Pain & Inflammation
This is the most important nursing diagnosis to monitor in clients receiving opioid therapy.
Risk for Impaired Gas Exchange
This condition causes thickened nails in elderly adults.
Fungal infection.
The breath sound expected when airway diameter narrows with mucus production.
Wheezes.
A client with constipation who only passes liquid stool after 7 days likely has this condition.
Encopresis (or fecal impaction with overflow).
Traction prior to surgery helps accomplish these two things.
Relieve muscle spasms & maintain bone alignment.
After cataract removal, the MOST important instruction is to avoid anything that increases this.
Intraocular pressure.
A client taking large does of salicylates should immediately report this symptom of toxicity.
ringing in the ears (tinnitus)
The most important instruction for taking antibiotics for skin infection.
Complete the full prescription.
The FIRST action during an acute asthma attack.
Administer bronchodilator.
The best dietary suggestion for chronic constipation.
Increase dietary fiber.
The nurse anticipates this type of prophylactic medication after knee arthroplasty.
Anticoagulation therapy.
Sudden confusion + fever 102.2°F in an elderly client most likely indicates this condition.
Delirium (r/t infection).
When discontinuing corticosteroids, the nurse knows this must always be done.
Taper the dose.
Clients with herpes zoster often receive these two medications to reduce pain and symptoms.
Acyclovir and prednisone.
A DVT patient suddenly develops chest pain and dyspnea. What is the primary intervention?
Apply oxygen via mask.
Before a liver biopsy, this test must be obtained.
Prothrombin time (PT).
Vibrant pain, swelling, and bone protrusion indicate this type of fracture.
Compound fracture.
The Ishihara chart is used to assess this.
Color vision.
A fentanyl patch patient now has a respiratory rate of 10/min. The nurse knows this is a concern because of this risk.
Respiratory depression.
How do you avoid shearing when moving a patient?
Lift the client, do not slide them
On a pneumothorax patient with a stab wound, a sucking chest wound requires this dressing type.
A vented (three-sided) dressing.
Rigid, boardlike abdomen with absent bowel sounds in appendicitis indicates this complication.
Peritonitis.
This nutrient helps with calcium absorption for fracture healing.
Vitamin D.
Memory loss and name confusion with rapid onset in LTC should prompt this FIRST action.
Obtain a urine sample for possible infection.
Elevated uric acid levels would make the nurse screen for this disorder.
Gout.
2x3 cm crater that is 0.5 cm deep. What stage is this pressure sore?
Stage III
A dislodged chest tube should be handled by performing this immediate intervention.
Cover the exit site.
In severe diarrhea lasting >3 days, the nurse monitors most closely for these 2 major problems.
Dehydration & electrolyte imbalances.
To help recover after a ruptured Achilles tendon, the patient should use this rehab approach.
Physical therapy.
When administering ear drops to an adult, the pinna should be moved in this direction.
Up and back.