Reduction of Risk Potential Assessment

The client has returned from surgery with a leg cast. 

What nursing assessment should be the priority at this time?

The client with bilateral cataracts is scheduled to have a cataract removed from the right eye.

After suffering head trauma, a client develops signs and symptoms of diabetes insipidus.

What nursing intervention is essential for monitoring the client’s condition?

When a client experiences an increased number of anginal episodes, a cardiac catheterization and coronary arteriogram are prescribed.

The nurse implements the teaching plan for cardiac catheterization and coronary arteriogram. What information the nurse provides is accurate?

The nurse covers the client’s leg venous stasis injury with a type of air-occlusive dressing.

What client should the nurse identify as at highest risk for acquiring gangrene of the foot?

The client is advised to undergo allergy skin testing and grading for level of response. Weekly injections for desensitization are prescribed. 

After the client receives the weekly injection of diluted antigens, what nursing instruction is essential?

The client’s oral cancerous lesion is surgically removed, and postsurgical radiation therapy is planned after discharge. 

When the nurse plans postoperative nursing care, what nursing intervention(s) should be implemented? Select all that apply.

A 45-year-old client is suspected of having cholecystitis.

If the cause of the client’s inflamed gallbladder is gallstones, the nurse would anticipate the laboratory data to indicate which finding?

Bladder retraining is progressing slower than expected due to the client’s mental and physical limitations. An indwelling catheter is inserted. 

After inserting an indwelling catheter into a male client, what technique is most appropriate for stabilizing the catheter to avoid damage to the penis?

The client’s breast tumor is confirmed as malignant, and she undergoes a left modified radical mastectomy. 

What nursing intervention(s) is appropriate to add to the client’s immediate postoperative care plan? Select all that apply.

During a prenatal class, participants ask about varicose veins and how to relieve the discomfort associated with them.

When teaching the class about varicose veins, what symptom should the nurse instruct clients to report immediately?

The nurse palpates the uterus to measure the fundal height of a pregnant woman at 40 weeks’ gestation.

A client with preterm contractions at 32 weeks’ gestation has an amniocentesis to assess fetal lung maturity. What laboratory test would the nurse monitor?

The nurse in a well-baby clinic assesses the growth and development of healthy infants and toddlers and uses that information as a basis for teaching.

The nurse is caring for a 6-year-old client with a history of attention deficit hyperactivity disorder (ADHD). When providing discharge instructions following a tonsillectomy, which client activity should be encouraged to prevent a post-tonsillectomy bleed?

A nurse provides nursing care and age-appropriate instruction for pediatric clients with minor injuries. Throughout the day, children with a variety of injuries present for medical care. 

What nursing instruction concerning ice applications is appropriate to give the parents of a 12-year-old child with a sprained ankle?

The health care provider prescribes four-point behavioral restraints.

Once the restraints have been applied, what objective evidence indicates to the nurse that the restraints are too tight? Select all that apply.

The client has returned from surgery with a leg cast.

What nursing assessment findings suggest that the client is developing fat embolism syndrome? Select all that apply.

The client with bilateral cataracts is scheduled to have a cataract removed from the right eye.

After cataract surgery, the client tells the nurse of severe pain in the operative eye. What nursing action is most appropriate?

Because medical treatment was unsuccessful, the client with acromegaly is scheduled for a transsphenoidal hypophysectomy.

When completing a postoperative evaluation, what location is essential to assess to ensure an absence of bleeding?

When a client experiences an increased number of anginal episodes, a cardiac catheterization and coronary arteriogram are prescribed.

The nurse recognizes an allergy to what substance presents a high risk when the client undergoes a cardiac catheterization?

A nurse gathers admission history from a 57-year-old client who is scheduled to have abdominal surgery. 1

When reviewing the client’s health history, what data correlate with a potential for developing thrombophlebitis? Select all that apply.

The nurse applies a pulse oximeter and records a reading of 88%. After repositioning and confirming the 88% result, the nurse notes a trend of 90% and 89% on previous readings.

Which nursing intervention is completed next?

A 60-year-old client who has been experiencing difficulty swallowing is scheduled for an esophagoscopy.

What statement to the nurse indicates the client understands the preparation before an esophagoscopy?

Because the client’s gallbladder was unable to concentrate and excrete bile, it could not be visualized by cholecystography. An ultrasound of the gallbladder is prescribed. The nurse explains the scheduled procedure to the client.

What comment indicates that the client has an accurate understanding of the preparation necessary for the ultrasound procedure?

A client with type 1 diabetes mellitus reports having urinary problems.

The health care provider prescribes a clean-catch midstream urine specimen for routine analysis. The nurse collects a cup and wipes for urine collection. What statement(s) should be included when the nurse instructs a female client about the technique for urine collection? Select all that apply.

The client’s breast tumor is confirmed as malignant, and she undergoes a left modified radical mastectomy.

On the basis of the location and extent of this client’s surgery, what postoperative complication(s) can the nurse anticipate the client may develop? Select all that apply.

The nurse leads a discussion with the group about distinguishing between danger signs and the common discomforts of pregnancy. 

The nurse considers prenatal teaching successful when the class correctly identifies what as a danger sign of pregnancy?

