When providing education for a client newly diagnosed with type 1 diabetes, which information is most important for the nurse to provide the client?
Explain the importance of counting carbohydrate intake.
Encourage wearing a medical alert identification bracelet.
Provide printed materials about the treatment of diabetes.
Teach how to recognize and treat hypoglycemia.
When caring for a client who had general anesthesia, which nursing protocol has the highest priority during the immediate postoperative period?
Record blood pressure q15 minutes.
Determine respiratory rate q10 minutes.
Evaluate temperature q15 minutes.
Assess level of consciousness q5 minutes.
A client with hypertension who was taking hydrochlorothiazide has a new prescription for hydrochlorothiazide in combination with valsartan, an angiotensin I antagonist. What assessment is most important for the nurse to complete before administering the medication?
Palpate for pedal edema.
Assess oxygen saturation.
Measure blood pressure.
Review intake and output.
A female reports to the nurse that she has uncontrollable urine loss when coughing or sneezing. Which action should the nurse recommend?
Urinate every two to three hours.
Drink non-caffeinated colas only.
Reduce intake of processed foods.
Limit the daily intake of water.
A male client with heart failure (HF) calls the clinic and reports of not being able to put on his shoes because being too tight. Which additional information should the nurse obtain?
How many hours did he sleep last night?
What time did he take his last medications?
Has his weight changed in the last several days?
Is he still able to tighten his belt buckle?
A nurse notes that bloody drainage is trickling from under the dressing of a client who had a thyroidectomy yesterday. Which action should the nurse take?
Remove the dressing and apply steri strips.
Apply pressure to client’s incision.
Assess the client’s ability to swallow.
Reinforce the dressing with sterile gauze.
When making a health visit to the home of a client with a history of seizures, the nurse observes the client experiencing tonic-clonic seizure activity. Which action should the nurse implement first?
Protect the client’s head with a pillow.
Observe the postictal breathing pattern.
Tell a family member to call emergency services.
Determine the trigger event.
An adult client who is experiencing an exacerbation of Crohn’s disease is admitted to the medical unit from the Emergency Department. When preparing for the client’s arrival to the unit, the nurse requests a lunch tray for the client. Which menu should the nurse choose?
Hamburger patty, mashed potatoes, green beans, and corn.
Oral nutritional supplement, herbal tea, and gelatin.
Chef salad with turkey, cheese, tomatoes, and ranch dressing
Chicken noodle soup and a toasted ham and cheese sandwich.
A nurse is providing care for clients on a medical unit where meals are served upon request. The nurse plans to administer a scheduled dose of 70/30 mixed insulins: insulin, isophane suspension and regular insulin at 0730 to a client with diabetes mellitus. Upon entering the room, the nurse learns that the client requested a late breakfast for 0930. Which action should the nurse take?
A. Offer the client a snack of juice and crackers.
Withhold the insulin until closer to the meal.
Notify the pharmacy of the meal time change.
Administer the insulin as scheduled at 0730.
A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cells. When notifying the healthcare provider, which information should the nurse provide first using the BAR (Situation, Background, Assessment, and Recommendation) communication process?
A. Preface the report by stating the client’s name and admitting diagnosis.
Obtain a PRN prescription for acetaminophen for fever over 101° F (38.3° C).
Explain specific reason for urgent notification.
Communicate the pre-transfusion temperatures.
A client with a history of heart failure is admitted to the cardiac unit with a serum sodium level of 128 mEq/L or mmol/L (SI). The client is instructed to limit fluid intake to 1500 mL per day, as prescribed. The client’s serum sodium level the following day is 122 mEg/L or mmol/L (SI). Which action should the nurse implement?
A. Encourage the client to add salt to the foods on each of the hospital meal trays.
Explain that the fluid restriction has restored the client’s electrolyte levels.
Consult with the healthcare provider to increase the client’s allowable fluid intake.
Reteach the client about the need to adhere to the prescribed fluid restrictions.
Following a transurethral resection of the prostate (TURP), a client is discharged from the hospital with an indwelling urinary catheter. Which instruction is most important for the nurse to include in the discharge teaching plan?
Drink 3 liters of water each day.
Clamp the catheter when taking a shower.
Eliminate all spicy foods from your diet.
Avoid driving a car for 2 weeks.
During a preoperative assessment, a client responds to a question about the use of addictive substances by stating, “It’s none of your business.” The nurse’s response should be based on which information?
The client’s compliance with the treatment regimen should be obtained prior to surgery.
