On the client’s right side
On the client’s left side
Directly in front of the client
Where the client like
Check respiration, circulation, neurological response.
Align the spine, check pupils, and check for hemorrhage.
Check respirations, stabilize spine, and check circulation.
Assess level of consciousness and circulation.
Increasing contractility and slowing heart rate.
Increasing AV conduction and heart rate.
Decreasing contractility and oxygen consumption.
Decreasing venous return through vasodilation.
Call for help and note the time.
Clear the airway
Give two sharp thumps to the precordium, and check the pulse.
Administer two quick blows.
Plan care so the client can receive 8 hours of uninterrupted sleep each night.
Monitor vital signs every 2 hours.
Make sure that the client takes food and medications at prescribed intervals.
Provide milk every 2 to 3 hours.
Stop the I.V. infusion of heparin and notify the physician.
Continue treatment as ordered.
Expect the warfarin to increase the PTT.
Increase the dosage, because the level is lower than normal.
24 hours later, when edema has subsided.
In the operating room.
After the ileostomy begin to function.
When the client is able to begin self-care procedures.
On the side, to prevent obstruction of airway by tongue.
Flat on back.
On the back, with knees flexed 15 degrees.
Flat on the stomach, with the head turned to the side.
Blood pressure is decreased from 160/90 to 110/70.
Pulse is increased from 87 to 95, with an occasional skipped beat.
The client is oriented when aroused from sleep, and goes back to sleep immediately.
The client refuses dinner because of anorexia.
Altered mental status and dehydration
Fever and chills
Hemoptysis and Dyspnea
Pleuritic chest pain and cough
Chest and lower back pain
Chills, fever, night sweats, and hemoptysis
Fever of more than 104°F (40°C) and nausea
Headache and photophobia
Chronic obstructive pulmonary disease (COPD)
Wake up on his own
Increased elastic recoil of the lungs
Increased number of functional capillaries in the alveoli
Decreased residual volume
Decreased vital capacity
Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter.
Increase in systemic blood pressure.
Presence of premature ventricular contractions (PVCs) on a cardiac monitor.
Increase in intracranial pressure (ICP).
Report incidents of diarrhea.
Avoid foods high in vitamin K
Use a straight razor when shaving.
Take aspirin to pain relief.
Leaving the hair intact
Shaving the area
Clipping the hair in the area
Removing the hair with a depilatory.
Loss of estrogen
Negative calcium balance
Areas of thickness or fullness
Changes from previous examinations.
Provide extra blankets and clothing to keep the client warm.
Monitor the client for signs of restlessness, sweating, and excessive weight loss during thyroid replacement therapy.
Balance the client’s periods of activity and rest.
Encourage the client to be active to prevent constipation.
Avoid focusing on his weight.
Increase his activity level.
Follow a regular diet.
Continue leading a high-stress lifestyle.
Avoid lifting objects weighing more than 5 lb (2.25 kg).
Lie on your abdomen when in bed
Keep rooms brightly lit.
Avoiding straining during bowel movement or bending at the waist.
When sexual activity starts
After age 69
After age 40
Before age 20.
Call the physician
Place a saline-soaked sterile dressing on the wound.
Take a blood pressure and pulse.
Pull the dehiscence closed.
A progressively deeper breaths followed by shallower breaths with apneic periods.
Rapid, deep breathing with abrupt pauses between each breath.
Rapid, deep breathing and irregular breathing without pauses.
Shallow breathing with an increased respiratory rate.
The attack is over.
The airways are so swollen that no air cannot get through.
The swelling has decreased.
Crackles have replaced wheezes.
Place the client on his back remove dangerous objects, and insert a bite block.
Place the client on his side, remove dangerous objects, and insert a bite block.
Place the client o his back, remove dangerous objects, and hold down his arms.
Place the client on his side, remove dangerous objects, and protect his head.
Infection of the lung.
Kinked or obstructed chest tube
Excessive water in the water-seal chamber
Excessive chest tube drainage
Stand him up and perform the abdominal thrust maneuver from behind.
Lay him down, straddle him, and perform the abdominal thrust maneuver.
Leave him to get assistance
Stay with him but not intervene at this time.
General health for the last 10 years.
Current health promotion activities.
Family history of diseases.
Apply lemon glycerin to the client’s lips at least every 2 hours.
Brush the teeth with client lying supine.
Place the client in a side lying position, with the head of the bed lowered.
Clean the client’s mouth with hydrogen peroxide.
Adult respiratory distress syndrome (ARDS)
Myocardial infarction (MI)
A 16-year-old female high school student
A 33-year-old day-care worker
A 43-year-old homeless man with a history of alcoholism
A 54-year-old businessman
To confirm the diagnosis
To determine if a repeat skin test is needed
To determine the extent of lesions
To determine if this is a primary or secondary infection
Adult respiratory distress syndrome (ARDS)
Chronic obstructive bronchitis
The patient is under local anesthesia during the procedure
The aspirated bone marrow is mixed with heparin.