A 29-year-old multiparous client who has had an uneventful, healthy pregnancy is admitted to the hospital. The health care provider informs the client that the active phase of the first stage of labor is in progress. The records also show that the full-term fetus is in the left occipitoposterior (LOP) position.

To prevent distention of the client’s bladder during the active phase of labor, what nursing intervention is most appropriate?

A young, first-time parent expresses concern regarding normal physical growth and development. The parent states, “I’m unsure when I need to childproof my home.”

The nurse is assigned the pictured client prior to surgery. What nursing action is most important for the nurse to include during the preoperative period?

A nurse provides nursing care and age-appropriate instruction for pediatric clients with minor injuries. Throughout the day, children with a variety of injuries present for medical care.

What nursing action is most appropriate when caring for a school-age child who is experiencing a nosebleed?

A 55-year-old client has multiple symptoms that do not resemble any specific disorder. The client is anxious and worried because no definite diagnosis has been made. 

When this client summons the nurse and reports feeling weak and dizzy, what nursing action should the nurse perform first?

The nurse suspects that the victim has rib fractures. 

What nursing assessment finding is the best indication that the client has a secondary complication from the fractured ribs?

While a client is waiting to undergo percutaneous transluminal coronary angioplasty (PTCA), the nurse administered the prescribed propranolol. 

What information validates that the nurse will be giving the medication to the right client? Select all that apply.

After a period of taking methimazole, the client with Graves’ disease will undergo a near-total thyroidectomy, which allows a small portion of the gland to remain. Potassium iodide solution 4 gtt P.O. is prescribed for 10 days before the scheduled surgery.

In preparation for potential postoperative complications following the thyroidectomy, what item is best for the nurse to keep at the client’s bedside?

A client has just completed a cardiac catheterization and coronary arteriogram.

In what position should the nurse maintain the client’s affected leg used for inserting the cardiac catheter?

The client is recovering from abdominal surgery that was performed 2 days earlier. 

Following the nurse’s assessment, what finding is most likely to predispose this client to developing venous thrombosis in a lower extremity?

The nurse applies a pulse oximeter and records a reading of 88%. After repositioning and confirming the 88% result, the nurse notes a trend of 90% and 89% on previous readings.

The nurse instructs a client on the use of an incentive spirometer. Place the sequence of steps in the correct order. Use all options.

A 75-year-old client with metastatic cancer of the esophagus is undergoing palliative treatment that includes total parenteral nutrition (TPN) administered through a central subclavian catheter. 

What nursing assessment is essential for evaluating the client’s response to the total parenteral nutrition (TPN)?

Ultrasound of the client’s gallbladder reveals several stones in the gallbladder. Two treatment options are discussed by the health care provider: lithotripsy or a laparoscopic cholecystectomy.

The client with cholelithiasis asks the nurse to review the key points of the lithotripsy procedure. What is the best nursing explanation to clarify how gallbladder stones are treated?

The client is scheduled for intravenous pyelography (IVP). The nurse prepares to administer a laxative to the client. 

When the client questions the reason for the laxative, what nursing explanation is accurate?

The client’s breast tumor is confirmed as malignant, and she undergoes a left modified radical mastectomy.

The client underwent a left modified radical mastectomy. What activity of daily living is most therapeutic for the nurse to recommend for preserving the hospitalized client’s muscle strength and joint flexibility in the arm on the operative side?

A 40-year-old participant, a gravida 5, para 1 in the 10th week of pregnancy, tells the nurse of concerns that her age may affect the health of the fetus. The participant asks the nurse if there is a test that can identify any genetic disorders that the fetus may have. 

At this point in the client’s pregnancy, what test is typically used to detect genetic disorders?

The client tells the nurse, “I think my water broke.” The nurse performs a nitrazine test and confirms that the membranes have ruptured. 

What color does the test strip turn if the membranes have ruptured?

A surgical repair of the myelomeningocele is successfully completed.

In planning the infant’s home care, what orthopedic consideration is essential for the nurse to include to diminish musculoskeletal problems?

The health care provider determines that the adolescent may be discharged home. The nurse provides discharge instructions to the client and parents. 

What instruction is essential to give the parents before discharge?

Approximately 36 hours after admission, the client with alcohol use disorder becomes restless and shouts that, “The bugs in this room are disgusting!”

Based on the change in the client’s condition, what nursing action is most appropriate to perform next?

An 80-year-old client who sustained a fall at a long-term care facility is suspected of having a fractured right hip.

When the nurse reviews the client’s medical record, what risk factor was likely the most significant for predisposing the client to the fracture?

The nurse is assigned to care for a client with a retinal detachment.

Of the following data, what nursing information provided in the client’s health history is most likely to have caused a retinal detachment?

After thyroidectomy surgery, the client is returned to the nursing unit in stable condition.

In what position should the nurse place the client?

A client has just completed a cardiac catheterization and coronary arteriogram.

When the client is returned to the room on the nursing unit, what should the nurse plan to do first?

The client will take warfarin on a daily basis.

The nurse instructs that, because of taking warfarin, the client should avoid eating foods containing large amounts of vitamin K. What food(s) should the nurse include in the teaching plan? Select all that apply.