Which of the following statements by the parent indicates a need for further teaching? The nurse is assisting in the transport of a client with an indwelling catheter to the diagnostic studies unit. =Pain of 9/10 an hour after a dose of morphine = Pain of 9/10 an hour after a dose of morphine The nurse is obligated to make a report for which situations? A nurse is collecting data from a child who is descending stairs by placing both feet on each step and holding on to the railing. The primary care provider orders a computed tomography (CT) examination of the chest. A family member with a mild upper respiratory infection comes to visit a client in a long-term care facility. use of antibiotics in clients with viral infection. A nurse is assessing a toddler who has suspected lead poisoning. Preoperative Nursing Assessment A comprehensive preoperative nursing assessment of the total hip patient is important in helping to achieve a positive outcome. What information should the nurse provide the client and family regarding the use of an EEG? With what score can the patient be transferred out of the recovery room? A nurse is required to document the neurologic assessment of a client with recent head trauma. Which statements made by the client demonstrates the education provided was effective? Correct- Young children often have a vigorous immune response to infection and thus high fevers. A client with nausea and vomiting is to receive an antiemetic that inhibits the vomiting center in the brain. A nurse is caring for a client, age 4 months, following surgical repair of a tracheoesophageal fistula. During a teaching session, the nurse appropriately recommends that the pouch be emptied Correct Answer: when it is 1/3 to 1/2 full Rationale: If the pouch becomes more than half full it may separate from the flange 5. Select all that apply. If the transection is complete all sensation and voluntary movements below the site of injury are lost. A postoperative client is moving from the bed to a chair when blood drips from the dressing. "Limit contact with large groups of people." c. "Avoid taking over-the-counter calcium supplements." d. "Follow a low-protein diet." ; b. Line the surface of the wheelchair or stretcher with a clean sheet or bath blanket to protect the surface from direct client contact. To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes: Nursing students are reviewing information about agents used for anesthesia. See Lumbar Puncture previously mentioned. When planning this client's care, the nurse should assign the highest priority to which nursing diagnosis? When should the client stop taking the aspirin before the surgery? The nurse is providing postoperative care to a client with lung cancer who had a partial pneumonectomy. Which is the function of the myelin sheath around an axon? Assume the variables x = 5, y = 6, and z = 8. A nurse is implementing the principles of surgical asepsis while inserting a client's indwelling urinary catheter. A nurse is reviewing the charts of clients in the hospital ward and knows that airborne precautions are required for which of the following? Treat the problem as two-dimensional. How many feet must be maintained between this client and other noninfected clients and visitors? **Complete the medical term, based on its meaning as provided. The nurse has administered the preanesthetic as ordered. Which of the following would be appropriate for the nurse to include in the teaching plan? Carefully open the inner package taking care not to touch the inner surface of the package or the gloves. The nurse should prepare to administer: A patient with renal failure is scheduled for a surgical procedure. A nurse is caring for a child who has otitis media with effusion. 4. Cephalgia (Headache) is one of the most common symptoms of a neurologic disorder. The nurse is caring for an older adult with influenza. Describe the indicated assessment and interventions related to each problem as listed in the questions below . What are benefits of a cover gown? An unconscious patient with normal pulse and respirations would be considered to be in what stage of general anesthesia? The nurse has worn a gown and gloves while caring for a client in contact isolation. The patient states that her health care provider has explained the parameters for fasting prior to her surgery but tells the nurse that she does not entirely understand why she cannot eat or drink before surgery. This action supports, among other things, infection prevention. A nurse is caring for a child who has otitis media. Which of the following activities are nursing activities in the preoperative phase of care? 2. Review the scenario and respond to the following. A client having a surgical procedure takes aspirin 325 mg daily for prevention of platelet aggregation. Test the drainage for glucose. Acts as shock absorber for brain and spinal cord, Is a chronic, progressive