NR 226 Medications PATIENT ASSESSMENT AND CARE PLAN 2023

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Patient Assessment and Care Plan - 2024/2025 Edition for Guaranteed Success in Exams

This comprehensive and updated resource provides a detailed patient assessment and care plan, tailored for the 2024/2025 academic year. Master the essential concepts and skills for patient care, and confidently excel in your exams. Get the latest guidelines, clinical best practices, and practice exercises to ensure success on your first attempt, leaving behind the stress of resits.

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NR 226 Medications PATIENT ASSESSMENT AND CARE PLAN 2023 HESI MED SURG V1 2017-2020 EXIT EXAM MOSTLY TESTED QUESTIONS WITH CORRECT ANSWERS SOLUTION Version 1. 1. a client with stage IV bone cancer is admitted to the hospital for a 1 to 10 scale. Which intervention should the nurse implement 2. During spring break, a young adult presents at the urgent care clinic and report headache. Which intervention is most important for the nurse to implement? 3. After a colon resection for colon cancer, a male client is moaning while being transported to unit (PACU). Which intervention should the nurse implement first? 4. Which nursing problem has the highest priority when planning care for a client with osteomalacia? 5. A client who took a camping vacation two weeks ago in a country with a tropical climate comes symptoms and diarrhea for the past week. Which finding is most important for the nurse report? 6. a client admitted to a surgical unit is being evaluated for an intestinal obstruction . the healthcare prescribed nasogatric tube(NGT) to be inserted and placed to intermittent low wall suction. Which intervention –to facilitate proper tube placement? 7. when explaining dietary quidelines to a client with acute glomerulonepheritis (AGN) , which instruction should the nurse include in the dietary teaching ? 8. a client with chronic kidney disease is started on hemodialysis, during the first treatment the client’s blood pressure 150/90 mm hg to 80/30 mm hg. Which action should the nurse take first? 9. a client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse spostoperative discharge instruction? 10. a client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood notifying the healthcare provider, what information should the nurse provide first using the SBAR (situation, background, assessment, and recommendation ) communication process? 11. Intermittent claudiation with leg pain… 12. Three months after Dx of T2DM pt and nocompliance to Tx regimen….. 13. Client with SIADH complains of dry mouth and thirsty…. 14. Client with emphysema with CT drain change from green to clear liquid. 15. Pt with multiple transplant reaction to report to HCP (healthcare prosional) 16. Fracture of left femur fixation complain of pain. 17. Nursing care goal for preop client. 18. Iron deficiency anemia client selected food requiring further teaching. 19. CVA client with expressive aphasia frustrated. 20. 2hrs Post op laparoscopy client demanding for food. 21. Nurse assisting PD client ambulate in hallway. 22. Xenograft for a Jewish clent with burn. 23. Laryngectomy and tracheostomy expectorate copious purulent secretion. 24. Client with emphysema and HF has edema, coughing and SOB. BNP is elevated. 25. Client with Blood glucose of 50mg/dl, before action. 26: Med order = 0.1875 mg; Available= 0.3mg per 1.2 ml 27. Heparin infusion order= 900 Unit per hr; Available= 25,000 Unit per 250 ml 28. Nurse calling HCP for client complaining of pain, SBAR report pattern. 29. Nursing care with higher priority when giving care. . 30. Bone cancer client with constipation complain of pain of 8 on 1-10 scale. 31. Pt with potassium level of 6.0, med to give. 32. In teaching a client newly diagnosed with multiple sclerosis (MS), which approach should the nurse emphasize as most likely to prevent an exacerbation of symptoms? 33. While assessing a client in a supine position, the nurse observes jugular vein distention. The client’s vital signs are: heart rate 110 beats/minute, respirations 28 breaths/minute, and blood pressure 160/88. What should the nurse take? 34. A client is recovering from a transurethral prostectomy. Which activity should be limited until after the first postoperative visit with his healthcare provider/; 35. a client who has a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse? 36. after a computer tomography (CT) scan with intravenous medium, a client returns to the room complaining of shortness of breath and itching. Which intervention should the nurse implement? 37. a client with newly diagnosed crohn’s disease asks the nurse about dietary restrictions. How should the nurse respond? 38. A female college student comes to the school’s health clinic complaining of urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first? 39. when preparing a teaching plan for a client newly diagnosed with diabetes mellitus, the nurse should describe which situation as requiring the most immediate action by the client or family? 40. Client is about to go to physical therapy but before that is having a wound debridement(whirlpool therapy)? What should the nurse do? Give analgesic. 41. Patient taking ferrous sulfate 42. Patient complaining of pain in the back/sacrum area 43. Patient complaining of leg pain 44. Emesis basin of coffee-ground vomit 45. Dosage calculation/Heparin Drip: 46. Dosage calculation: 47. Patient complaining of abdominal pain 48. Pt with eczema how will you know the medication is working 49. COPD patient with ABGs and elevated CO2 51) After a colon resection for colon cancer, a male client is moaning while being transported to unit (PACU). Which intervention should the nurse implement first? 