The findings are indicative of which nursing diagnosis? The nurse cannot auscultate bowel sounds and notes the client's abdomen is rigid. A group of nursing students is reviewing the various white blood cells and how they function in infection. A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Meningitis is an inflammation of the meninges, the membranes that cover the brain and the spinal cord. Avoid a diet that consists primarily of milk. What is the best response by the nurse? Many medications are available to control nausea and vomiting without oversedating the patient. \underline{~~~~~~~~~~~~~~~}~~~~~~~~~~~~~~~~~~~~~~~\text{HClO}_2 an 81-year-old man with active tuberculosis and a productive cough. Here are six (6) nursing care plans (NCP) and nursing care plan for prostatectomy: The nurse observes profuse sweating above the level of injury. The goal of postoperative care is to ensure that patients have good outcomes after surgical procedures. (C ) Urea forms an insoluble precipitate. d) The magma had abundant dissolved gas. Based on the nurse's knowledge of the most common hospital-acquired infections, which apparatus is most important to remove first? When planning care for a client in the postoperative period, prioritize nursing diagnoses in the sequence from highest to lowest priority? One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which nursing intervention is the most important? Which of the following findings should the nurse expect? **Complete the medical term, based on its meaning as provided. The nurse expects informed consent to be obtained for insertion of: The nurse recognizes that the older adult is at risk for surgical complications due to: The nurse recognizes older adults require lower doses of anesthetic agents due to: The client asks the nurse about ways to control pain other than taking pain medication. Describe the indicated assessment and interventions related to each problem as listed in the questions below . The nurses are collecting the contaminated material as per the double-bagging method. A nurse is caring for a 2-month-old infant who is postoperative following repair of a cleft lip and palate. Which statement by the client provides evidence that client teaching was effective? Which of the following clinical manifestations should the nurse expect? Move the bed to various places in the room or periodically rearrange the furnishings in the room. The nurse should respond with which of the following common names? Respiratory rate is 20, temperature is 99.8 (taken orally), heart rate is 87, and blood pressure is 124/70. b) The rock solidified at great depth.\ Assume the variables x = 5, y = 6, and z = 8. Neurons make up a nerve. A good outcome includes recovery without complications and adequate pain management . A nurse is providing health promotion teaching to the parents of an infant. This increase in pressure can cause the delicate structures to be moved, damaged, or destroyed. Preoperatively identifying a patient's individual needs and comorbidities can assist in this process. What lobe of the cerebral cortex is largely responsible for the ability of humans to achieve higher levels of mental functioning and is also involved with motor functions that direct body movements? A 79-year-old man is scheduled for surgical repair of an inguinal hernia. A client with urinary tract infection is prescribed phenazopyridine (Pyridium). Select all that apply. What area does the nurse know needs to be addressed before the client is taken to the operating room? Another objective of postoperative care is to assist patients in taking responsibility for regaining optimum health. A nurse is caring for a 4-year-old child who has a new diagnosis of diabetes mellitus and is distressed after an insulin injection. Select all that apply. A client with nausea and vomiting is to receive an antiemetic that inhibits the vomiting center in the brain. Which of the following play activities should the nurse recognize is therapeutic in helping the child deal with the injection? Routine nasal and rectal swabbing of a newly admitted hospital client has come back positive for methicillin-resistant Staphylococcus aureus (MRSA), indicating that the client is colonized with MRSA. Which system is responsible for preparing individuals for an emergency, known as the "fight-or-flight" response? Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dl and has vertigo when getting out of bed. The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. What means of transmission do nurses use transmission barriers to protect themselves from? A nurse is caring for a client admitted to the healthcare facility with a history of hypertension and right-sided hemiplegia. Which nursing statement would best decrease a client's anxiety before an emergency operative procedure? Select all that apply. Wear a mask when working within 3 feet of the client. A 33-year-old woman had a laparoscopic cholecystectomy performed this morning and was transferred at 15:00 to the postsurgical unit from PACU. They open in the back to reduce inadvertent contact with the client and objects. "Please get a mask from the staff upon entry and use a mask along with hand hygiene when visiting to prevent the spread of infection to your friend and others.". The patient is scheduled to receive epidural anesthesia. How many mL should the nurse administer? A nurse is caring for a 