Health Promotion and Maintenance 1
The nurse should emphasize this action when instructing a preoperative client on the prevention of DVTS.
What is the importance of leg exercises to improve circulation and reduce DVT risk, both pre- and post-surgery?
This class of medications, when mixed with foods containing tryptamine, can cause a hypertensive crisis.
What are MAOIs?
A nurse is assessing a toddler at a well-child visit. At this point in the physical examination, the nurse should examine the child's tympanic membrane.
What is the end?
This is the best positioning strategy to prevent aspiration in a post-operative client following abdominal surgery.
What is semi-Fowler's position due to reduced risk of aspiration and optimization of lung expansion?
Radionuclide imaging is used to detect this in patients complaining of CP.
What is damage to the heart musle?
Clients with OCD participate in ritualized, repetitive behavior secondary to this.
What is anxiety?
This manifestation is characteristic of a patient with bipolar 1 disorder during a manic episode.
What is inflated self-esteem?
A nurse is caring for a 12-month-old toddler who is hospitalized and confined to a room with contact precautions in place. The nurse should recommend these toys to meet the developmental needs of the client.
What are building blocks?
This is the most reliable indicator of fluid loss for an infant who has a 2-day history of vomiting and an elevated temperature.
What is body weight?
This is the priority nursing action for a client recovering from surgery who reports acute SOB and CP.
What is assess oxygen saturation and apply supplemental oxygen.
A nurse is performing a pre-college physical assessment on an adolescent. The nurse should anticipate administering this immunization.
What is the meningococcal polysaccharide vaccine?
The nurse should prioritize these symptoms to prevent complications in a client receiving electroconvulsive therapy (ECT).
What is prolonged confusion or disorientation after ECT.
A nurse is providing nutritional teaching to the mother of a preschooler and is recommending food options to provide 1 oz of grains. This food should be recommended by the nurse.
What is 1 cup of ready-to-eat cereal flakes or 1 6-inch flour tortilla?
This isolation precaution should be used when caring for patients exposed to pneumonic plague.
What is droplet precautions?
This is the priority intervention for a client with a sudden drop in blood pressure following moderate sedation.
What is administering IV fluids to stabilize blood pressure?
A nurse is caring for a client who just delivered a newborn. Following the delivery, this nursing action should be done first to care for the newborn?
What is clear the respiratory tract?
This is an early manifestation of Tardive Dyskinesia.
What is tongue thrusting and lip smacking?
A nurse is caring for a child who is on a clear liquid diet. At lunch, the child consumed ½ cup of juice, 3 oz gelatin, 1 oz of an ice pop, and 20 mL ginger ale. How many mL should the nurse record as the child's fluid intake?
What is 260 mL?
A patient with an NG tube to low wall suction is at risk for this electrolyte imbalance.
What is hypokalemia?
This is an adverse effect that the nurse should inform the client to expect following radiation treatment, which is not dependent on the radiation target site.
What is fatigue?
A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. The nurse expect to observe [blank] in this client?
What is excessive uterine enlargement? A hydatidiform mole is a rare tumor that forms inside the uterus at the beginning of a pregnancy and results in the over-production of tissue that would normally develop into the placenta.
When practicing therapeutic communication, the nurse must do these two things.
What are validate and inquire?
A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The client's ultrasound examination indicates that the fetus is small for gestational age (SGA). This intervention should be included in the newborn’s plan of care?
What is observe for meconium in respiratory secretions? -When a fetus is SGA, there is an increased risk for intrauterine hypoxia due to the presence of meconium in the amniotic fluid.
A nurse is assisting with transferring a client from the bed to a wheelchair. The nurse should do this first before beginning the transfer.
What is locking the wheels of the bed and the wheelchair?
The nurse should include the following manifestations when providing discharge teaching to a client with a new AV fistula as a sign of possible venous insufficiency.
Cold and numbness distal to the fistula site.