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 that the client can get adequate rest remind the client to call for assistance when getting out of bed
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?
“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 during my respiratory assessment.” “The client may need drug therapy and sodium restriction to treat the overload.”
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?
“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.” “I have a lot of green houseplants year-round throughout my home.”
The nurse has received shift report on the assigned client. Which client would the nurse anticipate to be at highest risk for skin breakdown?
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 and lives independently, except for driving a client with severe right-sided weakness from a stroke and residual peripheral neuropathy a client who had a right pneumothorax…
The nurse is preparing to remove a peripheral IV from a client. Which nursing action is the priority with this procedure?
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 dominant hand holding pressure on the site until hemostasis is achieved
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?
chest pain decreased appetite difficulty swallowing hematoma formation decreased pulses in the affected extremity
The nurse is preparing to perform a focused abdominal assessment on a client. Which is the correct order of this assessment?
inspection, auscultation, palpation, percussion inspection, palpation, percussion, auscultation inspection, percussion, auscultation, palpation inspection, percussion, palpation, auscultation
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?
“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’ve been so nauseated and throwing up.” “The pain is worse when I cough or move but feels better when I bend my right hip.”
The nurse is performing discharging instruction for a female client with cystitis. Which statement by the client indicates a need for further teaching?
“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 burning when I urinate, I will contact my physician.”
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?
seizures irritability restlessness disorientation severe headache nausea and vomiting