Client with eczema
During a home visit the nurse assesses the skin of a client with eczema who reports than an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?
a. an old friend with eczema came for visit
b. recently received an influenza immunization
c. corticosteroid cream was applied to eczema d. a grandson and his new dog recently visited
When explaining dietary guidelines to a client with acute glomerulonephritis (AGN) which instruction should the nurse include in the dietary teaching ?
e. select a protein rich food daily f. restrict sodium intake
g. eat high potassium foods
A male client who is 24hr post operative for an exploratory laparoctomy complains that he is starving because he has had no real food since before surgery. Prior to advancing his diet which intervention should the nurse implememt?
h. discontinue intravenous therapy
i. Obtain a prescription for a diet change
j. Auscultate bowel sound in all four quadrants
A client diagnose with stable angina secondary to ischemic heart disease has a prescription for sublingual (SL) nitroglycerin (NTG). The nurse should tell the client to follow which instructions if chest pain is not relieved after taking 3 NTG tables 5 min apart?
k. drive to the nearest emergency department
l. take another NTG SL tablet and lie down until angina subsides
m.call primary healthcare provider
n. call 911 pain is unrelieved and chew a tablet of aspirin 325mg
After taking orlistat (Xenical) for one week a femela client tells the home health nurse that she is experiencing increasingly frequent oily stools and flatus. What action should the nurse take?
a. obtain stool specimen to evaluate for occult blood and fat content
b. instruct the client to increase her intake of saturated fats over the next week c. ask the client to describe her dietary intake history for the last several days
d. advice the client to stop taking the drug and contact the healthcare provider
Two days after an abscess of the chin was drained the client returns to the clinic with fever chills and a maculopapular rash with pruritis. The client has taken an oral antibiotic and cleansed the wound today with provide iodine (Betadine) solution. Which intervention should the nurse implement first?
o. determine if the client has a history of diabetes p. assess airway patency and oxygen saturation
q. review recent medication history and allergies
r. obtain samples for complete blood count and cultures
A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the health care provider?
a. low back pain and hypotension
b. rhinitis and nasal stuffiness
c. delayed painful rash with urticarial
d. arthritic joint changes and chronic pain
A young adult male who has had type 2 diabetes mellitus (DM) is admitted to the intensive care unit with hyperglycemic nonketotic symdrome (HHNS). A sliding scale protocol for an isotonic IV solution with regular insulin is prescribed based on the results of a continuous blood glucose monitoring device that is attached to the clients central venous catheter. When the clients respirations become labored and his lungs sound indicate crackles what action should the nurse take?
e. collect a specimen for a white blood cell count and cultures
f. determine the clients glycosylated hemoglobin (A1C) (POSSIBLE ANSWER)
g. administer insulin IV push until the clients fluid volume is adjusted h. decrease infusion rate to address fluid overload
When preparing to apply a fentanyl (Duragesic) transdermal patch the nurse notes that the previously applied patch is intact on the clients upper back and the client denies pain. What action should the nurse take?
a. Remove the patch and consult with the healthcare provider about the client pain resolution
b. Place the patch on the clients shoulder and leave both patches in place for 12 hours
c. Administer an oral analgesic and evaluate its effectiveness before applying a new patch d. Apply a new patch in a different location after removing the original patch
