply an initial dressing of gauze and replace with transparent dressing within 24 hours - An initial x-ray should be taken to ensure proper placement Cardiovascular and Hematologic Disorders: teaching client about food interaction with Warfarin -----Kale, spinach -Brussels sprouts -collard greens, mustard greens -green tea -grapefruit juice, alcohol Angina and MI: Client teaching about nitroglycerin Nitrogylcerin prevents coronary artery vasospasm and reduces preload and afterload. Used to treat angina and help with BP. - Place nitro under tongue to dissolve - Take up to two more doses of nitro at 5-min intervals - Stop activity and rest Headache is a common side effect Orthostatic hypotension Osteoporosis: Teaching about self administration of Alendronate Take with 8oz water in the early morning before eating Remain upright for 30 minutes after taking medication Diabetes Mellitus Management: teaching about self administration of insulin Rotate injection sites - Inject at a 90 degree angle. Aspiration is not necessary - Advise client to eat at regular intervals, avoid alcohol intake and adjust insulin to exercise and diet to avoid hypoglycemia - When mixing insulin's, draw up the shorter acting insulin into the syringe first and then the longer acting insulin. IV therapy: Performing Venipuncture on an older adult client a 22-24 gauge catheter is best to use on older adults Tie the tourniquet sparingly and try to avoid veins in the hand Dosage calculations: Calculating IV infusion rate Ex: nurse is preparing to administer dextrose 5% in water 500 mL IV to infuse over 4 hours. The nurse should set the IV infusion pump to deliver how many mL/hr -Volume (mL)/Time (hr) = X -500 mL/5hr = 125 mL/hr IV therapy: Medication administration Know -Right Patient -Right drug -Right Dose -Right Time -Right Route Arthoplasty: Pain control Analgesics - opiods (epidural, PCA, IV, Oral) NSAIDS Continuous peripheral nerve block Ice or cold therapy to reduce swelling Head of bed slightly elevated and the affected leg in a neutral position. place a pillow or abduction device between the legs when turning to the unaffectedNe side Pain management: PCA Small frequent dosing ensure consistent plasma levels Morphine and Dilaudid Let nurse know if the pump doesn't control the pain Client is the only person to push the button Pain management: Interventions to promote postoperative recovery Managing acute severe pain with short term around the clock administration of opiods parental route is best for immediate short term relief GI therapeutic procedures: D/C TPN therapy Never abruptly stop TPN, gradually decrease (10%) to allow body adjustment. Monitor vital signs q 4-8 hours GI therapeutic procedures: Shortage of TPN Solution Clients receiving TPN frequently need supplemental regular insulin. Keep dextrose 10% in water at the bedside in case the solution runs out. this minimizes the risk of hypoglycemia Nutrition Assessment: Caring for a client with pancreatitis increased serum glucose -reduce pancreatic stimulation through NPO; NG tube is inserted to suction gastric contents -snacks high in calories in order to maintain weight ECG and Dysrthymia monitoring: Analyzing ECG Watch for manifestations of dysrhythmias (chest pain, decreased LOC, SOB) and hypoxia. Remove leads, print ECG report and notify the provider ECG and Dysrthymia monitoring: Performing 12 lead ECG Prepare client for 12 lead if prescribed - Position client in supine position with chest exposed - wash skin to remove oils - Attach one electrode to each of the clients extremities by applying electrodes to flat surfaces above the wrist and ankles and the other 6 electrodes to the chest, avoiding chest hair. Instruct client to remain still Neurologic Diagnostic Procedures: Preparing for a lumbar puncture Instruct client to void before procedure and have them stretch over an overbed table if sitting is preferred - Monitor the puncture site for several hours to ensure the site clots and to decrease the risk of post lumbar puncture headaches COPD: Expected ABG results Hypoxemia (decreased PaO2, less than 80) Hypercarbia (increased PaO2, greater than 45) Respiratory acidosis, metabolic alkalosis compensation Hematologic Diagnostic Procedures: Laboratory findings to report ----RBC: 4.2-5.4 and 4.7-6.1 WBC: 5-10,000 Platelets: 150-400,000 Hgb: 12-16 and 14-18 Hct: 37-47% and 42-52% PT: 11-12.5 sec aPPT: 1.5-2 times normal range of 30-40 INR: 2-3 on warfarin Acid base imbalance: Interpreting ABG results 1) Look at pH 7.35 acidosis 7.45 Alkalosis 2) PaCo2 and HCO3 35 or 45 PaCO2 is respiratory 22 or 26 is metabolic Diabetes Mellitus Management: Evaluating Glycemic Control Monitor with HbA1c expected reference range is 4-6% acceptable target for clients with diabetes 6.5-8% indicator of average blood glucose for the past 120 days Electrolyte Imabalances: Increasing the risk for digoxin toxicity Hypokalemia and client receiving digoxin increases the risk for digoxin toxicity Respiratory Diagnostic Procedures: Client positioning for thoracentesis Position the client sitting upright with his arms and shoulders raised and supported on pillows and/or on an overbed table and with his feet and legs well supported Hepatitis and Cirrhosis: Client positioning following a biopsy Assist the client into a supine position with the upper right quadrant of the abdomen exposed Cushing Disease/ Syndrome: Priority Actions Daily weights Monitor I&O assess for hypervolemia monitor for skin breakdown Fractures and Immobilization devices: Assessing for complications (795) Fat embolism: Dyspnea, chest pain and decreased oxygen saturation Decreased mental acuity Respiratory distress Tachycardia Tachypnea Fever Osteomyelitis: Constant bone pain Edema Fever Possible elevated sedimentation rate Gastrointestinal Therapeutic Procedures: Ostomy complications Necrosis: pale pink or bluish/purple in color intestinal obstruction: abdominal pain, absent bowel sounds, distention, n/v Burns: Priority action during resuscitation phase Maintain airway and ventilation rapid fluid resuscitation (0.9% NaCl or LR's) Inflammatory Disorders: Assessing a client who has a friction rub Assess lung sounds in all fields Friction rub occurs from -Pericarditis -Myocarditis -Rheumatic endocarditis Diabetes mellitus management: Recognizing Hypoglycemia Confusion Shaking (tremors) Hunger Diaphoresis Tachycardia Meningitis: Assessing for client findings Constant Headache -Stiff neck - Photophobia - Fever and chills - Nausea and vomiting - Altered LOC - Positive Kernigs and Brudzinski's signs Peripheral Vascular Diseases: Arterial Revascularization used for severe claudication and or limb pain at rest - maintain adequate circulation - check pedal and dorsalis pulse -Note color, temperature, sensation and cap refill