55-year-old postoperative client. Which of the following information should the nurse include in the teaching? An experienced nurse is teaching a student nurse about the proper use of hand hygiene. What assessment findings would be a priority for the nurse to alert the provider? Dendrites are short, highly branched extensions of the cell body. Which of the following instructions should the nurse provide to the parent? The nurse is teaching the client about patient-controlled analgesia. Avoid touching the outer surfaces of the gown. Based on this information, what type of precautions should the nurse initiate and review the procedures with staff members? A nurse is caring for a 55-year-old postoperative client. What is the priority action by the nurse? A polymerase chain reaction. Select all that apply. Select all that apply. What assessment data may indicate that the patient does have a paralytic ileus? The client is receiving 0.9% normal saline at 75 mL/h, has a nasogastric tube to low wall suction with 200 mL every 8 hours of light yellow fluid, and a wound drain with 50 mL of dark red drainage every 8 hours. The nurse is caring for a client diagnosed with bladder cancer and requiring a cystectomy. Which of the following would the nurse expect to include in the client's plan of care? Select the stage during which the OR nurse knows not to touch the patient (except for safety reasons) because of possible uncontrolled movements. "As a nurse, I am required by law to report suspected child abuse.". Which is the function of the myelin sheath around an axon? What is the magnitude of the impulse on the passenger during the collision. The client states, "I'm really nervous about this surgery. Multiple Choice Q09 The nurse reminds the visitor of a client with an antibiotic-resistant infection that gloves are necessary. While assessing this patient, what characteristic symptom would the nurse expect to find? A nurse is performing a sterile dressing change on a client and notices that there is a hole in one of the sterile gloves. The lens opacity reduces visual acuity. Which of the following would the instructor include in this plan about these agents and this type of anesthesia? A client is scheduled to undergo surgical creation of an ileal conduit. A nurse is planning care for a 10-month-old infant who is 8 hr postoperative following cleft palate repair. Which pieces of personal protective equipment should be removed first? What would the nurse expect to asses? A client comes to the clinic for a follow-up visit. The appropriate nursing intervention is which of the following? (Select all that apply.). The primary reason for this vaccine is: it is a vaccine given to booster antibodies towards the tetanus pathogen. The nurse is preparing to don sterile gloves for a procedure that requires surgical asepsis. The nurse is assisting in the transport of a client with an indwelling catheter to the diagnostic studies unit. The client begins to complain of increased abdominal pain and begins to vomit. What related complication should the nurse be aware of? The nurse is evaluating the effectiveness of discharge teaching for a client with an oxalate urinary stone. The students demonstrate understanding of the information when they identify which cell as important in synthesizing immunoglobulins? Used to evaluate vascular lesions, neoplasms, abscesses, and areas of cerebrovascular ischemia. The child weights 55 lbs. The nurse would expect the healthcare provider to further assess the client for a midbrain disorder based on what function of the midbrain? Cover the wound with a sterile, saline - soaked dressing 4. Person A is stationary on the dock. An elderly client arrives at a healthcare facility with complaints of loss of sensation. Both of the child's parents have a smoking history. A school nurse is assessing an adolescent who reports feeling shaky and is having difficulty speaking and concentrating on the questions the nurse is asking. A swimmer moves through the water at an average speed of 0.22 m/s. 176. A life threatening condition that has a sudden onset as respiratory muscles become too weak to function. Which of the following actions by the nurse is inappropriate? The nurse should understand that these actions are developmentally appropriate at which of the following ages? Which stage of surgical anesthesia is also known as excitement? The client received general anesthesia for the procedure and has opioid pain medications prescribed. During the surgical procedure, the client exhibits tachycardia, generalized muscle rigidity, and a temperature of 103F. Nurses' Notes 1300: Client reports intermittent abdominal pain as 5 on a scale of 0 to 10 on left side of abdomen. c) The magma formed some crystals before rising closer to the surface and solidifying.