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The home health nurse is interviewing an older client with a history of mild heart failure and rheumatoid arthritis. The client reports “feeling pretty good, except for the pain and stiffness in my joints when I first get out of bed.” Which member of the health care team would be the most appropriate to aid in the client’s report of pain?
A patient who has cancer will need ongoing treatment for pain. Which brochure is the nurse most likely to prepare that addresses questions related to the first-line treatment of cancer pain?
While inserting an indwelling urinary catheter in a female client, the nurse observes urine flow in the tubing. What action should be taken next?
While caring for a school-age child with congestive heart failure the nurse notes the development of an arrhythmia on the cardiac monitor. Which medication is most likely causing the change in this client’s cardiac status?
While performing a physical examination of a 10-month-old infant, the nurse notes raw moist weeping macules and papules of skin on the child’s genitals, upper thighs and bottom. How should the nurse document this finding?
Which technique should be used by the nurse to obtain a sterile urine specimen using a straight catheter?
What should the prenatal clinic nurse conclude to be a contraindication for maternal serum alpha-fetoprotein (AFP) testing for a pregnant client?
Which strategy is most important for the nurse to use when assisting a client with myasthenia gravis to devise a daily routine?
While the nurse is inserting a nasogastric tube, a client becomes dyspneic and cyanotic. What action should the nurse implement first?
Which statement by a school-aged client going to summer camp indicates the best understanding of Lyme disease’s mode of transmission?
While teaching a female Korean-American client about her medications, the nurse observes that she appears very serious, does not smile, and avoids looking at the nurse. Which expected outcome statement best directs this client’s plan of care? The client will
While receiving an intravenous vesicant as part of medical treatment the client begins to complain of pain and burning at the venous access site. What action should the nurse take at this time?
Which statement by a client being treated for infertility indicates an understanding of treatment?
The nurse is assessing a client who has been receiving opioid medication via patient-controlled analgesia. What is an early sign that alerts the nurse to a possible adverse opioid reaction?
The charge nurse of a long-term care facility is reviewing the methods and assessment tools that the staff nurses are using to assess pain. Which nurse is using the best method to assess pain?
The nurse assigns an LPN/LVN to administer prochlorperazine 10 mg orally to an older adult patient experiencing nausea. Which specific instruction would the nurse give the LPN/LVN regarding monitoring this patient after the drug has been given?
The health care provider (HCP) prescribes a bisacodyl 10 mg suppository rectally for an older adult who has not had a bowel movement for over 5 days. Which actions are accurate when the nurse administers this drug rectally? Select all that apply.
A patient with end-stage renal disease is refusing any further treatments. Which response is appropriate for the nurse to make?
Nurses in the intensive care unit are having a high incidence of burnout after a period in which several long-term patients died in the unit despite having received aggressive care. Which strategies can the nurse manager implement to help the staff deal with these issues? (Select all that apply.)
The nurse auscultates a murmur at the fifth intercostal space at the midclavicular line on the left side. The nurse realizes that this is caused by which incompetent heart valve?
A new graduate asks the preceptor why the hospital is not using heparin in the hemodynamic flush bags. What is the correct response?
To perfuse the coronary arteries, a patient needs a mean arterial pressure (MAP) of at least 60 mm Hg. Which blood pressure reading will not provide an adequate MAP?
The nurse is choosing the appropriate lead to monitor the patient’s electrocardiogram rhythm. For which patient would lead II be the most appropriate lead?
The nurse is caring for a patient who was just placed on mechanical ventilation and is observing the patient’s vital signs. The nurse knows that positive-pressure ventilation can lead to which problems? (Select all that apply.)
A patient does not respond to verbal stimuli, so the nurse applies painful stimulus and notes the patient’s reaction. The patient clenches his teeth, and his arms are extended, adducted, and hyperpronated. The nurse recognizes this activity is indicative of which finding?
The nurse is assisting with a lumbar puncture and notes that the cerebrospinal fluid (CSF) is a smoky color. The nurse knows that this finding is suggestive of which abnormality?
The nurse is admitting a patient with a head injury. Which parameters will the nurse evaluate as part of the patient’s neurologic assessment? (Select all that apply.)
During assessment, the nurse notes that the patient has pinpoint pupils. What could cause this finding? (Select all that apply.)
The postoperative craniotomy patient has a serum osmolality of 320 mOsm/L and urine output of 400 mL/h for the past 3 hours with a urine specific gravity of 1.003. Which treatment would the nurse anticipate the practitioner ordering for this patient?
The nurse is trying to decrease the temperature of the patient in thyroid storm. Which treatment should the nurse question?
An older female patient admitted with weight gain, depression, and cold intolerance has respiratory acidosis and hypoventilation. She is unarousable. Which treatment would the nurse anticipate the practitioner ordering for this patient?