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2. The nurse is caring for a patient with a pulse oximeter probe in place. Which of the following situations requires an intervention by t2. The emitting and receiving sensors of the probe are directly opposite each other.3. The hand with the probe attached is directly beneath a procedure light to prevent chilling.he nurse?
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2) correct placement of equipment3) CORRECT— don’t expose the probe to direct sunlight or strong light, gives inaccurate results, coverwith dry washcloths; rotate site every 4 h to prevent skin irritation
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4. The nurse in the outpatient clinic receives a phone call from a client diagnosed with type 1 diabetes.The client reports that his blood sugar at 7:00 am was 200. The nurse should include which of thefollowing in the client’s plan of care?
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3. Instruct the client to obtain a blood sugar at 3 am.assess the blood sugar to determine if hyperglycemia is caused by Somogyi effect,normal or elevated blood glucose at bedtime, hypoglycemia at 2–3 am, and a rebound hyperglycemia in the morning
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12. The nursing assistant reports to the nurse that four of the patients are vomiting. Which of thefollowing patients should the nurse see FIRST?1. A client 2 days postop after abdominal surgery with a nasogastric tube attached to low suction.2. A client diagnosed with cirrhosis of the liver with extensive ascites.3. A client diagnosed with lung cancer undergoing chemotherapy.4. An elderly client diagnosed with irritable bowel syndrome (IBS).
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Strategy: “FIRST” indicates priority1) CORRECT— assess for patency of the NG tube; muscle spasms associated with vomiting causessevere pain and can threaten the integrity of the wound2) at risk for dehydration; integrity of wound more important3) at risk for electrolyte imbalance and dehydration; determine if NG tube is patent4) due to age, at significant risk for fluid and electrolyte imbalance, potential problem
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The charge nurse on the medical unit reviews physician’s orders for four newly admitted patients.The nurse should question which of the following orders?A bone imaging study for a patient with multiple myeloma.
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(2.) CORRECT—every contrast medium has a risk for causing reactions; benefit vs. risk should beconsidered; multiple myeloma involves overproduction of plasma cells, with resultant destruction of bone and of bone marrow products; multiple myeloma is unique as a neoplastic condition that is better detected with a plain radiograph than with a nuclear scan; if a bone scan is done, false-negative results occur
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17. The nurse cares for clients in a physician’s office. A client complains of a sore throat and fever.Culture indicates the client has group A beta-hemolytic Streptococcus infection and urinalysis reveals a large amount of protein and a large number of red blood cells. The physician prescribes antibiotics. The client informs the nurse that he would like to schedule a follow-up appointment in 6 weeks after the client returns from an international conference. Which of the following actions should the nurse take NEXT?1. Determine if the client is allergic to penicillin.2. Instruct the client to schedule an appointment before leaving the country.
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1) while penicillin is the most common drug for treatment of acute glomerulonephritis, the primary focus is determining client is in good health and able to attend the conference2) CORRECT— must determine client’s renal status; has symptoms of acute glomerulonephritis
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18. The nursing assistant reports to the nurse that a client diagnosed with type 1 diabetes complains,“The room is spinning around me.” Which of the following responses by the nurse is MOST important?1. “Did the client eat breakfast?”2. “Has the client experienced episodes of vomiting?”3. “Is the client in bed?”4. “Has the client had this problem before?”
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Strategy: “MOST important” indicates discrimination is required to answer the question.1) moderate hypoglycemia can cause headache, light-headedness, and confusion; appropriate question to ask, but client safety takes priority2) vertigo may cause vomiting; priority is client safety3) CORRECT— priority is client safety; client should sit down to prevent falling4) nurse should focus on current situation; not appropriate question for the nursing assistant
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20. A patient returns to the medical unit after placement of a split-thickness autograft to a burn on the right arm. The nurse identifies that the highest priority at this time will need to be given to which of the following interventions?1. Managing pain at the recipient site.2. Immobilizing the graft.3. Minimizing light exposure.4. Observing for signs of rejection
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Strategy: Determine the outcome of each answer. Is it desired?(1.) not highest priority; donor site is usually more painful than recipient site because of exposed nerveendings; autograft means a layer of the patient’s own unburned skin is removed and grafted to the burnwound(2.) CORRECT—graft adherence to the site is essential for vascularization and "taking" or survival of the graft; immobilization of the graft is critical; a thin fibrin network develops quickly after graft placement but it takes 7–10 days for the graft to really adhere, and longer than that to mature(3.) no need for minimizing light exposure at this time; patient needs to be taught that once donor andrecipient sites have healed, they should completely avoid direct sunlight for 1 year because of the skin’sincreased sensitivity to ultraviolet rays(4.) once pressure dressings are removed (3–5 days), continual assessing of the graft for healing should be done related to vascularization, such as continued adherence to the site, absence of necrotic graft tissue, dusky color, or sharp line of color demarcation
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