\ You are caring for a client preoperatively who is very anxious and fearful about their surgery. Which of the following drug classifications may cause respiratory depression from an associated electrolyte imbalance during anesthesia? Record your answer using a whole number. B. How should the nurse respond? A nurse is admitting a child who has leukemia and a critically low platelet count. Nurses play a key role in reducing both the spread of disease and adverse outcomes for clients. What is the primary action taken by the nurse? observe the colleague and take no further action. This nurse also has another client today who has an upper respiratory infection. d.The nurse is caring for a client with a C. difficile infection. Which nursing diagnosis is appropriate for the client with a new ileal conduit? What precautions should the nurse take when caring for this client? As a circulating nurse, what task are you solely responsible for? The nurse is caring for a 75-year old client on the first post-operative day following a mitral valve replacement due to mitral stenosis.The nurse has identified the following potential complications and developed a nursing diagnosis and goals for each potential complication. How will the team proceed with care? The car's mass is $1150 \mathrm{~kg}$. What priority measures to avoid cross-contamination should the nurse provide? The nurse takes the opportunity to teach the family member about preventing the spread of the cold. Each time symptoms reappear, they are more severe and of longer duration. B. A nurse is assessing a client for signs and symptoms of infection. Do you think it will be ok?" Huntington's disease is a chronic, progressive, hereditary condition in which brain cells in the basal ganglia prematurely die. The nurse is providing postoperative care to a client with lung cancer who had a partial pneumonectomy. $$ Which of the following findings should the nurse expect the client to manifest with acute lead poisoning? The nurse should place a sign with which of the following warnings over the child's bed? Which client should the nurse determine is at greatest risk for vancomycin-resistant enterococci (VRE) infection? Nursing Nursing questions and answers The nurse is caring for a 40-year-old client who is 2 hours postoperative following an appendectomy. Select all that apply. Which of the following positions would the nurse expect the client to be positioned on the operating table for renal surgery? While assessing the patient at the beginning of the shift, the nurse noted decreased breath sounds, crackles, and a mild cough. A nurse is caring for a child who has influenza. Which of the following techniques could the nurse employ to assist this client? Which of the following actions should the nurse suggest to the parent? Which precautions will the nurse begin? The nurse should perform the compressions using which of the following techniques? The nurse working with a patient after an ileal conduit notices that the pouching system is leaking small amounts of urine. You are doing a preoperative assessment on a patient going to surgery. \text{BrO}_2^-~~~~~~~~~~~~~~~~~~~~~~~~~~~~~\underline{~~~~~~~~~~~~~~~} A nurse is caring for a client who is three hours post op from open abdominal surgery. The most common presenting objective symptoms of a urinary tract infection in older adults, especially in those with dementia, include? Which client would require a negative flow room? Pour the liquid into a sterile container within the sterile field. Select all that apply. NA. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. A sudden or gradual interruption of blood supply to a vital center in the brain is a stroke, AKA CVA or Cerebral (brain) infarct. Record your answer using a whole number. What condition might increased ICP indicate? A nurse is planning care for a client who ingested a large amount of acetylsalicylic acid. The client's vital signs are Temp 97.2F, HR 105, RR 24 and BP 110/50. A nurse is providing care for a client who recently underwent craniotomy for surgical resection of a brain tumor. Select all that apply. Hand hygiene is needed after contact with objects near the client. A nurse is teaching a parent of a child who has hemophilia how to control a minor bleeding episode. Preoperative Nursing Assessment A comprehensive preoperative nursing assessment of the total hip patient is important in helping to achieve a positive outcome. Place the client on NPO status 2. D. "Have your child sit with her head tilted forward and hold pressure on her nose for 10 minutes.". A post op client reports severe abdominal pain. A nurse is providing nutritional teaching to the mother of a preschooler and is recommending food options to provide 1 oz of grains. Select all that apply. What part of the central nervous system has its major divisions as the cerebrum, cerebellum, and medulla oblongata? Which nursing action carries the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)? A nurse is caring for a school-aged child who has a systemic disorder and is receiving antibiotics, immunosuppresants, and corticosteroids. Which of the following actions should the nurse take? Which of the following statements should the nurse make? A nurse is admitting a 6-month-old infant who has dehydration. The child's parent asks the nurse what the common name for this disease is. The child reports soreness in his mouth and refuses to eat. "I will keep my baby in an upright position after feedings.". When is the ideal time to discuss preoperative teaching. How will the nurse document this condition? The client becomes upset stating, "You did not wash your hands!" Which of the following findings should the nurse expect? The client's vital signs are Temp 97.2F, HR 105, RR 24 and BP 110/50. In gathering information for the client, which urinary diversion would the nurse select? D. Initiate the use of a PCA pump for pain control. With what score can the patient be transferred out of the recovery room? What postoperative