After a frontal craniotomy, a patient returns to the neurosurgery unit. Which of the following orders might the nurse expect for the patient?
• Administering Oxygen at 2 liters per minute is an appropriate order. Oxygen is needed to prevent hypoxia that could lead to cerebral edema
• Orders to administer dexamethasone would be expected. Dexamethasone can reduce or prevent cerebral edema
• Raising the head of bed to 30 degrees reduces cerebral edema
• Putting the patient in Trendelenburg's position would be contraindicated because it would increase blood flow to the brain, raising ICP
• Clustering activities is not advised because it can contribute to raised ICP. Spacing activities out allows the patient's ICP to come back to baseline before performing any other activities.
• Infusing IV fluids at 160 ml/hr may be too high for this patient. It can lead to fluid overload and increased ICP. Following a craniotomy, a patient’s fluid intake is restricted to 1-2 liters per day
A patient has a skin lesion on his shoulder. The nurse would suspect melanoma if the lesion had which of the following characteristics?
When caring for a clinically stable patient with chronic kidney disease (CKD), the nurse consults with the dietician who advises inclusion of which foods in his diet?
What members of the health care team should be consulted for a patient with a stage II sacral ulcer?
A patient with progressive muscle weakness and poor balance is suspected of having muscular dystrophy. What test would the nurse expect the physician to order to confirm the diagnosis?
A patient has been diagnosed with left-sided congestive heart failure, and is confused about return of oxygenated blood from the lungs. To clarify the confusion, the nurse explains all chambers of the heart dealing with blood circulation. The nurse is correct when she tells the client:
A nurse is teaching a patient with hyperparathyroidism how to prevent hypercalcemia. The nurse should include which of the following in her medical counseling?
A nurse is caring for a client with a gout flare-up. Which of the following indicate appropriate care?
A patient returns to the unit after a cerebral arteriogram. Which of the following interventions will the nurse perform?
The nurse is preparing to defibrillate a patient with ventricular fibrillation. The nurse should double-check the synchronizer switch because:
After reviewing materials for a musculoskeletal exam, a nursing student understands that dislocation rarely happens in the:
A nurse is assessing a patient for hemorrhage after he underwent a transsphenoidal hypophysectomy. Which of the following signs may be present?
The nurse is providing instructions to a patient with a muscle strain of the right biceps femoris. Which of the following instructions should the nurse include?
A diabetic patient is admitted to the hospital with a blood glucose of 395 mg/dl. The nurse assesses the patient for which clinical manifestations of hyperglycemia?
The nurse is caring for a deteriorating patient going into cardiogenic shock. The nurse expects to note which manifestations?
The nurse is evaluating a patient with decreased cardiac output related to a myocardial infarction. Which of the following indicates improved cardiac output?
A patient with a history of stroke asks the nurse to explain the difference between a cerebrovascular accident (CVA) and a transient ischemic attack (TIA). The nurse correctly answers:
A client admitted to the ICU due to unresponsiveness is diagnosed with cerebrovascular accident (CVA) and started on nasogastric tube feedings. Which of the following should be performed if gastric residual is more than 100ml?
A patient is to undergo an endoscopic retrograde cholangiopancreatography (ERCP) and it is the nurse's responsibility to provide education before and after the procedure. Which of the following statements by the patient indicates a need for further teaching?
A patient is being cared for by a home-health nurse. The patient has jaundice and is complaining of pruritus. Which of the following interventions can the patient implement to reduce pruritus?
While analyzing a patient's 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:
A 30-year-old patient has been treated at the emergency department for a head injury and is to be discharged. As the nurse provided health instruction to the family, she explained signs of complications and the appropriate measures to perform if they occur. Which statement by the patient's spouse requires further teaching?
In the teaching plan for the client with heart failure (HF), the nurse includes the definition of the condition. Select all the appropriate descriptions of HF.
A nurse is assisting a post-stroke patient with using a wheelchair. A safe transport from the bed to the wheelchair is observed when which of the following is implemented?
The nurse is caring for a patient at risk for premature ventricular contractions (PVCs). While monitoring the patient's EKG rhythm, the nurse should look for:
A nurse is providing instructions to a patient with gastroesophageal reflux disease (GERD). The nurse should include which information?
The nurse is reviewing the x-ray of a patient with a fractured humerus. The x-ray shows one side of the bone is broken while the other side is bent. What type of fracture is this?
The nurse is preparing to ambulate a patient to a chair after a total knee replacement. In order to protect the knee, the nurse should:
A patient is seen in the clinic for symptoms consistent with gastroesophageal reflux disease. The nurse should expect which common symptoms?
A home health nurse is examining a patient with a hiatal hernia. Which of the following would the nurse note as a classic sign of hiatal hernias?
The nurse is providing discharge instructions to a patient with rheumatoid arthritis. In order to reduce joint discomfort, the patient should:
A patient is admitted to the cardiac unit after having a myocardial infarction. Prioritize the nurse's next actions.
1. Insert an IV.
2. Hook the patient up to a cardiac monitor.
3. Initiate thrombolytic therapy.
4. Provide the patient with water.
The nurse is caring for a patient in the advanced stages of cirrhosis. While making menu selections, the nurse should suggest increasing:
The nurse is providing instructions to a patient with hemorrhoids. The nurse should recommend which of the following?
A patient with right lower quadrant abdominal pain is suspected of having appendicitis. The nurse explains to the patient that the most common cause of appendicitis is:
The nurse is educating a patient with cirrhosis about lifestyle changes. Which of the following statements by the patient indicates the need for additional education?
The nurse is caring for a patient that developed severe osteomyelitis after sustaining a hip fracture. The nurse would prioritize which physician order?
A patient is brought to the emergency department with complaints of chest pain radiating to the shoulder and shortness of breath. Which of the following lab tests is most important to obtain and evaluate?