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,Terms in this set (90)
A nurse is assessing a group of clients for indications of role changes. The nurse should
identify that which of the following clients is at risk for experiencing a role change?
A client who has multiple sclerosis and is experiencing progressive difficulty ambulating.
A nurse is providing follow-up care for a client who sustained a compound fracture 3 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
A nurse is caring for a client who is postoperative. Complete the diagram by dragging from the
choices below to specify what condition the client is most likely experiencing, two actions the
nurse should take to address that condition, and two parameters the nurse should monitor to
assess the client's progress.
- Hypovolemia
- Initiate fluid challenge and insert a large-gauge IV.
- Monitor blood pressure and urine output.
The nurse should insert a large-gauge IV and initiate a fluid challenge because the client is
most likely experiencing hypovolemia as evidenced by the client's restlessness, tachycardia,
hypotension, decreased pulses, cool extremities, and decreased urine output. The nurse
should monitor the client's urine output and blood pressure to evaluate the effectiveness of
treatment.
, A nurse is providing teaching to a client who has stage II cervical cancer and is scheduled for
brachytherapy. Which of the following instructions should the nurse include?
"You will need to stay still in the bed during each treatment session."
A nurse is caring for a client who is receiving dialysis treatment. For each potential nursing
intervention, click to specify if the intervention is indicated or not indicated.
Indicated:
- Place the client in Trendelenburg position.
- Notify the provider immediately.
- Administer a 0.9% sodium chloride 200 mL IV bolus.
- Apply oxygen at 2 L/min via nasal cannula.
Not Indicated:
- Obtain the client's blood glucose level.
- Perform a 12-lead ECG.
A nurse is assessing a client who has had a suspected stroke. The nurse should place the
priority on which of the following findings?
Dysphagia
A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty. Which
of the following actions should the nurse take?
Place a pillow between the client's legs.
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 is providing preoperative teaching for a client who is scheduled for an open
cholecystectomy. Which of the following actions should the nurse take?
Demonstrate ways to deep breathe and cough.