The aspiration site is the posterior or anterior iliac crest.
The recipient receives cyclophosphamide (Cytoxan) for 4 consecutive days before the procedure.
Call the physician
Document the patient’s status in his charts.
Prepare oxygen treatment
Raise the side rails
Crowd red blood cells
Are not responsible for the anemia.
Uses nutrients from other cells
Have an abnormally short life span of cells.
Predominance of lymhoblasts
Abnormal blast cells in the bone marrow
Elevated thrombocyte counts
Explain the risks of not having the surgery
Notifying the physician immediately
Notifying the nursing supervisor
Recording the client’s refusal in the nurses’ notes
The 58-year-old client who was admitted 2 days ago with heart failure, blood pressure of 126/76 mm Hg, and a respiratory rate of 22 breaths/minute.
The 89-year-old client with end-stage right-sided heart failure, blood pressure of 78/50 mm Hg, and a “do not resuscitate” order
The 62-year-old client who was admitted 1 day ago with thrombophlebitis and is receiving L.V. heparin
The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving L.V. dilitiazem (Cardizem)
Eversion of the right nipple and mobile mass
Nonmobile mass with irregular edges
Mobile mass that is soft and easily delineated
Nonpalpable right axillary lymph nodes
No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis
Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis
Can't assess tumor or regional lymph nodes and no evidence of metastasis
Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis
"Keep the stoma uncovered."
"Keep the stoma dry."
"Have a family member perform stoma care initially until you get used to the procedure."
"Keep the stoma moist."
Colon and rectal cancer
Miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face.
Chest pain, dyspnea, cough, weight loss, and fever.
Arm and shoulder pain and atrophy of arm and hand muscles, both on the affected side.
Hoarseness and dysphagia.
Prostate-specific antigen, which is used to screen for prostate cancer.
Protein serum antigen, which is used to determine protein levels.
Pneumococcal strep antigen, which is a bacteria that causes pneumonia.
Papanicolaou-specific antigen, which is used to screen for cervical cancer.
"Avoid drinking liquids until the gag reflex returns."
"Avoid eating milk products for 24 hours."
"Notify a nurse if you experience blood in your urine."
"Remain supine for the time specified by the physician."
Carcinoembryonic antigen (CEA)
Abdominal computed tomography (CT) scan
Slight asymmetry of the breasts.
A fixed nodular mass with dimpling of the overlying skin
Bloody discharge from the nipple
Multiple firm, round, freely movable masses that change with the menstrual cycle
White blood cells (WBCs)
The client lies still.
The client asks questions.
The client hears thumping sounds.
The client wears a watch and wedding band.
Obtaining an X-ray of the bones every 3 years is recommended to detect bone loss.
To avoid fractures, the client should avoid strenuous exercise.
The recommended daily allowance of calcium may be found in a wide variety of foods.
Obtaining the recommended daily allowance of calcium requires taking a calcium supplement.
Joint flexion of less than 50%
Elbow contracture secondary to spasticity
Loss of muscle contraction decreasing venous return
Deep vein thrombosis (DVT) due to immobility of the ipsilateral side
Hypoalbuminemia due to protein escaping from an inflamed glomerulus
It appears only in men
It appears on the distal interphalangeal joint
It appears on the proximal interphalangeal joint
It appears on the dorsolateral aspect of the interphalangeal joint.
Osteoarthritis is gender-specific, rheumatoid arthritis isn’t
Osteoarthritis is a localized disease rheumatoid arthritis is systemic
Osteoarthritis is a systemic disease, rheumatoid arthritis is localized
Osteoarthritis has dislocations and subluxations, rheumatoid arthritis doesn’t
A walker is a better choice than a cane.
The cane should be used on the affected side
The cane should be used on the unaffected side
A client with osteoarthritis should be encouraged to ambulate without the cane
9 U regular insulin and 21 U neutral protamine Hagedorn (NPH).
21 U regular insulin and 9 U NPH.
10 U regular insulin and 20 U NPH.
20 U regular insulin and 10 U NPH.
Calcium gluconate (Kalcinate)
They contain exudate and provide a moist wound environment.
They protect the wound from mechanical trauma and promote healing.
They debride the wound and promote healing by secondary intention.
They prevent the entrance of microorganisms and minimize wound discomfort.
Reduced blood urea nitrogen (BUN)
Infusing I.V. fluids rapidly as ordered
Encouraging increased oral intake
Administering glucose-containing I.V. fluids as ordered
Urine glucose level.
Fasting blood glucose level.
