palpitations lower extremity edema uncomfortable feeling of pressure in the chest nausea
The nurse is caring for a client who has just returned from surgery for an ascending colostomy. The nurse plans to include reinforcement teaching for the client and spouse. Which statements should the nurse include in the teaching?
The colostomy will begin functioning within 24 hours. A large amount of bleeding may be present at the stoma site. The first stools will be liquid and will gradually become more formed. A healthy stoma is reddish-pink and moist and protrudes about 2 cm from the abdominal wall.
The nurse is caring for a client with compartment syndrome. The client’s husband asks what causes the condition. Which of the following will the nurse share with the client’s husband?
It can be present in severe burns. Most cases are caused by fractures. It can be caused by severe infiltration of IV fluids. It occurs with failure to ambulate after surgical procedures. Untreated high blood sugars are a contributing factor in some cases.
The nurse is assessing the reflexes of a full-term newborn infant. Which of the following is true regarding newborn reflexes?
The Babinski reflex disappears after 1 year of age. Complete fencing response disappears by 2 months. The stepping or “walking” reflex is present until 3 – 4 months. The Moro reflex is present at birth and disappears by 6 months.
The nurse is observing a student nurse administer an otic medication to an adult client. The nurse knows the student nurse requires additional teaching when which of the following actions is observed?
positions client in prone position follows the six rights of medication administration applies nonsterile gloves pulls the pinna back and up
The nurse is visiting a client at home who is using a transdermal fentanyl patch. The nurse knows the client requires additional education based on which of the following statements?
“I apply the patch when I have breakthrough pain.” “I store my patches in a private location away from my grandchildren’s reach.” “I remove my old patch before applying a new one.” “I enjoy orange juice for breakfast.”
The nurse is preparing a client with acquired immunodeficiency syndrome (AIDS) for discharge home. Which of the following statements by the client indicates a need for further teaching by the nurse?
“I do not need to limit my time in public places.” “I may share food from serving dishes with others at a restaurant.” “I may use public restrooms.” “I may donate blood.”
The physician orders an MRI of the spine with infusion for an adult female. Which of the following findings in the client’s history should the nurse report to the physician?
allergy to shellfish congestive heart failure (CHF) chronic cystitis metformin administered daily
The nurse is administering afternoon medications, which include an antihypertensive med and aspirin for pain relief. Which of the following should the nurse do first before administering the medications?
match the client’s date of birth and name on his wristband with the same information on the medication order ask the client his name and date of birth ask the client to confirm the medication ordered and compare this with the medication order match the client’s name and room number with the medication order