Kaplan Trainer 2 – Flashcards
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The nurse cares for a client diagnosed with Meniere's syndrome. The nurse stands directly in front of the client when speaking. Which best describe the rationale for the nurse's position?
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The client does not have to turn the head to see the nurse. -> by decreasing movement of client's head, vertigo attacks may be decreased
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A client diagnosed with an adjustment disorder with depressed mood has the greatest chance of success in activities that require psychic and physical energy if the nurse schedules activities at which time?
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During the morning hours. -> client with reactive depression has the highest level of physical and psychic energy in the morning
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When obtaining a specimen from a client for sputum culture and sensitivity (C and S), the nurse identifies which instruction is best?
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Upon awakening, cough deeply and expectorate into a container.-> specimens should be obtained in the early morning because secretions develop during the night.
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The home care nurse performs an assessment of a client diagnosed with pneumonia secondary to chronic pulmonary disease. Which nursing goal is MOST appropriate?
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Improve the status of ventilation-> to improve the quality of ventilation refers to levels of carbon dioxide and oxygen
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A client receives a blood transfusion and experiences a hemolytic reaction, The nurse anticipates which assessment findings?
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1. Hypotension 2. Low back pain 4. fever
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The nurse evaluates the nutritional intake of the adolescent girl attending camp. The adolescent eats all the food provided. Each of the 3 meals contains foods from all areas of the "My Food Plate," average about 900 calories, and has 3 mg of iron. The adolescent menstruates monthly and is of appropriate weight for height. Which BEST describes the adolescent's intake?
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the diet is high in calories and low in iron -> 900x3= 2,700 calories/day (she only needs 2000). Iron is low (she needs 8 mg/day)
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The nurse assesses a client diagnosed with a spinal cord injury. Which assessment findings by the nurse suggest the complication of autonomic dysreflexia?
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2. severe pounding HA 3. Profuse sweating 6. nasal congestion
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The client reports a severe HA, nausea, and photophobia. the health care provider orders a CBC and a lumbar puncture (LP). which lab result would the nurse expect if a diagnosis of bacterial meningitis is made?
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CSF cloudy Hgb 13g/L HCT 38% WBW 18,000/mm3
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The client is admitted to the outpatient oncology unit for routine chemotherapy transfusion. the client's current lab report is WBC 2,500 mm3, RBC 5.1 million/mm3, total serum calcium 9.3 mg/dL. based on the lab values, the nurse determines which is the priority nursing diagnosis?
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risk for infection related to low WBC count
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When assessing orientation to person, place, and time for an elderly hospitalized client, which principle should be understood by the nurse?
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the stress of an unfamiliar environment may cause confusion
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The nurse team consists of one RN, two LPNs/LVNs, and 3 nursing NAP. the RN should care for which client?
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the client declining medication to treat cancer of the colon
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The 4-year-old is admitted with drooling and an inflamed epiglottis. during the assessment, the nurse identifies which symptoms is indicative of an increase in respiratory distress?
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Tachypnea -> increase in the respiratory rate is an early sign of hypoxia, also for tachypnea
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Which assessment information indicates to the nurse the client has hypocalcemia?
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Positive trousseau's sign
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A client receives morphine sulfate after admission of the ED in acute respiratory distress. The client is very anxious, edematous, and cyanotic. which finding should the nurse recognize as the desired response to the medication?
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decrease in anxiety
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A client develops a low intestinal obstruction. The nurse anticipates which findings?
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1. Nausea 2. vomiting 5. abdominal distention
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The nurse plans discharge teaching for a client after a lumbar laminectomy. Which muscles or muscles does the nurse instruct the client to exercise regularly?
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abdominal -> strenghtening the abdominal muscles adds support to for the muscles supporting the lumbar spine
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A client with type 1 diabetes asks the nurse why the health care provider prescribed regular insulin instead of intermediate-acting insulin. which response by the nurse is BEST?
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"blood glucose levels can be controlled more accurately with regular insulin" -> tighter blood glucose controls occurs with regular insulin, especially initially
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Promethazine hydrochloride 25 mg IV push is ordered for a client. Prior to administering this medication to the client, the nurse should check which assessment?
