A 56-year-old client meets with the nurse for education about a
recently diagnosed atrial fibrillation. The client verbalizes
concerns about being away from work too long and doubts about
the necessity of having blood tests every week, as the client has
no symptoms. Which is the best motivational statement by the
nurse for this client? Correct Answer "The medicine and blood
work can help prevent blood clots, which can lead to strokes.
What do you know about warfarin therapy?"
A client has expressed great relief at the improvement in their
hearing after irrigation of the ear canal yielded a large amount of
impacted cerumen. This client was experiencing a sensory
alteration related to: Correct Answer sensory reception.
A client has received morphine for reports of pain at a recent
surgical incision site. After receiving the medication, the client
starts picking at the bedsheets and saying, "Get the bugs off my
bed, I can feel them crawling on me!" Which nursing diagnosis
is appropriate for this client? Correct Answer Disturbed
Sensory Perception: Tactile related to side effects of medication
as evidence by client statement of "Get the bugs off my bed, I
can feel them crawling on me."
A client receiving epidural analgesia asks the nurse to put the
head of the bed all the way down to sleep better. What is the
correct response by the nurse? Correct Answer "It is important
that we keep the head of your bed elevated at least 30 degrees
because this position helps to minimize the risk of respiratory
depression."
,A client states during the interview that he has pain in his lower
back. He states it is a 10 on a scale of 0 to 10 when he is asked
to turn. The nurse should: Correct Answer avoid a position
change that requires turning.
A client tells the nurse that the client often has a difficult time
falling asleep at night. What suggestion offered by the nurse
may assist the client in achieving sleep? Correct Answer a
snack containing carbohydrates and protein
A client who is postoperative Day 1 has rung the call light twice
during the nurse's shift in order to request assistance transferring
to a bedside commode. In both cases, however, the client has
been unable to defecate. In light of the fact that the client's last
bowel movement was the morning of surgery, what action
should the nurse first take? Correct Answer Facilitate a more
private setting, such as assisting the client to a bathroom.
A client with a history of advanced liver disease comes to the
emergency department (ED) with dehydration. White blood cell
count shows elevation in bands and neutrophils. When preparing
to catheterize the client, what color urine does the nurse
anticipate will drain? Correct Answer dark brown, cloudy
A client with difficulty sleeping is prescribed ramelteon. The
client asks the nurse, "How does this medicine work?" Which
information would the nurse include in the response? Correct
Answer Activates the receptors for the hormone melatonin
, A client with no significant medical history reports experiencing
diarrhea over the past week. Which assessment question will the
nurse ask? Select all that apply. Correct Answer "Have you
started a new medication?"
"What are your normal bowel habits?"
"Do you use laxatives?"
A neonatal nurse is caring for a 2-day-old infant who
experienced shoulder subluxation during delivery. What pain
assessment scale should the nurse use to assess this client's pain?
Correct Answer CRIES Pain Scale
A nurse assesses a client with an ostomy appliance and notes
that the stoma is protruding into the bag. How should the nurse
respond to this assessment finding? Correct Answer Have the
client rest for half an hour and then reassess.
A nurse in a family clinic asks a client, "How do you spend a
typical day?" How does identifying the client's pattern of daily
living contribute to the plan of care? Correct Answer It helps
the nurse create a hospital routine with a similar set of sensory
situations.
A nurse is administering continuous closed bladder irrigation to
a client. After performing this intervention, the nurse observes
that the irrigation solution is not flowing at the prescribed rate.
Which actions should the nurse take? Select all that apply.
Correct Answer Raise the bag 3 to 6 in (7.5 to 15 cm).
Check the tubing for kinks or pressure points.
Open the clamp all the way.
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