a client awaiting a bed on the medical floor a client receiving continuous renal replacement therapy (CRRT) a client on an insulin drip with a large abdominal wound attached to a wound vacuum a client who has just returned from surgery to replace pacemaker wires and is being externally paced
A nurse has received report on the day’s clients. In planning morning rounds, which client is the priority to see?
a new admission with a UTI and fever a client who is NPO for surgery later in the morning a client complaining of nausea after eating breakfast a client recently complaining of shortness of breath
The nurse is teaching a female client who is experiencing urge incontinence how to manage her condition at home. Which statement by the client indicates a need for further explanation by the nurse?
“I will be cured in four weeks if I follow the bladder retraining instructions.” “I will perform the pelvic muscle exercises daily.” “I will wait five minutes once I get the urge to urinate to go to the bathroom.” “I will empty my bladder when I first get up in the morning.”
A 22-year-old female primigravida who is at 36 weeks’ gestation is seen in the ED with a low platelet count, ALT of 68 U/L, AST of 55 U/L, and a continuous, severe headache that has lasted three days. The nurse prepares for what to occur?
amniocentesis ultrasound of the baby delivery of the baby C-section
The nurse is assessing a client at home who is receiving outpatient hemodialysis 12 hours a week. The nurse knows the client needs further instruction about proper diet when he states which of the following?
“I drink prune juice when I’m constipated.” “I drink ginger ale with lunch.” “I drink 1 cup of milk with my dinner.” “My bread choice is white rather than whole grain.”
A nursing student is assigned to a client with an endotracheal tube on a ventilator. Upon entering the client’s room the primary care nurse is alerted by observing which of the following?
The head of the bed is elevated 45 degrees. The cuff on the endotracheal tube is inflated. Normal saline is present at the bedside table. The client is wearing an intermittent compression device on each leg.
The nurse is caring for a client who just had a supratentorial craniotomy to remove a tumor. The nurse will implement which of the following in the client’s plan of care? Select all that apply.
check the dressing every 8 hours for excessive drainage assess the pupils for signs of increased intracranial pressure position the client flat with the head rotated away from the surgical site monitor the client’s respiratory status, including rate and pattern of breathing notify the health care provider if the dressing is saturated or the client…
The nurse is talking to a client and his family about hepatitis. Which of the following statements by a family member indicate understanding of the nurse’s teaching? Select all that apply.
“Hepatitis D only occurs with hepatitis B.” “Hepatitis A can occur at any time of the year.” “Hepatitis D is transmitted through contaminated drinking water.” “Hepatitis A can be spread by uncooked shellfish and contaminated water or milk.” “Hepatitis B is spread by contact with blood or body fluids, sexual contact, or sharing dirty needles.”
The nurse is monitoring the labs of a client admitted with viral hepatitis. Which of the following lab findings would the nurse expect for this client? Select all that apply.
decreased ALT levels increased AST levels elevated ammonia levels low serum albumin levels shortened prothrombin time