Exhibits

What should the nurse include in post discharge care education? Select all that apply.

Give only clear liquids for several days

Avoid any kind of bath or shower

Monitor for fever

Keep a pressure dressing on the site for one week

The child may take ibuprofen for pain

Alert the physician if the site bleeds or swells.

Answer and Explanation

Correct Answer : C,E,F

A. Typically, there is no need to restrict a child to clear liquids for several days post-cardiac catheterization unless specified by the physician.
B. Bathing should be avoided if the catheterization was done through the groin, but showers are usually permitted after 24 hours, provided the water does not directly hit the incision site.
C. Monitoring for fever is important as it can be a sign of infection.
D. A pressure dressing is usually kept on the site for the first few hours post-procedure, not for an entire week.
E. Ibuprofen can be given for pain, but it's important to follow the physician's advice regarding dosage and frequency.
F. It is crucial to alert the physician if the site bleeds or swells as this could indicate a complication from the procedure.

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Correct Answer is D

Explanation

A. Difficulty staying asleep may indicate a sleep disorder or psychological stress but is not directly related to the client's diabetes mellitus or hypertension.
B. Blood pressure of 130/80 mm Hg is within the normal range for adults and does not require further follow-up unless there are specific concerns related to the client's medical history.
C. Dark yellow urine may indicate dehydration, which could be related to the client's diabetes mellitus and hypertension. However, it is not as concerning as the elevated serum creatinine
level.
D. Serum creatinine level of 1.6 mg/dL (141.44 μmol/L) is elevated above the normal range for both females and males. This finding suggests impaired kidney function, which is a significant concern for a client with a history of type 2 diabetes mellitus and hypertension. Further follow- up and evaluation are necessary to assess kidney function and determine appropriate
interventions.

A. Initiate neurological monitoring every 2 hours. B. Assess bilateral breath sounds. C. Review client's daily medications. D. Palpate suprapubic region for urinary retention.

Correct Answer is A

Explanation

A. Initiating neurological monitoring every 2 hours is critical for a client with a TIA. This allows for early detection of any changes in neurological status, which could indicate worsening conditions or the onset of a stroke. Monitoring helps ensure prompt intervention if symptoms escalate.

B. While assessing bilateral breath sounds is important for overall respiratory function, it is not the most urgent priority in managing a TIA. Neurological assessments take precedence in this situation.

C. Reviewing the client's daily medications is important for understanding potential risk factors and management, but it is a secondary intervention. Neurological monitoring takes priority in the acute phase of care for a TIA.

D. Palpating the suprapubic region for urinary retention is more relevant in clients at risk for retention due to neurological or urological issues but is not a primary concern in managing a TIA. The focus should be on neurological function.

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Exhibits What should the nurse include in post discharge care education? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a history of type 2 diabetes mellitus and hypertension who arrives at the clinic for a scheduled visit. Which finding requires further follow-up by the nurse? Creatinine: Female: [0.5 to 1.1 mg/dL (44 to 97 μmol/L)] Male: [0.6 to 1.2 mg/dL (53 to 106 μmol/L)]

Correct Answer is D

Explanation

When admitting a client with a diagnosis of transient ischemic attack (TIA, which intervention is most important for the nurse to include in this client's plan of care?

Correct Answer is A

Explanation

Exhibits Based on the assessment and blood gas results, which 3 orders should the nurse expect from the healthcare provider?

A client with chronic obstructive lung disease who is receiving oxygen at 1.5 L/minute by nasal cannula is currently short of breath. Which action should the nurse take?

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An older resident of an extended care facility has recurrent urinary tract infections. The nursing care plan includes the goal, "Increase daily intake of fluids." Which nursing intervention is most useful in assisting the resident to meet this goal?

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

The nurse is caring for a client with the sexually transmitted infection (STI) genital herpes. The client reports having had prior sexually transmitted infections. Which response should the nurse provide?

Exhibits

What should the nurse include in post discharge care education? Select all that apply.