Nightingale 266 course
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| The nurse working on a telemetry unit finds a client unconscious and in pulseless ventricular tachycardia (VT). The client has an implanted automatic defibrillator. What action should the nurse implement? | Shock the client with 200 joules per hospital policy.
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| How should the nurse position the electrodes for modified chest lead one (MCL I) telemetry monitoring? | Positive polarity right chest nipple line, negative polarity left chest nipple line, ground left shoulder.
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| Which symptoms should the nurse expect a client to exhibit who is diagnosed with a pheochromocytoma? | Headache, diaphoresis, and palpitations.
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| A client is admitted for further testing to confirm sarcoidosis. Which diagnostic test provides definitive information that the nurse should report to the healthcare provider? | Lung tissue biopsy.
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| The nurse is providing dietary instructions to a 68-year-old client who is at high risk for development of coronary heart disease (CHD). Which information should the nurse include? | Increase intake of soluble fiber to 10 to 25 grams per day.
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| A female client is brought to the clinic by her daughter for a flu shot. She has lost significant weight since the last visit. She has poor personal hygiene and inadequate clothing for the weather. The client states that she lives alone and denies probl | Collect further data to determine whether self-neglect is occurring.
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| A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg. Which action should the nurse implement? | Give an antihypertensive medication.
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| A splint is prescribed for nighttime use by a client with rheumatoid arthritis. Which statement by the nurse provides the most accurate explanation for use of the splints? | Prevention of deformities.
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| The nurse is interviewing a male client with hypertension. Which additional medical diagnosis in the client's history presents the greatest risk for developing a cerebral vascular accident (CVA)? | Diabetes mellitus.
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| A client is placed on a mechanical ventilator following a cerebral hemorrhage, and vecuronium bromide (Norcuron) 0.04 mg/kg q12 hours IV is prescribed. What is the priority nursing diagnosis for this client? | Impaired communication related to paralysis of skeletal muscles.
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| Which postmenopausal client's complaint should the nurse refer to the healthcare provider? | Episodes of vaginal bleeding.
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| A client receiving cholestyramine (Questran) for hyperlipidemia should be evaluated for what vitamin deficiency? | K.
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| A 58-year-old client who has been post-menopausal for five years is concerned about the risk for osteoporosis because her mother has the condition. Which information should the nurse offer? | Calcium loss from bones can be slowed by increasing calcium intake and exercise.
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| When teaching diaphragmatic breathing to a client with chronic obstructive pulmonary disease (COPD), which information should the nurse provide? | Place a small book or magazine on the abdomen and make it rise while inhaling deeply.
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| Which intervention should the nurse plan to implement when caring for a client who has just undergone a right above-the-knee amputation? | Place a large tourniquet at the client's bedside.
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| A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L. Which action is most important for the nurse to implement? | Initiate continuous cardiac monitoring.
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| A postmenopausal client asks the nurse why she is experiencing discomfort during intercourse. What response is best for the nurse to provide | Estrogen deficiency causes the vaginal tissues to become dry and thinner.
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| The nurse is planning to initiate a socialization group for older residents of a long-term facility. Which information would be most useful to the nurse when planning activities for the group? |
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| In preparing a discharge plan for a 22-year-old male client diagnosed with Buerger's disease (thromboangiitis obliterans), which referral is most important? | Smoking cessation program.
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