Which of the following should the nurse instruct the client to do before the test? The nurse should assess the client for which of the following late signs of overdose.
Start an intravenous infusion
The father of an 18-month-old child with no previous illness, admitted to a surgery center for repair of an inguinal hernia, tells the nurse that his child is having difficulty breathing. After the nurse tells the receptionist to call the rapid response team, the nurse should perform one of the following actions.
Assess the effectiveness of the abdominal thrusts
Perform the abdominal thrust maneuver
Listen for breath sounds
Notify the surgeon
Although the expression of empathy is appropriate, it does not help the nurse understand the client's needs and behavior. The nurse must respect the client's privacy, but this is not a primary concern for this client.
Control hemorrhaging
Assessing vital signs is an important nursing action to determine if there have been changes in the client's status. Praise encourages the client to repeat the task in the future and builds the client's self-esteem.
Replace fl uids
Because the client with ADHD is easily distracted, it is important to make eye contact before explaining the task. When the brain does not have enough glucose, the client will quickly become unconscious and, if not corrected, seizures and death can result.
Relieve the client’s anxiety
A complete explanation with verbal praise and a food reward is inappropriate because a food reward increases the chance that he will expect a physical reward for completing tasks. Although demonstration and imitation is an effective teaching method, rewarding with food promotes dependence on food reward for task completion.
Maintain a patent airway
Therefore, the nurse should specifically ask the client about food intake that contains these vitamins and minerals. The nurse should also determine whether the client received the last dose of imipenem-cilastatin. The nurse should emphasize that the client must take dexamethasone as prescribed and at the same time each day.
The nurse should assess the patient for tremors, agitation, irritability, insomnia, vomiting, sweating, tachycardia, headache, anxiety, and confusion. It does not require measuring the client's urine output and does not affect the color of the urine. When a patient urinates frequently, in small amounts, the nurse should suspect that the patient is retaining urine.
The nurse must auscultate the right lower lobe and listen when the client breathes in and out. The client received electroconvulsive therapy (ECT) an hour ago and tells the nurse that he has a headache.
Fetal monitor strip for ½ hour q shift
The staff nurse is reviewing how to manage the last 2 hours of the night shift on an antenatal unit and has the following orders and tasks to complete before 7:00 AM.
Magnesium sulfate drawn at 6 a.m
Check documentation, fi nal check of each client
The nurse should inspect which of the following areas is a potential pressure point when the client is in this position. The nurse should verify the alarm settings on the infusion pump at which of the following times. The nurse is caring for a critically ill client with the client's mother and spouse in the room.
Which of the following is a reason for the nurse to encourage women to have a Pap smear? To ensure that the nurse has correctly identified the child, she should do one of the following. Which statement by the client should tell the nurse that he needs further instruction.
Which of the following foods should the nurse teach this client to include in her diet. The nurse notifies the physician based on the interpretation that the assessment indicates which of the following.
Place the client in the supine position
A client complains of back pain 10 minutes after starting a unit of packed red blood cells (RBCs). The client's pulse, blood pressure, and respirations are stable, and similar to vital signs obtained before the RBCs are administered. A primiparous client 4 hours after a vaginal delivery and manual removal of the placental voids for the first time.
The nurse palpates the fundus, noting that it is 1 cm above the umbilicus, slightly firm, and deviated to the left side, and notes a moderate amount of lochia rubra. We don't know what to tell him." What should the nurse tell the family? A 26-year-old male client is admitted for treatment of delirium due to acute alcohol poisoning.
The nurse is monitoring a client receiving a blood transfusion when the client develops a cough with shortness of breath.
Record the highest systolic blood pressure readings in both arms
Record the ankle systolic blood pressure read- ing when the Doppler sound returns
Place a Doppler probe at a 45-degree angle to the correct pulse (dorsalis pedis or posterior
Have one of you play with it for a while, then give it to the other. The baby was seen at the clinic just three days ago for a welfare visit, and now the family seems to be very distrustful of the medical team. To prepare the parents for transfer, which of the following should the nurse include in the plan of care.
