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38 Cards in this Set
- Front
- Back
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A client had a right lobectomy because of cancerous tumor, chest tubes are in place with suction at zoom water pressure what nursing action is implemented to prevent complications |
Encourage coughing while splinting the chest incision with both hands |
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Which intervention is the most important for the PN and implement when applying an ice pack to a clients |
Use protective cover to wrap the bag |
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a new mother is breastfeeding her newborn for the first time after delivery and complaines of nipple pain when the baby sucks, based on this complaint, what action the PN take |
Ensure that all the areolar tissue of the nipple is in the infant mouth |
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The PN is planning to admin and oral preparations of iron supplement to a patient, which liquid or food should the oral iron be administered with |
Orange juice |
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A female client is hospitalized for treatment of a myasthenic crisis. which factor in the clients HX is the most likely trigger of this crisis |
Recently had the flu and a cold |
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The PN is preparing to give a client a complete bed bath, to promote the client's recovery which action is best for the nurse to implement |
Allow client to participate in the procedure |
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The PN is assigning tasks to the UAP who is giving basic care to a group of residents in a long term care facility, which task should be completed by a licensed personal rather than the UAP |
Regulate a 3 Way catheter irrigation solution for a client with a bladder infection |
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The PN observe a UAP performing oral hygiene on an unconscious client who is lying in a flat side lying position with an emesis basin on a towel under the chin. what action to the PN and take? |
Praise the UAP for positioning the client safely and correctly |
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When a newly admitted client arrives on the unit, the clients daughter hands a large bag containing the client meds to the PN assisting the charge nurse with the admission process, what action should the PN take? |
Work with the charge nurse to make a list of all the meds |
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Which cell type is responsible for maintaining the bone matrix once it is formed? |
Osteocyte |
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The PN medicated a male client for pain at 2000 but at 2100 he tells the PN that" I just can't relax", how should the PN respond? |
Offer to provide the client with a back rub to help him relax |
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A gravida 1 para 1 client is scheduled to be discharged from the post partum unit with her infant, which action by the mother should the PN identify as a need for further information about infant care? |
Leaves her baby on the bed while in the shower |
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The PN is reviewing the pre-op checklist for a client who is admitted for an emergency exploratory laparotomy which action , should the PN implement? |
Determine the status of the diagnostic results and reports- report the hemoglobin and hematocrit results to the surgeon |
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The PN prepares to admin morphine sulfate 15 mL IM to a post-op client. Before admin the narcotic analgesic, the PN should recognize that morphine necessitates monitoring which parameters? |
CNS depression and monitor for respiratory depression |
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The PN is preparing a client for vaginal insertion of a med. What should the PN ask the client to do before the med is administered? |
Go to the bathroom to urinate |
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Where is melanin located? |
Epidermis |
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Immediately after logrolling a client to a lateral position, what actions should the PN perform? |
Maintain alignment by supporting the head, back and extremities with pillows |
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When assisting a client to get out of bed, which action will the PN take first? |
Place the bed in the lowest position |
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During fecal impaction removal, an elderly male client complains of feeling dizzy and cold, what intervention should the PN implement? |
Stop the procedure and observe for a reduction in symptoms before continuing |
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The PN is administrating eye drops into both eyes, on which surface should the PN drop the medication? |
The conjunctival sac |
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Which landmarks should the PN identify when preparing to admin an IM injection into the ventrogluteal site? |
1 inch below the iliac crest between, spread fingers as the palm is placed on the greater trochanter |
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A client with diabetes receives NPH insulin at 0700 in assessing the client's at 1600, the PN finds that the client is diaphoretic and confused. Which intervention should the PN implement first? |
Give 4 ounces of orange juice |
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Following the dressing change of an abdominal surgical wound, a client expresses concern to the PN about the scar that might result from the wound. Which response is best for the PN to provide? |
Tell me more about your concerns regarding an abdominal scar |
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The client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the PN implement first? |
Describe the functions of the PN |
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During morning care, the PN provide oral hygiene every 2 hours identifies sordes is developing for a client who had a stroke, which intervention should the PN implement? |
Provide oral hygiene every 2 hours |
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When entering the room of an elderly female resident of a long term facility, the PN finds one of the male residents in the bed with her, what initiation action should the PN take? |
Close the door and report the finding to the charge nurse |
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An elderly client who had a colon resection 8 days ago is straining at stool the PN observes sudden spillage of serosanguinous drainage from the clients and wound followed by appearance bauel on the skin, what complications has occurred? |
Evisceration |
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A client with a compound fracture of the left ankle is being discharged with a below the knee cast. Before the client goes home which instructions should the PN provide a client? |
Do not attempt to scratch the skin under the cast |
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The PN talking with an adult male client who says that he is satisfied with how he has lived his life, according to Erikson staging theory, the client is in which stage? |
Integrity vs despair |
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Which client vital signs should the PN report to the charge nurse? |
A 12 hour postoperative client with a BP of 90/50 and a pulse of a 120bpm |
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What cellular organelle functions as the powerhouse of the cell by producing cellular energy? |
Mitochondria |
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When administering a saline enema, the PN inserts the enema tubing 3 inchs into the clients rectum, and elevates the container 6 inches above the clients body, when the clamp is opened, the solution does not infuse, what action should the PN take? |
Raise the saline container 6 inches higher |
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The PN is preparing to transfer a client with diabetes to a bedside chair. The client tells the nurse that his feet are burning, what action should the PN implement? |
Determine how long the client has experienced this sensation |
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The client experiences a muscle strain or sprain to the ankle, which intervention should the PN implement for an acute soft tissue injury? |
Apply ice to the injured site at 15 minute intervals for the first 24 hours |
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The PN is contributing to a care plan for an adolescent female client with anorexia nervosa, which outcome statement or goal would be most appropriate for this client? |
She will consume at least 50% of all meals |
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After a tonsillectomy, a 10 year old child begins to swallow excessively, which intervention is most important for the PN to implement? |
Report vital signs and swallowing to RN |
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Which site should the PN use when administering a RhoGAM injection to the Rh negative post partum client? |
Gluteus maximus |
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A client is admitted to the psychiatric unit and tells the PN that the FBI agent Nigel and his cover is Jesus Christ. The PN recognize these thought patterns as examples of which conditions? |
Delusions of grandiosity |
