Sensory and Safety
This communication technique gives a client with expressive aphasia adequate time to formulate a response.
What is allowing extra response time?
These involuntary rhythmic movements are a common extrapyramidal adverse effect of antipsychotic medication.
What are tremors?
Localized warmth, tenderness, and a red streak along a peripheral IV vein indicate this complication.
What is phlebitis?
This respiratory finding involves a high-pitched musical sound most commonly associated with narrowed lower airways.
What is wheezing?
This is the single most effective action nurses can take to prevent the spread of infection in health care settings.
What is hand hygiene?
A client taking warfarin reports black, tarry stools. This complication requires prompt assessment.
What is gastrointestinal bleeding?
This hearing test compares bone conduction with air conduction using a vibrating tuning fork.
What is the Rinne test?
This medication class can cause dry mouth, constipation, urinary retention, and blurred vision.
What are anticholinergics?
This intervention should occur immediately when a nonvesicant IV infusion infiltrates surrounding tissue.
What is stopping the infusion?
This assessment finding is a late manifestation of significant hypoxemia, often seen as bluish discoloration of the skin or mucosa.
What is cyanosis?
A nurse caring for a client with Clostridioides difficile should use this method of hand hygiene after providing care.
What is washing hands with soap and water?
An older adult suddenly develops confusion, agitation, and new urinary incontinence. The nurse should assess for this underlying problem.
What is an acute infection?
This intervention helps a hospitalized client experiencing sensory deprivation by increasing meaningful social interaction.
What is encouraging family visits?
This common adverse effect of opioid analgesics requires the nurse to monitor bowel function and consider preventive interventions.
What is constipation?
This sterile technique is used when accessing or caring for an IV catheter to reduce catheter-related bloodstream infections.
What is aseptic technique?
This action before tracheal suctioning helps reduce the risk of procedure-related hypoxemia.
What is preoxygenating the client?
A client with suspected pulmonary tuberculosis requires this category of transmission-based precautions.
What are airborne precautions?
A client with a blood glucose of 48 mg/dL is awake and able to swallow. This is the priority initial treatment.
What is administering 15 grams of fast-acting carbohydrate?
A client with conductive hearing loss may hear a tuning fork louder in this ear during a Weber test.
What is the affected ear?
This complication should be suspected when a client taking an ACE inhibitor develops swelling of the lips and tongue.
What is angioedema?
A client receiving rapid IV fluids develops crackles, dyspnea, and elevated blood pressure. These findings indicate this complication.
What is fluid volume overload?
This position promotes drainage of secretions from selected lung segments using gravity.
What is postural drainage?
When removing PPE, this item is generally removed first because it is likely to be heavily contaminated.
What are gloves?
A client receiving enteral nutrition suddenly develops coughing, respiratory distress, and decreased oxygen saturation. This complication should be suspected.
What is aspiration?
This nursing action reduces injury risk for a client with impaired vision when entering an unfamiliar hospital room.
What is orienting the client to the room and keeping objects in consistent locations?
A client receiving digoxin develops nausea, visual halos, and an irregular heartbeat. These findings suggest this medication complication.
What is digoxin toxicity?
This potentially fatal complication should be suspected when a client with a central venous catheter suddenly develops dyspnea, chest pain, and hypotension following line manipulation.
What is an air embolism?
This immediate nursing action is indicated when a tracheostomy client becomes distressed and a mucus plug is suspected.
What is assessing airway patency and suctioning as indicated?
A nurse enters the room of a client with suspected measles. This type of room ventilation is required to reduce airborne transmission.
What is a negative-pressure airborne infection isolation room?
A client has a potassium level of 6.8 mEq/L with peaked T waves on the ECG. This prescribed IV medication should be prioritized to stabilize the myocardium.
What is IV calcium gluconate?