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        • Safe and Effective Care Environment—Safety and Infection Control
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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 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

Physiological Integrity—Reduction of Risk Potential

The nurse is caring for a homeless client brought to the emergency department with a diagnosis of heat stroke. Which key features of heat stroke would the nurse expect to note upon assessment?

Posted on April 20, 2022 by NCLEX.ME Nurse

a body temperature of 104.2°F heart rate of 116 and blood pressure of 78/52 heart rate of 49 and blood pressure of 152/90 heart rate of 120 and respiratory rate...

Physiological Integrity—Reduction of Risk Potential

The nurse is caring for a client who just returned from a total hip arthroplasty. A student nurse is helping provide care for this client. Which action by the student nurse requires intervention by the nurse?

Posted on April 20, 2022 by NCLEX.ME Nurse

The student nurse floats the client’s heels with a pillow. The student nurse positions the client with the legs adducted. The student nurse applies the sequenti...

Physiological Integrity—Reduction of Risk Potential

The nurse is assessing a client with a stage 3 pressure ulcer. Which finding is consistent with this type of pressure ulcer?

Posted on April 20, 2022 by NCLEX.ME Nurse

Eschar is present on at least part of the wound. Full-thickness skin loss is present with undermining. Partial-thickness skin loss of the epidermis is present. ...

Physiological Integrity—Reduction of Risk Potential

The nurse is assessing a client with a diagnosis of chronic obstructive pulmonary disease (COPD) exacerbation. Which finding would be expected for this client?

Posted on April 20, 2022 by NCLEX.ME Nurse

hypoxemia and hypocarbia hyperoxemia and hypocarbia hypoxemia and hypercarbia hyperoxemia and hypercarbia

Physiological Integrity—Reduction of Risk Potential

The nurse is caring for a client with seizure disorder. Which statement regarding seizure precautions is correct?

Posted on April 20, 2022 by NCLEX.ME Nurse

Padded tongue blades should be at the bedside. Oxygen and suctioning should be at the bedside. Padding bed rails with blankets can help prevent injury. Restrain...

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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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