The 25-year-old client who has a C6 spinal cord injury is crying and asks the nurse, “Why did I have to survive? I wish I was dead.” Which statement is the nurse’s best response? 1. “Don’t talk like that. At least you are alive and able to talk.” 2. “God must have something planned for […]
The client diagnosed with peptic ulcer disease is being discharged. Which nursing task can be delegated to the unlicensed assistive personnel (UAP)? 1. Complete the discharge instructions sheet. 2. Remove the client’s saline lock. 3. Clean the client’s room after discharge. 4. Check the client’s hemoglobin and hematocrit
Which information should the nurse discuss with the client to prevent an acute exacerbation of diverticulosis? 1. Increase the fiber in the diet. 2. Drink at least 1,000 mL of water a day. 3. Encourage sedentary activities. 4. Take cathartic laxatives daily.
The client has gastroesophageal reflux disease. Which HCP order should the nurse question? 1. Elevate the head of the client’s bed with blocks. 2. Administer pantoprazole (Protonix) four (4) times a day. 3. A regular diet with no citrus or spicy foods. 4. Activity as tolerated and sit up in a chair for all meals
The nurse is assessing the client with a pneumothorax who has a closed-chest drainage system. Which data indicate the client’s condition is stable? 1. There is fluctuation in the water-seal compartment. 2. There is blood in the drainage compartment. 3. The trachea deviates slightly to the left. 4. There is bubbling in the suction compar
The client receiving a continuous heparin drip complains of sudden chest pain on inspiration and tells the nurse, “Something is really wrong with me.” Which intervention should the nurse implement first? 1. Increase the heparin drip rate. 2. Notify the health-care provider. 3. Assess the client’s lung sounds. 4. Apply oxygen via nasal cannula
The client diagnosed with cancer of the larynx has had a partial laryngectomy. Which client problem has the highest priority? 1. Impaired communication. 2. Ineffective coping. 3. Risk for aspiration. 4. Social isolation. Which psychosocial client problem should the nurse write for the client diagnosed with cancer of the lung and metastasis to the brain? […]
The unlicensed assistive personnel (UAP) notifies the nurse the client diagnosed with chronic obstructive pulmonary disease is complaining of shortness of breath and would like his oxygen level increased. Which intervention should the nurse implement? 1. Notify the respiratory therapist (RT). 2. Ask the UAP to increase the oxygen. 3. Obtain a STAT pulse oximeter […]
The 85-year-old client diagnosed with severe end-stage chronic obstructive pulmonary disease has a chest x-ray incidentally revealing an eight (8)-cm abdominal aortic aneurysm (AAA). Which intervention should the nurse implement? 1. Discuss possible end-of-life care issues. 2. Prepare the client for abdominal surgery. 3. Teach the client how to do pursed-lip breathing. 4. Talk with […]
Which assessment data indicate the client has developed a deep vein thrombosis (DVT) in the left leg? 1. A negative Homans’ sign of the left leg. 2. Increased left-leg calf circumference. 3. Elephantiasis of the left lower leg. 4. Brownish pigmentation of the left lower leg.