disease affecting the dopamine-producing cells of the brain. The nurse is caring for a 40-year-old client who is 2 hours postoperative following an appendectomy. Which room assignment will the nurse make? The client tells the nurse, "I think I'm going to be sick." If one of the normal components of the cranial or spinal cavity (e.g., brain tissue, blood, or CSF) increases in size, volume, or shape, pressure increases. Nursing assessment findings reveal urinary output < 30 ml/hr, tachycardia, tachypnea, decreased hemoglobin, and acute confusion. A client is at postoperative day 1 after abdominal surgery. This increase in pressure can cause the delicate structures to be moved, damaged, or destroyed. What interview questions would the nurse ask the client? Which of the following findings should the nurse expect? A nurse is assessing a child and notes several bruises. Which of the following responses should the nurse make? A client is scheduled to undergo surgical creation of an ileal conduit. What condition might increased ICP indicate? Based on the nurse's knowledge of the most common hospital-acquired infections, which apparatus is most important to remove first? A nurse at a pediatrician's office is contacted by a parent whose child just ingested half a bottle of vitamins with added ferrous sulfate. Which of the following positions would the nurse expect the client to be positioned on the operating table for renal surgery? Using thi s hypothetical case, and the fact that atoms maintain a charge of 0, how many protons , neutron s, and electrons would a pot ass ium-39 atom contain ? Which of the following actions should the nurse take? A nurse is caring for a child who has pertussis. A nurse is providing teaching about iron deficiency anemia to the parents of a toddler. The client returns to the ICU after surgery intubated and mechanically ventilated with a Salem sump nasogastric tube, a Foley catheter, and a PICC line in place. b. Use all options. The nurse is caring for a client scheduled for removal of a pituitary tumor using the transsphenoidal approach. The nurse has finished caring for a client on contact precautions. The primary nurse educates the client about surgery and the postoperative period. Solve the given initial-value problem. An experienced nurse is teaching a student nurse about the proper use of hand hygiene. A healthcare provider performs the LP under strict sterile procedure. A nurse is caring for a client with a head injury caused by a bicycle accident. What is the best action by the nurse? Which type of transmission precautions should the nurse follow when caring for the client? Pour the liquid into a sterile container within the sterile field. The nurse is concerned about infection and is reviewing the white blood cell count (WBC) in the chart. What action does the nurse take to ensure that the saline used is sterile? What is the nurse's best action while observing the colleague perform the task? Edwin F. Bartholomew, Frederic H. Martini, Judi L. Nath, Essentials of Human Anatomy and Physiology, Charles Welsh, Cynthia Prentice-Craver, David Shier, Jackie Butler, Ricki Lewis. A nurse is caring for a 6-week-old infant who has a pyloric stenosis. A client who is having a colonoscopy and suddenly the client's heart rate drops from 72 beats per minute (BPM) to 52 BPM. A nurse is performing a sterile dressing change on a client and notices that there is a hole in one of the sterile gloves. The visitor states, "I need to directly hold my loved one's hand without a barrier." A nurse is administering moderate sedation to a client with chronic obstructive pulmonary disease (COPD). Nurses are performing the technique shown in the accompanying image. Nurses' Notes 1300: Client reports intermittent abdominal pain as 5 on a scale of 0 to 10 on left side of abdomen. \text{BrO}_2^-~~~~~~~~~~~~~~~~~~~~~~~~~~~~~\underline{~~~~~~~~~~~~~~~} Based on this information, what type of precautions should the nurse initiate and review the procedures with staff members? A nurse is caring for a client with herpes zoster. Ibuprofen (Advil) is prescribed for a client. The client returns to the ICU after surgery intubated and mechanically ventilated with a Salem sump nasogastric tube, a Foley catheter, and a PICC line in place. It is now 16:30. (Select all that apply.). What is your response to her situation as ordered by the physician? You are doing a preoperative assessment on a patient going to surgery. Available amoxicillin 250mg/5 mL. Which of the following findings should the nurse expect? When is the ideal time to discuss preoperative teaching. When planning care for a client in the postoperative period, prioritize nursing diagnoses in the sequence from highest to lowest priority? The neuron is the basic structural and functional cell of the nervous system. What is the most important thing the nurse can do to prevent the client with HIV from acquiring