To help prevent osteoporosis in a client who has had bariatric surgery
Which intervention should the nurse implement to help prevent osteoporosis in a client who has had bariatric surgery?
Administer supplemental iron.
Encourage increased intake of milk.
Identify foods high in vitamin D.
Discuss importance for vitamin A.
In planning nursing care in the immediate postoperative period, which factor has the highest priority in determining the frequency of vital sign assessment?
Unit policy and procedures.
Staffing considerations.
Healthcare provider’s prescription.
Client’s condition.
At bedtime, a female client with dementia becomes increasingly confused and agitated because she believes someone is standing in her room. Which action is best for the nurse to implement?
Put a night light on in the room.
Reassure her that she is alone.
Give an anxiolytic at bedtime.
Provide soft music at bedside.
A nurse assesses a male client with hyperthyroidism and identifies that the client has exophthalmos and lid retraction. What pathophysiological factor is the likely cause of these findings?
Medication reaction,
Ocular immobility,
Bacterial infection.
Fluid accumulation
A client taking antibiotics for three days to treat a Streptococcal throat infection returns to the clinic reporting a fine itchy rash across the chest and arms. The nurse auscultates pulmonary wheezing and an elevated heart rate. Which action should the nurse implement?
Apply a hypoallergenic cream to the rash.
Provide a mask for the client to wear.
Swab the throat for a rapid strep test.
Instruct client to stop taking the antibiotics.
The nurse is caring for an older male client with Parkinson’s disease and notices hesitation and then freezing when the client approaches the doorway. Which action should the nurse implement? (Select all that apply.)
Gently push the client to begin movement.
Remove any obstacles in the client’s path.
Provide the client with emotional support.
Instruct the client to cross his legs.
Encourage the client to move faster.
The nurse is assessing the feet of an older adult with a 10-year history of type 2 diabetes mellitus. The client denies tingling or numbness in the feet. Which intervention is most important for the nurse to implement?
Assess the client’s toenails for fungal growth.
Encourage the client to wear closed-toed shoes.
Determine how the client’s toenails are cut.
Use 2 pin points on feet to check client’s feeling.
A client is admitted with a ruptured diverticulum and peritonitis. The client’s vital signs are blood pressure 70/40 mmH, heart rate 126 beats/minute, respirations 32 breaths/minute, and a temperature 103.2° F (39.6° C). The client’s urine output is 25 mL/hour. Which action should the nurse implement?
Infuse IV antibiotics and crystalloids fluids.
Give antipyretics q4 hours for fever.
Place the client in Trendelenburg position.
Review complete blood cell counts.
A client with pernicious anemia takes supplemental folate and self-administers monthly Vitamin B12 injections. The client reports feeling increasingly led. Which laboratory value should the nurse review?
Serum electrolytes.
Complete blood count.
Liver enzymes.
Platelet count.
The home health nurse instructs the client with chronic obstructive pulmonary disease (COPD) to report any respiratory infection to the healthcare provider as soon as possible. Which statement describes the first signs of infection this client should report?
Early morning coughing and expectoration.
Change in color of sputum.
Fever and chills.
Increase in diameter of the chest.
The nurse is caring for a client with urolithiasis who reports of severe flank and abdominal pain. Which action should the nurse implement?
Maintain client on strict bedrest
Encourage a high-calcium diet
Strain all urine
Limit fluid intake
The nurse is caring for a client with diabetes mellitus type 2 who is admitted with a blood glucose level of 900 mg/dL (49.95 mmol/L) Two hours after medical treatment is initiated, the client’s blood glucose level is 400 mg/dL (22.2 mol/L). Which client statement requires immediate follow up by the nurse?
I feel nervous and anxious.
I am urinating a great deal.
I have a strange taste in my mouth.
I am thirsty and my lips are very dry.
The nurse is caring for a client that had a thyroidectomy 24 hours ago. The client reports experiencing numbness and tingling of the face. Which intervention should the nurse implement?
Inspect the neck for increase in swelling.
Monitor for presence of Chvostek’s sign.
Open and prepare the tracheostomy kit.
Assess lung sounds for laryngeal stridor.
A client with colitis reports to the clinic for a follow-up visit. The client is currently taking an anti-inflammatory medication daily and reports occasional bloody diarrhea, fatigue, and night sweats. Which assessment is most important for the nurse to obtain?
Body weight.
Oral temperature.
Blood pressure.
Lung sounds.
The nurse is caring for an older client who is admitted due to a change in mental status after two days of nausea and vomiting. The client’s home medications include subcutaneous insulin, a daily antihypertensive, and a daily diuretic. Which intervention should the nurse implement first?
Obtain a capillary blood glucose level.
Check accuracy of medication list.
Insert an indwelling Foley catheter.
Establish mental status baseline.
After several days of coughing and taking acetaminophen to treat temperatures of 101° F (38.3° C), a client with diabetes mellitus (DM) is admitted to the hospital with an upper respiratory infection. Several hours after admission, the client reports having a severe headache and feeling dizzy. Which intervention should the nurse implement first?
A. Administer an antipyretic.
Reassess vital signs.
Obtain a fingerstick glucose.
Obtain sputum for culture.
In planning care for a postoperative client with hypovolemic shock, which problem is most important to include in the plan of care?
Disturbed sleep pattern.
Fatigue.
Risk for falls.
Ineffective tissue perfusion.
The nurse is caring for a postoperative client who is at risk for malignant hyperthermia. The client develops muscle rigidity and the body temperature increases from 1000 F to 1039 F (37.80 C to 39.4° C) within one hour. In addition to contacting the healthcare provider, which additional action should the nurse take?
A. Implement protective isolation precautions.
Provide warming blankets to prevent chilling.
Review most recent white blood cell count (WBC).
Monitor cardiac rhythm and vital signs continuously.
The nurse observes that a newly admitted client with Parkinson’s disease exhibits a mask like facial appearance. Which additional nursing assessment takes priority in response to this finding?
Speech patterns.
Neck flexion.
Respiratory rate.
Swallowing ability.
An older client with advancing Parkinson’s disease exhibits increasing confusion with agitation and hallucinations during morning showers and at breakfast mealtime. Which action should the nurse take?
Awaken the client earlier to begin morning care.
Reduce the client’s interaction with others during day.
Clarify reality when experiencing hallucinations.
Use distraction and therapeutic communication skills.
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