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The nurse would place a client who sustained a head injury in which position to prevent increased intracranial pressure (ICP)?
The nurse assesses the client diagnosed with acquired immunodeficiency syndrome (AIDS) for early signs of Kaposi’s sarcoma. What characteristics would be consistent with that lesion? Select all that apply.
When a client who sustained a chest injury is suspected of experiencing a pleural effusion, the nurse would assess for which typical manifestations of this respiratory problem? Select all that apply.
After a client diagnosed with pleural effusion had a thoracentesis, a sample of fluid was sent to the laboratory. Analysis of the fluid reveals a high red blood cell count. Based on this test result, what was the case of this client’s pleural effusion?
The nurse is scheduling a client diagnosed with possible diverticulosis for a series of diagnostic studies of the gastrointestinal (GI) system. Which of these studies would the nurse schedule last to avoid altering the results of the remaining tests?
The nurse is caring for a client who is scheduled to have a liver biopsy to rule out liver cancer. Before the procedure, it is important for the nurse to assess which parameter to assure client safety?
The nurse is caring for a client diagnosed with pneumonia. To ensure tolerance of the activity, the nurse would plan to take the client for a short walk after which of the following?
The nurse inserts an indwelling Foley catheter into the distended bladder of a postoperative client who has not voided for 8 hours. After the tubing is secured and the collection bag is hung on the bed frame, the nurse notices that 900 mL of urine has drained into the collection bag. What is the appropriate nursing action for the safety of this client?
The nurse has a prescription to administer amphotericin B intravenously to the client diagnosed with histoplasmosis. Which would the nurse specifically plan to implement during administration of the medication to minimize the client’s risk for injury? Select all that apply.
A client who experienced repeated pleural effusions from inoperable lung cancer is to undergo pleurodesis. What intervention would the nurse plan to implement after the primary health care provider injects the sclerosing agent through the chest tube?
A client with a posterior wall bladder injury has had surgical repair and placement of a suprapubic catheter. What intervention would the nurse plan to implement to prevent complications associated with the use of this catheter?
A newborn infant is diagnosed with esophageal atresia. Which assessment finding supports this diagnosis?
A client undergoes transurethral resection of the prostate (TURP). Which solution would the nurse infuse postoperatively for continuous bladder irrigation (CBI)?
A client diagnosed with acquired immunodeficiency syndrome (AIDS) is being admitted to the hospital for treatment of a Pneumocystis jiroveci respiratory infection. Which intervention would the nurse include in the plan of care to assist in maintaining the comfort of this client?
A client with significant flail chest has arterial blood gases (ABGs) that reveal a Pao2 of 68 and a Paco2 of 51. Two hours ago the Pao2 was 82 and the Paco2 was 44. Based on these changes, which item would the nurse assure easy access to in order to help ensure client safety?
A client experiencing empyema is to have a bedside thoracentesis performed. The nurse plans to have which equipment available in the event that the procedure itself is not effective?
The nurse caring for a client being treated for severe back pain is preparing to administer an opioid via an epidural catheter. Before administering the medication, the nurse aspirates and obtains 5 mL of clear fluid. Based on this finding, which action would the nurse take?
The nurse is planning care for a client with a chest tube attached to a Pleur-Evac drainage system for the management of pleural effusion. The nurse would include which interventions in the plan? Select all that apply.
The nurse is assisting a client recovering from pneumothorax with a chest tube to get out of bed, when the chest tubing accidentally gets caught in the bed rail and disconnects. While trying to reestablish the connection, the Pleur-Evac drainage system falls over and cracks. The nurse would take which action to minimize the client’s risk for injury?
When planning care for a client diagnosed with Cushing’s syndrome, the nurse would include which intervention to prevent a common complication of this disorder?
A client with a central venous catheter who is receiving total parenteral nutrition (TPN) suddenly experiences signs/symptoms associated with an air embolism. The nurse would implement which interventions to minimize the client’s risk for injury? Select all that apply.
Which observation by the nurse indicates a need to suction a client with an endotracheal (ET) tube attached to a mechanical ventilator to help manage a pneumothorax? Select all that apply.
A client who has been diagnosed with carbon monoxide poisoning is asking that the oxygen mask be removed. The nurse shares with the client that the oxygen may be safely removed once the carboxyhemoglobin level decreases to less than which level?
