An older client presents to the emergency department with abdominal pain due to constipation. The nurse is providing a list of high-fiber foods to the client that the healthcare provider has recommended. Which action should the nurse implement when reviewing the list of foods?
Turn on overhead lig...
An older client presents to the emergency department with abdominal pain due to
constipation. The nurse is providing a list of high-fiber foods to the client that the
healthcare provider has recommended. Which action should the nurse implement when
reviewing the list of foods? - ANSWER-Turn on overhead lights while giving instructions
The nurse leading a care team on a medical unit is assigning client care to a practical
nurse (PN) and a unlicensed assistive personnel (UAP). Which activity should the nurse
delegate to the UAP? - ANSWER-Anchor an inserted urinary catheter and place with
tape
A client with persistent low back pain has received a prescription for electronic
stimulator (TENS) unit. After the nurse applies the electrodes and turns on the power,
the client reports feeling a tingling sensation. How should the nurse respond? -
ANSWER-Determine if the sensation feels uncomfortable
The nurse enters a male client's room to administer oral medications and finds an
unlicensed assistive personnel (UAP) providing personal care to the client. The client is
lying in a supine position, and his condition has obviously deteriorated. He is weak,
pale, and diaphoretic. What is the priority nurse action? - ANSWER-Advise the UAP to
stop providing care so the nurse can assess the client's condition
In formulating the nursing care plan for a client diagnosed with Parkinson's disease,
which nursing problem has the highest priority? - ANSWER-Impaired physical mobility
relative to muscle rigidity
The nurse is caring for a client who has a history of excessive saliva production and is
scheduled for a surgical procedure. Which medication should the nurse anticipate being
prescribed the healthcare provider? - ANSWER-Diphenhydramine
A client with diabetes mellitus tells the nurse that she uses cranberry juice to help
prevent UTI. - ANSWER-Advise patient that cranberry juice does not prevent infection
, The nurse is developing a plan of care for a client with cardiomyopathy. Which
intervention should the nurse include to reduce cardiac workload? - ANSWER-Provide a
bedside commode for toileting
The nurse is caring for a client who has been admitted with recurring headaches. To
assess the quality of the client's pain - ANSWER-Ask the client to describe pain
A client receiving mesalamine 800 mg by mouth three times a day. Which assessment
should the nurse perform to assess the effectiveness of the medication? - ANSWER-
Bowel sounds
The nurse is assessing an adolescent female diagnosed with anorexia nervosa who is
admitted to the unit with severe malnutrition and electrolyte imbalance. Which
pathological process results from the adolescent's consistent maladaptive behavior? -
ANSWER-Amenorrhea
A client with type 2 diabetes mellitus and hypertension is admitted with cellulitis of the
right leg due to an embedded thorn from gardening. The client is receiving an
intravenous infusion for antibiotic administration and is on bed rest with the right leg
elevated on a pillow. Which finding should the nurse identify may indicate an emerging
situation? - ANSWER-Headache
A young adult who is hit with a baseball bat on the temporal area of the left skull in
consvious when admitted to the ED and is transferred to the Neurological Unit to be
monitored for signs of a closed head injury. Which assessment finding is idicative of a
develpping epidural hemoatoma? - ANSWER-Altered consciousness within the first 24
hours after injury
A client with diabetes insipidus has a average urinary output of 500 ml of dilute urine
every hour for the last 4 hours. Which laboratory test is most important for the nurse to
monitor? - ANSWER-Urine specific gravity
A client who is a veteran comes to the emergency department appearing tense, anxious
and having difficulty concentrating on the questions the nurse is asking during the
health history. Which statement is most important for the nurse to document? -
ANSWER-I can't forgive myself for leaving my buddy behind
A client with chronic renal insufficiency is preparing for discharge from the hospital.
Which information is most important for the nurse to include in the client's discharge
teaching? - ANSWER-Strategies to promote independent self care
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