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The patency of the client's vein
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A client returns from surgery after a right mastectomy with an IV of 0.9% NaCl infusing at 100mL/h into the left forearm. Several hours later, the IV infiltrates. The nurse supervises a student nurse preparing to insert a new peripheral IV catheter. The nurse should intervene in which situation?
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the student nurse selects a site close to wrist joint. -> movement in area could cause displacement
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The nurse develops care plans for these clients. The nurse should plan to use a restraint for which client?
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an infant after a cleft lip repair -> arm restraints are necessary to prevent infant from rubbing or otherwise disturbing suture line
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The nurse knows which action is an important consideration in the care of a newborn with fetal alcohol syndrome?
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replace vitamins depleted as a results of poor maternal diet.-> frequently, maternal diet is poor and infant is malnourished; adequate intake of B complex vitamins is necessary for normal CNS
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The client has a newly inserted peritoneal dialysis catheter. The student nurse changes the dressing under the supervision of the RN. In which order does the student correctly perform the steps of this procedure?
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1. remove old dressing using clean gloves. 2. open package containing providone-iodine cotton swabs 3. clean the insertion site using a circular motion from the insertion site outward 4. apply two sterile precut 4x4s to the catheter insertion site. 5. securely tape the edges of the sterile dressing with paper tape.
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The nurse assesses the client immediately after an exploratory laparotomy. which nursing observation indicates the complication of intestinal obstruction.
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distended abdomen with reports of pain -> if an obstruction is present, the abdomen will become distended and painful
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The nurse observes a student nurse auscultate the lungs of a client. The nurse knows that the student nurse is correctly auscultating the right middle lobe (RML) if the stethoscope is placed in which position?
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right anterior chest between the fourth and sixth intercostal space
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During a prenatal visit, the client states, "I have been very nauseated during my first trimester, and I don't understand the reason." which response by the nurse is BEST?
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"the nausea is caused by an elevation in the hormones."
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The nurse determines which action has HIGHEST priority when caring for the client diagnosed with hypoparathyroidism?
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plan to measures to deal with cardiac dysrhythmias.
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A client has a NG tube connected to intermittent low suction. at 0700, the nurse documents there is 235 mL of greenish drainage in the suction container. At 1500, the nurse notes that there is 445 mL of greenish drainage in the suction container. Twice during the shift, the nruse irrigates the Levin tube with 30 mL of NS, as ordered by the health care provider. Which is the actual amount of drainage from the NG tube for 0700 to 1500?
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150mL 445-235=210-60= 150mL
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The nurse cares for a client during a radium implant. During the removal of the implant, it is MOST important for the nurse to take which action?
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document the date and time of removal together with the total time of implant treatment.
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the client diagnosed with addison's disease comes to the health clinic. When assessing the client's skin, the nurse expects to make which observation?
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darker skin that is more pigmented-> increase in melonacyte-stimulating hormone results in "eternal tan."
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The NAP reports to the RN that the client with anemia reports weakness. Which response by the nurse to the NAP is BEST?
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"set up the client's lunch tray."
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During an initial interview at an outpatient clinic, a 34-year-old single parent tells the nurse of having had difficulty forming relationships and is worried that the 7-year-old child will have the same problem. Which statement, if made by the nurse, is BEST?
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"children develop trust from birth to 18 months of age."
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A client diagnosed with metastatic lung cancer is admitted to the hospital. The client's orders include DNR and morphine 2 mg/h by continuous IV infusion. When the nurse assesses the client, the client's BP is 86/50, resp are 8, and the client is nonresponsive. Naloxone hydrochloride, 0.4 mg IV is ordered stat. In planning care for this client, it is important for the nurse to consider which action?
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a dose of naloxone may need to be repeated in 2-3 minutes-> half-life of naloxone is short; may go back into resp depression; may need to be repeated
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The health care provider order chlorpromazine to control an alcoholic client's restlessness, agitation, and irritability following surgery. The nurse should check the order with the health care provider because of which rationale?
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the nurse believes that the client's symptoms reflect alcohol withdrawal
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The nurse prepares a client for a MRI. which client statement indicates to the nurse that teaching is successful?
