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Category: Physiological Integrity—Reduction of Risk Potential

Physiological Integrity—Reduction of Risk Potential

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?

Posted on April 20, 2022 by NCLEX.ME Nurse

RSS 1 RSS 2 RSS 3 RSS 4 RSS 5 RSS 6

Physiological Integrity—Reduction of Risk Potential

The nurse is evaluating clients for risk of heparin-induced thrombocytopenia (HIT). Which client is at greatest risk for HIT, based on the nurse’s assessment?

Posted on April 20, 2022 by NCLEX.ME Nurse

a male client who just completed a 1-week course of heparin a male client taking enoxaparin for management of unstable angina a female client receiving heparin ...

Physiological Integrity—Reduction of Risk Potential

A 2-month-old infant has been brought to the ED. Which finding by the nurse would raise suspicion for shaken baby syndrome?

Posted on April 20, 2022 by NCLEX.ME Nurse

failure to track with the eyes crying without tear production bruising to the arms and shoulders greater-than-expected head circumference and bulging fontanels

Physiological Integrity—Reduction of Risk Potential

The nurse is teaching a group of student nurses about radiation therapy. Which would the nurse include in the teaching?

Posted on April 20, 2022 by NCLEX.ME Nurse

The dose is always more than the exposure. Clients receiving brachytherapy are radioactive. Clients receiving teletherapy are not radioactive. Beta particles ar...

Physiological Integrity—Reduction of Risk Potential

The nurse is caring for a client in the cardiac unit and notices the client’s rhythm changes from normal sinus rhythm to coarse ventricular fibrillation. Which is the priority nursing action?

Posted on April 20, 2022 by NCLEX.ME Nurse

call a code blue check the client and check the leads initiate CPR while waiting on help to arrive prepare to start the client on a diltiazem (Cardizem) drip cl...

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...

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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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