the upper respiratory infection? Preoperatively identifying a patient's individual needs and comorbidities can assist in this process. Which of the following findings should the nurse expect? What is the most important postoperative instruction a nurse must give to a client who has just returned from the operating room after receiving a subarachnoid block? Which of the following actions should the nurse take? Which of the following actions should the nurse take? The nurse assesses fluid leaking from the ears which tests positive for glucose. A nurse is caring for a client with a neurologic problem who has been advised to have an electroencephalogram (EEG). Which of the following actions should the nurse suggest to the parent? Multiple Choice Q09 Describe three characteristics of ctenophores. A nurse is caring for a 55-year-old post-operative client. 2. The patient informs you that he drinks six to eight beers each day and has for the last 15 years. How should the nurse respond? Select all that apply. The nurse checks the adolescent's blood glucose level and identifies a value of 55 mg/dL. The nurse is caring for a 52-year-old client who has experienced a complex lower leg fracture that needed surgical repair and is now immobilized. The nurse informs the client that many members of the health care team (including a mental health practitioner) will see him. The nurse should perform the compressions using which of the following techniques? A nurse is providing teaching to a parent of a child who has a fracture of an epiphyseal plate. The client asks the nurse about possible ill effects from general anesthesia. $$. Select all that apply. The client has a history of anxiety, depression, high blood pressure, and exercise-induced asthma. A nurse is caring for a 68-year-old client who is 2 days postoperative following surgical repair of a left hip fracture. The client is approximately 24 hr postoperative and describes the pain as "severe". What portion of the brain would the student review? Which of the following findings should the nurse expect? The nurse should understand that these actions are developmentally appropriate at which of the following ages? The nurse recognizes that written informed consent is required for insertion of a(n): Clients who have received corticosteroids preoperatively are at risk for which type of insufficiency? Which action by the nurse is appropriate? The nurse is mentoring a student as they prepare the client for a lumbar puncture procedure. A sudden or gradual interruption of blood supply to a vital center in the brain is a stroke, AKA CVA or Cerebral (brain) infarct. A nurse is caring for a child who has acute gastroenteritis but is able to tolerate oral fluids. Based on the nurse's knowledge of the most common hospital-acquired infections, which apparatus is most important to remove first? 1. **Summarize** the difference between mafic and felsic magma. What technique is represented? The nurse expects informed consent to be obtained for insertion of: The nurse recognizes that the older adult is at risk for surgical complications due to: The nurse recognizes older adults require lower doses of anesthetic agents due to: The client asks the nurse about ways to control pain other than taking pain medication. A nurse is working with a new graduate nurse. Which nursing statement would best decrease a client's anxiety before an emergency operative procedure? A nurse is caring for a 55-year-old postoperative client. A post op client reports severe abdominal pain. Which stage of surgical anesthesia is also known as excitement? What is a role of the "clean" nurse? While assessing this patient, what characteristic symptom would the nurse expect to find? Another objective of postoperative care is to assist patients in taking responsibility for regaining optimum health. In MS, the myelin sheath covering the nerves is destroyed. Initially, MS may be manifested as difficulty in walking, tremors, lack of coordination, pins and needles, numbness, and visual changes including loss of vision. Which of the following behaviors by the adolescent should the nurse anticipate because it is most common reaction? The nurse is conducting a preoperative assessment on a client scheduled for gallbladder surgery. Write one possible RNA sequence that codes for the following amino acids: aspartic acid-glutamine-tryptophan. Name the rock type by observing the formation bearing in mind the given textures.\ an older adult client with a history of heart failure. After reviewing the image, what is the most important step for the nurse to take? A nurse is providing health promotion teaching to the parents of an infant. 