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"this procedure will take about 90 min to complete. There will be no discomfort."
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A miller-abbott tube is ordered a client. The nurse knows that the main reason this tube is inserted is for which reason?
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removes fluid and gas from the small intestine-> miller-abbott tube provides for intestinal decompression; intestinal tube is often used for treatment of paralytic ileus
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The nurse cares for a client during an acute manic episode. The nurse identifies which client behaviors as most characteristic of mania?
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2. grandiose delusions. 4. difficulty concentrating 5. agitation
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The adult client is admitted to the hospital unit diagnosed with hep A. Which precautions does the nurse include in the client's overall care during hospitalization?
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standard precautions-> sources for this virus are salva, feces, and blood; use contact isolation if fecal incontinence
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Which assessment findings should the nurse recognize as pertinent to a diagnosis of Cushing's syndrome?
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thin extremities with easy bruising
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The health care provider prescribes estrogen 0.635 mg daily for a 43-year-old woman. The nurse identifies which symptom as a common initial side effect of this medication?
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nausea
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The nurse cares for the client diagnosed with a recurrent UTI. the health care provider prescribes ciprofloxacin. The nurse instructs the client to limit intake of which fluid?
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Milk -> should limit intake of alkaline foods and fluids
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The nurse recognizes which symptoms as characteristic of a panic attack?
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2. palpitations 3. decreased perceptual field 5. diaphoresis 6. fear of going crazy
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When caring for a client with myasthenia gravis, it is MOST important for the nurse to consider which action?
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assess muscle groups toward the end of the day
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The nurse supervises can given to a group of clients on the unit. The nurse observes a staff member entering a client's room wearing gown and gloves. The nurse knows the staff member is caring for which client?
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an 18-month-old with respiratory syncytial virus
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The nurse cares for a client admitted 2 days ago with a diagnosis of closed head injury. If the client develops diabetes insipidus, the nurse will observe which symptoms?
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2. cracked lips 5. urinary output 4L/24 hours 6. urine specific gravity of 1.004
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The nurse reviews procedures with the health care team. The nurse should intervene if the RN staff member makes which statement?
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"it is my responsibility to explain the surgery and ask the client to sign the consent form."
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The nurse develops a comprehensive care plan for the young client diagnosed with anorexia nervosa. The client is referred to assertiveness skills classes. This is an appropriate intervention because the client may exhibit which problem?
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Self-identify and self-esteem issues
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The school nurse conducts on childcare at the local high school. During the class, one of the participants asks the nurse what age is best to start toilet training a child. Which is the BEST response by the nurse?
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20 months of age
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The geriatric residents of a long-term care facility participate in a reminiscing group. the nurse identifies which goal as the primary goal of this type of group activity?
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provides an environment for social interaction and companionship.
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The nurse recognizes which nursing intervention is most important when caring for a client just placed in physical restraints?
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check that the restraints have been applied correctly
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The older client with a hs of HTN and angle-closure glaucoma visits the clinic for a routine check-up. which med, if ordered by the health care provider, should the nurse question?
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Tetrahydrozoline, 2 drops in both eyes 3 times daily
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A client returns from surgery with a fine, reddened rash notes around the area where providone iodine prep had been applied prior to surgery. Nursing notation in the client's document should indicate with observation?
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notation on an allergy list and notification of the health care provider
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a nurse discusses changes due to aging with a group at the senior citizen center. The nurse knows which change in the urinary elimination pattern normally occurs with aging?
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nocturia-> decreased ability to concentrate urine increases urine formation and increased nocturnal urine production leads to need to awaken to void
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A middle-aged client is brought to the ED after being raped in the home. the client asks the nurse to call the spouse to come to the ED. the nurse knows that the most common reaction of significant others to a rape victim is reflected in which behavior?
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emotionally distressed and needing assistance
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An older client has a modified radical mastectomy and axillary dissection. which nursing diagnosis is a correctly stated, priority nursing diagnosis for the client immediately after the procedure?
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pain related to surgical incision
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The nurse cares for a client diagnosed with paranoid schizophrenia. the nurse knows that questioning the client about the client's false ideas will elicit which response?
