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18 Cards in this Set

  • Front
  • Back
The nurse is teaching a female client who uses a contraceptive diaphragm about reducing the risk for toxic shock syndrome (TSS). Which information should the nurse include?
Do not leave the diaphragm in place longer than 8 hours after intercourse.

Contact a healthcare provider when a sudden onset of fever greater than 101F appears
A client is admitted with a medical diagnosis of Addisonian crisis. When completing the admission assessment, the nurse expects this client to exhibit which clinical manifestations?
Hypotension, Rapid weak pulse, and palpitations
(Addisonian crisis=shock)
The nurse is caring for critically ill clients. Which client should be monitored for teh development of distributive shock? A client with
Neurogenic shock. Neurogenic shock is the rarest form of shock. It is caused by trauma to the spinal cord resulting in the sudden loss of autonomic and motor reflexes below the injury level. Without stimulation by sympathetic nervous system the vessel walls relax uncontrolled, resulting in a sudden decrease in peripheral vascular resistance, leading to vasodilation and hypotension. (Spinal cord injury)
A client is admitted to the hospital with a diagnosis of Type II diabtes mellitus and influenza. Which categories of illness should the nurse should the nurse develop goals for the client's plan of care?
One chronic and one acute illness.
The nurse should be correct in withholding a dose of digoxin in a client with congestive heart failure without specific instruction from the healthcare provider if the client's
Serum potassium level is 3.
When preparing a client who has had a total laryngectomy for discharge, which instruction is most important for the nurse to include in the discharge teaching?
Tell the client to carry a medic alert card stating that he is a total neck breather.
The nurse is completing an admission interview and assessment on a client with a history of Parkinson's disease. Which question should provide information relevant to the client's plan of care?
Have you ever been frozen in one spot unable to move?
A 46 year old female client is admitted for acute renal failure secondary to diabetes and hypertension. Which test is the best indicator of adequate glomerular filtration?
Serum creatinine
Despite several eye surgeries, a 78 year old client who lives alone has persistent vision problems. The visiting nurse is discussing painting the house with the client. The nurse suggests that the edge of the steps should be painted which color?
Medium Yellow
While working in the emergency room, the nurse is exposed to a client with active TB. When should the nurse plan to obtain a TB skin test?
Four to six weeks after the exposure.
A client is brought to the Emergency Center after a snow-sking accident. Which intervention is most important for the nurse to implement?
Review teh EKG tracing.
Airway, breathing, and circulation are priorities in client assessment and treatment. Continuous cardiac monitoring is indicated (A) because hypothermic clients have an increased risk for dysrhythmias. Coagulations studies (A) and re-warming procedures (C and D) can be initiated after a review of the ECG tracing
The nurse is planning care for a client who is having abdominal surgey. To achieve desired postoperative outcomes, the nurse includes interventions that promote mobilization, such as turn, cough, deep breathe, and early ambulation. Which additional intervention should the nurse include?
Administer analgesics prior to encouraging progressive activities and ambulation.
The nurse working in a postoperative surgical clinic is assessing a woman who had a left radical mastectomy for breast cancer. Which factor puts this client at greatest risk for developing lymphedema?
She sustained an insect bite to her left arm yesterday.
Physical examination of a comatose client reveals decorticate posturing. Which statement is accurate regarding this client's status based upon this finding?
Severe dysfunction of the cerebral cortex has occurred
decorticatg=inward
Which symptom should the nurse expect a client to exhibit who is known to have a
pheochromocytomia?
Headache, diaphoresis, and palpitations
During CPR, when attempting to ventilate a client's lung, the nurse notes that the chest is not moving. What action should the nurse take first?
Reposition the head to validate that the head is in the proper position to open the airway.
Which intervention should the nurse plan to implement when caring for a client who has just undergone a right above the knee amputation?
Place a large tourniquet at the client's bedside.
Prior to a cardiac catheterization, which activity should the nurse have the client practice?
Valsalva's maneuver and coughing.