The nurse is teaching a pregnant client about prenatal nutritional needs. The nurse would include which information in the client’s teaching plan?
A client is admitted to the hospital with a diagnosis of acute bacterial pericarditis. Which assessment findings are associated with this form of heart disease? Select all that apply.
A client is admitted to the hospital with a diagnosis of Cushing’s syndrome. The nurse monitors the client for which problem that is likely to occur with this diagnosis?
An assessment of a client’s vocal cords with suspected malignancy requires indirect visualization of the larynx. Which instruction would the nurse give the client to facilitate this procedure?
The nurse is caring for a client scheduled for a bilateral adrenalectomy for treatment of an adrenal tumor. What information would the nurse give the client about the postsurgical needs?
The nurse is caring for a client who is scheduled for an adrenalectomy. The nurse plans to administer which medication in the preoperative period to prevent Addisonian crisis?
The nurse is preparing a client diagnosed with Graves’ disease to receive radioactive iodine therapy. What information would the nurse share with the client about the therapy?
A client arrives at the emergency department with upper gastrointestinal (GI) bleeding that began 3 hours ago. What is the priority action?
A client who has experienced an acute kidney injury is prescribed a fluid restriction of 1500 mL per day. Which interventions would the nurse implement to assist the client in maintaining this restriction? Select all that apply.
A client is intubated and receiving mechanical ventilation after experiencing lung aspiration. The primary health care provider has added 7 cm of positive end-expiratory pressure (PEEP) to the client’s ventilator settings. The nurse would assess for which expected but adverse effect of PEEP?
The client diagnosed with chronic kidney disease is scheduled for hemodialysis. When would the nurse plan to administer the client’s daily dose of enalapril to ensure its effectiveness?
The nurse is preparing to provide postsurgical care for a client after a subtotal thyroidectomy. The nurse anticipates the need for which item to be placed at the bedside to minimize the client’s risk for injury?
When caring for a client diagnosed with myasthenia gravis, the nurse would be alert for which manifestations of myasthenic crisis? Select all that apply.
The nurse is encouraging the client to cough and deep breathe after cardiac surgery to avoid developing pneumonia. The nurse ensures that which item is available to maximize the effectiveness of this procedure?
The nurse, caring for a patient being treated for a bowel obstruction is preparing to administer an intermittent tube feeding through a nasogastric (NG) tube assesses for residual volume. How do the resulting data assist in assuring the client’s safety?
The nurse is caring for a client scheduled to undergo a renal biopsy to confirm suspected malignancy. To minimize the risk of postprocedure complications, the nurse reports which laboratory results to the primary health care provider before the procedure?
A client who survived a house fire is experiencing respiratory distress, and an inhalation injury is suspected. What would the nurse monitor to determine the presence of carbon monoxide poisoning?
The nurse is assigned to care for a client experiencing hypertonic labor contractions. The nurse plans to conserve the client’s energy and promote rest by performing which intervention?
A client diagnosed with acute pyelonephritis is scheduled for an intravenous pyelogram this morning. During report the nurse learns that the client vomited several times during the night and continues to report being nauseated. What intervention would the nurse implement to assure the client’s safety regarding the scheduled procedure?
The nurse is planning care for a client who has experienced a T3 spinal cord injury. The nurse would include which intervention in the plan to prevent autonomic dysreflexia (hyperreflexia)?
The nurse is assessing the respiratory status of a client with pleural effusion after a thoracentesis has been performed. The nurse would become concerned with which assessment finding?
The nurse monitors a client prescribed a thiazide diuretic as part of treatment from hypertension for which clinical manifestations of hypokalemia? Select all that apply.
The nurse is preparing to administer a tuberculin skin test to a client. The nurse determines that which area is to be used for injection of the medication?
Which questions would the nurse ask when assessing a client for possible manifestations of Ménière’s disease? Select all that apply.
A client has been diagnosed with left tension pneumothorax. Which finding observed by the nurse indicates that the pneumothorax is rapidly worsening? Select all that apply.
A client is admitted to the hospital with a diagnosis of right lower lobe pneumonia. The nurse auscultates the affected lung area, expecting to note which type of breath sounds?
The nurse is caring for a 33-week pregnant client who has experienced a premature rupture of the membranes (PROM). Which interventions would the nurse expect to be part of the plan of care? Select all that apply.