Diagnostic and therapeutic procedures for female reproductive disorders: Discharge teaching for abdominal hysterectomy well balanced diet (high in protein) Hormonal therapy restrict activity for as long as 6 weeks avoid use of tampons look for foul smelling drainage and temp 100F Arthroplasty: Preventing complications following hip arthoplasty Follow position restrictions to avoid dislocation - use elevated seating - straight chairs with arms - abduction pillow or a pillow between client legs - externally rotate toes Cancer disorders: client teaching following partial glossectomy Client need for alternate communication following surgery -head of bed elevated to reduce edema -report leakage of fluid from the suture line or swallowing difficulty -thicken liquids -frequent oral hygiene Meningitis: Planning interventions for care (53) Isolate client as soon as meningitis is expected -Implement fever reduction measures -report to public health department -Bed rest with HOB 30 degrees -Provide quiet environment and minimize exposure to bright light -Avoid coughing and sneezing which increased ICP -Maintain safety and seizure precautions Chest tube insertion and monitoring: Maintaining drainage system First Chamber: Drainage collection Second Chamber: Water seal Third Chamber: Suction control Position client in semi-fowlers to high-fowlers position to promote optimal lung expansion - Tidaling with movement is expected in the water seal chamber - Cessation of tidaling in the water seal chamber signals lung reexpansion - Continuous bubbling in the water seal chamber (air leak finding) Diabetes Mellitus Management: Sick Day Management Monitor blood glucose every 3-4 hours Continue to take insulin or oral hypoglycemia agents consume 4oz sugar free liquid every 30 minutes meet carb needs with soft foods Test urine for ketones Head Injury: indications of increased intracranial pressure Severe headache - Deteriorating LOC - Dilated, pinpoint or asymmetric pupils - Alteration in breathing pattern - Abnormal posturing - cerebrospinal fluid leakage Hemodialysis and Peritoneal Dialysis: Intervening for decreased dialysate flow rate ----- Reposition client -milk tubing -check tubing for kinks or closed clamps -Tell client to avoid constipation by taking stool softeners and consuming a diet high in fiber Respiratory management and mechanical ventilation: caring for a client who has an ET tube ---- Maintain a patent airway -assess the position and placement of tube - Suction oral and tracheal secretions to maintain tube patency - Soft wrist restraints - Maintain cuff pressure below 20mm Hg TB: Discharge teaching about TB Continue medication therapy for its full duration of 6-12 months -continue with follow-up care for 1 year -Sputum samples every 2-4 weeks, no longer contagious after 3 neg samples -proper hand hygiene -wear N95 Electrolyte imbalances: Treatment of hypokalemia IV potassium supplement Never administer IV bolus Encourage foods high in K Fluid imbalances: Assessment findings Hypo: Increased Hct Increased urine specific gravity increased serum sodium Hyper: Decreased Hct Normal sodium decreased electrolytes, BUN and creatinine Respiratory alkalosis Fluid Imbalances: Clinical manifestations of hypervolemia Tachycardia bounding pulse hypertension muscle weakness headache ascites orthopnea crackeles distended neck veins Fluid Imbalances: Clinical manifestations of Dehydration Hyperthermia tachycardia thready pulse hypotension decreased CVP tachypneic hypoxia dizziness syncope confusion thirst decreased cap refill Hyperthyroidism: Caring for a client following a thyroidectomy Client in high fowlers position, support head and neck with pillow and avoid neck extension check surgical site for excessive bleeding have trach supplies immediately available Hypocalcemia can occur Anemias: Manifestations of anemia Pallor Fatigue irritability dypnea sensitivity to cold tachycardia bright red tongue (vit b12 deficiency) Hemodialysis and Peritoneal Dialysis: Manifestations of Peritonitis Severe abdominal pain which worsens with movement Anemias: Administering Epoetin Alfa Monitor for an increase in blood pressure Monitor Hgb and Hct twice a week Hepatitis and Cirrhosis: Priority findings to report Supine position for liver biopsy Report: Hepatitis - Fever - Vomiting - Dark-colored urine - clay colored stools - Jaundice Cirrosis - Cognitive changes - Ascities -Jaundice - Petechiae - Palmar erythema -fruit or musty odor Heart failure and pulmonary edema: treatment of cardiomyopathy Loop Diuretics (Lasix) Afterload reducing agents: Ace Inhibitors (Enalapril) Inotropic agents: Digoxin Beta Blockers: Metoprolol Vasodilators: Nitroglycerine Disorders of the eye: Age related macular degeneration Number 1 cause of vision loss in people 60 Dry Macular Degeneration: Smokers HTN Female Short body stature Family History Diet lacking carotene and Vitamin A - Lack of depth perception - Distorted objects - Blurred vision - Loss of central vision - Blindness Disorders of the eye: Indications of Glaucoma Open Angle - Headache - Mild eye pain - loss of peripheral vision - decreased acommodation - Elevated IOP (21) Angle- Closure - Rapid onset of elevated IOP - Decreased or blurred vision - Halos around lights - non reactive pupils - severe pain and nausea - photophobia Posterior Pituitary Disorders: Medications to treat diabetes insipidus Desmopressin acetate (DDAVP) - Notify weight gain 2 lbs in 24 hours Cabamazepine (Tegretol) -Notify sore throat, fever or bleeding Vasopressin (Pitressin) - Notify headache or confusion Head injury: Identification of altered respiratory patterns Cheyne stokes respirations central neurogenic hyperventilation apnea Emergency Nursing principles and management: Priority action for abdominal trauma (9) ---- ABCDE (Airway, breathing, circulation, disability and exposure) Hemodynamic Shock: Priority intervention for hypovolemic shock Continuously monitor airway and vital signs Administer fluids (0.9% NaCl or Lactated Ringers) Have resuscitation equipment available Hypertension: Action for hypertensive crisis Administer IV anti-hypertensives therapies, such as nitroprusside, nicardipine and labetaolol Monitor BP every 5-15 minutes Assess neurological status Monitor Cardiac status Emergency Nursing principles and management: Emergency Illness management (9) Always assess airway, breathing and circulation FIRST Fractures and immobilization devices: Assessing for compartment syndrome (795) ---- Compartment Syndrome assessment: Pain Paralysis Paresthesia Pallor Pulselessness Intense pain with movement numbness, burning and tingling are early signs Asthma: Identifying pathophysiology Chronic inflammatory disorder of the airways -Mucosal edema - Bronchoconstriction - Excessive mucus production - Dyspnea - Chest tightness - Anxiety/Stress -Wheezing -Coughing - Poor O2 Parkinsons disease: Expected findings Stooped posture - Slow, Shuffling gait - Slow speech - Tremors - Muscle rigidity - Bradykinesia/ Akinesia -Autonomic Symptoms - Difficulty chewing and swallowing - Drooling - Dysarthria - Difficulty with ADL's - Mood swings - Dementia Rheumatoid Arthritis: Client teaching about early indications Pain at rest with movement Morning stiffness fatigue joint swelling warmth and erythema Acute kidney injury and chronic kidney disease: Metabolic changes associated with chronic kidney disease Metabolic acidosis Heart Failure and Pulmonary Edema: Recognizing manifestations of left sided heart failure ----- Dyspnea, Orthopnea (SOB while laying down), nocturnal dyspnea - Fatigue - Displaced apical pulse (hypertrophy) - S3 heart sound (gallop) - Pulmonary congestion - Frothy sputum - Altered mental status - Decrease in urine output Respiratory Failure: Manifestations of Acute respiratory failure ABG values: Room air, PaO2 60 and SaO2 90 PaO2 50 in conjunction with a pH less than 7.30 - lack of perfusion to the capillary bed Blood and blood product transfusions: Monitoring for adverse response to multiple blood transfusions cute Hemolytic: chills, fever, low back pain, tachycardia, flushing, hypotension Febrile: chiils, fever, flushing, headache Mild Allergic: itching, urticaria and flushing Anaphylactic: wheezing, dyspnea, chest tightness cyanosis and hypotension Hemodialysis and Peritoneal Dialysis: Assessment of an arteriovenous fistula Alert nurse of signs of disequilibrium syndrome such as nausea and headache - Check for thrill or bruit - Eat well balanced meals that include foods high in folate (beans, green vegetables) and increase protein A nurse is receiving report on a client who is postoperative following an open repair of Zenker's Diverticulum. The nurse should anticipate the surgical incision to be in which of the following locations? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) A.) Throat A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following assessment findings should the nurse expect? Hypoactive bowel sounds A nurse is providing discharge instructions to a client who has a partial thickness burn of the hand. Which of the following instructions should the nurse include? Wrap fingers with individual dressings A nurse is assessing a client following the administration of magnesium sulfate 1g IV bolus. For which of the following adverse effects should the nurse monitor? Respiratory Paralysis A nurse is assessing a client's hydration status. Which of the following findings indicated fluid volume overload Distended neck veins A nurse is assessing a client following the administration of IV penicillin G. Which of the following findings should indicate to the nurse that the client is experiencing an anaphylactic reaction? Flushing A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Which of the following statements made by the client reflects an understanding of the teaching? My joints ache because I have Lyme disease. A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first? Obtain vital signs A nurse is assessing a client following IV urography. Which of the following findings is the priority? Swollen lips A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following statements by the client indicates an understanding of the teaching? I will count my heart beats before taking this medication. A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching? I will monitor my blood pressure while taking this medication. A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following should the nurse plan to administer? Regular insulin 20 units IV bolus A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago. The nurse should identify which of the following findings as an indication of a myocardial infarction(MI)? Troponin I 8 ng/mL A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take? Remain with the client for the first 15 min of the infusion. A nurse is assessing a client who had extracorporeal shock wave lithotripsy(ESWL) 6 hr ago. Which of the following findings should the nurse expect? Stone fragments in the urine A nurse is teaching a group of newly licensed nurses about pain management for older adult clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? Ibuprofen can cause gastrointestinal bleeding in older adult clients. A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? Loosen restrictive clothing A nurse is assessing a client who has Cushing's disease. Which of the following findings should the nurse expect? muscle atrophy A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure ulcer. Which of the following actions should the nurse take? Use a 30mL syringe A nurse is reviewing the laboratory results of a client who had a recent exposure to hepatitis C virus. Which of the following tests should the nurse identify as indicating the presence of hepatitis C antibodies? Enzyme immunoassay (EIA) A nurse in an emergency department is assessing a client who has a detached retina. Which of the following should the nurse expect the client to report? It's like a curtain closed over my eye. A nurse is assessing heart sounds of a client who reports substernal precordial pain. Identify which of the following sounds the nurse should document in the client's medical record by listening to audio clip. (Click on the audio button to listen to the clip.) Murmur S4 Pericardial friction rub Ventricular gallop Pericardial friction rub A nurse is caring for a client who has active bleeding from peptic ulcer disease. Which of the following findings is an indication that the client is experiencing compensatory shock? ---- Increased heart rate A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify that which of the following findings requires further screening? Shellfish allergy A nurse is providing teaching to a client who has a recent diagnosis of constipation-predominant irritable bowel syndrome. Which of the following instructions should the nurse include in the teaching? Consume at least 30 g of fiber daily A nurse is caring for a client who has type 1 diabetes mellitus and has had acute bronchitis for the past 3 days. Which of the following statements should the nurse include when instructing the client? Take insulin even if you are unable to eat your regular diet. A nurse is reviewing the laboratory report of a client who is receiving nonsurgical treatment for Cushing's disease. Which of the following laboratory findings should the nurse identify as a positive outcome of the treatment? Decreased sodium A nurse is reviewing the laboratory results of a client who has AIDS and is taking amphotericin B for a fungal infection. The nurse should identify that which of the following values is an indication of an adverse effect of the medication? BUN 34 mg/dL An older adult client is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration? Urine specific gravity is 1.045 A nurse is caring for a client who has had a cerebrovascular accident. Which of the following findings indicates that the client has homonymous hemianopsia? The client has to turn her head to see the entire visual field. A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus and is planning a trip. Which of the following instructions should the nurse include in the teaching? Take additional pairs of shoes. A nurse is providing teaching to a client who has end-stage kidney disease and is waiting for a kidney transplant. Which of the following information should the nurse provide? Hemodialysis is sometimes needed following surgery. A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The nurse should postpone the testing and report to the provider which of the following findings? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) Disease process Laboratory findings Current medications Family history Current medications A nurse is assessing a client who is receiving morphine via a PCA pump. Which of the following findings indicates an adverse effect of the medication? Urinary retention A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing's triad? Bradycardia A nurse is providing teaching for a female client who has recurrent urinary tract infections. Which of the following information should the nurse include in the teaching? Void before and after intercourse A nurse is providing education to a client who has tuberculosis (TB) and his family. Which of the following information should the nurse include in the teaching? Family members in the household should undergo TB testing A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurse's priority? Apply firm pressure to the insertion site A nurse is caring for a client who has cirrhosis of the liver with esophageal varies. Which of the following activities should the nurse instruct the client to avoid? Straining to have bowel movements A nurse is developing a teaching plan for a client who has gout. Which of the following recommendations should the nurse include? Decrease intake of purine meats A nurse is providing dietary teaching to a client who has celiac disease. Which of the following food choices should the nurse identify as an indication that the client understands the teaching? ----Grilled chicken breast A nurse is providing discharge instructions to a client following an upper gastrointestinal series with barium contrast. Which of the following information should the nurse provide? Increase fluid intake A nurse in an emergency department is caring for a client who reports chest pain of 8 on a pain scale of 0 to 10. Which of the following actions should the nurse take first? Administer morphine A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect? Low urine specific gravity A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following findings is an indication of lung re-expansion Bubbling in the water- seal chamber has ceased. A nurse is caring for a client who has HIV. Which of the following findings indicates a positive response to the prescribed HIB treatment? Decreased viral load A nurse is caring for a client who is 4 hr postoperative following an open reduction internal fixation of the right ankle. Which of the following assessment findings should the nurse report to the provider? Extremity cool upon palpation A home health nurse is assigned to a client who was recently discharged from a rehabilitation center after experiencing a right-hemispheric cerebrovascular accident(CVA). Which of the following neurologic deficits should the nurse expect to find when assessing the client? (Select all that apply.) Expressive aphasia Visual spatial deficitis Left hemianopsia Right hemiplegia One-sided neglect Visual spatial deficits Left hemianopsia One-sided neglect A nurse in an ICU is planning care for a client who is in cariogenic shock. The nurse should prepare to administer which of the following medications to increase cardiac output? ---- Dopamine A nurse is caring for a client who has viral pneumonia. The client's pulse oximeter readings have fluctuated between 79% and 88% for the last 30 min. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen? ---- Nonrebreather mask A client who has emphysema is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first? Instruct the client to allow the machine to breathe for him. A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following non pharmacological interventions should the nurse suggest to the client to reduce pain? ---- Alternate application of heat and cold to the affected joints. A nurse is assessing a client who is taking carvedilol for heart failure. which of the following findings is the priority for the nurse to report to the provider? Weight gain A client who has a diagnosis of Clostridium difficile is placed on contact precautions. Which of the following actions should the nurse take? Leave a stethoscope in the room for blood pressure monitoring. A nurse is teaching a client who has a cardiac dysrhythmia about the purpose of undergoing continuous telemetry monitoring. Which of the following statements by the client reflects an understanding of the teaching? This identifies if the pacemaker cells of my heart are working properly. A nurse is caring for a client who has pancreatitis. The nurse should expect which of the following laboratory results to be below the expected reference range? Calcium A nurse is caring for a client who has a stage III pressure ulcer. Which of the following findings contributes to delayed wound healing? Urine output 25 mL/hr A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction? Low back pain and apprehension A nurse is caring for a client who has a cervical spinal cord injury sustained 1 month ago. Which of the following manifestations indicates that the client is experiencing autonomic dysreflexia (AD)? Heart rate 52/min A nurse is reviewing the laboratory results of a client who has cirrhosis. Which of the following laboratory plus should the nurse expect? Elevated bilirubin level A nurse is assessing a client who is at risk for development of pernicious anemia resulting from peptic ulcer disease. Which of the following images depicts a condition caused by pernicious anemia? A.) depicts oral candidiasis/thrush B.) depicts dry oral mucous membrane C.) depicts glossitis D.) depicts a healthy tongue dull in color C.) depicts glossitis, which can indicate pernicious anemia. Glossitis, a smooth red tongue, is also a manifestation of deficiencies in vitamin B6, zinc, niacin, or folic acid. A nurse is caring for a client who is experiencing an acute myocardial infarction. The nurse should identify which of the following findings as a manifestation of cardiogenic shock? ---- Hypotension A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and note clots in the client's indwelling urinary catheter and a decrease in urinary output. Which of the following actions should the nurse take? Irrigate the indwelling urinary catheter A nurse is obtaining the health history of a client who has an abdominal aortic aneurysm. Which of the following findings should the nurse expect? Bruit heard over the middle upper abdomen. A nurse is administering meperidine IM in the right deltoid of a client. The nurse aspirates the pulse back blood in the syringe. Which of the following actions should the nurse take? ---- Dispose of the medication A nurse is preparing to administer amikacin 500 mg by intermittent IV bolus to a client. Available is amikacin mg in dextrose 5% in water (D5W) 200 mL to infuse over 30 min. