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Category: Physiological Adaptation

Physiological Adaptation

The nurse is reviewing morning labs for a client. Which lab value requires immediate intervention by the nurse?

Posted on March 4, 2022 by NCLEX.ME Nurse

calcium 9.8 mg/dL sodium 137 mEq/L chloride 104 mEq/L potassium 3.1 mEq/L

Physiological Adaptation

The nurse is performing the Glasgow coma scale on a client. The assessment is as follows: eye opening, to pain; motor response, localizes pain; verbal response, inappropriate words. The nurse interprets which score is correct for this client?

Posted on March 4, 2022 by NCLEX.ME Nurse

9 10 11 12

Physiological Adaptation

The nurse is caring for a client with a Braden score of 13. How does the nurse interpret this client’s risk of skin breakdown?

Posted on March 4, 2022 by NCLEX.ME Nurse

high risk mild risk severe risk moderate risk

Physiological Adaptation

The nurse is caring for a client with a sacral wound. The wound is full thickness, measures 4 cm × 6 cm with irregular borders, and is covered by a layer of black collagen. Which is this wound stage?

Posted on March 4, 2022 by NCLEX.ME Nurse

Stage I Stage II Stage III unstageable

Physiological Adaptation

The nurse is caring for a client with cardiogenic shock. The nurse expects which signs present with this client? Select all that apply.

Posted on March 4, 2022 by NCLEX.ME Nurse

hypertension; slow, labored breathing decreased urine output; warm, pink skin increased urine output; cool, clammy skin hypotension; weak pulse; cool, clammy sk...

Physiological Adaptation

The nurse is caring for a client who has been diagnosed with pulseless electrical activity (PEA). Following effective CPR and administration of epinephrine, which is the next priority nursing action?

Posted on March 4, 2022 by NCLEX.ME Nurse

check for a pulse insert a urinary catheter prepare to shock the client administer a bolus of sodium bicarbonate

Physiological Adaptation

The nurse is caring for a client with abdominal aortic aneurysm. Which observation by the nurse indicates the need for immediate intervention?

Posted on March 4, 2022 by NCLEX.ME Nurse

complaints of yellow-tinted vision sudden onset of frothy, pink sputum urinary output of 75 mL/hr. per urinary catheter complaints of sudden and severe back pai...

Physiological Adaptation

The nurse is caring for a client who presents to the ED with the following arterial blood gas (ABG) results:

Posted on March 4, 2022 by NCLEX.ME Nurse

The nurse is caring for a client who presents to the ED with the following arterial blood gas (ABG) results: pH 7.32 PaCO2 47 mm Hg HCO3 24 mEq/L PaO2 91 mm Hg ...

Physiological Adaptation

The nurse is caring for a client at risk for postpartum hemorrhage. Which early sign of hemorrhage should the nurse monitor for this client?

Posted on March 4, 2022 by NCLEX.ME Nurse

coma hypotension restlessness cool, clammy skin

Physiological Adaptation

The nurse is caring for a 9-year-old boy who presented to the ED after a penetrating injury from a BB gun. The client is diagnosed with a hyphema. The nurse proceeds to place the client in which position?

Posted on March 4, 2022 by NCLEX.ME Nurse

flat in bed semi-Fowler’s Trendelenburg’s lateral on the unaffected side

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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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