difficulties can the nurse anticipate for this patient? A nurse is caring for a client who is being treated for a nervous system disorder. The nurse advises the patient with chronic pyelonephritis that he should: A woman comes to her health care provider's office with signs and symptoms of kidney stones. Two nurses are collecting the contaminated items and soiled linen from the room of an older adult client with a urinary tract infection. Which of the following is the appropriate response to the statement, "I'm so nervous about my surgery"? After the cable snaps and the safety system fails, an elevator cab free-falls from a height of 36 meters. Which room assignment will the nurse make? The nurse is assisting a colleague with wound care. The client has a history of anxiety, depression, high blood pressure, and exercise-induced asthma. A nurse is providing teaching to a parent of a child who has Hirschsprung disease and is scheduled for initial surgery. Which of the following actions should the nurse take? It is located below the thalamus is also part of the diencephalon, Is a long mass of nerve cells and fibers extending through a central canal on the dorsal side (back of the body). Before providing preoperative and postoperative instructions to the client, nurse Gail asks the surgeon which prostatectomy procedure will be done. The client returns to the ICU after surgery intubated and mechanically ventilated with a Salem sump nasogastric tube, a Foley catheter, and a PICC line in place. A team of nurses is caring for a client with tuberculosis. Which of the following instructions should the nurse include in the teaching? A. Select all that apply. A bearded nurse needs to assess the condition of a client with pulmonary tuberculosis (TB). Before discharge, the nurse should provide which instruction? Which of the following interventions should the nurse include in the plan of care? When planning this client's care, the nurse should assign the highest priority to which nursing diagnosis? Following percutaneous nephrolithotomy, the client is at greatest risk for which nursing diagnosis? There are four stages of general anesthesia. They have not been fitted an N95 respirator. The physician tentatively diagnoses right ureterolithiasis (renal calculi). What is your response to her situation as ordered by the physician? The nurse knows that adequate preoperative teaching and learning is important for what reason? When explaining to the client about collecting the specimens, the nurse would inform the client that the specimens will be collected daily for: Every 2 hours, the nurse turns and repositions the client who is experiencing frequent diarrhea. Be addressed before the client not auscultate bowel sounds and notes clear nasal drainage from the room cells... Of grains critically low platelet count a healthcare facility with a patient going to surgery to be addressed before client... Transmission do nurses use transmission barriers to protect themselves from prostatectomy procedure will be done the highest priority which! Assessing a client with lung cancer who had a laparoscopic cholecystectomy performed this morning and transferred! Patient at the beginning of the following techniques could the nurse include in the of! Nurse Gail asks the nurse take requires surgical asepsis spinal cord providing preoperative and postoperative instructions the..., high blood pressure is 124/70 and a nurse is caring for a 55 year old postoperative client a sudden onset as respiratory muscles become too to... Nurse employ to assist this client 's plan of care magnitude of the findings! Surgical anesthesia is also known as excitement large amount of acetylsalicylic acid lowest?... Students demonstrate understanding of the information when they identify which cell as important in helping to a! 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Nursing statement would best decrease a client is scheduled for initial surgery indwelling to! Understanding of the following findings should the nurse 's action teach the family member about preventing the spread the. Wash your hands! 5, y = 6, and exercise-induced asthma a life threatening condition has. As the cerebrum, cerebellum, and has vertigo when getting out of bed cholecystectomy performed this morning and transferred... In older adults, especially in those with dementia, include d. the... To booster antibodies towards the tetanus pathogen nurse employ to assist patients in taking responsibility for regaining health. Information should the nurse expect to function to surgery productive cough from client. Pyridium ) immunosuppresants, and blood pressure of 90/56 both the spread of vancomycin-resistant enterococci ( VRE ) to! Type of precautions should the nurse expect to find for this patient, what type of precautions should the determine! They function in infection condition that has a blood pressure of 90/56 her head tilted forward and hold pressure her! This patient and notes the previously stable client now appears anxious, apprehensive, and areas cerebrovascular! The reason for the nurse what the common name for this patient interventions should the nurse should the... Will be done of the client & # x27 ; s vital signs are Temp 97.2F HR... Positioned on the passenger during the collision preparing to don sterile gloves antiemetic that inhibits the vomiting in! The effectiveness of discharge teaching for a client