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) 400 mL/hr A nurse is caring for a client who is undergoing renal dialysis to treat end-stage kidney disease (ESKD). The client reports muscle cramps and a tingling sensation in his hands. Which of the following medications should the nurse plan to administer? calcium carbonate A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following laboratory findings should the nurse expect? BUN 32 mg/dL A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions should the nurse anticipate taking? Slow the infusion rate A nurse is planning care for a client who has community-acquired pneumonia. Which of the following interventions should the nurse include in the plan of care? Monitor the client for confusion A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. Which of the following assessment findings is the nurse's priority? Increased respiratory secretions A nurse is providing teaching to a client who is at risk for developing type 1 diabetes mellitus. The nurse should inform the client that which of the following manifestations indicate diabetes? (Select all that apply.) Polyuria Dysphagia Polydipsia Photophobia Neuropathy Polyuria Polydipsia Neuropathy A nurse is providing teaching to a client who has hypothyroidism and is receiving levothryoxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medication? Calcium A nurse is caring for a client who is receiving total parenteral nutrition (TPN) and is NPO. When reviewing the chart, the nurse notes the following prescription: capillary blood glucose AC and HS. Which of the following actions should the nurse take? Contact the primary care provider to clarify the prescription A nurse is caring for a client who has increased intracranial pressure (ICP) and is receiving mannitol via continuous IV infusion. The nurse should report which of the following adverse effects of this medication to the provider? Crackles heard on auscultation A nurse is assessing an older adult client who has heart failure and takes digoxin. Which of the following findings should the nurse recognize as an indication of digoxin toxicity? Bradycardia A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which of the following statements should the nurse identify as an indication that the client understands the teaching? I will use my hands rather than a washcloth to clean the radiation area. A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement. Which of the following statements should the nurse make? Ginkgo biloba can cause an increased risk for bleeding. A nurse in a provider's office is assessing a client who has hypertension and takes propranolol. Which of the following findings should indicate to the nurse that the client is experiencing an adverse reaction to this medication? Report of a night cough A nurse is providing teaching to a client who has angina and a new prescription for sublingual nitroglycerin. Which of the following instructions should the nurse include? Store the medication in its original container A nurse is caring for a newly admitted client who has a gastric hemorrhage and is going into shock. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) Adminiser oxygen via a nonrebreather mask. -Initiate IV therapy with a large bore catheter -Insert NG tube -Administer ranitidine A nurse is planning acre for a client who has a sealed radiation implant for cervical cancer. Which of the following interventions should the nurse include in the plan of care? Keep a lead-lined container in the client's room A nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. The client experiencing excessive stools. Which of the following findings is an adverse effect of this medication? Hypokalemia A nurse is assessing a client who has a comminuted fracture of the femur. Which of the following findings should the nurse identify as an early manifestation of a fat embolism. ---- Dyspnea A home health nurse is providing teaching to a client who has a stage I pressure ulcer on the greater trochanter of his left hip. Which of the following instructions should the nurse include in the teaching? Change position every hour. A nurse on a medical-surgical unit is reviewing the medical record of an older adult client who is receiving IV fluid therapy. Which of the following client information should indicate to the nurse that the client requires a revision of his IV therapy prescription? (Click on the "Exhibit" button for additional information about the client. There are three tabes that contain separate categories of data.) Blood Pressure Prescribed medications Oxygen saturation BUN BUN A nurse is caring for a client who has a peripherally inserted central catheter (PICC). Which of the following actions should the nurse take to manage the PICC? Flush the PICC line with 10 mL NS before and after medication administration. A nurse is preparing a client who has supra ventricular tachycardia for elective cardioversion. Which of the following prescribed medications should the nurse instruct the client to withhold for 48 hr prior to cardioversion? Digoxin A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation. Which of the following values should the nurse identify as a desired outcome for this therapy? NR 2.5 A nurse admits a client who has anorexia, low-grade fever, night sweats, and productive cough. Which of the following actions should the nurse take first? Initiate airborne precautions A nurse is reviewing the medical record of a client who has systemic lupus erythematosus. Which of the following findings should the nurse expect? Facial butterfly rash. A butterfly rash is a manifestation of SLE. It appears as a dry red rash on the clients cheeks and nose and can disappear during times of remission. A nurse is caring for a client