A health care provider prescribes famotidine (Pepcid) for a client with dyspepsia. What is important to include about this medication in a teaching program for this client?
Although a nurse is unable to identify any obvious signs or symptoms of bleeding, a client repeatedly has tested positive for occult blood in the stool. Which laboratory result is a concern considering this client’s history?
A nurse is caring for a client with severe gastritis who vomited a large amount of blood. A lavage is ordered by the health care provider. Which response does the nurse expect when using a room temperature irrigating solution?
A blood transfusion is initiated after a client has had emergency surgery. What should the nurse do first when the client develops fever, chills, and low back pain?
When entering a room, a nurse finds new parents looking at their newborn, who is lying in the bassinet with eyes wide open. What action should the nurse take in response to this infant’s behavior?
A nurse determines that a postpartum client is gravida 1 and para 1. Her blood type is B negative, and her baby’s blood type is O positive. What should the nurse include in the plan of care?
While changing a newborn’s diaper, a client expresses concern about a small spot of red vaginal discharge on the diaper. How should the nurse respond to this concern?
What concept of death should a nurse expect a preschoolage child to have?
A nurse is assessing a client with major depression. Which clinical manifestation reflects a disturbance in affect related to depression?
A client is admitted to the birthing unit in active labor. An amniotomy is performed. What physiologic change does the nurse expect to occur after the procedure?
A nurse is caring for a client in labor. What client response indicates that the transition phase of labor probably has begun?
A client with a history of alcohol abuse says to the nurse, “Drinking is a way out of my depression.” Which strategy probably is most effective for the client at this time?
A nurse explores with a client who has a history of drug abuse the possibility of joining Narcotics Anonymous (NA). What is a major reason NA is helpful in treating addictive behavior?
A client undergoes cardiac catheterization via the femoral artery because of a history of bilateral mastectomies. What is the most important nursing action after the procedure?
A client with heart failure is on a drug regimen of digoxin (Lanoxin) and furosemide (Lasix). The client dislikes oranges and bananas. Which fruit should the nurse encourage the client to eat?
A client in whom sexual dysfunction is diagnosed comments to the nurse, “Well, I guess my sex life is over.” What is the most appropriate response by the nurse?
A hospitalized client hurriedly approaches the nurse, saying that it sounds like there is a roaring fire in the bathroom. In reality, the client’s roommate has just turned the shower on full force. What term best describes this experience?
A newborn with acquired herpes simplex virus infection is being discharged. Which developmental pattern is important for the nurse to teach the parents to monitor?
A health care provider prescribes tolterodine (Detrol) for a client with an overactive bladder. What is most important for the nurse to teach the client to do?
A nurse is selecting toys for a 5-month-old infant. Which toy should not be given to the infant?
An infant who was just circumcised is to be discharged with his parents. What should the nurse include in the discharge instructions about postcircumcision care?
A client in a mental health facility with the diagnosis of bipolar disorder, manic phase, is argumentative, domineering, and exhibitionistic. A visitor reports that this client is running down the hall scaring people. What should the nurse do first?
An older adult is admitted to a nursing home with the diagnosis of dementia. When the nurse is assessing this client’s mental status, what question best tests the ability for abstract thinking?
A male client receiving hemodialysis undergoes surgery to create an arteriovenous fistula. Before discharge, the nurse discusses care at home with the client and his wife. Which statement by the client’s wife indicates that further teaching is required?
An older adult male with dementia is admitted to a nursing home. His wife appears frail, tired, and angry when she first visits her husband. She remarks to the nurse in a sarcastic tone, “Let’s see what you can do with him.” What is the nurse’s most therapeutic response?
A client is admitted to the hospital with a diagnosis of myasthenia gravis. For which common early clinical finding should the nurse assess the client?
What should the nurse emphasize when providing discharge instructions for a client with the diagnosis of Addison disease?
A newborn is admitted to the neonatal intensive care unit (NICU) with a myelomeningocele. What is the priority nursing intervention during the first 24 hours?
A client with multiple sclerosis is in remission. Which diversional activity should the nurse encourage that best meets the client’s needs while in remission?
A parent whose newborn infant son has a cleft lip and palate asks the nurse, “How should I feed my baby because he has difficulty sucking?” What information should the nurse provide concerning a safe feeding technique for this infant?
A client at 16 weeks’ gestation calls the nurse at the prenatal clinic and states that her partner just told her he has genital herpes. What should the nurse include when teaching the client about sexual activity?
Early in the ninth month of pregnancy a client experiences painless vaginal bleeding and is admitted to the hospital. What should the client’s plan of care include?
Which criterion should a nurse use when assessing the gestational age of a preterm infant?
What client behavior indicates to the nurse that a client with schizophrenia, undifferentiated type, is improving and that the client’s plan of care can be updated?
A client who has a diagnosis of paranoid schizophrenia and has been violent in the past is admitted to the psychiatric unit. What should the nurse do before performing an admission interview?
What is the priority when the nurse is establishing a therapeutic environment for a client?
What is the main reason why a nurse raises three of the four side rails on the bed of a 63-year-old client who has had surgery for a fractured hip?
A 41/2-year-old child is brought to the emergency department with a fractured tibia. Which type of fracture should the nurse anticipate will be diagnosed because it is the most frequently encountered fracture in children of this age?
A health care provider prescribes transdermal fentanyl (Duragesic) 25 mcg/hr every 72 hours. What is most important for the nurse to do during the first 24 hours after starting the fentanyl?
A client enters the emergency department, reporting shortness of breath and epigastric distress. What should be the triage nurse’s first intervention?
A client is scheduled for a vacuum aspiration abortion to terminate a pregnancy. What should the nurse’s teaching plan include?
A client asks for and receives instruction regarding birth control methods. She elects to use a diaphragm with a spermicide. What disadvantage of using a diaphragm should be explained to the client?
A client’s sputum smears for acid-fast bacillus (AFB) are positive, and transmission-based precautions are instituted. What should the nurse teach family members to do?
A health care provider prescribes psyllium (Metamucil) 3.5 g twice a day for constipation. What is most important for the nurse to teach this client?
A nurse is caring for a client with heart failure. The health care provider orders a 2 g sodium diet. What should the nurse include when explaining how a low-salt diet helps achieve a therapeutic outcome?
A client has surgery to repair a fractured right hip. Where should the nurse stand when assisting the client to ambulate?
A preschool-age child has been restricted to bed rest since admission to the hospital. As a response to improvement, the child becomes interested in playing. Based on the child’s developmental level and activity restriction, what should the nurse provide?
A newborn is Rh positive, and the mother is Rh negative. The infant is to receive an exchange transfusion. The nurse explains to the parents that their baby will receive Rh-negative blood because:
An emergency tracheotomy is performed on a child with acute epiglottitis, and the child is receiving humidified air via a tracheotomy collar. When caring for this child, what early clinical manifestations of hypoxia should alert the nurse to suction the tracheotomy?
A nurse is caring for a client with a spinal cord injury during the immediate postinjury period. What is the primary focus of nursing care during this immediate phase?