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40 Cards in this Set

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Which action should the nurse implement when administering a prescription drug that should be given on an empty stomach?
Give one hour before or two hours after a meal.
Average transit time from stomach to duodenum is 2 hours.
The nurse is caring for a client who is unable to void. The plan of care establishes an objective for the client to ingest 1000ml of fluid between 7am and 3pm. Which client response should the nurse document that indicates a sucessful outcome?
Drinks 240ml of fluid five times during the shift.
A client with metastatic cancer is preparing to make decisions about end of life issues. When the nurse explains a durable power of attorney for health care, which description is accurate?
It will identify someone that can make decisions for your health care if you are in a coma or vegetative state.
The nurse is caring for a client who is the daughter of a local politician. When the nurse approaches a man who is reading the names on the hall doors, he identifies himself as a reporter for the local newspaper and requests information about the client's status. Which standard of nursing practice should the nurse use to respond?
Confidentiality
A client with acute hemorrhagic anemia is to receive four units of packed RBC's (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement?
Ensure the accuracy of the blood type match.
A male client who had abdominal surgery has a nasogastric tube to suction, oxygen per nasal cannula, and complains of dry mouth. Which action should the nurse implement?
Apply a water soluble lubricant to the lips, oral mucosa, and nares.
Petroleum based products are flammable.
A client with chronic renal failure selects a scramble egg for his breakfast. Which action should the nurse take?
Commend the client for selecting a high biologic value protein.
The nurse is administering meds through a NG tube which is connected to suction. After ensuring correct tube placement, what action should the nurse take next?
Flush the tube with water.
NGT should be flushed before, after, and in between each med adminstered.
The nurse notices that the mother of a 9 year old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take?
Continue asking the mother questions about the child.
When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?
Loosen the right wrist restraint.
A client who is 5'5 tall and weighs 200lbs
is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment?
What vitamin and mineral supplements do you take?
Vitamins affect meds.
An african american grandmother tells the nurse that 4 year old grandson is suffering with miseries. Based on this statement, which focused assessment should the nurse conduct?
Inquire about the source and type of pain.
Different cultural have different words.
In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly
often follows relocation to new surroundings.
The nurse is instructing a client with high chholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective?
I will limit my intake of beef to 4 ounces per week.
saturated fat from animal > cholesterol
The nurse is interviewing a female client whose spouse is present. During the nterview, the spouse answers most of the questions for the client. Which action is best for the nurse to implement?
Ask the spouse to step out for a few minutes.
A young mother of three complains of increased anxiety during her annual physical exam. What information should the nurse obtain first?
Nutritional history
A nurse takes a female client to the examination room and asks her to remove her clothes and put on an examination gown with the front open. The woman states "I have special undergarments that I do not remove for religious reasons." How should the nurse respond?
Tell me about your undergarments so we can discuss how you can have your examination comfortably.
The nurse determines that a client's body weight is 105% above teh standardized height-weight scale. Which related factor should the nurse include in the nursing diagnosis, "Imbalanced nutrition: more than body requirements?
Inadequate lifestyle changes in diet and exercise.
A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client
Demonstrates the wound care procedure
correctly
An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings?
Fowlers' (Semi-sitting)
The nurse plans a teaching session with a client but postponses the planned session based on which nursing diagnosis?
Activity intolerance related to postoperative pain.
The nurse is preparing to adminster IV fluid to a client with a strict fluid restriction. IV tubing with which feature is most important for the nurse to select?
Buterol attachment
An elderly resident of a long-term care facility is no longer able to perform self care and is becoming progressively weaker. The resident previously requested that no resusciative efforts be performed, and the family requests hospice care. WHat action should the nurse implement first?
Notify the healthcare provider of the family's request.
Prior to transferring a client to a chair using a mechanical lift, what is teh most important client characteristic the nurse should assess?
Tolerance of exertion.
Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status?
Chocolate pudding
The nurse observes that a male client has removed the covering from an ice pack applied to his knee. Which action should the nurse take first?
Observe the appearance of the skin under the ice pack.
While instructing a male client's wife in the performance of passive range of motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement?
Acknowledge that she is supporting the arm correctly.
When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action will the nurse implement first?
Note which actions were not implemented.
The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP?
Report the vital signs to the nurse.
During a visit to the outpatient clinic, the nurse assess a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure?
Degree of flexion and extension of the client's knee joint.
The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding?
Ptosis of the left eyelid.
A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take?
Request and document the name of the certified translator.
The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrated correct use of the inhaler?
During the inhalation.
The nurse observes an unlicensed personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usage range. What action is most important for the nurse to implement?
Reassess the client's blood pressure using a larger cuff.
A client is brought into the emergency department following a sudden cardiac arrest. A full code is started. FIve minutes later the family arrives with a durable power of attorney signed by the client requesting that no extraordinary measures be taken, including intubation, to save the client's life. What action should the nurse take?
Stop the code immediately.
The nurse dons gown, mask with eyeshield, and gloves before entering a client's room that has airborne precautions. Upon leaving the client's room, in which sequence should the nurse remove the personal protective equipment?
Remove gloves, gown, mask, wash hands
When documenting assessment data, which statement should the nurse record in the narrative nursing notes?
S1 murmur auscultated in supine position:
Objective data
An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intendive aerobic exercise program 3 to 4 times a week and to take stress managment classes. After praising the client for his decision, which instruction is most important for the nurse to provide?
Be sure to have a complter physical exam before beginning your planned exercise program.
A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow?
8am, 4pm, 1200 midnight.
q 8hrs
The nurse is preparing to administer a high volume saline enema to a client. Which information is most important for the nurse to obtain prior to administering the enema?
History of inflammatory bowel disorder

scrymptoms: diarhhea, hematuria, perforation