who is receiving plasmapheresis through a venous access site. Which of the following actions should the nurse take? Check electrolyte levels before and after therapy. Plasmapheresis can cause citrate induced hypocalcemia. Therefore the nurse should monitor the clients electrolyte levels before and after therapy. A nurse is assessing a client who has Graves disease. Which of the following images should indicate to the nurse that the client has exophthalmos? The nurse should identify an outward protrusion of the eyes is exophthalmos a common finding of graves disease. An overproduction of the thyroid hormone causes edema of the extraocular muscle and increases fatty tissue behind the eye which results in the eyes protruding outward. Exophthalmos can cause the client to experience problems with vision including focusing on objects as well as pressure on the optic nerve. A nurse is performing a cardiac assessment for a client who had a myocardial infarction 2 days ago. Which of the following actions should the nurse take first after hearing the following sound? ----Listen with the client on his left side. When providing nursing care the nurse should first use the least invasive intervention. Therefore after auscultating a murmur the first action the nurse should take is to place the client on his left side and listen to his heart again. A nurse is providing teaching to an older adult female client who has stress incontinence and a BMI of 32. Which of the following statements by the client indicates an understanding of the teaching question mark I am dieting to lose weight. Excess weight cut creates increased abdominal pressure that can result in stress incontinence. A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the following results should the nurse expect? Paco2 of 56. A client who has COPD retains paco2 due to the weakening and the collapse of the alveolar sacs which decreases the area and lungs for gas exchange and causes the paco2 to increase above the expected reference range. A nurse is providing teaching to a client who is perimenopausal and has a prescription for hormone replacement therapy. For which of the following adverse effects should the nurse instruct the client to notify the provider? Select all that apply Calf pain, numbness in the arms and intense headache. Calf pain is an indication of DVT and the client should report this finding to the provider immediately. Numbness in the arms can indicate cerebrovascular accident which is an adverse effect of hormone replacement therapy and an intense headache can indicate a cerebrovascular accident. A nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. Which of the following statements by the client indicates an understanding of the teaching? I am taking this medication to increase my energy level. The goal of erythropoietin therapy is to increase the level of hematocrit and clients who have anemia. When the medication is effective the client should have a decreasing fatigue and an improvement and activity tolerance. A nurse is teaching a client who has venous insufficiency about self-care. Which of the following statements should the nurse identify as an indication that the client understands teaching? I will wear clean graduated compression stockings everyday. The client should apply a clean pair of graduated compression stockings each day and clean soiled stockings with mild detergent and warm water by hand. A nurse is preparing to present a program about atherosclerosis at a health fair. Which of the following recommendations should the nurse plan to include? Select all that apply Follow a smoking cessation program maintain an appropriate weight eat a low-fat diet and increase fluid intake. Smoking cessation is an important lifestyle modification to prevent Arthur sclerosis and preventing obesity through diet and exercise can help prevent atherosclerosis. Eating a low fat diet decreases LDL cholesterol and can prevent atherosclerosis. A nurse is caring for a client who is 12 hours post-operative following a total hip arthroplasty. Which of the following actions should the nurse take? Place a pillow between the clients legs. The nurse should place a pillow between the clients legs to prevent hip dislocation. A nurse is reviewing the medication history of a client who is to undergo allergy testing. The nurse should instruct the client to discontinue which of the following medications before the testing? ----... A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the following actions should the nurse take first? Check for the type and number of units of blood to administer. According to evidence based practice the nurse should first confirm that the type and number of units of blood to administer matches what is indicated in the clients medication administration record. A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron supplement. Which of the following statements by the client indicates an understanding of the teaching? I will eat more high-fiber foods. The client should eat high-fiber foods to help prevent constipation which is a common adverse effect of oral iron supplements. A nurse is caring for a client who is post-operative following a total hip arthroplasty. Which of the following laboratory values should the nurse report to the provider? HGB of 8. The nursery report and HGB level of 8 which is below the expected reference range and as an indicator of postoperative hemorrhage or anemia. A nurse is caring for a client who has a leg cast and is returning demonstration on the proper use of crutches while climbing stairs. Identify the sequence the client should follow when demonstrating crutch use Place body weight on the crutches Advance the unaffected leg onto the stair shift weight from the crutches to the unaffected leg and then bring the crutches and the affected leg up to the stair A nurse is caring for a client who is on bed rest and has a new prescription for enoxaparin subcutaneous. Which of the following actions should the nurse take? Administer the medication at the same time each day. The nurse administer the medication to the client at the same time each day to maintain consistent serum levels A nurse is reviewing the laboratory results of a client who has aplastic anemia. Which of the following findings indicates a potential complication? White blood cell count of 2000. This white blood cell count is below the expected reference range and indicates a risk for severe immunosuppression. A nurse in an emergency department is admitting a client who reports dyspnea and shortness of breath. Which of the following actions is the priority for the nurse to perform prior to administering oxygen? Determine if the client has a history of COPD. According to evidence based practice the nurse should first