181. In assessing a client twelve hours following transurethral resection of the prostate (TURP), the nurse observes that the urinary drainage tubing contains a large amount of clear pale pink urine a... nd the continuous bladder irrigation is infusing slowly. What action should the nurse implement? - ✔✔Ensure that no dependent loops are present in the tubing. 182. The healthcare provider prescribes the antibiotic Cefdinir (cephalosporin) 300mg PO every 12 h for a client with postoperative wound infections. Which feeds should the nurse encourage this client to eat? - ✔✔Yogurt and/or buttermilk. 183. The charge nurse is making assignment on a psychiatric unit for a practical nurse (PN) and newly license register nurse (RN). Which client should be assigned to the RN? - ✔✔A young male with schizophrenia who said voices is telling him to kill his psychiatric. 184. A client at 30 week gestation is admitted due to preterm labor. A prescription of terbutaline sulfate 8.35 mg is gives subcutaneously. Based on which finding should the nurse withhold the next dose of this drug? - ✔✔Maternal pulse rate of 162 beats per min 185. In assessing an older female client with complication associated with chronic obstructive pulmonary disease (COPD), the nurse notices a change in the client's appearance. Her face appears tense and she begs the nurse not to leave her alone. Her pulse rate is 100, and respirations are 26 per min. What is the primary nursing diagnosis? - ✔✔Anxiety related to fear of suffocation. 186. A client with a cervical spinal cord injury (SCI) has Crutchfield tongs and skeletal traction applied as a method of closed reduction. Which intervention is most important for the nurse to include in the client's a plan of care? - ✔✔Provide daily care of tong insertion sites using saline and antibiotic ointment 187. A client arrives on the surgical floor after major abdominal surgery. What intervention should the nurse perform first? - ✔✔Determine the client's vital sign. 188. A client is admitted to the emergency department with a respiratory rate of 34 breaths per minute and high pitched wheezing on inspiration and expiration, the medical diagnosis is severe exacerbation of asthma. Which assessment finding, obtained 10 min after the admission assessment, should the nurse report immediately to the emergency department healthcare provider? - ✔✔No wheezing upon auscultation of the chest. 189. The nurse is planning a class for a group of clients with diabetes mellitus about blood glucose monitoring. In teaching the class as a whole, the nurse should emphasize the need to check glucose levels in which situation? - ✔✔During acute illness 190. A 350-bed acute care hospital declares an internal disaster because the emergency generators malfunctioned during a city-wide power failure. The UAPs working on a general medical unit ask the charge nurse what they should do first. What instruction should the charge nurse provide to these UAPs? - ✔✔Tell all their assigned clients to stay in their rooms. 191. The nurse is auscultating is auscultating a client's heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio file to select the option that applies.) - ✔✔Murmur 192. The healthcare provider changes a client's medication prescription from IV to PO administration and double the dose. The nurse notes in the drug guide that the prescribed medication, when given orally, has a high first-pass effect and reduce bioavailability. What action should the nurse implement? - ✔✔Administer the medication via the oral route as prescribed 193. A client refuses to ambulate, reporting abdominal discomfort and bloating caused by "too much gas buildup" the client's abdomen is distended. Which prescribed PRN medication should the nurse administer? - ✔✔Simethicone (Mylicon) 194. The public nurse health received funding to initiate primary prevention program in the community. Which program the best fits the nurse's proposal? - ✔✔Vitamin supplements for high-risk pregnant women. 195. When assessing and adult male who presents as the community health clinic with a history of hypertension, the nurse note that he has 2+ pitting edema in both ankles. He also has a history of gastroesophageal reflex disease (GERD) and depression. Which intervention is the most important for the nurse to implement? - ✔✔Review the client's use of over the counter (OTC) medications. [Show More]
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