A client is admitted to the medical department due to pneumonia associated with influenza. Which of the following interventions promote airway patency?
•Increasing fluid intake will facilitate easy expectoration of mucus secretions that accumulate in the airway.
•Frequent turning promotes airway patency. Clients with an altered level of consciousness should be turned at least every 2 hours and should be placed in side-lying positions, unless contraindicated, to prevent aspiration.
•Applying chest physiotherapy is an aggressive measure to maintain airway patency and may be required by certain conditions. This may need a doctor’s order.
A client was diagnosed with insulin-dependent diabetes and acute heart failure and was admitted to the hospital for medical management. What are the appropriate pharmacological interventions to help reduce myocardial workload and improve ventricular pump performance?
The nurse is instructing a newly-diagnosed diabetic. The nurse should inform the patient that diet and exercise affects insulin requirements. The nurse should include in the patient's instructions:
The nurse is caring for a patient complaining of chest pain related to pericarditis. To help relieve the pain, the nurse should instruct the patient to:
The nurse is assessing a patient with a fractured ulna. The nurse notes the bone is protruding through the skin. What type of fracture is this?
The nurse is caring for a patient who had a myocardial infarction three days ago. The nurse should assess for which abnormal heart sound?
A nursing student is assigned to a patient with rheumatoid arthritis. Which of the following statements regarding rheumatoid arthritis is incorrect?
The nurse is providing care for a patient admitted due to a thyroid storm. The nurse performs a comprehensive physical assessment and is most likely to discover which of the following?
The nurse is providing discharge instructions to a patient with osteoporosis. Which of the following should be included in the discharge instructions?
The nurse is caring for a patient with pericarditis. Knowing that this condition places the patient at risk for cardiac tamponade, the nurse should monitor for:
The nurse is caring for a patient after a closed reduction of a fractured humerus. While monitoring for a fat embolism, the nurse should be alert for which symptoms?
A nurse is caring for a client with fluid overload. The nurse knows that the typical findings in a client with fluid excess include which of the following?
A patient is scheduled for a computerized tomography (CT) scan. Which of the following is an appropriate statement by the nurse?
Nurses can expect which of the following interventions to help regulate or treat patients with atrial flutter?
A patient is seen in the emergency department for a myocardial infarction and cardiogenic shock. The physician assesses the patient for contraindications to an intra-aortic balloon pump (IABP). Which of the following is an absolute contraindication?
A client who underwent pneumonectomy two days ago has the nursing diagnosis of ineffective airway clearance related to increased secretions and decreased coughing effectiveness due to pain. Which among the following nursing care interventions can help the client achieve effective airway clearance?
A patient with chronic renal failure is being treated with continuous ambulatory peritoneal dialysis (CAPD). The nurse realizes this process:
The nurse is caring for a patient immediately following a kidney transplant. As the patient starts to develop a hyperacute rejection, the nurse should prepare the patient for:
A patient complains to the nurse that she leaks urine while exercising. All other assessment data is normal, so the nurse suspects that this problem is:
A nurse is using the Braden scale to assess a patient's risk for pressure ulcer formation. The patient's sensory perception is slightly limited, she is occasionally moist, she is chairfast, her mobility is slightly limited, nutrition is adequate, and friction is a potential problem. What is this patient's risk?
The nurse is administering several scheduled medications to a patient with acute renal failure. The nurse should frequently assess the patient for:
A nurse is educating a patient with emphysema that requires oxygen use at home via nasal cannula. The nurse should instruct the patient not to exceed what flow rate?
A nurse is assessing a patient with glomerulonephritis. The nurse asks the patient about a recent history of:
A nurse is caring for a newly admitted patient following a burn injury. The nurse suspects an inhalation injury. Which of the following assessment findings would support his suspicion?
A nurse is using the Braden scale to help predict a patient's pressure ulcer risk. The patient's sensory perception is very limited, she is occasionally moist, she is bedfast, her mobility is very limited, nutrition is adequate, and friction is a potential problem. What is this patient's total Braden score?