assess if the client has COPD. Administering oxygen can worsen chronic hypercarbia in a client who has COPD A nurse in a provider's office is caring for a client who requests sildenafil to treat erectile dysfunction. Which of the following statements should the nurse make? You will not be able to use sildenafil if you are taking nitroglycerin. The client should not use sildenafil when taking nitroglycerin because both medications can cause vasodilation and lead to significant hypotension A nurse is in a provider's office is providing teaching to a client who has a urinary tract infection and a new prescription for ciprofloxacin. Which of the following instructions should the nurse include Avoid taking magnesium containing antacids with this medication. The nurse should instruct the client to take Ciprofloxacin either two hours before or 6 hours after taking an antacid but not to take Ciprofloxacin with an antacid because magnesium containing antacids decrease the absorption of Ciprofloxacin A nurse is providing follow-up care for a client who sustained a compound fracture three weeks ago. The nurse should recognize that an unexpected finding for which of the following laboratory values is a manifestation of osteomyelitis and should be reported to the provider ---- Sedimentation rate. And increased sedimentation rate occurs when a client has any type of inflammatory process such as osteomyelitis A nurse is caring for a client who has hypothyroidism. Which of the following manifestations should the nurse expect Constipation. A client who has hypothyroidism can experience constipation due to the decrease in the client's metabolism resulting and slow motility of the gastrointestinal tract. The nurse should instruct the client to increase fiber and fluid and take to reduce the risk of constipation A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After ensuring a patent Airway which of the following interventions is the priority ---- applying oxygen via face mask because the priority intervention is for the nurse to apply oxygen using a high-flow non-rebreather mask to deliver oxygen at 90 to 100% Where would you palpate to assess for an inguinal hernia The nurse should palpate at the right groin area because an inguinal hernia forms of the peritoneum which contains part of the intestine and can protrude into the scrotum in males A nurse is checking the ECG Rhythm strip for a client who has a temporary pacemaker the nurse notes a spike or a pacemaker artifact followed by a QRS complex. Which of the following actions should the nurse take Document that depolarization has occurred. When a pacing stimulus is delivered to The ventricle a spike appears on the ECG Rhythm strip this bike should be followed by a QRS complex which indicates pacemaker capture or depolarization A nurse is caring for a client who is eight hours post-operative following a total hip arthroplasty the client is unable to void on the bed pan Which of the following actions should the nurse take first Scan the bladder with a portable ultrasound the first action should be using the nursing process which is assisting the client scanning the bladder with a portable ultrasound device will determine the amount of urine in the bladder A nurse is caring for a client who is receiving tpn a new bag is not available when the current infusion is nearly completed which of the following actions should the nurse take Administer dextrose 10% in water until the new bag arrives. Tpn Solutions have a high concentration of dextrose therefore if a t-pn solution is temporarily unavailable the nurse administer dextrose 10% or 20% and water to avoid a precipitous drop in the client's blood glucose level A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for Omeprazole. The nurse should instruct the client that the medication provides Relief by which of the following actions Suppressing gastric acid production. I love her soul is a proton pump inhibitor it relieves manifestations of gastric ulcers by suppressing gastric acid production A nurse is providing discharge teaching to a client who is to self administer heparin subcutaneously. Which of the following responses by the client indicates an understanding of the teaching I will use an electric razor to shave. Heparin is an anticoagulant that places the client at risk for bleeding therefore the nurse should instruct the client to use an electric razor when shaving to reduce the risk of cuts to the skin a nurse is caring for a client following excavation of her endotracheal tube 10 minutes ago. Which of the following findings should the nurse report to the provider immediately Strider. Using the Urgent vs. Non-urgent approach to client care the nurse should determine that the priority finding a Strider. Strider can indicate and narrowing Airway or possible obstruction caused by edema or laryngeal spasms the nurse should report the finding immediately Implement an intervention a nurse is caring for a client who had a nephrostomy tube inserted 12 hours ago. Which of the following findings should the nurse report to the provider The client reports back pain the nurse should notify the provider if the client reports back pain which can indicate that the nephrostomy tube is dislodged or clogged A nurse is assessing a client while suctioning the clients tracheostomy tube which of the following findings should indicate to the nurse that the client is experiencing hypoxia The clients heart rate increases because hypoxia related to suctioning can cause the clients heart rate to increase if this occurs the nurse should discontinue the sectioning and immediately oxygenate the client with 100% oxygen the nurse should instruct the client to take three or four deep breaths prior to suctioning to reduce the risk for hypoxia A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish and ureterostomy. Which of the following statements should the nurse include in the teaching Cut the opening of The Skin Barrier one eighth of an inch wider than the stoma. The client should cut the opening of The Skin Barrier 1/8 inch wider than the stoma to minimize irritation of the skin from exposure to urine A nurse is teaching a client who has atrial fibrillation about the purpose of wearing a Holter monitor. Which of the following information should the nurse include in the teaching This device can detect when you have an irregular heart rate because it reports and transmits electrical impulses of the heart and alerts the nurse to dysrhythmias myocardial injury or conduction defects a Holter monitor allows the client freedom of movement while cardiac activity is recorded A nurse is providing discharge teaching to a client who has heart failure and a new prescription for potassium sparing diuretic which of the following