HESI PN FUNDAMENTALS 3.Which drug does a nurse anticipate may be prescribed to produce diuresis and inhibitformation of aqueous humor for a client with glaucoma?
Chlorothiazide (Diuril)
Acetazolamide (Diamox)
Bendroflumethiazide (Naturetin)
Demecarium bromide
(Humorsol)
A client receiving s...
HESI PN FUNDAMENTALS 3
Which drug does a nurse anticipate may be prescribed to produce diuresis and inhibitformation of aqueous humor for a client with glaucoma?
Chlorothiazide (Diuril)
Acetazolamide (Diamox)
Bendroflumethiazide (Naturetin)
Demecarium bromide
(Humorsol)
A client receiving steroid therapy states, "I have difficulty controlling my temper which is sounlike me, and I don't know why this is happening." What is the nurse's best response?
Tell the client it is nothing to worry about.
Talk with the client further to identify the specific cause of the problem.Instruct the
client to attempt to avoid situations that cause irritation.
Interview the client to determine whether other mood swings are being experienced.
A client receiving steroid therapy states, "I have difficulty controlling my temper which is sounlike me, and I don't know why this is happening." What is the nurse's best response?
Tell the client it is nothing to worry about.
Talk with the client further to identify the specific cause of the problem.Instruct the
client to attempt to avoid situations that cause irritation.
Interview the client to determine whether other mood swings are being experienced.
The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit. The nurse applies a cooling blanket and administers an antipyretic medication. The nurse explains thatthe rationale for these interventions is to:
Promote equalization of osmotic pressures.
Prevent hypoxia associated with
diaphoresis. Promote integrity of
intracerebral neurons.
Reduce brain metabolism and limit hypoxia.
A health care provider prescribes 500 mg of an antibiotic intravenous piggyback (IVPB) every 12 hours. The vial of antibiotic contains 1 g and indicates that the addition of 2.5 mL of sterile water will yield 3 mL of reconstituted solution. How many milliliters of the antibiotic should be added to the 50 mL IVPB bag? Record your answer using one decimal place. mL
1.5
The nurse is caring for a non-ambulatory client with a reddened sacrum that is unrelieved by repositioning. What nursing diagnosis should be included on the client's plan of care? Risk for pressure ulcer
Risk for impaired skin integrity
Impaired skin integrity, related to infrequent turning and repositioning Impaired skin integrity, related to the effects of pressure and shearing force
A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissuedown to the underlying fascia. The nurse should document the assessment finding as whichstage of pressure ulcer?
Stage I Stage II Stage III
Unstageable
A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the wound can be staged. A stage I pressure ulcer is defined as an area of persistent redness with no break in skin integrity. A stage II pressure ulcer is a partial-thickness wound with skin loss involving the epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion, blister, or shallow crater. A stage III pressure ulcer involves full thickness tissue loss with visible subcutaneousfat. Bone, tendon, and muscle are not
exposed.
A client is being admitted for a total hip replacement. When is it necessary for the nurse toensure that a medication reconciliation is completed? Select all that apply.
After reporting severe pain On admission to the hospital
Upon entering the operating room Before transfer to a rehabilitation facility
At time of scheduling for the surgical procedure
Medication reconciliation involves the creation of a list of all medications the client is taking and comparing it to the health care provider's prescriptions on admission or when there is a transfer to a different setting or service, or discharge. A change in status does not require medication reconciliation. A medication reconciliation should be completed long before entering the operating room. Total hip replacement is elective surgery, and scheduling takes place before admission; medication reconciliation takes place when the client is admitted.
A client is taking lithium sodium (Lithium). The nurse should notify the health care provider for which of the following laboratory values?
White blood cell (WBC) count of 15,000 mm3 Negative protein in the urine
Blood urea nitrogen (BUN) of 20
mg/dL Prothrombin of 12.0 seconds
White cell counts can increase with this drug. The expected range of the WBC count is 5000
to 10,000 mm3 for a healthy adult. Urinalysis, BUN, and prothrombin are not necessary and
these arenormal values. Often when a family member is dying, the client and the family are at different stages
ofgrieving. During which stage of a client's grieving is the family likely to require more emotional nursing care than the client?
Anger
Denial
Depression
Acceptance
In the stage of acceptance, the client frequently detaches from the environment and may become indifferent to family members. In addition, the family may take longer to accept the
inevitable death than does the client. Although the family may not understand the anger, dealing with the resultant behavior may serve as a diversion. Denial often is exhibited by the client and family members at the same time. During depression, the family often is able to offer emotional support, which meets their needs.
The client asks the nurse to recommend foods that might be included in a diet for diverticular disease.Which foods would be appropriate to include in the teaching plan? Select all that apply.
Whole grains
Cooked fruit and vegetables Nuts and seeds
Lean red meats
Milk and eggs
With diverticular disease the patient should avoid foods that may obstruct the diverticuli. Therefore the fiber should be digestible, such as whole grains, and cooked fruits and vegetables. Milk and eggshave no fiber content but are good sources of protein. In clients with diverticular disease, nuts and seeds are contraindicated as they may be retained and cause inflammation and infection, which is known as diverticulitis. The client should also decrease intake of fats and red meats.
A nurse is obtaining a health history from the newly admitted client who has chronic pain inthe knee. What should the nurse include in the pain assessment? Select all that apply.
Pain history, including location, intensity, and quality of pain
Client's purposeful body movement in arranging the papers on the bedside table
Pain pattern, including precipitating and alleviating factors
Vital signs such as increased blood pressure and heart rate
The client's family statement about increases in pain with ambulation
Accurate pain assessment includes pain history with the client's identification of pain location, intensity, and quality and helps the nurse to identify what pain means to the client. The pattern of pain includes time of onset, duration, and recurrence of pain and its assessment helps the nurse anticipate and meet the needs of the client. Assessment of the precipitating factors helps the nurse prevent the pain and determine it cause. Purposeless movements such as tossing and turning or involuntary movements such as a reflexive jerking may indicate pain. Physiological responses such as elevated blood pressure and heart rate are most likely to be absent in the client with chronic pain. Pain is a subjective
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