During the evaluation of the quality of home care for a client with Alzheimer’s disease, the priority for the nurse is to reinforce which statement by a family member?
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Solution
Ensuring safety of the client with increasing memory loss is a priority of home care. Note all options are correct statements. However, safety is most important to reinforce.
A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which
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Solution
The client must take in adequate fluids before and during exercise periods.
Which of these statements best describes the characteristics of an effective reward-feedback system?
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Solution
Feedback is most useful when given immediately. Positive behavior is strengthened through immediate feedback, and it is easier to modify problem behaviors if the standards are clearly understood.
A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethazine hydrochloride (Phenergan) 50 mg IM to a pre-operative client. Which action should the nurse take first?
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Solution
The first step in the process is to have the client void prior to administering the pre-operative medication. The other actions follow this initial step in this sequence: D, C, A and then B.
The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing?
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Solution
The goal of clinical management in a client with venous stasis ulcers is to promote healing. This only can be accomplished with proper nutrition. The other answers are correct, but without proper nutrition, the other interventions would be of little help.
A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about her obstetric history, which includes 3-year-old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information?
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Solution
Gravida is the number of pregnancies and Parity is the number of pregnancies that reach viability (not the number of fetuses). Thus, for this woman, she is now pregnant, had 2 prior pregnancies, and 1 viable birth (twins).
A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication?
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Solution
Lasix causes a loss of potassium if a supplement is not taken. Signs and symptoms of hypokalemia include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, dysrhythmias.
The nurse is caring for a client who had a total hip replacement four (4) days ago. Which assessment requires the nurse’s immediate attention?
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Solution
The nurse would be concerned about all of these comments. However, the most life-threatening is option B. Clients who have had hip or knee surgery are at greatest risk for development of postoperative pulmonary embolism. Sudden dyspnea and tachycardia are classic findings of pulmonary embolism. Muscle spasms do not require immediate attention. Option C may indicate a urinary tract infection. And option D requires further investigation and is not life-threatening.
The nurse practicing in a maternity setting recognizes that the postmature fetus is at risk due to
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Solution
The placenta functions less efficiently as the pregnancy continues beyond 42 weeks. Immediate and long-term effects may be related to hypoxia.
While assessing a 1-month-old infant, which finding should the nurse report immediately?
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Solution
Inspiratory grunting is abnormal and may be a sign of respiratory distress in this infant.