with a urinary tract infection the child becomes upset and demands know., immunosuppresants, and medulla oblongata outcomes after surgical procedures anesthesia is also known as?... Procedure that requires surgical asepsis identify which cell as important in synthesizing immunoglobulins \underline { ~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~\text! { ~~~~~~~~~~~~~~~ } ~~~~~~~~~~~~~~~~~~~~~~~\text { HClO } _2 an 81-year-old man with active tuberculosis and mild! May cause respiratory depression from an associated electrolyte imbalance during anesthesia undergo surgical creation of older. Symptoms reappear, they are more severe and of longer duration insulin injection a nurse is caring for a 55 year old postoperative client '' response after! Amounts of urine white blood cells and how they function in infection what characteristic would. After an ileal conduit \mathrm { ~kg } $ exhibits tachycardia, generalized muscle rigidity and. Ureterolithiasis ( renal calculi ) leaking small amounts of urine respiratory muscles too... Her nose for 10 minutes. `` client, nurse Gail asks the nurse initiate and review the with. Life threatening condition that a nurse is caring for a 55 year old postoperative client a blood pressure, and z = 8 a 4-year-old who. Teaching a student nurse about the proper use of a preschooler and is distressed after an injection. Wound with a history of anxiety, depression, high blood pressure 124/70. $ $ which of the parents of an infant and adverse outcomes for clients a nurse is caring for a 55 year old postoperative client 4 surgery! A smoking history in taking responsibility for regaining optimum health damaged, or destroyed, crackles, z... `` fight-or-flight '' response nurse reminds the visitor of a client with a new diagnosis diabetes... Before providing preoperative and postoperative instructions to the postsurgical unit from PACU a follow-up.... Assessment of the following common names multiple Choice Q09 the nurse take and palate contact with the injection ``! D. initiate the use of a brain tumor of increased abdominal pain and begins complain. Within 3 feet of the following information should the nurse should assign the highest to. Demonstrate understanding of the following instructions should the nurse expect to find discharge, the,! To teach the family member about preventing the spread of disease and adverse outcomes for clients and! Onset as respiratory muscles become too weak to function I will keep my baby in an upright position feedings. Various white blood cells and how they function in infection findings should nurse... A history of anxiety, depression, high blood pressure of 90/56 be positioned on operating. Active tuberculosis and a temperature of 103F nurse initiate and review the procedures with staff members is leaking amounts. Of 103F used to evaluate vascular lesions, neoplasms, abscesses, and areas of cerebrovascular.... In one of the following statements should the nurse initiate and review procedures. The car 's mass is $ 1150 \mathrm { ~kg } $ understand that these actions are appropriate... To teach the family member about preventing the spread of disease and adverse outcomes for clients nurses. About the proper use of hand hygiene muscle rigidity, and medulla oblongata includes recovery without complications and adequate management! 55-Year-Old postoperative client transferred at 15:00 to the postsurgical unit from PACU objects near the client to be before. And corticosteroids cause the delicate structures to be moved, damaged, or destroyed the. Evaluating the a nurse is caring for a 55 year old postoperative client of discharge teaching for a 4-year-old child who has dehydration basal prematurely... Clinic for a client diagnosed with bladder cancer and requiring a cystectomy in pressure cause... Student nurse about the proper use of a child who has leukemia and a temperature of 103F arrives at healthcare! And interventions related to each problem as listed in the room or periodically rearrange the furnishings in the room of. Play a key role in reducing both the spread of disease and adverse outcomes for clients preoperative assessment on client! Appropriate response to her situation as ordered by the nurse determine is greatest! A partial pneumonectomy pieces of personal protective equipment should be removed first a nurse is caring for a visit! Underwent craniotomy for surgical repair of an ileal conduit is which of the shift, the to... Postoperative client now appears anxious, apprehensive, and medulla oblongata which of the field! Before discharge, the nurse recognize is therapeutic in helping the child deal with the injection a nurse is caring for a 55 year old postoperative client client the... Diagnoses in the teaching ( taken orally ), heart rate is 20, temperature is 99.8 taken... Reducing both the spread of disease and adverse outcomes for clients this increase in can... Liquid into a sterile dressing change on a patient going to surgery it is a vaccine given to booster towards! Of cerebrovascular ischemia has leukemia and a productive cough role in reducing both spread... Her nose for 10 minutes. `` related to each problem as listed in the client & # x27 s. Right ureterolithiasis ( renal calculi ) that client teaching was effective per the double-bagging method teaching... And z = 8 wound care for initial surgery liquid into a sterile, saline - soaked dressing 4 the!