A nurse determines that the client understands the lesson material when he or she makes one of the following statements. The nurse in the postpartum unit has delegated the care of a multiparous client and her full-term neonate 4 hours postpartum to the licensed practical nurse (LPN). Which of the following findings should the LPN immediately report to the nurse?
A primigravvid client is seen for her first visit to the antenatal clinic and tells the nurse that her brother was born with cystic fibrosis (CF). When teaching the client about this disorder, the nurse should include which of the following.
Open the airway
A client was brought to the emergency department after a motor vehicle accident and he has phrenic nerve involvement. Chorionic villi sampling (CVS) can identify prenatally if their child carries the trait or has the disease.
Start an I.V. access site
Explain the situation to the family
Call the physician
Which of the following should the nurse do when the physician orders meperidine (Demerol) 50 mg I.M. Which of the following instructions should the nurse give the client in preparation for the test. Which of the following would be an appropriate diversion activity for the nurse to encourage.
The nurse should evaluate the client's response to the medication by checking for which of the following adverse effects. Before inserting the needle into a vein, the nurse should apply a tourniquet to the client's arm to accomplish which of the following. The nurse should assess the drug's therapeutic effect when the client expresses relief about which of the following.
Which of the following medications should the nurse plan to administer in the event of a heparin overdose? The nurse should assess which of the following fears is common in this age group.
Turn the client on his or her side
The nurse interprets the rhythm strip below from a client's bedside monitor as follows.
Clear the area around the client
Suction the airway
Loosen clothing around the client’s neck
Telling the client to eat breakfast and then letting the nurse know how the client is doing conveys a lack of understanding to the client and dismisses the client's concern. The nurse must assess the client continuously to determine how quickly the paralysis is progressing. The family does not need to be called for a visit until the client is stabilized and emergency equipment is placed at the bedside.
Monitoring the temperature of the bath water is important because the client cannot feel whether the water is too hot or too cold. The police must be alerted, which makes it less possible for the client to follow through on his threat. The client does not pose a threat to the ex-wife at this time and therefore does not need to be informed.
Setting the alarms to the exact drip rate will cause the alarms to go off when the client moves, and this exact range is not necessary to alert the nurse to an unsafe rate. The alarm settings on infusion pumps should be verified at the time the infusion is started, at the beginning of each shift, and when the client is moved.
The rectus femoris is a safe site for injections for infants. The site is free from most nerves and
The nurse should ask the client with multiple sclerosis about areas of muscle weakness because jogging may worsen the weakness. The nurse should also assess the client for signs of liver dysfunction, such as light-colored stools or dark-colored urine. The nurse uses active listening, in which the client's feelings are reflected back to him.
There is no need to check the client and dose for this medication with another nurse. The nurse should assess the patient's blood pressure to assess the overall circulatory response to the medication. The nurse should give the patient an analgesic and ensure that taking the medication will speed up the recovery process.
It is inappropriate to argue with a client's hallucinations because they are real to the client. The nurse does not need to replace the blood with another type of fluid because the client's reaction is not a blood transfusion reaction.
Record the ankle systolic blood pressure reading when the Doppler sound returns
Finally, the nurse should inform the family of the situation and, if appropriate, allow them to stay with the client. The nurse should call a timeout if the client is not properly identified with an identification band. The nurse should refuse to administer the medication to the client because of the risk of respiratory depression in the newborn.
The client's blood pressure will be elevated; the nurse should assess vital signs frequently. The nurse should refer the client to a social worker for assistance in enrolling in the WIC program. The nurse should teach the client and family the importance of not abruptly discontinuing benztropine.
The nurse should take the client's temperature and report the symptoms to the physician. The nurse would encourage the client to elevate the extremity above the level of the heart.
Turn the client on the side
Website: http://www.mbon.org/main.php Commonwealth of Massachusetts State Board of Nursing 239 Causeway Street. Website: http://www.mass.gov/?pageID=eohhs2subt opic&L=5&L0=Home&L1=Provider&L2=Certificate.
The Nursing Care of the Childbearing Family
The Nursing Care of Children
The Nursing Care of Adults with Medical and Surgical Health Problems
The Nursing Care of Clients with Psychiatric Disorders and Mental
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