To facilitate healing of the surgical area, a nasogastric tube may be utilized and tube feedings may be implemented.
The client will be unable to maintain any oral intake as long as the tracheotomy is in place.
Nutritional and/or gastric feedings will not be attempted for approximately 3 weeks to decrease the incidence of aspiration.
Because the client is dependent on the ventilator, nutritional intake will be delayed.
Dexamethasone suppression test.
Drug toxicology screen.
Glasgow coma scale.
Client thinking pattern.
Occurrence of hallucinations.
The client has edema of the lower extremities.
Physical exam of the client reveals the presence of lanugo.
The client has ulcerated mucous membranes of the mouth.
The client has dry, yellowish color of the skin.
Evaluate the urine output.
Obtain the client’s weight.
Determine the patency of the IV line.
Measure pulmonary artery pressures.
The nursing assistant answers the phone while wearing gloves.
The nursing assistant log rolls the patient to provide back care.
The nursing assistant places an incontinent pad under the patient.
The nursing assistant positions the patient on the left side, head elevated.
Sore throat, fever, increased fatigue, vomiting, diarrhea.
Dry mouth, nasal stuffiness, weight gain.
Rapid heartbeat, frequent headaches, yellowing of eyes or skin.
Weakness, staggering gait, tremor, feeling of drunkenness.
A patient post coronary artery bypass graft (CABG) having the atrioventricular (AV) wires removed later in the day.
A patient with type 1 diabetes scheduled for a cardiac catheterization later today.
A patient 1 day postoperative with an epidural catheter in place.
A patient diagnosed with cardiomyopathy being evaluated for a heart transplant.
Check the radial pulses bilaterally and compare.
Evaluate the skin temperature and tissue turgor in the area.
Assess sensation of each foot while the child closes her eyes.
Apply baby powder to decrease skin irritation under the cast.
Perform a straight catheterization.
Offer the client the bedpan.
Put the baby to breast.
Massage the uterine fundus.
A small amount of white mucus is aspirated from the NG tube.
The contents aspirated from the NG tube have a pH of 3.
No bubbles are seen when the nurse inverts the NG tube in water.
The client says he can feel the NG tube in the back of his throat.
Client is in the supine position.
The head of the bed is elevated 30 degrees.
The client is lying on the right side.
An eye shield is over the right eye.
Risk for constipation related to immobilization.
Risk for impaired skin integrity related to immobilization and secretions.
Risk for wound infection related to involuntary bowel secretions.
Risk for fluid volume excess related to secretions.
Promote ventilation and prevent respiratory acidosis.
Increase oxygenation and removal of secretions.
Increase pH and facilitate balance of bicarbonate.
Prevent respiratory alkalosis by increasing oxygenation.
Death is punishment for his/her actions.
Death is inevitable and irreversible.
Death is temporary and gradual.
Death as a concept based on past experience.
"It is best to buy new shoes in the morning."
"Have each foot measured every time you buy new shoes."
"Buy shoes a half-size larger than your foot size so the fit is roomy."
"Buy vinyl shoes because they won’t lose their shape easily."
Petal the edges of the cast to prevent irritation.
Elevate the client’s left arm on two pillows.
Apply cool, humidified air to dry the cast.
Ask the client to move the fingers to maintain mobility.
Direct the LPN/LVN to obtain the child’s vital signs.
Ask the mother if the child’s sutures are still intact.
Tell the nursing assistant to take the child for a walk.
Check to see when the child last received pain medication.
High protein, high fat, and high calories.
High protein, low fat, and high calories.
Low protein, low fat, and low carbohydrate.
High protein, high fat, and low carbohydrate.
these tests are valuable screening tests for prostatic cancer.
the level of PSA is decreased in clients with renal stones.
the tests reflect the level of renal involvement in acid-base problems.
the level of PSA is elevated in clients in early-stage renal failure.
Apply warm soaks to the infiltration site, start a new IV, and continue IV medications.
Wait 2 hours, reassess the client, and restart the IV if the client has wheezing or labored breathing.
Restart the IV and continue the previous medication schedule.
Call the physician and recommend that the IV medications be changed to PO.
Provide adequate hygiene and nutrition.
Decrease environmental stimuli.
Slowly involve the client in unit activities.
Administer and monitor sedative and mood-stabilizing medications.
"I have been having difficulty with my hearing."
"I lose my balance easily."
"I can't tell the difference between a sweet and sour taste."
"It is not easy for me to remember names and faces."
A fat-free meal the evening before the examination and radiopaque tablets at bedtime.