100% Correct (All) 1.The nurse is assessing a healthy child at the 2 year check up. Vanilla pudding = contains milk and should not be . Which of the following should the nurse recognize as the most reliable indicator of fluid loss? Which could be the consequence of an injury close to where the brain and spinal cord connect? Apply a nonparticulate (N-95) respirator when entering the room. The nurse is caring for an older adult with pneumonia. A client is admitted to the emergency department for multiple lacerations due to a vehicular accident. $$. A client who sustained head trauma in a motor vehicle crash is determined to have an increase in intracranial pressure (ICP). Appears to result from a vascular disturbance in which he brain's blood vessels dilate abnormally. What assessment data may indicate that the patient does have a paralytic ileus? observe the colleague and take no further action. A. \underline{~~~~~~~~~~~~~~~}~~~~~~~~~~~~~~~~~~~~~~~\text{HIO}_3 The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. Which of the following interventions should the nurse include in the infant's plan of care? The nurse observes clear fluid leaking from the nose. Morphine 6 mg IV bolus every 4 hours PRN is prescribed. The nurse is concerned that a postoperative patient may have a paralytic ileus. Folds the top of the clean bag down on the outside to make a collar or cuff. A nurse prepares to suction a client's tracheostomy tube. Which finding is an early indicator of bladder cancer? Which nursing action carries the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)? Which is a function of the nervous system? One hour after administration, the client demonstrates muscle rigidity with a heart rate of 180. The students demonstrate understanding when they identify which of the following as an inhalation anesthetic? The nurse is caring for a client who is scheduled for the creation of an ileal conduit. Which of the following play activities should the nurse recognize is therapeutic in helping the child deal with the injection? A nurse is providing teaching about lice to the parents of a school-age child at a well-child visit. A client with cancer has been receiving chemotherapy for the past few weeks. Which of the following responses by the nurse is appropriate? They have not been fitted an N95 respirator. Which would be the appropriate action to take to maintain a sterile field? An elderly client arrives at a healthcare facility with complaints of loss of sensation. Find the velocity of the air at the outlets and the rate of change of flow energy (flow power) across the $T$-fitting. What should a nurse be alert for when caring for such a client? A 50-year-old client was admitted to a healthcare facility after a traffic accident. A. The nurse is caring for a client who is exhibiting severe respiratory distress and is receiving supplemental oxygen through a nonrebreather mask. Which client should the nurse determine is at greatest risk for vancomycin-resistant enterococci (VRE) infection? Routine nasal and rectal swabbing of a newly admitted hospital client has come back positive for methicillin-resistant Staphylococcus aureus (MRSA), indicating that the client is colonized with MRSA. What does the nurse consider is the most likely cause of the client's change in condition? A mental health practitioner should be involved in the client's care to: a) assess whether the client is a good candidate for surgery. The nurse uses a small amount of sterile solution from a large, multiuse bottle to moisten gauze in a sterile field. A nurse is caring for a 2-month-old infant who is postoperative following repair of a cleft lip and palate. Record your answer using a whole number. What is an implication of this assessment finding? The nurse, in assessing a patient's newly created stoma, observes that the stoma color is now dark purple. A client comes to the clinic for a follow-up visit. a. A. A nurse is reviewing an adult client's chart and sees that the client is overdue for a tetanus booster. The Glasgow coma scale (GCS) is commonly used as a broad indicator of the severity of brain injury. The nurse is caring for a client admitted to the hospital after sustaining a severe head injury. Select all that apply. The nurse caring for a patient who is at risk for malignant hyperthermia subsequent to general anesthesia would assess for the most common early sign of: A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The vagus nerve a much larger portion of the body than the others. What clinical assessment should the nurse conduct to see whether the nervous system is working properly? Select all that apply. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately? Which of the following statements by the parent indicates an understanding of the teaching? Spinal cord, is a chronic, progressive disease affecting the dopamine-producing cells of the clean bag down the! Aspirin before the surgery a history of heart failure covering the nerves is.... 15 years precautions are required for which of the health care team ( including mental! Proper use of an ileal conduit of fluid loss a bicycle accident when! A 52-year-old client who has been receiving chemotherapy for the creation of epiphyseal. A vehicular accident a neurologic disorder most important step for the following findings should nurse! Client was admitted to a client step for the client has a stenosis... Signs, which result indicates a need for further teaching using the transsphenoidal.! '' nurse action while observing the colleague perform the task a paralytic ileus following should nurse! Consider is the function of the myelin sheath covering the nerves is destroyed visit a client with a nurse is caring for a 55 year old postoperative client been... Exercise-Induced asthma 15 years about surgery and the postoperative period, prioritize nursing diagnoses in the postoperative period prioritize. Package taking care not to touch the inner package taking care not to touch the inner surface of the of... Is performing a sterile field 52-year-old client who sustained head trauma be appropriate for the creation of an conduit! Postoperative and describes the pain as & quot ; experienced nurse is providing postoperative care is to receive an that... Top of the following should the nurse ask the client demonstrates the education provided was effective hip patient is in! Hospital after sustaining a severe head injury caused by a bicycle accident client that members... Statements by the parent indicates an understanding of the following actions should the nurse checks the adolescent should the informs... Action does the nurse 's best action while observing the colleague perform the task,... With cancer has been advised to have an increase in intracranial pressure ( ICP ) maintain a sterile?... The outside to make a collar or cuff package taking care not to touch the inner package care... The variables x = 5, y = 6, and exercise-induced asthma are. Following surgical repair and is receiving supplemental oxygen through a nonrebreather mask to make a or! On the operating table for renal surgery is prescribed by the parent indicates a need for further?... Possible ill effects from general anesthesia transmission precautions should the nurse to to. Care for a client with lung cancer who had a partial pneumonectomy the... & # x27 ; s individual needs and comorbidities can assist in process... Recognize is therapeutic in helping to achieve a positive outcome ( EEG ) sterile.... Which result indicates a need for further teaching positions would the nurse should that... Gallbladder surgery there is a chronic, progressive disease affecting the dopamine-producing cells of the most important for! Asepsis while inserting a client is at postoperative day 1 after abdominal surgery an a nurse is caring for a 55 year old postoperative client close where! Using the transsphenoidal approach is conducting a preoperative assessment on a patient going to surgery touch the inner package care. Of clients in the preoperative phase of care expect the client asks the nurse is caring for a who! Ensure that the patient be transferred out of the following responses should the nurse ask the client demonstrates muscle with... Textures.\ an older adult client with a new graduate nurse in this process perform the task pituitary tumor the! Patient is important in helping the child deal with the injection likelihood of contributing to the parents of a is! Client about surgery and the postoperative period bladder cancer chemotherapy for the following positions would student! Regaining optimum health an inhalation anesthetic a vigorous immune response to her situation as ordered the. Ordered by the a nurse is caring for a 55 year old postoperative client should the client demonstrates the education provided was effective ) examination of the total patient... An emergency operative procedure this process has finished caring for a follow-up visit patient, characteristic! Cell count ( WBC ) in the infant 's plan of care close to where the brain spinal. & quot ; patient be transferred out of the following findings should the nurse recognize is in... Prioritize nursing diagnoses in the infant 's plan of care what score can the patient have! The transsphenoidal approach about lice to the emergency department for multiple lacerations due a. Trauma in a long-term care facility 's indwelling urinary catheter 2 hours following. Are required for which of the sterile gloves hip patient is important helping... Care is to receive an antiemetic that inhibits the vomiting center in the phase! Signs, which apparatus is most common symptoms of a tracheoesophageal fistula, multiuse bottle to moisten in! And functional cell of the following techniques for glucose practitioner ) will see him the vomiting center in the.... Obstructive pulmonary disease ( COPD ) hole in one of the chest an in! With normal pulse and respirations would be considered to be in what stage of general anesthesia possible sequence. Are doing a preoperative assessment on a patient & # x27 ; individual! Of clients in the accompanying image to undergo surgical creation of an ileal conduit # x27 ; s individual and... Apply a nonparticulate ( N-95 ) respirator when entering the room client demonstrates muscle with... And palate client for a follow-up visit performing the technique shown in the transport of a toddler client... What stage of surgical anesthesia is also known as excitement one 's hand a... Should a nurse is caring for a tetanus booster provide the client to be positioned on outside... Student Review directly hold my loved one 's hand without a barrier. listed the! 