Serum fructosamine level.
Glycosylated hemoglobin level.
Glucocorticoids and androgens
Catecholamines and epinephrine
Mineralocorticoids and catecholamines
Norepinephrine and epinephrine
Acid phosphatase level
Serum calcitonin level
Alkaline phosphatase level
Carcinoembryonic antigen level
Nights sweats, weight loss, and diarrhea
Dyspnea, tachycardia, and pallor
Nausea, vomiting, and anorexia
Itching, rash, and jaundice
The baby can get the virus from my placenta."
"I'm planning on starting on birth control pills."
"Not everyone who has the virus gives birth to a baby who has the virus."
"I'll need to have a C-section if I become pregnant and have a baby."
"Put on disposable gloves before bathing."
"Sterilize all plates and utensils in boiling water."
"Avoid sharing such articles as toothbrushes and razors."
"Avoid eating foods from serving dishes shared by other family members."
Pallor, bradycardia, and reduced pulse pressure
Pallor, tachycardia, and a sore tongue
Sore tongue, dyspnea, and weight gain
Angina, double vision, and anorexia
Page an anesthesiologist immediately and prepare to intubate the client.
Administer epinephrine, as prescribed, and prepare to intubate the client if necessary.
Administer the antidote for penicillin, as prescribed, and continue to monitor the client's vital signs.
Insert an indwelling urinary catheter and begin to infuse I.V. fluids as ordered.
Fine motor tremors.
Bilateral hearing loss.
Enzyme-linked immunosuppressant assay (ELISA) test.
Electrolyte panel and hemogram.
Stool for Clostridium difficile test.
Flat plate X-ray of the abdomen.
Quantification of T-lymphocytes.
Enzyme-linked immunosorbent assay (ELISA).
Western blot test with ELISA.
Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN) and creatinine levels
Low levels of urine constituents normally excreted in the urine
Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
Electrolyte imbalance that could affect the blood's ability to coagulate properly
Platelet count, prothrombin time, and partial thromboplastin time
Platelet count, blood glucose levels, and white blood cell (WBC) count
Thrombin time, calcium levels, and potassium levels
Fibrinogen level, WBC, and platelet count
A client with hepatitis A who states, “My arms and legs are itching.”
A client with cast on the right leg who states, “I have a funny feeling in my right leg.”
A client with osteomyelitis of the spine who states, “I am so nauseous that I can’t eat.”
A client with rheumatoid arthritis who states, “I am having trouble sleeping.”
A 35-year-old admitted three hours ago with a gunshot wound; 1.5 cm area of dark drainage noted on the dressing.
A 43-year-old who had a mastectomy two days ago; 23 ml of serosanguinous fluid noted in the Jackson-Pratt drain.
A 59-year-old with a collapsed lung due to an accident; no drainage noted in the previous eight hours.
A 62-year-old who had an abdominal-perineal resection three days ago; client complaints of chills.
Blood pressure 138/82, respirations 16, oral temperature 99 degrees Fahrenheit.
The client supports his head and neck when turning his head to the right.
The client spontaneously flexes his wrist when the blood pressure is obtained.
The client is drowsy and complains of sore throat.
Encourage the client to change positions frequently in bed.
Administer Demerol 50 mg IM q 4 hours and PRN.
Apply warmth to the abdomen with a heating pad.
Use comfort measures and pillows to position the client.
Assess for a bruit and a thrill.
Warm the dialysate solution.
Position the client on the left side.
Insert a Foley catheter
The client holds the cane with his right hand, moves the can forward followed by the right leg, and then moves the left leg.
The client holds the cane with his right hand, moves the cane forward followed by his left leg, and then moves the right leg.
The client holds the cane with his left hand, moves the cane forward followed by the right leg, and then moves the left leg.
The client holds the cane with his left hand, moves the cane forward followed by his left leg, and then moves the right leg.
Ask the woman’s family to provide personal items such as photos or mementos.
Select a room with a bed by the door so the woman can look down the hall.
Suggest the woman eat her meals in the room with her roommate.
Encourage the woman to ambulate in the halls twice a day.
The client slowly pushes the walker forward 12 inches, then takes small steps forward while leaning on the walker.
The client lifts the walker, moves it forward 10 inches, and then takes several small steps forward.
The client supports his weight on the walker while advancing it forward, then takes small steps while balancing on the walker.
The client slides the walker 18 inches forward, then takes small steps while holding onto the walker for balance.
Increased sensitivity to the side effects of medications.
Decreased visual, auditory, and gustatory abilities.
Isolation from their families and familiar surroundings.
Decrease musculoskeletal function and mobility.
Encourage the client to perform pursed lip breathing.
Check the client’s temperature.
Assess the client’s potassium level.
Increase the client’s oxygen flow rate.