What signs of cannula displacement should the nurse monitor for at an arterial line insertion site? - correct answer - Swelling
- Fluid leakage
- Blanching
- Poor arterial waveform
The nurse has determined that a bedridden client diagnosed with a stroke is at risk for venous thromboembolism (...
NCLEX STUDY GUIDE WITH SOLITIONS
What signs of cannula displacement should the nurse monitor for at an arterial line insertion site? - correct answer - Swelling
- Fluid leakage
- Blanching
- Poor arterial waveform
The nurse has determined that a bedridden client diagnosed with a stroke is at risk for venous thromboembolism (VTE). What interventions should the nurse initiate? - correct answer - Measure the calf and thigh daily
- Apply sequential compression devices to the legs
- Position paralyzed leg with each distal joint higher than the proximal joint
- Passive range of motion several times a day
The nurse is preparing to teach a client about post percutaneous transluminal coronary angioplasty (PTCA) care. Which teaching points should the nurse include? - correct answer - Reporting any chest discomfort following percutaneous intervention
- Avoid lifting more than 10 pounds until approved by healthcare provider.
- remain on bed rest for a minimum of 4 hours
- Fluids need to be increased to flush the dye used during the procedure from the kidneys
The nurse would make which recommendations when conducting community health teaching about obesity to a group of adolescents? - correct answer - 60 minutes of moderate-intensity physical activity 7 days a week
- Girls should take a least 13,000 steps daily and boys should take 11,000 steps daily
- TV viewing and video game playing should be 2 or fewer hours each day.
Which signs and symptoms would concern the nurse if assessed in a client post radical neck surgery? - correct answer - Positive Trousseau's sign
- Leg cramps The nurse providing palliative care to a client would include which outcomes in the teaching plan? - correct answer - Maintaining the client's quality of life
- Minimizing family caregiver stress
- Managing the client's pain
- Managing the client's and family's emotional needs
- Attending to the client's spiritual needs
Which nursing intervention represents secondary prevention level? - correct answer Providing care for clients in a shelter for abused women indicates that a problem has been identified and is
being monitored to prevent the problem from getting worse. The focus of secondary prevention is early detection, use of referral services, and rapid initiation of treatment to stop the progress of the disease.
An elderly client living in a long-term care facility fell 8 hours ago causing a laceration on the occipital area of the skull and steri-strips were applied for closure. Which signs/symptoms would
indicate to the nurse that the client should be transferred to the emergency department? - correct answer - Sudden emotional outbursts.
- Client report of blurred vision.
- Headache unrelieved by acetaminophen.
The nurse is caring for a client diagnosed with Addison's disease. Which finding would indicate to the nurse that a client has received excessive mineralocorticoid replacement? - correct answer - Weight gain of 4 pounds in one week
- Serum potassium of 3.2 mEq
The nurse is caring for a client with cirrhosis of the liver and suspects that the client may be developing hepatic encephalopathy. Which assessments by the nurse suggest that the client is developing this complication? - correct answer - Asterixis
- Lethargy
- Amnesia
- Behavioral changes
A nurse is planning a health fair in a Hispanic community composed of primarily young adults. What would be essential for the nurse to provide to this community at the health fair? - correct
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