RN Adult Med Surg B 2019

I will take my temperature once a day. A client who has AIDS is immunocompromised and is at risk for infection. The client should check their temperature daily to identify a temperature greater than 37.8° C (100° F), which is an early manifestation of an infection.

10 seconds after inhaling R: The client should hold their breath for 10 seconds after inhaling so the medication can move deep into the airways.

Troponin 8 ng/mL R: Troponins are proteins present in skeletal and cardiac muscle that are involved with muscle contraction. The elevation of either troponin T or troponin I is an indication of cardiac injury. The client's laboratory value is above the expected reference range for troponin I, indicating an MI has occurred.

The client is reporting back pain. R: The nurse should notify the provider if the client reports back pain, which can indicate that the nephrostomy tube is dislodged or clogged.

I will no longer floss my after brushing my teeth. R: The nurse should instruct the client to avoid flossing teeth to prevent gum inflammation, which could create the opportunity for infection

numbness can occur along the inside of the affected arm. R: The nurse should instruct the client that numbness can occur near the incision and along the inside of the affected arm due to nerve injury.

flex the foot every hour when awake. R: The nurse should instruct the client to flex the foot every hour to reduce the risk for thromboembolism and promote venous return.

walk for 30 min 4 times per week

I will refer u to community resources that can provide support R: The nurse should provide the client with support resources, including community programs, to assist the client with acceptance of body image changes.

constipation R: A client who has hypothyroidism can experience constipation due to the decrease in the client's metabolism, resulting in slow motility of the gastrointestinal tract. The nurse should instruct the client to increase fiber and fluid intake to reduce the risk for constipation.

discontinuing w/ treatment is your choice if it is your wish to do so. R: The nurse should recognize the client's right to refuse the treatments and inform the client of this right. The nurse should advocate for the client and offer to contact the provider for the client.

apply oxygen via face mask R: Evidence-based practice indicates that the priority intervention is for the nurse to apply oxygen. The nurse should use a high-flow nonrebreather mask to deliver oxygen at 90% to 100%.

INR 2.5 range is INR (2-3)

a tingling sensation replacing pain

low urine specific gravity R: An expected finding for a client who has diabetes insipidus is a urine specific gravity between 1.001 and 1.005. Decreased water reabsorption by the renal tubules is caused by an alteration in antidiuretic hormone release or the kidneys' responsiveness to the hormone.

you will have an implant placed twice each month for the duration of the treatment

irrigate the indwelling urinary catheter R: (Bleeding and blood clots from the bladder are expected after a TURP, and continuous irrigation is used to keep clots from obstructing the urinary tract. The rate of irrigation may be titrated to keep the clots from forming, but the nurse should also check the vital signs because hemorrhage is the most common complication of prostatectomy.)

distended neck veins R: The nurse should identify distended neck and hand veins as indicators of fluid volume overload.

high BUN levels R: The client's Hct and BUN levels indicate dehydration and require an increase in the IV fluid infusion rate.

pain that increases w/ passive movement r: The nurse should identify that a client who has compartment syndrome experiences pain that increases with passive movement. Compartment syndrome results from a decrease in blood flow in the extremity caused by a decrease in the muscle compartment size due to a cast that is too tight.

ginkgo biloba can cause increase risk for bleeding R: Ginkgo biloba increases blood flow and is effective in decreasing the pain associated with peripheral artery disease. The supplement also decreases platelet aggregation, which in turn increases the risk for bleeding. Clients who have been prescribed antiplatelet medications, such as aspirin, should avoid taking ginkgo biloba without first speaking with their provider.

keep the client occupied with a manual activity R: The nurse should provide the client with a manual activity such as a puzzle or an art project. This can help to distract the client from the IV catheter.

sore, red, beefy, and shiny tongue R: This image depicts glossitis, which can indicate pernicious anemia. Glossitis, a smooth red tongue, is also a manifestation of deficiencies in vitamin B6, zinc, niacin, or folic acid.

drink 240 ml of water after administration

Keep a lead-lined container in the client's room R: The nurse should keep a lead-lined container and forceps in the client's room in case of accidental dislodgement of the implant.

throat R: Zenker's diverticulum, or pharyngeal pouch, is a herniation of the esophagus occurring through the cricopharyngeal muscle in the midline of the neck. Repair of the diverticulum is accomplished through an open incision in the client's neck.

