The nurse identifies which of the following findings is a characteristic of chronic pain?
Weight gain or loss, fatigue.
A patient with acute pain has a physician's order for morphine 8 mg IV every 3-4 hrs prn pain. The patient asks the nurse for the medication at bedtime. Prior to administering the pain medication, the nurse should take which of the following actions?
Assess location, character and intensity of pain.
On the first preoperative day, a patient develops a fever. The nurse auscultates crackles bilaterally in both lobes. The nurse understands which of the following complications of surgery is probably developing?
Atelectasis: secretions block the bronchioles and the alveoli collapse, causing hypoventilation.
The nurse identifies which of the following lab findings reflects signs and symptoms of an infection?
WBC of 16,000/mm3
The nurse understands which of the following behaviors is helpful to a patient to facilitate a bowel movement?
Increase dietary bulk.
The nurse notices that an elderly patient has rednenned area on the coccyx. Which of the following actions should the nurse take FIRST?
Reposition the patient every 1-2 hours.
The nurse knows that aspirin, if given in high, prolonged doses, may precipitate which of the following physiological changes?
The nurse identifies which of the following diets BEST meet the needs for a person with multiple wounds?
High vitamin-C, high-protein, high-carbohydrate diet.
The nurse helps a pt to cough and deep breathe after surgery. It is desirable for the patient to assume which of the following positions?
Several days postoperatively, a pt complains of pain, tenderness, and redness in the right calf. Which of the following are critical signs and symptoms the nurse should assess for NEXT?
Chest pain and shortness of breath.
In which of the following situations would the nurse consider withholding morphine until further assessment is complete?
Patient's level of consciousness fluctuates from alert to lethargic.
The nurse performs discharge teaching for a patient given warfarin (Coumadin). The nurse determines further teaching is required if the patient makes which of the following statements?
I should look for yellow-tinged complexion.
To promote evening rest and sleep for patients who are immobilized in bed, it is MOST important for the nurse to provide which of the following?
Which of the following actions is essential for the nurse to perform after administering preoperative medication to a patient?
Raise the side rails of the bed.
The client is admitted to the hospital with a temp of 101 degrees Fahrenheit and a WBC count of 3,000/mm3. The nurse should institute which of the following precautions?
Neutopenic precautions because patient is immunosuppressed.
The nurse instructs a patient about how to successfully establish exercise program. The nurse determines further teaching is required if the patient makes which of the following statements?
I should start by running 5 miles a day.
The nurse understands the purpose of a drain wound is which of the following?
Keep the tissues close together so healing can occur.
A client comes to the ER after puncturing his foot with a dirty nail. The cliet states that his last Td immunization was 6 years ago. Which of the following actions should the nurse take FIRST?
Determine how many Tds the patient has received. If the client received at least 3 Tds administer tetanus toxoid booster to prevent development of tetanus. If less then 3, administer both Td and tetanus immune globulin.
The home care nurse cares for a patient with a fractured humerus due to a fall in the home. Which of the following, if observed by the nurse, requires immediate intervention?
The client ambulates wearing socks.
The nurse observes a staff member prepare to leave the room of a patient on droplet precautions. The nurse should intervene if which of the following occurs?
The staff member holds onto the outer surface of the facemask while pulling mask away from face.
The nurse observes a staff member enter the patient's room wearing a protective respiratory device. The nurse determines care is appropriate if the the staff member is caring for which of the following patients?
A pt diagnosed with varicella.
A patient returns from abdominal surgery with an order for morphine sulfate IV q 3-4 hrs prn pain. During the first 24 hours after surgery, which of the following actions by the nurse is BEST?
Administer pain medication every 3 hours.
The nurse knows an important fact about warfarin (Coumadin) is...
it has a prolonged action. Duration is 2-5 days.
The nurse counsels a patient about how to maintain an adequate intake of protein. The nurse determines further teaching is required if the patient chooses which of the following foods?
Orange juice and white bread.
The nurse explains to the patient that the MOST Vitamin C can be found in which of the following?
Fresh orange juice.
The nurse identifies that a 5'6" woman's diet is appropriate if the patient consumes how many calories?
1,900 calories per day.
The home care nurse visits an elderly patient living alone on a limited income. The patient's diet primarily consists of carbohydrates. Based on an understanding of the nutritional needs of the elderly, which of these interpretations by the nurse of the patients diet is most appropriate?
The patient should increase the intake of protein.
The nurse prepares 4 patients for surgery. The nurse is MOST concerned about the psychological adjustments of which of the following patients?
A 26 yr old man scheduled for the Whipple procedure due to cancer of the pancreas.
A patient requires a dressing change. The LPN/LVN assigned to care for the patient reports to the registered nurse that she once observed a similar dressing change while in nursing school, but has never performed the procedure herself. The registered nurse should take which action?
Complete the dressing change while the LVN/LPN observes.
The nurse cares for a postoperative patient with an NG tube. Which of the following observations by the nurse is the MOST reliable indication that the NG tube is correctly positioned?
pH aspirate of is 3.