52) SIADH : Give hard candy for thrist 53) Emotional prepareness before surgery ATI Adult Nursing (NUR 105) Med Surg test questions 06: Individual and Family Homeostasis, Stress, and Adaptation Graded A, Latest Questions and Answers with Explanations, All Correct Study Guide, Download to Score A Individual and Family Homeostasis, Stress, and Adaptation 1. A nurse is meeting with a young woman who has recently lost her job after moving with her husband to a new city. She describes herself as being anxious and pretty depressed. What principle of stress and adaptation should be integrated into the nurses plan of care for this patient? 2. You are the nurse caring for an adult patient who has just received a diagnosis of prostate cancer. The patient states that he will never be able to cope with this situation. How should you best understand the concept of coping when attempting to meet this patients needs? 3. The nurse is with a patient who has learned that he has glioblastoma multiforme, a brain tumor associated with an exceptionally poor prognosis. His heart rate increases, his eyes dilate, and his blood pressure increases. The nurse recognizes these changes as being attributable to what response? 4. You are the nurse caring for a 72-year-old woman who is recovering from a hemicolectomy on the postsurgical unit. The surgery was very stressful and prolonged, and you note on the chart that her blood sugars are elevated, yet diabetes does not appear in her previous medical history. To what do you attribute this elevation in blood sugars? 5. A patient tells the nurse that she does not like to go to the doctor and is feeling anxious about being in this place. When the nurse checks her blood pressure, it is elevated along with her heart rate. The nurse rechecks her blood pressure about 10 minutes later and it is normal. The patient asks the nurse if she should be concerned that she may have hypertension. What statement should guide the nurses response? 6. A patient presents to the health center and the nurse practitioners assessment reveals an enlarged thyroid. The nurse practitioner believes the thyroid cells may be undergoing hyperplasia. How would the nurse practitioner explain this condition to the patient? 7. A mother has brought her young son to the emergency department (ED). The mother tells the triage nurse that the boy was stung by a bee about an hour ago. The mother explains to the nurse, It hurts him so bad and it looks swollen, red, and infected. What can the triage nurse teach the mother? 8. You are caring for an older female patient who is being treated for acute anxiety. She has a nursing diagnosis of Ineffective Coping related to a feeling of helplessness. What would be the most appropriate nursing intervention? 9. A 35-year-old woman comes to the local health center with a large mass in her right breast. She has felt the lump for about a year, but was afraid to come to the clinic because she was sure it was cancer. What is the most appropriate nursing diagnosis for this patient? 10. The nurse at the student health center is seeing a group of students who are interested in reducing their stress level. The nurse identifies guided imagery as an appropriate intervention. What will be included in the nurses intervention? The nurse cares for a client diagnosed with superficial partial thickness burn. The nurse should assign the client to a room with which client? - ANSWER A client diagnosed with Cushing's Syndrome. The nurse observes client care on a geriatric unit. The nurse should intervene in which situation? - ANSWER A student nurse assists the client to stand from a sitting position by grasping the client's elbows. The nurse evaluates the results of the client's purified protein derivative (PPD) 2 1⁄2 days after the injection. The nurse noted the induration is 4 mm. which action by the nurse is most appropriate? - ANSWER Inform the client the results are negative The nurse cores for the client with a history of schizophrenia. The nurse expects to note which speech pattern? - ANSWER Repetition of the words used by the nurse. The nurse cares for a 6-month-old infant. The parents report that the infant had severe diarrhea for twelve hours. The nurse anticipates which finding? - ANSWER Depresses anterior fontanel. The nurse cares for a client receiving hydrocodone every 6 hours prn for pain. The client reports pain at 1600. The nurse notes that the hydrocodone was last administered at 1200, and the nurse proceeds to administer hydromorphone at 1615. After discovering the error, how should the nurse record the occurrence? - ANSWER Hydromorphone given at 1615; health care provider notified. B/P 122/80, RR 16." The male client asks the nurse, "Why am I experiencing erectile dysfunction (ED)?" The nurse reviews the client's medications. The nurse recognizes that which classification increases the risk for ED? - ANSWER Antihypertensive medications. The nurse in the hospital cafeteria overhears two nursing assistive personnel (NAP) discuss the client's condition. What is the PRIORITY action for the nurse to take? - ANSWER Inform the employees about patient confidentiality and the client's right to privacy. The nurse cares for a client diagnosed with dehydration. The plan of care indicates the client is to drink two ounces of fluid every hour. The nurse determines the goal is met if which is recorded on the intake and output (I&O) sheet for an eight-hour shift? - ANSWER 480 ml The nurse and LPN/LVN care for clients on a medical-surgical unit. The RN should delegate which activity to the LPN/LVN? - ANSWER Take the blood pressure and heart rate before administration of enalapril. The nurses care for the client diagnosed with tuberculosis. Before discontinuing airborne precautions, the nurse must confirm which? - ANSWER No acid-fast bacteria are in the sputum. The nurse cares for the client at 28 weeks gestation diagnosed with a complete placenta previa. The nurse determines discharge teaching is effective if the client makes which statement to her husband? - ANSWER I'm sorry to tell you we can't have sexual relations The nurse prepares the client diagnosed with myxedema for discharge. Which action should the nurse teach related to body temperature? - ANSWER "Put on multiple layers of clothes until you fell comfortably warm." The nurse cares for clients in the labor and delivery unit. The nurse anticipates which client is a candidate for induction of labor? - ANSWER The client diagnosed with preeclampsia. The nurse cares for the client diagnosed with HIV. The nurse determines which goal is MOST important? - ANSWER Prevent infections. The nurse educator presents an in-service on acyanotic heart disease. Which is the most common symptom of this disorder that the nurse educator should include? - ANSWER Presence of an audible heart murmur. The nurse provides care for the client diagnosed with pneumonia who has postural drainage twice a day. Which client response indicates to the nurse that treatment is effective? - ANSWER "I am coughing up more sputum." The risk management department plans a program to reduce errors. Which is the most common cause of errors in medication administration? - ANSWER Failure to follow routine policy and procedures. The nurse cares for the school-aged child newly diagnosed with type 1 diabetes. The nurse instructs the family that the child's insulin needs will decrease during which situation? - ANSWER Active exercise The nurse cares for the client receiving lactulose. The nurse determines the medication is effective if which is observed? - ANSWER The client is alert and oriented to person, place and time. The nurse cares for the three-year-old prior to a surgical procedure. Which behavior indicates that the child is coping with preoperative preparation? - ANSWER The child talks about the picture of a nurse and client while coloring the picture using a number of bright colored crayons. The nurse instructs the client after a total hip arthroplasty. The client will utilize which assistive devices in the home? - ANSWER SATA: A long-handled shoehorn. A reaching device. A raised toilet seat. A shower bench. The client reports vomiting and diarrhea for three days. Which assessment finding does the nurse anticipate? - ANSWER Decreased blood pressure. The nurse cares for the client in active labor. The health care provider orders an oxytocin infusion. Which action should the nurse take FIRST after initiating the infusion? - ANSWER Time and record the length and strength of the contractions. The intensive care nurse cares for the client two hours after a myocardial infarction is diagnosed. The nurse's PRIORITY is to focus on which action? - ANSWER Relieve pain. The home health nurse instructs the family how to "allergy-proof" their preschooler's bedroom. The nurse determines teaching is successful if which of the following is observed? - ANSWER There are no pictures hung on the walls. The nurse cares for infants in the newborn nursery. Which observation requires the nurse to contact the physician? - ANSWER Uneven skin folds are noted on a the upper legs of a Mexican-American female born 6 hours ago. The nurse cares for the client diagnosed with partial thickness burns to the entirety of both arms. Using the Rule-of-Nines, the nurse estimates the injury is which percentage? - ANSWER 18% The home care nurse visits the client diagnosed with late stage Parkinson's disease. The client sits in a wheelchair. Which statement, if made by the caretaker, indicates to the home care nurse teaching is effective? - ANSWER "My Client should push the hips up from the wheelchair for about 10 seconds every hour or so." The home care nurse makes a visit to the client diagnosed with heart failure. The client reports having difficulty sleeping at times. The nurse should take which action FIRST? - ANSWER Obtain a thorough sleep assessment history. The nurse cares for the client admitted to the critical care unit. The nurse observes splinter hemorrhages in the nails, painful nodules on the fingertips and splenomegaly. It is MOST important for the nurse to take which action? - ANSWER Auscultate the precordium for murmurs. (ENDOCARDITIS) The nurse instructs the client about stable angina. The nurse determines teaching is effective if the client makes which statement? - ANSWER My chest pain can occur if I overexert myself. The nurse cares for the client in pain. Which factor is MOST important to determine if the client is a candidate for patient controlled analgesia? - ANSWER The client is mentally alert. The nurse received report from the previous shift. Which client should the nurse see FIRST? - ANSWER The client scheduled for discharge later in the day and is reporting increased shortness of breath. The nurse reviews the arterial blood gas Patient Assessment and Care Plan - 2024/2025 Edition for Guaranteed Success in Exams NR 226 PATIENT ASSESSMENT AND CARE PLAN WITH COMPLETE SOLUTIONS 2023

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