A nurse is assessing a patient with cirrhosis. The nurse should know that which of the following would indicate late stage liver deterioration?
• Hepatic deterioration, the later stages of cirrhosis, causes encephalopathy due to the increased levels of ammonia in the blood. This results in a diminished level of consciousness, confusion, flapping tremor of the hands (asterixis), and a sweet odor to the breath is often noted.
• Weight loss and muscle weakness occur long before the later stages of cirrhosis.
• Low urine output would be due to kidney deterioration.
The nurse is assessing the hepatojugular reflux in a patient with congestive heart failure. To perform this assessment technique correctly, the nurse should
The nurse is creating a care plan for a patient with Cushing's syndrome. Which of the following nursing diagnoses is most appropriate?
A nurse is providing instructions to a patient diagnosed with impetigo. Which of the following is important in the prevention of impetigo transmission?
A surgical floor nurse is caring for a post-operative client who has undergone a total thyroidectomy. Which of the following are important nursing assessment measures during post-operative care?
A patient with osteoporosis is post-op day two in the hospital after a hip fracture. Which of the following would improve her outcomes?
A patient with Cushing's syndrome is being treated in the hospital. Which of the following is an appropriate nursing intervention to help prevent complications?
The physician is planning to wean a patient off a ventilator and asks the nurse for which of the following data which is important for assessing the patient's ventilatory status?
A patient who sustained a fractured fibula has developed compartment syndrome. The nurse explains compartment syndrome to the patient knowing that:
A nurse is assessing a patient with acute pancreatitis. The nurse should be aware of which assessment findings that support the diagnosis?
An 82-year-old patient is having trouble maintaining regular bowel movements. The nurse is providing instruction and tells the patient to avoid:
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 has developed pyelonephritis after being treated for a urinary tract infection. Which of the following interventions is most important?
The nurse is reviewing the complete blood count (CBC) of a healthy patient. Which of the following white blood cells should the nurse expect to be most numerous?
A client with an indwelling urinary catheter needs a urine specimen. To obtain a specimen from a Foley catheter, the nurse should first:
A nurse enters the patient's room to address a ventilator alarm. The alarm states "low-pressure" in the ventilator closed system, but after checking the ventilator and endotracheal (ET) tube, the nurse cannot determine the cause of the alarm. What action should the nurse perform next?
The nurse is providing ostomy care for a patient after a colectomy. The patient is complaining of the foul odor coming from the ostomy. The nurse instructs the patient to consume more odor eliminating foods, such as:
A nurse is caring for an intubated patient on a mechanical ventilator. The patient is in need of endotracheal (ET) suction. The nurse should expect to find which of the following?
The nurse is providing discharge teaching to a patient who underwent a coronary artery bypass graft (CABG). Which of the following should the nurse explain is common in the weeks following surgery, but will likely resolve without treatment?
The nurse has administered several rapid fluid infusions to treat diabetes insipidus. The nurse assesses the patient for water intoxication, expecting to note
A nursing student is assigned to a patient with rheumatoid arthritis. Which of the following statements regarding rheumatoid arthritis is incorrect?
The nurse is caring for a patient who had a myocardial infarction three days ago. The nurse should assess for which abnormal heart sound?
The nurse is providing discharge instructions to a patient with congestive heart failure (CHF). Which of the following foods should the nurse tell the patient to avoid?
The nurse who is caring for an older client with severe dehydration knows that the best indicators of hydration status are