Placement of a retention urinary catheter to facilitate dilation of the bladder sphincter.
Cleansing enemas the evening before to provide for adequate visualization of the urinary tract.
Explaining the importance of following directions regarding voiding during the test.
Anger and frustration.
Awareness of vulnerability.
Increased social isolation.
Increased sensory stimulation.
"Your hair will be carefully washed prior to the procedure."
"This is a noninvasive procedure that takes about 30 minutes."
"A sedative will be given to you shortly before the procedure."
"You will not be allowed to eat 4 to 6 hours before the procedure."
The baby is Rh-negative, the mother is Rh-negative, and the father is Rh-positive.
The mother is Rh-negative, the baby is Rh-positive, and there is a negative direct Coombs.
The mother is Rh-positive and previously sensitized, and the baby is Rh-negative.
The mother is Rh-positive, the baby is Rh-negative, and there is a history of one incomplete pregnancy.
The client puts the right leg on the step, then the cane, followed by the left leg.
The client leads with the cane, followed by the right leg and then the left leg.
The client advances the right leg, followed by the left leg and the cane.
The client puts the cane on the step and advances the left leg, followed by the right leg.
A patient at 16 weeks’ gestation admitted with hyperemesis and receiving IV fluids.
A patient at 26 weeks’ gestation in premature labor and receiving terbutaline (Brethine).
A patient at 32 weeks’ gestation with a placenta previa and ruptured membranes.
A patient at 37 weeks’ gestation with pregnancy-induced hypertension and epigastric pain.
failure to thrive.
fluid volume deficit.
altered health maintenance.
A bulge in the lower right quadrant.
Pain at the umbilicus radiating down into the groin.
A burning sensation in the midepigastric area each day before lunch.
Complaints of awakening at night with heartburn.
apical pulse for 60 seconds.
A 20-year-old in traction for multiple fractures of the left lower leg.
A 35-year-old with recurrent fever of unknown origin.
A 50-year-old recovering alcoholic with cellulitis of the right foot.
An 89-year-old with Alzheimer’s disease awaiting nursing home placement.
Assessment of ADL (self-care) ability.
Mini-Mental Status Examination (MMSE).
Abnormal Involuntary Movement Scale (AIMS).
Modified Overt Aggression Scale (MOAS).
Decreased respiratory rate and bradycardia.
Normal blood pressure and pulse.
Increased respiratory rate and tachycardia.
Diaphoresis with cool, clammy skin.
Pattern of alternating diarrhea and constipation.
Chronic diarrhea stools occurring 10 to 12 times per day.
Diarrhea and vomiting with severe abdominal distention.
Bloody stools with increased cramping after eating.
Assess drainage from Penrose drains.
Observe dressings for signs of excessive bleeding.
Elevate the stump for no less than 40 hours.
Provide cast care on the affected extremity.
Minimizes the bacterial count in the mouth.
Softens the mucous membranes of the tongue before surgery.
Stimulates the microcirculation of the mouth.
Hydrates the tissues of the gums.
The boy plays with a large truck with another child.
The boy talks on a toy telephone and imitates his father.
The boy works on a puzzle with several other children.
The boy holds and cuddles a large stuffed animal.
"If you are having a ‘bad’ day, postpone your exercises until the next day."
"Passive exercises are better for you than active exercises."
"When inflammation is severe, decrease the number of repetitions of the exercise."
"You can substitute your normal household tasks for your exercises to provide variety."
Measure both limbs with the tape measure and compare.
Depress the skin and rank the degree of pitting.
Describe the swelling in the affected area.
Pinch the skin and note how quickly it returns to normal.
Two doses of diphtheria, tetanus, and pertussis vaccine.
Measles, mumps, and rubella vaccines.
A booster dose of the inactivated polio vaccine.
Chickenpox and smallpox vaccines.
Take the medication with milk or antacids to decrease GI problems.
The medication should always be taken with meals.
Use a maximum-protection sunscreen when outdoors.
Crackers and juice will help decrease gastric irritation.
A reaction to the sedative medication.
A worsening course of the withdrawal syndrome.
An exacerbation of the schizophrenia process.
The process of aging and the effects of delirium.
Intolerance to heat.
Intolerance to cold.
The patient is anxious and restless.
There is a small amount of dark drainage on the dressing.
The patient complains of persistent pain at the operative site.
The skin is cool above the operative site.
"I love my family with all my heart, even though they don’t love me."
"I was unable to take my final exams because I was unable to write."