By law, information regarding drug addictions must be obtained before surgery can be initiated.
Any drug addictions will necessitate a delay in surgery until drug screening can be performed.
Many addictive substances cause interactions with other medications, including anesthesia.
A nurse establishes a nursing problem of, “fatigue related to inability to rest comfortably secondary to rheumatoid arthritis”. Which nursing intervention should the nurse include in the plan of care?
Instruct the client about the importance of maintaining bedrest
Consult the discharge planner about transferring the client to an assisted living center.
Offer assurance that the fatigue inducing stage of the disease does not last.
Assist the client with learning how to set priorities and pace activities
A client recently diagnosed with Crohn’s disease calls the clinic about several of her concerns. Which client comment should the nurse report to the healthcare provider?
Constipation for 2 days after eating cheese
Request to schedule another colonoscopy
Abdominal pain relieved by defecation
Bloody diarrhea after eating grilled beef
Which dietary instruction is most important for the nurse to explain to a client who has had gastric bypass surgery?
Chew slowly and thoroughly.
Sip fluids with each meal.
Reduce intake of fatty foods.
Eat small frequent meals.
A client newly diagnosed with hypothyroidism tells the nurse a plan to take the thyroid hormone replacement therapy until the thyroid gland returns to its normal size. How should the nurse respond?
Remind the client to come for regular checkups to assess the size of the gland.
Emphasize to the client that hormone replacement therapy is a lifelong need.
Assure the client that once surgery is performed, the gland will shrink rapidly.
Advise the client that serum hormone levels are more important than gland size.
The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with type 2 diabetes. Which outcome should the nurse include in the plan of care for this client?
The client’s blood pressure readings will be less than 160/90 mmHg.
The client’s hemoglobin A1C will be less than 7.0% (0.07) in 3 months.
The nurse will encourage the client to walk thirty minutes every day.
The nurse will demonstrate the procedure for accurate eye care.
While preparing a client with suspected appendicitis for an abdominal ultrasound, the nurse notes that the client is experiencing localized rebound tenderness in the right lower quadrant of the abdomen. Based on this information, which nursing intervention should the nurse implement?
Continue to prepare the client for the ultrasound.
Obtain a chest x-ray in preparation for surgery.
Administer the oral analgesic prescribed for PRN use.
Hold the ultrasound until the healthcare provider is notified.
A client with progressive heart disease receives a prescription for furosemide. Which intervention should the nurse implement?
Supplement diet with a daily banana.
Record usual eating patterns.
Document abdominal girth.
Measure ankle circumference daily.
The nurse mixes diphenhydramine 25 mg in a 100 mL bag of normal saline, which is to be administered over 30 minutes. The IV pump should be set to administer how many mL/hour? (Enter numeric value only.)
A client who is receiving packed red blood cells suddenly develops nausea and vomiting. Which action should the nurse take first?
Assess the client’s blood pressure.
Notify the healthcare provider.
Stop the infusion of blood.
Administer an antiemetic.
The nurse observes that a client with Parkinson’s disease (PD) has a mask-like face. Which follow-up assessment is most important for the nurse to implement?
Observe appearance of oral mucosa.
Assess patterns of speech.
Note frequency of drooling.
Determine ability to chew and swallow.
While taking the health history of a male adolescent client, the nurse learns that he is currently taking an anticonvulsant drug for a seizure disorder. He also tells the nurse that he is embarrassed by the appearance of his gums. Which drug is this client taking?
Valproic acid.
Phenobarbital.
Phenytoin.
Carbamazepine.
An older adult male resident of a long-term care facility, whose average blood pressure over the past week was 180/98 mmHg, receives a prescription for an antihypertensive medication. Which intervention is most important for the nurse to include in this client’s plan of care?
Measure and record the client’s urinary output every day.
Provide client with dietary teaching regarding a cardiac diet.
Obtain client’s vital signs every 4 hours when awake.
Obtain a blood pressure reading before client gets out of bed
A client recently diagnosed with early stage Alzheimer’s Disease receives a prescription for donepezil, an acetylcholinesterase inhibitor. Which content should the nurse include in the client medication teaching?
Explain that the psychiatrist has prescribed the maximum dose and will decrease it gradually.
Encourage the client to avoid foods high in Vitamin K, such as green leafy vegetables.
Instruct the client to get monthly liver function studies to assess for liver failure.
Discuss the fact that donepezil may slow the progression of the disease over the next year.
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Providing education for a client newly diagnosed with type 1 diabetes, which information is most important for the nurse to provide the client
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