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cause the client to defend the idea-> contraindicated; encourages client to engage in further distortion of reality.
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The health care provider suggests play therapy for the 7-year-old child having some difficulty adjusting to the parent's impending divorce. the nurse identifies which reason this type of therapy is effective for this age group?
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young children have difficulty verbalizing emotions
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The home care nurse plans activities for the day. in which order does the nurse see these clients?
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1. the elderly client who used all the diuretic medi and is expectorating pink-tinged mucus 2. the client discharged yesterday after IV heparin therapy for a DVT 3. the elderly client with pneumonia discharged from the hospital 3 days ago. 4. the client who is breastfeeding a 2-say-old infant born 5 days before the due date
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The nurse prepares discharge teaching for the parents of newborn. Which information should the nurse provide to the parents regarding the accuracy of a PKU test?
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the initial specimen should be collected as close to discharge as possible and may be repeated within 2 weeks.
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An elderly client receives PN for several weeks. If the PN were abruptly discontinued, the nurse expects the client to exhibit which s/s?
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diaphoresis, confusion, and tachycardia-> insulin levels remain heigh while glucose levels decline; results in hypoglycemia; will also see restlessness, HA, weakness, irriability, apprehension, and lack of muscle coordination
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Which is the best method for the nurse to use when evaluating the effectiveness to tracheal suctioning?
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auscultates the chest for change or cleaning of adventitious breath sounds
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The nurse anticipates a client diagnosed with a gastric ulcer to experience pain at which time?
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one-half to 1 hour after a meal
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The older adult receives dexamethasone for chronic lymphocytic leukemia. it is most important for the nurse to report which finding to the health care provider?
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serum K 3.4 serum Ca 7.8
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A client at 16 weeks gestation undergoes an amniocentesis. The client asks the nurse what the health care provider will learn from this procedure. the nurse's response will be based on an understanding that which condition can be detected by an amniocentesis?
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hemolytic disease of the newborn
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The client is at the clinic to have a hemoglobin A1C performed. which client statement indicates to the nurse an understanding to the procedure?
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"this test indicates how well my blood sugar has been controlled the past 4 months."
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The health care provider prescribes lithium carbonate 300 mg PO QID for an adult client. The nurse in the outpatient clinic instructs the client about the med. the nurse should encourage the client to maintain an adequate intake of which substance?
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sodium -> alkali metal salt acts like sodium ions in the body; excretion of lithium depends on normal sodium levels; sodium reduction causes marked lithium retention; leading to toxicity
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The nurse cares for a homebound client with a urinary catheter. the client's spouse states the catheter is obstructed. Which observation by the nurse confirms this suspicion?
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the nurse notes the bladder is distended
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Which action is the most reliable client measure for the nurse to use to evaluate the client response to diuretic therapy?
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obtain daily weights.
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Which pscyhosocial stage does the nurse identify as a priority to consider while planning for a 20-year-old client?
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intimacy vs. isolation
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the health care provider at the clinic diagnoses graves' disease for a client. the nurse expects the client to exhibit which symptom?
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weight loss of 10 lb in 3 weeks
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The clinic nurse obtains a health hx from the client newly diagnosed with Buerger's disease. the nurse expects the client's presentation to include which symptom?
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digital sensitvity to cold -> vasculitis of blood vessels in upper and lower extremities
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a client with AIDS is admittd with a tentative diagnosis of late AIDS dementia complex. the nursing assessment is most likely to reveal which finding?
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disorientation to person, place, and time
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The nurse cares for a client the first day postoperative after a transurethal prostatectomy (TURP). the client has a continuous bladder irrigation (CBI). the client's spouse asks why the client has the CBI. which response by the nurse is best?
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"the CBI enables urine to keep flowing." -> CBI prevents formation of clots that can lead to obstruction and spasm in the postoperative TURP client
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The nurse cares for a client receiving haloperidol. the nurse should anticipate which side effects?
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blood dyscarsia and extrapyramindal symptoms
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an adolescent is scheduled for a below-knee (BK) amputation following a motorcycle accident. The nurse knows preoperative teaching for this client should include which information?
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encourage the client to share feelings and fears about the surgery