information should the nurse include in the teaching Try to walk at least 3 times per week for exercise because the development of a regular exercise routine can improve outcomes in clients who have heart failure A nurse is caring for a client who has chronic glomerulonephritis with oliguria which of the following findings should the nurse identify as a manifestation of chronic glomerulonephritis ---- Hyperkalemia as a result of kidney failure because kidney failure results in decreased excretion of potassium A nurses in an acute care facility is caring for a client who is at risk for seizures which of the following precautions should the nurse implement Ensure that the client has a patent IV in the event that the client requires medication to stop seizure activity A nurse is caring for a client who has bilateral pneumonia and an spo2 of 88% the client is dyspneic and productive cough and is using accessory muscles to breathe which of the following actions should the nurse take first Place the client in a high Fowler's position A nurse is caring for a client who has a new diagnosis of hyperthyroidism which of the following is the priority assessment finding that the nurse should report to the provider Blood pressure of 170 over 80 because using the Urgent vs. Non-urgent approach to client care the nurse determines that the priority funding is a systolic blood pressure of 170 which indicates that the client is at risk for thyroid storm A nurse is reviewing the medication history of a client who is to undergo allergy testing the nurse should instruct the client to discontinue which of the following medications before testing - ---Prednisone because it is a glucocorticoid that can cause the client to have false negative test results they should discontinue antihistamine medications several weeks prior to testing A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take? Place a pressure bag around the flush solution. The nurse should place a pressure bag around the flush solution because the pressure from an artery is greater than that of the line A nurse is caring for a client who has a new prescription for tpn the client is to receive 2,000 kcalories per day the t-pn solution has 500 kcalories per liter the IV pump should be set at how many milliliters per hour 167 milliliters per hour A nurse is providing teaching to a client who has AIDS which of the following statements by the client indicates an understanding of the teaching I will take my temperature once a day a client who has AIDS is immunocompromised and is at risk for infection the client should take his temperature daily to identify a temperature greater than 100 degrees which is an early manifestation of an infection A nurse is assessing a client who has peripheral artery disease which of the following findings should the nurse expect Hair loss on the lower legs the nurse should expect a client who is Peripheral arterial disease to have hair loss on the lower legs as a result of impaired arterial circulation affecting follicular growth A nurse is providing teaching to an older adult client who has cancer and a new prescription for an opioid analgesic for pain management which of the following information should the nurse include in the teaching You should increase your fiber intake to prevent constipation because opioids slow paracelsus in the gastrointestinal tract which causes constipation A nurse is planning care for a client who is scheduled for a thoracentesis which of the following interventions should the nurse include in the plan Encourage the client to take deep breaths after the procedure to read expand the lung A nurse is caring for a client who has a prescription for Enalapril the nurse should identify which of the following findings as an adverse effect of the medication Orthostatic hypotension because dilation of arteries and veins causes orthostatic hypotension which is an adverse effect of Enalapril A charge nurse is instructing a newly licensed nurse about caring for a client who has MRSA which of the following statements by the newly licensed nurse indicates an understanding of the teaching I will leave assessment equipment in the room to use on this client the nurse should follow contact precautions and use dedicated equipment when assessing the client to prevent cross-contamination with other clients A nurse is caring for a client who recently had a stroke of the right hemisphere which of the following manifestations should the nurse expect Impulsive behavior A nurse is caring for a client who is exhibiting manifestations of a febrile reaction while receiving a blood transfusion which of the following medications should the nurse administer ---- Acetaminophen to reduce fever and decreased the manifestation of the febrile reaction manifestations of a febrile reaction include tachycardia fever hypotension and chills the nurse should discontinue the transfusion and return the blood bag and tubing to the blood bank A nurse is assessing a client who has hypokalemia which of the following manifestations should the nurse expect Decreased peristalsis due to a decrease in gastrointestinal smooth muscle contraction a nurse is caring for a client who is experiencing supraventricular tachycardia upon assessing the client the nurse observes the following findings heart rate 200 per minute blood pressure 78 over 40 and respiratory rate 30 per minute which of the following actions should the nurse take - ---Perform synchronized cardioversion A nurse is providing dietary teaching to a client who is post-operative following a thyroidectomy with removal of the parathyroid glands the nurse should instruct the client to include which of the following foods that has the greatest amount of calcium in her diet 12 almonds because they are the best source of calcium to recommend because they contain 36 milligrams of calcium removal of the parathyroid glands which regulate calcium in the body can result in hypocalcemia A nurse is caring for a client who has dka which of the following findings should indicate to the nurse at the client's condition is improving Glucose of 272 because a glucose reading less than 300 indicates Improvement in the client's status A nurse is performing a dressing change for a client who is recovering from a hemicolectomy when removing the dressing with the nurse notes that a large part of the bowel is protruding through the abdomen which of the following actions should the nurse take first Call for help because evidence based practice indicates that the nurse should first stay with the client and call for assistance the client will require emergency surgery and is at risk for shock therefore the nurse should attain immediate assistance A nurse is caring for a client who presents to a clinic for a one-w