“I had my leg removed because of diabetes.” “My exercises are going well.” “My left leg hurts after I wrap my stump.” “I use canes to walk to the bathroom.”
The nurse is caring for a client receiving IV heparin therapy for a pulmonary embolism. Which lab values would the nurse expect to order on this client?
hematocrit HDL and LDL PT, PTT, INR troponin level
The nurse is caring for a client post-op day 1 for a bowel resection. The client is receiving pain medication via a patient-controlled analgesic pump (PCA) but states that her pain is severe and the pain pump is not providing adequate relief. Which is the priority nursing action for this client?
assess vital signs and pain for location, quality, and intensity reposition the client with the head of bed elevated 30 degrees offer nonpharmacologic pain relief measures since the medication dose cannot be increased press the PCA button to deliver a bolus and ask family members to press the button for the client if she is…
The nurse is caring for a client who is at risk for altered fluid balance. Which signs and symptoms of dehydration would the nurse expect to find in this client? Select all that apply.
bounding pulses increased hematocrit orthostatic hypotension diminished bowel sounds decreased urine specific gravity
The nurse is caring for a client diagnosed with a cerebral aneurysm. Which precautions would the nurse put in place for this client? Select all that apply.
keep the room dark and avoid direct, bright lights allow frequent visitors to provide social interaction to the client administer deep vein thrombosis (DVT) prophylaxis as ordered encourage the client to breathe deep and cough to clear secretions keep the client on bed rest in a side-lying or semi-Fowler’s position
The nurse is caring for a first-time mother who is asking how to help her baby sleep through the night as the baby gets older. Which recommendation should the nurse tell the mother?
“Rock her to sleep every night until she is in a deep sleep.” “Give diphenhydramine 12.5 mg orally to put the baby to sleep.” “If she starts waking up a lot in the middle of the night, put her in the bed with you.” “Give the last feeding as late as possible, and put her…
The nurse is caring for a 7-year-old child with constipation. The child’s mother asks the nurse what she can do to help prevent another episode. What information would the nurse include in her response?
“Give enemas until the child runs clear.” “Give laxatives daily on a regular basis.” “Provide lots of milk and sugary foods to promote defecation.” “Have the child sit on the toilet for 5 to 10 minutes about 20 to 30 minutes after meals to encourage defecation.”
The nurse is caring for a client with Crohn’s disease. How should the nurse educate the client regarding nutrition and hydration?
Drink coffee each morning, as this can help stimulate the appetite. Avoid enteral supplements, as they may decrease the appetite for solid foods. Select high-calorie, low-fiber, high-protein, and high-vitamin foods for each meal. Drink clear liquids as soon as they are tolerated, and then progress the diet rapidly in order to obtain needed nutrients.
The nurse is taking a history from a client in an outpatient clinic. The client has been taking duloxetine (Cymbalta) for fibromyalgia. Which of the following over-the-counter medications would cause the nurse some concern if the client says she is taking it?
aspirin garlic supplements vitamin B6 cough medicine with dextromethorphan