The nurse is preparing to transfer a client from the ED to the orthopedic unit. She knows that adhering to the hospital policy for client handoffs best ensures which of the following?
privacy Patient’s Bill of Rights continuity of care case management
The nurse is teaching feeding protocol to the spouse of a client who experienced a severe stroke. Which statement by the spouse indicates a need for further explanation by the nurse?
“I will not let him use a straw.” “I will turn on the television during meals.” “Instead of whole pills, I will crush the pill and place it in custard.” “He will sit up for a half hour after eating.”
The nurse is caring for a client after he experienced a seizure (postictal). Which intervention would the nurse expect not to perform?
return client to pre-seizure activity administer medications as appropriate reorient as necessary assess neurologic and vital signs
The nurse is seeing a client in the clinic who has shingles (herpes zoster). The client is concerned about spreading the disease to others. How should the nurse respond?
It is only possible to have one episode of the disease. Persons with leukemia are at higher risk. Persons of all ages should receive the zoster vaccine (Zostavax). Persons between 30 and 40 years old are at high risk.
The nurse is assisting the health care provider to perform a renal biopsy. Which position should the nurse place the client in?
in the semi-Fowler’s position on the same side of the kidney to be biopsied on the side opposite of the kidney to be biopsied prone with a pillow under the shoulders and abdomen
The nurse is caring for a client receiving hemodialysis. During hemodialysis, the client becomes anxious, experiencing tachypnea and hypotension. The nurse suspects which complication of hemodialysis?
air embolism clotting of the graft site dialysis encephalopathy disequilibrium syndrome
The nurse is caring for a client who has a lithium level of 2.2 mEq/L. Based on this lab value, what would the nurse anticipate to do in order to care for this client? Select all that apply .
prepare to administer IV fluids notify the health care provider order a mechanical soft diet for the client administer the next dose of lithium when it is due observe the client for confusion and slurred speech
The nurse is caring for a client who just arrived in the PACU following a colonoscopy with polyp removal. The client’s level of sedation is assessed using the Ramsay Sedation Scale (RSS). The client responds quickly, but only to commands. What Ramsay score would the nurse chart for this client?
RSS 1 RSS 2 RSS 3 RSS 4 RSS 5 RSS 6
A client recently diagnosed with atrial fibrillation is being discharged home on digoxin (Lanoxin). The nurse is providing education to the client and family. Which client statement indicates the need for further teaching?
“I should take my medicine at the same time each day.” “If I miss a dose, I can take it as soon as I remember it.” “I need to call my doctor if my heart rate goes below 60 or above 110.” “Changes in my vision could be toxicity and should be reported immediately.”