"I don’t believe I have diabetes. I feel perfectly fine."
"If my wife was a better housekeeper I wouldn’t have such a problem."
The client draws up the regular insulin first, then the NPH.
The client gently rotates the insulin bottle before withdrawing the dose.
The client rotates injection sites following the guide on the printed diagram.
The client administers the insulin while it is still cold from the refrigerator.
Administer the medication slowly, at 20 to 25 cc/h.
Change the primary IV solution.
Hang the piggyback infusion bag higher than the primary infusion bag.
Obtain an infusion pump prior to administration.
A nurse and client wear masks during a dressing change for the central catheter used for total parenteral nutrition.
A nurse injects insulin through a single-lumen percutaneous central catheter for a client receiving total parenteral nutrition.
A nurse applies lip balm to his/her lips immediately after performing a blood draw to obtain a specimen.
A nurse wears a disposable particulate respirator when administering rifampin to a client with tuberculosis.
Control of other people.
Avoid severe levels of anxiety.
Express and manage anxiety.
Obtain daily weights and evaluate weight loss.
Observe the infant’s ability to take in fluids.
Place a full bottle of Pedi-Lyte at the bedside.
Start an intravenous infusion.
Sensation loss in an upper extremity.
Clonic jerks in the affected foot.
Paresthesia in the affected leg.
Chorea in the upper and lower extremities.
The urinary output is increased.
Bright-red drainage or clots are present.
Dark-brown drainage is present.
The client complains of pain.
A client with bipolar disorder walks into the day room in her underwear and begins dancing.
A client with depression says to the nurse, "My plan is complete, and I’m ready to go for it."
A client recovering from substance abuse complains that another client is harassing him.
A client with schizophrenia tells the nurse that it’s "God’s will" that he destroy the "evil TV."
Decrease the IV rate to 20 mL/h and notify the physician.
Decrease the IV rate to 100 mL/h and continue to monitor the client.
Discontinue the IV and start oxygen at 6 L/min.
Assess for infiltration of the IV solution.
Hemiplegia, hypertension, tachycardia.
Respiratory failure, flaccid paralysis, urinary retention.
Peripheral edema, hypertension, pulmonary congestion.
Diminished reflexes, pain, paresthesia.
Hold the medication and count the respirations.
Hold the medication and call the physician.
Take an apical pulse and then give the medication.
Give the mediation as ordered.
Sensory–perceptual alterations: visual.
Altered thought processes.
Ineffective individual coping.
Impaired social interaction.
A client with AIDS dementia complex who requires a urine specimen.
A client complaining of postoperative pain after repair of a torn rotator cuff.
A client with GI bleeding due to a duodenal ulcer who is receiving packed cells.
A client with type 1 diabetes receiving prednisone for a herniated disk.
a slowing early in the contraction, and is usually a normal finding.
a slowing early in the contraction, and is usually an abnormal finding.
a slowing at the peak of the contraction, and is usually a normal finding.
a slowing at the peak of the contraction, and is usually an abnormal finding.
"The test involves x-ray examination of the entire spinal column to determine the extent of myelin breakdown."
"The test involves injection of a contrast medium into a suspected ruptured vertebral disk, allowing radiographic visualization of the disk."
"The test involves a lumbar puncture with injection of contrast medium, allowing x-ray visualization of the vertebral canal."
"The test involves x-ray examination of the vertebral column following injection of air into the subarachnoid space."
Recommend that the physician decrease the client’s medication dosage.
Recommend that the treatment team reevaluate the client’s treatment plan.
Give the client privileges to walk around the hospital by himself.
Ask the family to begin planning for the client’s discharge.
"What part of the body was affected by the seizure?"
"What is the family history of seizure disorders?"
"What was your son doing before the seizure?"
"How long has it been since his last episode of seizures?"
Avoid strenuous activity.
Eat more foods with increased bulk.
Decrease fluid intake to decrease urinary losses.
Use oral laxatives so that a bowel pattern emerges.
The patient complains of acute pain from a partial-thickness burn affecting the lower left leg.
The patient’s blood pressure is 140/90, pulse is 90, and respiration is 28.
The patient’s level of consciousness fluctuates from alert to lethargic.
The patient exhibits restlessness, anxiety, and cold, clammy skin.
Gives isoniazid (INH) to a client with tuberculosis.
Administers an IM injection to a client with rubella.
Delivers a food tray to a client with hepatitis.
Changes the dressing for a client with a draining abscess.
Hand-washing represents an attempt to manipulate the environment to make it more comfortable.
