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        • Safe and Effective Care Environment—Safety and Infection Control
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        • Physiological Integrity—Physiological Adaptation
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        • Physiological Integrity—Basic Care and Comfort
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Author: NCLEX.ME Nurse

Physiological Integrity—Reduction of Risk Potential

The nurse is teaching a newly admitted client about fall prevention. The nurse understands that which of the following interventions can help prevent client falls?

Posted on April 20, 2022 by NCLEX.ME Nurse

keep personal articles within reach explain the use of the call light system keep the bed in the lowest position with all side rails up dim the room lights so t...

Physiological Integrity—Reduction of Risk Potential

A student nurse is discussing fluid overload with the staff nurse. Which statement by the student nurse indicates a need for further explanation by the staff nurse?

Posted on April 20, 2022 by NCLEX.ME Nurse

“Pitting edema is the best indicator of fluid overload.” “The client may have distended veins in the hands and neck.” “I may hear moist crackles in the lungs du...

Physiological Integrity—Reduction of Risk Potential

The nurse is teaching a client and her family about home care following a laryngectomy. Which statement by the client indicates a need for further teaching from the nurse?

Posted on April 20, 2022 by NCLEX.ME Nurse

“I will purchase a Medic-Alert bracelet.” “I can wear loose-fitting turtlenecks to cover the stoma.” “I can resume water aerobics once my doctor says it is okay...

Physiological Integrity—Reduction of Risk Potential

The nurse has received shift report on the assigned client. Which client would the nurse anticipate to be at highest risk for skin breakdown?

Posted on April 20, 2022 by NCLEX.ME Nurse

an elderly client who is up to the chair for meals with assistance a 24-year-old client with diabetes whose hemoglobin A1C is 6.4% a client who is legally blind...

Physiological Integrity—Reduction of Risk Potential

The nurse is preparing to remove a peripheral IV from a client. Which nursing action is the priority with this procedure?

Posted on April 20, 2022 by NCLEX.ME Nurse

checking for an intact catheter tip washing the hands and donning gloves charting the client’s tolerance to the procedure removing catheter slowly using the dom...

Physiological Integrity—Reduction of Risk Potential

The nurse is caring for a client who has just returned from the cardiac catheterization lab. Which complications of cardiac catheterization require immediate intervention by the nurse?

Posted on April 20, 2022 by NCLEX.ME Nurse

chest pain decreased appetite difficulty swallowing hematoma formation decreased pulses in the affected extremity

Physiological Integrity—Reduction of Risk Potential

The nurse is preparing to perform a focused abdominal assessment on a client. Which is the correct order of this assessment?

Posted on April 20, 2022 by NCLEX.ME Nurse

inspection, auscultation, palpation, percussion inspection, palpation, percussion, auscultation inspection, percussion, auscultation, palpation inspection, perc...

Physiological Integrity—Reduction of Risk Potential

A client in the emergency department is complaining of abdominal pain after an episode of nausea and vomiting. Which statement by the client to the nurse necessitates prompt notification of the health care provider?

Posted on April 20, 2022 by NCLEX.ME Nurse

“I started hurting when I got up this morning to go to work.” “My grandmother had to have her appendix out many years ago.” “I haven’t eaten anything because I’...

Physiological Integrity—Reduction of Risk Potential

The nurse is performing discharging instruction for a female client with cystitis. Which statement by the client indicates a need for further teaching?

Posted on April 20, 2022 by NCLEX.ME Nurse

“I should void before and after intercourse.” “I should wear loose-fitting cotton underwear.” “I can continue using spermicide for birth control.” “If I have bu...

Physiological Integrity—Reduction of Risk Potential

A college student presents at the emergency department after being thrown off a horse. Head injury with increased intracranial pressure (ICP) is suspected. The nurse understands that late signs of increased ICP include which manifestations?

Posted on April 20, 2022 by NCLEX.ME Nurse

seizures irritability restlessness disorientation severe headache nausea and vomiting

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POSTS

  • The ED nurse receives a client who is bleeding profusely from a gunshot wound. Which action by the nurse will best help this client avoid complications of extreme blood loss?
  • The nurse is preparing to remove a client’s abdominal stitches as ordered by the health care provider. Which is the correct action by the nurse?
  • The nurse is caring for a client with veno-occlusive disease. Which manifestations of this condition would the nurse expect to find?
  • The nurse is caring for a client with a gastric ulcer. Which menu choice by the client indicates an understanding of the nurse’s dietary teaching?
  • The nurse comes upon a client in the clinic who appears to have experienced a sudden cardiac arrest. After retrieving the automated external defibrillator (AED), the nurse knows to use the equipment in the following manner, as per the American Red Cross. List the steps in order. Use all the steps.

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