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Carbamazepine is prescribed to treat the client.
Because carbamazepine can cause liver dysfunction, what should the nurse inform the client to report if it develops?
A nurse applies prolonged pressure to the injection site of a client who is receiving anticoagulant therapy.
What is an accurate analysis of the nurse’s action when performed after administering the injection to a client who is concurrently receiving heparin?
Leuprolide is prescribed for the client after the prostatectomy.
What statement(s) by the client provides the best evidence that he understands the benefits associated with this type of hormonal therapy? Select all that apply.
A total hip replacement (hip arthroplasty) is planned for a 70-year-old client with osteoarthritis. The client is told to stop taking enteric-coated aspirin 1 week before surgery.
What statement by the nurse is the best explanation for discontinuing the medication?
The client reports having acute pain in the incisional area after coronary artery bypass graft (CABG) surgery.
When the client uses a patient-controlled analgesia (PCA) infusion pump, what nursing instruction is most important to include?
The nurse reads that the client is taking lithium carbonate to treat bipolar disorder and suspects that the client has not been taking the medication as prescribed.
When the nurse reviews information about lithium carbonate with the client, what instruction(s) is important to stress? Select all that apply.
A 10-year-old child who has juvenile idiopathic arthritis (JIA), formally called juvenile rheumatoid arthritis (JRA), is seen in the joint disorders specialty clinic 2 weeks after an acute episode of the disorder. The nurse discusses home care with the child and parents.
What statement by the child indicates teaching about the use of ibuprofen has been effective?
A client who wears a hearing aid is frustrated by the loud and shrill noise (feedback) that is occasionally heard.
After instilling medication into the client’s ear, what nursing instruction is most appropriate?
A client is diagnosed with angina pectoris. Sublingual nitroglycerin tablets are prescribed for whenever the client experiences chest pain.
What side effects should the nurse instruct the client are most closely associated with the use of nitroglycerin tablets? Select all that apply.
During the administration of a cleansing soapsuds enema, a client experiences cramping and has the urge to defecate.
When the nurse is inserting a rectal suppository to relieve constipation, what nursing action is most appropriate?
A nurse on the obstetrics unit cares for several high-risk pregnant clients.
What client(s) is most likely to be identified as being at high risk for pregnancy complications? Select all that apply.
Before undergoing surgery for a fractured hip, an older adult client is placed in Buck’s traction.
What nursing assessment technique is best for assessing circulation in the leg in Buck’s traction?
During the nurse’s initial physical assessment of an older client who was just transferred from a nursing home, the nurse notes that the client has a pressure injury on the left hip and sacrum.
Based on the etiology of pressure injuries, what nursing intervention is best for promoting the client’s skin integrity?
The client will continue radiation treatment as an outpatient after discharge from the hospital.
What nursing instruction about being in the outdoor environment is most important to include in the client’s discharge plan?
The client returns from surgery with an infusing I.V., nasogastric tube, a T-tube for bile drainage, and a Jackson-Pratt tube for wound drainage in place.
The nurse should anticipate implementing which interventions when managing the client’s T-tube? Select all that apply.
A 24-hour urine collection is prescribed for the client with possible Cushing’s syndrome.
What statement is correct concerning the collection of urine for a 24-hour specimen?
The client tells the nurse, “I think my water broke.” The nurse performs a nitrazine test and confirms that the membranes have ruptured.
What actions should the nurse perform immediately after the membranes are ruptured? Select all that apply.
A cervical halter type of skin traction is applied to a client who has experienced a whiplash injury in a motor vehicle accident.
When the nurse makes rounds at the beginning of the shift, what observation requires the nurse’s immediate attention?
The client with a pulmonary embolism suddenly experiences chest pain and dyspnea and tells the nurse, “I think I am dying.”
The nurse attaches a pulse oximeter to the client’s finger. What nursing action(s) is appropriate at this time? Select all that apply.
A 24-year-old woman is being treated for endometriosis. A laparoscope will be used to remove ectopic tissue.
If the client experiences all of the following symptoms after the laparoscopy, which would the nurse attribute directly to the endoscopic procedure?
The health care team is informed that skin autografting is planned for the client with burns.
Following an autograft of skin, what is most appropriate to include in the care plan?
The nursing team develops a care plan for a client who has been diagnosed with cancer of the larynx. The client is scheduled for a total laryngectomy. After surgery, the client is taken to the recovery room until stabilized.
The nurse is assembling supplies kept at the bedside. The nurse selects a cuffed tracheostomy tube per health care provider’s prescriptions. The nurse anticipates the selection is to prevent which outcome?
A small window in the plaster of the hip spica cast is cut to inspect the underlying tissue.
What assessment findings suggest that the client in the hip spica cast may be developing a response to room confinement known as cast syndrome?
A 50-year-old client is scheduled for a heart transplant. Because of the client’s anxiety, the client has difficulty comprehending the nurse’s information.
During the postoperative period, what is the best rationale for the nurse frequently assessing the client’s fluid status?
A 2-week-old newborn with a diagnosis of coarctation of the aorta is being cared for in the high-risk nursery.
What admission data best correlates with the diagnosis?
The mother asks the nurse when the newborn will be tested for HIV, and how long it usually takes before HIV-positive newborns develop acquired immunodeficiency syndrome (AIDS).
What statement by the nurse about HIV testing is most appropriate?
A middle-aged client presents to the clinic with vague symptoms of malaise and headache. Even though these symptoms are rather unremarkable, the client is diagnosed with acute glomerulonephritis.
When the client with glomerulonephritis reports having a headache that is rated a 7 on a scale of 0 to 10, with 10 being the most pain, what nursing action should be performed next?
The nurse is caring for an older adult client who has been diagnosed with myasthenia gravis.
When the nurse obtains the client’s medical history, what clinical sign would the client most likely report?
A nurse working in a health care provider’s office receives a telephone call from a frantic person whose family member is choking on a piece of hard candy.
The nurse knows that the correct way to position the hands when performing the abdominal thrust maneuver is with the thumb side of the closed fist on what part of the victim’s abdomen?
Ultrasound reveals that a resident of a long-term care facility has an abdominal aortic aneurysm.
The nurse reviews the client’s health history. What finding(s) indicates factors that have contributed to the development of an abdominal aortic aneurysm? Select all that apply.