The nurse is assessing the client with a total knee replacement 2 hours postoperative. Which information requires notification of the doctor? A. Bleeding on the dressing is 3cm in diameter. B. The client has a temperature of 100.6°F (38.1°C). C. The client’s hematocrit is 26%. D. The urinary output has been… Read More »
An elderly client with an abdominal surgery is admitted to the unit following surgery. In anticipation of complications of anesthesia and narcotic administration, the nurse should: A. Administer oxygen via nasal cannula B. Have narcan (naloxone) available C. Prepare to administer blood products D. Prepare to do cardio resuscitation … Read More »
A client with Addison’s disease has been admitted with a history of nausea and vomiting for the past 3 days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement? A. Daily weights B. Intake/output measurements C. Sodium and potassium levels monitored D. Glucometer readings… Read More »
A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurse’s next action be? A. Obtain a crash cart B. Check the calcium level C. Assess the dressing for drainage D. Assess the blood pressure for… Read More »
Molly Sue is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy. Her mother states to the nurse that it is hard to see Molly Sue with no hair. The best response for the nurse is: A. “Molly Sue looks very nice wearing a hat”. B. “You should not worry about her hair,… Read More »
A client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate action for the nurse to take? A. Call security for assistance and prepare to sedate the client. B. Tell the client to calm down and ask him if he would like to… Read More »
The client with Alzheimer’s disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting: A. Agnosia B. Apraxia C. Anomia D. Aphasia Correct Answer: A.… Read More »
The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as: A. Chronic fatigue syndrome B. Normal aging C. Sundowning D. Delusions Correct Answer: C. Sundowning Increased confusion at night is… Read More »
The client with confusion says to the nurse, “I haven’t had anything to eat all day long. When are they going to bring breakfast?” The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response would be best for the nurse to make? A. “You know… Read More »
The client is admitted to the chemical dependence unit with an order for continuous observation. The nurse is aware that the doctor has ordered continuous observation because: A. Hallucinogenic drugs create both stimulant and depressant effects. B. Hallucinogenic drugs induce a state of altered perception. C. Hallucinogenic drugs produce severe respiratory depression.… Read More »