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Terms in this set (20)

A patient/client who is lactose intolerant is recovering from a surgical procedure. What impact does the nurse expect this to have on progression of diet as tolerated?
The client's full liquid diet may need to be altered because this diet contains milk product
The nurse must provide an elastic bandage to support a client's sprained ankle. Which action should the nurse take during this procedure?
Moderately stretch bandage and wrap from distal to proximal extremity
The nurse is to conduct an admission interview on a 74-year-old patient who is hearing impaired. What should the nurse do to enhance to client's hearing ability?
Position self in client's line of vision
The nurse would assess for which signs of morphine overdose in a patient receiving controlled analgesia?
A decrease in BP and respiratory rate
An adult patient who has been hospitalized for 3 days is having trouble sleeping. The nurse noted confusion on waking hours. What is the most appropriate diagnosis for this patient?
Disturbed sleep pattern
When planning care of a patient with dementia, which of the following outcomes would be a priority?
Preventing injury
The nurse is changing an abdominal dressing on a patient 4 days post op. The nurse noted moderate amounts of serosanguinous drainage, wound edges not approximated, and puffy tissue protruding through the wound. What condition should the nurse suspect from these manifestations?
evisceration
The nurse is working in a STI clinic using communication skills to assess patients and provide health education. When developing a rapport with the adolescent client the nurse uses which approach?
Consistently give honest information
An older client has been recently diagnosed with a UTI and displays sudden onset of confusion. Which of the following is he most likely experiencing?
Delirium
A patient diagnosed with a terminal illness states, "what's left for me? I feel hopeless." The nurse determines that which of the following would be the best response?
It must be difficult feeling as if there is no hope"
Vital signs, level of consciousness, and skin color that you observe are which type of data?
Objective data
A patient tells the nurse that acupuncture really helps ease pain of terminal illness. How should the nurse react to this?
Understand that this is an appropriate intervention
A patient is about to undergo a skin biopsy to determine if a skin lesion is malignant. The client asks how much the biopsy will hurt. Which is the best response by the nurse?
"You may feel discomfort while the localized anesthetic is administered but this will numb the area of the biopsy"
The nurse working with a terminally ill patient wishes to support the family in end of life care. To do this the nurse should do what?
Respect patient wishes to the extent possible by law
A nurse has received report on a patient being admitted with anemia who requires a blood transfusion. The nurse will anticipate which assessment finding?
Tachycardia
A school nurse is planning a health class on accidents and injuries for high school students. Which topic is the most important to include?
Motor-vehicle related injures
A nurse is caring for a client who is receiving enteral feedings due to dysphagia. Which of the following positions should the nurse use for safe care of this client?
Semi-fowler's
The nurse would implement which of the following as a requirement of care specific to the patient who has tuberculosis?
Private room with negative airflow
The nurse would take which actions to comply with principles of medical asepsis?
Wash hands before and after assisting client with personal hygiene
Which precaution would the nurse implement when admitting a client with scabies to the nursing unit?
Contact precautions
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