Fundamentals
When communicating with a client who speaks a different language, which best practice would the nurse implement?
Arrange for an interpreter to translate
The nurse has provided medication instructions to a client with an iron deficiency anemia who will be taking iron supplements. Which statement made by the client indicates an understanding of this medication?
"I need to increase my fluid intake."
The client with lung cancer and a right-sided pleural effusion seen on chest x-ray is being prepared for a thoracentesis. The nurse would assist the client to which position for the procedure?
Leaning forward over a table to open up the rib cage
A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client?
Respiratory Distress
A fasting blood glucose screening test is performed on a pregnant client. The results indicate that the blood glucose level is 140 mg/dL (8 mmol/L). The nurse would anticipate that which treatment measure would most likely be prescribed next for the client?
3-hour glucose tolerance test
A client's blood gas results reveal acidosis. What are some signs and symptoms the nurse would expect to see?
Headache, lethargy, weakness, and confusion
(acidosis causes CNS depression)
The nurse teaches a client newly diagnosed with type 1 diabetes about storing Humulin N insulin. Which statement indicates to the nurse that the client understood the discharge teaching?
"I can store the open insulin bottle in the kitchen cabinet for 1 month."
Risk factors for patients after a thoracentesis include:
Pneumothorax
Hypoxia
Hypotension (if too much fluid is removed)
A client presents to the emergency department with upper gastrointestinal bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client?
Assess Vital Signs
What is a normal Sodium level (Na+)
135-145
A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse would assess the client for which signs and symptoms characteristic of this disorder?
Headache, restlessness, and confusion
Metformin is prescribed for a client with type 2 diabetes mellitus. What is the most common side effect that the nurse would include in the client's teaching plan?
Gastrointestinal disturbances
When performing a thoracentesis, what intercostal space do you never go below due to risk of peritoneal perforation?
8th ICS
The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a rapid ventricular rate of 150 beats/minute. The nurse would next assess the client for which finding?
Hypotension
A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg, and HCO3– is 22 mEq/L. The nurse interprets the results as indicating which condition?
Respiratory acidosis without compensation
The natural sedative in meat and milk products (especially warm milk) that can help induce sleep is
Tryptophan
Nurse Mackey is monitoring a patient for adverse reactions during barbiturate therapy. What is the major disadvantage of barbiturate use?
Potential for drug dependence
What type of preparation is indicated for thoracentesis?
Sterile!
The nurse is assessing the client's condition after cardioversion. Which observation would be of highest priority to the nurse?
Maintaining patient airway
The nurse reviews the arterial blood gas results of a client with emphysema and notes a pH of 7.30, Paco2 of 58 mm Hg, Pao2 of 80 mm Hg, and Hco3 of 27 mEq/L. The nurse interprets that the client has which acid–base disturbance?
A client has just returned from the cardiac catheterization laboratory. The left-sided femoral vessel was used as the access site. How would the nurse position the client?
Supine, with the head of the bed elevated about 15 to 30 degrees
Levothyroxine is prescribed for a client diagnosed with hypothyroidism. Upon review you find out the client is also taking warfarin. Which modification to the plan of care would the nurse review?
Decreased dosage of Warfarin (Levothyroxine accelerates the degradation of vitamin K–dependent clotting factors. As a result, the effects of warfarin are enhanced)
Max amount that should be removed during a thoracentesis?
1,000ml
A client is scheduled for a cardiac catheterization to diagnose the extent of coronary artery disease. The nurse places highest priority on telling the client to report which sensation during the procedure?
Chest Pain
Your patient is on Warfain and realized he has taken too much of his medicine. You draw a prothrombin tie and note the result of 37 seconds. What do you expect to do with the next dose?
Hold the next dose