Extremity cool upon palpation R: The nurse should report indicators of reduced circulation, such as pallor, cool temperature, or paresthesia of the client's extremity. These findings can indicate that the client is at risk for developing acute compartment syndrome.

Pericardial friction rub R: The nurse is hearing a pericardial friction rub, which is a scratchy, high-pitched sound associated with infection, inflammation, or infiltration and can be a manifestation of pericarditis. A pericardial friction rub is best heard with the diaphragm of the stethoscope.

facial butterfly rash R: A butterfly rash is a manifestation of SLE. It appears as a dry, red rash on the client's cheeks and nose and can disappear during times of remission.

Hemodialysis is sometimes needed after surgery. R: When a kidney comes from a deceased donor, it might not function immediately, requiring the recipient to continue hemodialysis postoperatively.

change position every hour R: Changing position every 1 to 2 hr decreases pressure on bony prominences. The nurse should also instruct the client to limit the angle of the hips when in a lateral position to no more than 30°. This positioning prevents direct pressure on the trochanter.

increase fiber intake to avoid constipation R: The nurse should instruct the client that constipation is an adverse effect of verapamil. The client should increase fiber intake to promote regular bowel function.

create complete outfits and allow the client to select one each day.

Bubbling in the water-seal chamber has ceased. R: Bubbling in the water seal chamber ceases when the lung re-expands.

dyspnea

Low back pain and apprehension R: Hemolytic transfusion reactions result from the infusion of incompatible blood products and create a systemic inflammatory response. Manifestations include low back pain, hypotension, tachycardia, and apprehension.

compress the drain reservoir after emptying R: Compressing the reservoir creates a vacuum that draws fluid out of the wound, through the drain, and into the reservoir.

avoid direct exposure to sun

reading less than 300 R: A glucose reading less than 300 mg/dL indicates improvement in the client's status.

heart rate

high fiber foods

- Calf pain. Numbness in the arms. - Intense headache. - Calf pain is an indication of deep vein thrombosis. - Numbness in the arms and intense headache indicate a cerebrovascular accident.

Regular insulin 20 units IV bolus

abdominal surgery states something popped when i coughed

bathe the client using chlorhexidine solution

tachycardia 110/min R:One of the first signs of hemorrhage is an increase in the heart rate from the client's baseline, which occurs to compensate for blood loss.

sore throat

restlessness

WBC count 2,000/mm3- This value is below the expected reference range and indicates a risk for severe immunosuppression.

Check for the type and number of units of blood to administer.

Ibuprofen can cause gastrointestinal bleeding in older adult clients.

Document that depolarization has occurred.

Place a tracheostomy tray at the bedside.

temp 102

Alternate application of heat and cold to the affected joints

My joints ache because I have Lyme Disease

This identifies if the pacemaker cells of my heart are working properly.

Prepare to suction the client's airway.Loosen restrictive clothing on the client.The nurse should not restrain the client or inset anything into the client's mouth.The nurse should keep the client flat on her back or turned onto her side during a seizure to prevent aspiration.

airborne

Consume at least 30 g of fiber daily

stidor R: Stridor can indicate a narrowing airway or possible obstruction caused by edema or laryngeal spasms.

scan the environoment by turning your head from side to side

place personal items, such as pictures, at the client's bedside

Family members in the household should undergo TB testing

I can speak to the provider about incorporating acupuncture into your treatment plan

BUN 34 mg/dL

slow the infusion rate

sedimentation rate R: An increased sedimentation rate occurs when a client has any type of inflammatory process, such as osteomyelitis.

- Administer oxygen via a nonrebreather mask - Initiate IV therapy with a large bore catheter - Insert NG tube - Administer Ranitidine

prednisone or Fludrocortisone

HR 54/min A client who is experiencing AD will exhibit multiple manifestations, including bradycardia, severe headache, and flushing.

avocados strawberry bananas

shellfish

propofol

crackles heard on auscultation R: Mannitol is an osmotic diuretic that prevents the reabsorption of water in the kidneys, thus increasing urinary output. With the exception of the brain, mannitol can leave the vascular system at the capillary site, which can result in edema. The nurse should identify crackles as a manifestations of pulmonary edema and notify the provider. Other manifestations include dyspnea and decreased oxygen saturation.

Crackles heard on auscultation