Hand-washing externalizes the anxiety from a source within the body to an acceptable substitute outside the body.
Hand-washing helps the client avoid undesirable thoughts and maintain some control over guilt and anxiety.
Hand-washing helps maintain the client in an active state to resist the effects of depression.
With the affected hip internally rotated and flexed.
With the affected hip adducted when turned.
In the supine position with the knees elevated 90 degrees.
Side-lying with the affected hip in a position of abduction.
Describe the procedure to the child in short, concrete terms while talking calmly.
Allow the child to play with the equipment during the procedure.
Involve the girl’s older sister in explaining the procedure.
Show the child a diagram of the urinary system.
Guarantees secure placement of the tracheostomy tube in the airway.
Prevents ischemia of the tracheal wall by distributing the pressure applied to it.
Decreases the chance of aspiration into the trachea.
Protects the trachea from ischemia and edema.
Disruption in short- and long-term memory.
Transient confusional state.
Tonic neck reflex.
Give the digoxin.
Hold the digoxin.
Notify the physician.
Recheck the pulse.
Test the client’s deep tendon reflexes to observe for weakness.
Check the client’s pupils with a penlight and observe for constriction.
Have the client stand with eyes closed and observe for swaying.
Ask the client to show her teeth and stick out her tongue.
Place the client in soft hand restraints or chair restraints.
Monitor wandering behaviors during a 7-day period.
Keep the lounge’s television volume on a low level.
Encourage a diet high in protein, iron, and vitamins.
view her appearance as "skinny."
be hypoactive and withdrawn.
want to talk about and plan her meals.
have a close relationship with her mother.
There is swelling under the sutures.
There is crusting around the incision line.
The incision line is red.
The incision line is approximated.
Teach new skills for adjusting to the aging process.
Adjust the environment to meet the client’s individual needs.
Encourage competitive activities to keep the client physically strong.
Provide unstructured activities with frequent changes to increase stimulation.
A client receiving a blood transfusion who complains of a dry mouth.
A client is scheduled to receive heparin and the PTT is 70 seconds.
A client is receiving ciprofloxacin (Cipro) and complains of a fine macular rash.
A client is receiving IV potassium and complains of burning at the IV site.
Rinse the bag and change the formula every 4 hours.
Rinse the bag and change the formula every shift.
Change the bag and formula every shift.
Rinse the bag and change the formula every 2 hours.
Increase during pregnancy and decrease after delivery.
Decrease during pregnancy and increase after delivery.
Increase during pregnancy and remain increased after delivery.
Decrease during pregnancy and fluctuate after delivery.
"Gastric ulcers have an increased association with clients who experience increased psychological pressures."
"The pain of a duodenal ulcer usually occurs 2 to 4 hours after meals."
"Clients with gastric ulcers often gain weight, as food alleviates the pain."
"Antacids such as Maalox are seldom prescribed for clients with duodenal ulcers."
"Are you afraid of dying?"
"Why do you ask that question?"
"Only God knows that answer."
"We won’t leave you alone."
"My son may have dizziness for 24 hours."
"My son can drink carbonated beverages if he vomits."
"My son may complain of nausea."
"My son will probably have a headache."
Allow the patient to use the phone.
Confront the patient about his anger and inappropriate plan of action.
Do not allow the patient to use the phone because he is an involuntary patient.
Set limits on the patient’s phone use because he has been unable to control his behavior.
Record the observation.
Encourage the child to move the foot.
Cover the colder foot with a sock.
Notify the physician.
Acetone odor to the breath, polyuria, and flushed skin.
Irritability, tachycardia, and diaphoresis.
Headache, nervousness, and polydipsia.
Tenseness, tachycardia, and anorexia.
Encourage the client not to do anything without thinking it through very carefully.
Explain to the client that anything she tells the nurse is kept strictly confidential.
Report this to staff members in order to protect the client.
Encourage the client to tell the nurse more about what she is feeling.
"Pull up on the overhead trapeze while you push down on your right foot to lift your body."
"With your right arm, grasp the bedside rail on the opposite side and pull yourself over gently."
"I’ll raise the head of the bed 45 degrees, and then you lean forward and rotate your hips to the left."
"Swing your right leg over your left leg and turn from your waist down, keeping your legs straight."
1 year old.
2 years old.
3 years old.
5 years old.
A pregnant woman who states that her clothing is wet.
A young man with blood pulsating from a cut on the right leg.
A preschool child who is screaming and crying uncontrollably.
An unconscious woman with the right leg shorter than the left leg.