A client with an elevated temperature, fatigue, and labored breathing is admitted with a diagnosis of pneumonia. Which of the following nursing interventions should be started to assist with airway clearance?
•Incentive spirometry helps maximize inhalations and exhalations.
•Frequently changing sides allows maximum expansion on alternate sides of the chest.
•Deep breathing encourages oxygenation before controlled coughing.
•Adequate hydration helps the patient expectorate mucus by thinning out pulmonary excretions.
•The orthopneic position does not need to be prevented. This is an adaptation of the high-Fowler's position and helps the client in exhaling as he or she can press the lower part of their chest against the table.
•The supine position causes organs to shift towards the chest, restricting deep breathing. Placing the patient in semi-Fowler's position allows for maximum chest expansion.
The nurse is providing discharge instructions to a patient with a nasogastric (NG) tube. If the NG tube becomes clogged, the nurse should instruct the patient to:
The nurse is assessing a client with moderate dehydration. Which of the following assessment findings are characteristic of this condition?
A patient recently diagnosed with psoriasis is being instructed on the precipitating factors associated with this disease. Which of the following should the nurse include?
A nurse is providing instructions to a patient with gastroesophageal reflux disease (GERD). The nurse should include which information?
A patient is admitted to the cardiac unit after having a myocardial infarction. Prioritize the nurse's next actions:
1. Insert an IV.
2. Begin cardiac monitoring.
3. Initiate thrombolytic therapy.
4. Provide the patient with water.
The nurse is caring for a patient with a small bowel obstruction. When planning the patient's care, the nurse should consider the immediate goal to be:
The nurse is caring for a patient with an arteriovenous (AV) fistula on the right arm for hemodialysis treatments. To promote safety, the nurse should do which of the following?
The nurse is caring for a patient who developed severe osteomyelitis after sustaining a hip fracture. The nurse would prioritize which physician order?
The nurse is assessing a patient who underwent a cholecystectomy 2 days ago. The nurse notes that the patient has no bowel sounds. What should the nurse do next?
While assessing a patient suspected of having hypothyroidism, the nurse would expect to observe which of the following symptoms?
A 43-year-old male is seen at the clinic with reports of weight gain and fatigue. He is noted to have a wide "moon" face with a ruddy complexion. The patient is diagnosed with Cushing's disease, most likely caused by
The nurse is caring for a patient with fulminant ulcerative colitis. The nurse would be alert for which of the following symptoms associated with severe fulminant ulcerative colitis?
A patient is admitted to the hospital for a pulmonary embolism. The nurse assesses the patient knowing that which of the following is commonly reported?
While analyzing a patient's electrocardiogram (EKG), the nurse notes that there are four small boxes from the beginning of the P wave to the beginning of the R wave. The PR interval is
Which is an appropriate goal for a patient with chronic obstructive pulmonary disease (COPD) and a nursing diagnosis of activity intolerance related to alterations in oxygen transport?
The nurse is assessing a patient with pneumonia. The patient says "ninety-nine" several times while the nurse is auscultating her lungs. The nurse clearly hears the patient's words throughout the lungs. What term is used to describe this finding?
A nurse is caring for a patient that sustained a traumatic chest injury causing flail chest. The nurse assesses the patient for which distinctive characteristic of flail chest?
The nurse is discharging a patient who underwent a left knee arthroscopy. The patient understands the discharge instructions if the patient states the need to:
The nurse is assessing a newly admitted patient and asks about family health history. Which of the following diseases has a familial basis?
A dialysis nurse is treating a client with newly diagnosed acute renal failure who is receiving dialysis for the first time. Which common complication must the nurse look out for?
A nurse has tested negative for HIV after a recent exposure to contaminated blood. Which of the following is correct?
A patient walks into the emergency department after being bitten by a deer tick. The patient is nervous about Lyme disease. The nurse informs the patient that
A patient is being evaluated for polycystic kidney disease (PKD). The nurse assesses the patient expecting to note which common symptoms?
A nurse is administering a tuberculosis (TB) skin test to a patient at high risk for TB. During patient education, the nurse should include which of the following facts about the tuberculosis skin test?
The nurse is assisting the physician with the removal of a chest tube following the resolution of a pneumothorax. The nurse should instruct the patient to do which of the following during removal?
The nurse is caring for a patient suspected of having systemic scleroderma. The nurse explains to the patient that systemic scleroderma
A patient who is to be discharged after being diagnosed with multiple myeloma is given instructions by the nurse. It is very important for the nurse to remind the patient to
A patient is prescribed a 24-hour urine test after sustaining significant damage to the kidneys. The nurse advises the patient that the collection time for this test should start when?
The nurse is caring for a patient after a total laryngectomy. It is most important for the nurse to do which of the following?
The nurse is caring for a patient receiving a heparin infusion for the management of a pulmonary embolus (PE). The nurse observes bright red urine in the patient's catheter bag. What should be done first?
The nurse is caring for a patient diagnosed with pleurisy. Which of the following assessment findings is characteristic of pleurisy?
Which intervention(s) would the nurse expect to provide when caring for a patient with idiopathic thrombocytopenia purpura (ITP)?
The nurse is caring for a patient diagnosed with mitral valve stenosis. The patient complains of a cough and difficulty breathing when lying down. Upon assessment, the nurse notices the presence of
A client has moderate-to-severe hypotonic extracellular fluid loss. Which IV fluids can be administered to correct the fluid balance?
The nurse assesses a patient with a small bowel obstruction and an NG tube set to intermittent wall suction. The patient has been reluctant to ambulate and is complaining of continued pain and nausea. The nurse determines a nursing diagnosis of acute pain with a goal to reach the patient's acceptable pain level of 4 out of 10 by the end of