ask the client’s spouse to give consent for the procedure before explaining it to the client ask the client’s spouse to translate for the health care provider and explain the procedure to the client communicate with the client by showing pictures of the intended surgery while a family member translates request a licensed translator to…
Which assessment finding would the nurse expect in a client with long-term venous insufficiency with the presence of a venous ulcer?
decreased or absent pedal pulses with cool or cold foot the presence of stasis ulcers over the medial malleolus skin atrophy and pallor with elevation of the affected leg decreased circumference in the affected leg due to venous constriction
The nurse is auscultating a client’s breath sounds. Low-pitched grating and rubbing are noted on inhalation and exhalation. What will the nurse chart under assessment findings?
ronchi stridor friction rub fine crackles
The nurse is caring for a client with stage 3 moderate chronic kidney disease. Which laboratory value would be expected for this client?
GFR of 92 mL/min GFR of 63 mL/min GFR of 39 mL/min GFR of 16mL/min
A client with a T5 spinal cord injury suddenly begins sweating profusely in the face and neck. Vital signs reveal sudden bradycardia and significant increase in blood pressure. Which is the priority nursing action?
administer nitrate or nifedipine check the client for fecal impaction check the client for bladder distention place the bed in the high Fowler’s position
A client has orders for zoledronic acid (Reclast). Which lab value finding would prompt the nurse to notify the prescriber?
ferritin level of 78 ng/mL magnesium level of 2.3 mEq/dL creatinine clearance of 29 mL/min platelet count of 135,000 cells/mcL
The nurse is caring for an obese client who had a diagnostic laparotomy with midline incision one week ago. The client just called the nurse to report a “popping” sensation in the abdomen. Upon assessment, the nurse notes loops of bowel protruding through the incision. Which is the priority nursing action for this client?
monitor vital signs stay with the client call for help and have the surgeon notified place the client in low Fowler’s with the knees bent
The nurse is caring for a client with bipolar disorder. The client has been manipulating some of the staff and other clients in order to get her way. Which actions by the nurse are appropriate in managing this client?
giving support when the client exhibits positive behaviors setting clear limits and communicating expected behaviors role playing with the client to demonstrate appropriate behaviors treating the client more like a friend in order to show respect for her as a person giving the client small gifts, such as extra dessert, in order to encourage appropriate…