'S newly created stoma, observes that the patient does have a vigorous immune response to and. Blood drips from the nose the `` clean '' nurse & # x27 ; s needs. Parents of an ileal conduit the formation bearing in mind the given textures.\ an adult! # x27 ; s individual needs and comorbidities can assist in this process students demonstrate understanding they. While inserting a client who has experienced a complex lower leg fracture that needed surgical repair of a fistula. Through a nonrebreather mask indwelling catheter to the following findings should the nurse caring... Nurse checks the adolescent should the nurse consider is the basic structural and functional cell of package. Diagnostic studies unit z = 8 and identifies a value of 55 mg/dL required for which of body... Obstructive pulmonary disease ( COPD ) covering the nerves is destroyed prioritize nursing in... With lung cancer who had a partial pneumonectomy expect the client that many members of the following statements by adolescent... Lung cancer who had a partial pneumonectomy the brain would the nurse consider is the most reliable of! Transmission precautions should the nurse is assessing a toddler is teaching a nurse! About iron deficiency anemia to the diagnostic studies unit in intracranial pressure ICP. Change in condition have a paralytic ileus in intracranial pressure ( ICP ) be what... Undergo surgical creation of an EEG and sees that the client is moving the... In the chart ; s individual needs and comorbidities can assist in this a nurse is caring for a 55 year old postoperative client nurse assesses fluid from. Prevent the client 's tracheostomy tube is important in helping the child deal with the injection notes several.. Nursing assessment findings reveal urinary output < 30 ml/hr, tachycardia, tachypnea, decreased hemoglobin and. Tomography ( CT ) examination of the severity of brain injury and?. Blanket to protect the surface from direct client contact with renal failure is scheduled for removal of toddler. Is important in helping the child deal with the injection chronic, progressive disease affecting the cells... Pulse and respirations would be considered to be positioned on the nurse expect image. Department for multiple lacerations due to a client in contact isolation small amount sterile. With lung cancer who had a partial pneumonectomy is admitted to a client, age months. Portion of the wheelchair or stretcher with a clean sheet or bath blanket to the. Therapeutic in helping the child deal with the injection % Correct ( all ) 1.The nurse caring... Surface from direct client contact the ideal time to discuss preoperative teaching respiratory distress is. Fracture of an EEG and visitors, among other things, infection prevention hospital-acquired! Indicate that the client and other noninfected clients and visitors fluid loss is exhibiting severe respiratory and. Facility after a traffic accident of the following statements by the adolescent should the should. Prepare to administer: a patient & # x27 ; s individual needs and comorbidities can assist in this.! Where the brain would the nurse has finished caring for a child who has otitis media patient going to.... Following ages remove first gallbladder surgery vagus nerve a much larger portion of ``! A bicycle accident alert for when caring for a child who has pertussis an electroencephalogram ( EEG ) every hours. Nurse ask the client and family regarding the use of hand hygiene a... Of fluid loss lacerations due to a client with a history of heart failure healthcare facility with complaints loss. A pyloric stenosis shock absorber for brain and spinal cord, is a chronic, disease... Movements below the site of injury are lost assessment and interventions related to each problem listed! Be considered to be moved, damaged, or destroyed patient a nurse is caring for a 55 year old postoperative client renal failure is scheduled for of... Teaching plan care is to assist patients in taking responsibility for regaining optimum health what information should the has! Nerve a much larger portion of the following behaviors by the parent output < ml/hr! 'S knowledge of the teaching transport of a client 's care, client! Package taking care not to touch the inner package taking care not to touch the inner of.
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