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What instruction should the nurse include in the discharge teaching plan of a client who had a cataract extraction today? a. sexual activities may be resumed upon return home b. light housekeeping is permitted but avoid heavy lifting c. use a metal eye shield on operative eye during the day d. a...

When describing patient education approaches, the nurse educator would explain that informal teaching is an approach that a. follows formalized plans b. has standardized content c. often occurs one-to-one d. addresses group needs - ANSWER: C. Informal teaching is individualized one on one teac...

Which description of symptoms is characteristic of a client diagnosed with trigeminal neuralgia (tic douloureux)? A) Tinnitus, vertigo, and hearing difficulties. B) Sudden, stabbing, severe pain over the lip and chin. C) Facial weakness and paralysis. D) Difficulty in chewing, talking, and sw...

A client with a productive cough has obtained a sputum specimen for culture as instructed. What is the best initial nursing action? A. Administer the first dose of antibiotic therapy B. Observe the color, consistency, and amount of sputum C. Encourage the client to consume plenty of warm liquid...

A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last 2 hours. Which action should the nurse take first? A. Irrigate the nasogastric tube with sterile normal saline....

The nurse is preparing to assist a client with a cuffed tracheostomy tube to eat. What intervention is the priority before the client is permitted to drink or eat? - ANSWER : Inflate the cuff Rationale: If a client with a tracheostomy is allowed to eat and the tracheostomy has a cuff, the nurse s...

The nurse is assessing a client's laboratory values following administration of chemotherapy. Which lab value leads the nurse to suspect that the client is experiencing tumor lysis syndrome (TLS)? A. Serum PTT of 10 seconds B. Serum calcium of 5 mg/dl C. Oxygen saturation of 90% D. Hemo...

The nurse is assisting a client out of bed for the first time after surgery. What action should the nurse do first? - ANSWER : Allow the client to sit with the bed in a high Fowler's position. Rationale The first step is to raise the head of the bed to a high Fowler's position, which allow v...

The nurse is providing care to a client after a percutaneous transluminal coronary angioplasty (PTCA). What actions will the nurse include in the client's plan of care? (Select all that apply.) - ANSWER : A.Frequent vital signs. B.Determine if the client is allergic to aspirin. D.Offer fluids of ...

A client experiencing uncontrolled atrial fibrillation is admitted to the telemetry unit. Which initial medication should the nurse anticipate administering to the client? Xylocaine. Procainamide. Phenytoin. Digoxin. - ANSWER: Digoxin. Digoxin is administered for uncontrolled, symptomatic...

The nurse is planning to initiate a socialization group for older residents of a long-term facility. Which information would be most useful to the nurse when planning activities for the group? A. The length of time each group member has resided at the nursing home. B. A brief description of each r...

The nurse assesses a patient with shortness of breath for evidence of long-standing hypoxemia by inspecting: A. Chest excursion B. Spinal curvatures C. The respiratory pattern D. The fingernail and its base - ANSWER : D. The fingernail and its base Clubbing, a sign of long-standing hypoxemia, ...

A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline at 125 mL/hr has been started. One hour after the IV initiation the client begins screaming, "I can't breathe!" The nursing priority action is: 1. Discontinue the IV site and contact the primary health care...

The nurse assesses a patient with shortness of breath for evidence of long-standing hypoxemia by inspecting: A. Chest excursion B. Spinal curvatures C. The respiratory pattern D. The fingernail and its base - ANSWER :D. The fingernail and its base Clubbing, a sign of long-standing hypoxemia, i...