Which focused assessment finding warrants immediate intervention by the nurse?

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hesi remediation case study 1
Which assessment finding warrants immediate intervention by the nurse COPD?
Which assessment is most important for the nurse to complete?
Which is the most important intervention for the PN to implement for Dan's priority nursing diagnosis?

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hesi remediation case study 1

Question	Answer
Which assessment findings warrants immediate intervention by the nurse? (Select all that apply.)	Sudden painful inability to urinate. Painful, frequent urination.
The nurse initiates a focused physical examination to further investigate the client's symptoms. Which assessment finding would indicate that the client is experiencing urinary retention related to BPH?	Observance of bladder distention. Bladder is above the symphysis pubis when gently palpated. Observance of dribbling after voiding.
The client tells the nurse that he has cut back on drinking fluids to reduce symptoms. Which instruction is most important for the nurse to provide to the client?	Increase fluid intake to decrease the risk of developing a urinary tract infection.
Which information is most important for the nurse to include when explaining the need for these tests? (Select all that apply.)	Emphasize to the client that prostate enlargement may result in renal damage which these tests will evaluate. Inform the client that repeat testing is necessary as an enlarged prostate gland blocks urine flow and causes kidney damage.
	Advise the client that it is protocol for the healthcare provider (HCP) to conduct then recheck tests to compare previous results.
Which intervention should the nurse implement to address the client's concern?	Explain that PSA levels can be elevated with gland enlargement, as well as cancer, so more tests are needed.
What information should be included when teaching the client about terazosin?	This medication can cause dizziness so it should be taken at night.
Which nursing interventions promotes effective communication when teaching the client about finasteride? (Select all that apply.)	Liver function studies (LFTs) need to be monitored frequently. Most clients see significant change in BPH symptoms in 4 months. Protect the medication from light. Clients can experience breast enlargement. Clients can experience breast enlargement.
The client arrives at the clinic early for the uroflowmetry test and is asking the nurse to explain the procedure. Which nursing intervention best promotes effective communication?	Uroflowmetry is a non-invasive exam to measure the volume and flow of urine.
Which instruction should the nurse provide to the client before starting the procedure?	While voiding into a special toilet, urine flow pressure will be monitored.
Aware of the client's partner's body language, what action should the nurse implement?	Let the client's partner know that you will be glad to answer any questions they may have.
What action is most important for the nurse to take regarding the partner's minimal eye contact?	Tell the partner you noticed they appeared to look away when you were speaking.
Which postoperative intervention should the nurse perform first?	Observe the urinary drainage.
What action should the nurse take?	Document that the CBI is infusing correctly.
Which nursing intervention best promotes effective communication?	Instruct the client to try not to bear down around the catheter.
What action should the nurse take?	Stop the CBI, and irrigate the catheter.
What actions should the nurse take? (Select all that apply.)	Increase the flow rate of the CBI. Notify the HCP of the findings. Perform manual irrigation.
prescribes infusion of aminocaproic acid. prescription is for loading dose of aminocaproic acid IV 5 grams to be infused in 250 mL of 5% dextrose over 1 hour. The tubing drop factor is 15 gtt/mL. How many gtts/minute would the nurse set for the IV rate?	63
What focused assessment data could indicate the onset of a thrombotic complication?	Chest pain and dyspnea.
Which action should the nurse ensure is implemented to reduce the risk for a hemolytic transfusion reaction?	Verify the blood type and Rh factor with the RN who will start, and monitor, the infusion for the first 15-30 minutes.
Which action should the nurse implement first?	Assess the client for additional symptoms.
What action should the nurse take next after stopping the transfusion?	Infuse 0.9% sodium chloride solution through separate IV tubing.
The nurse instructs the UAP to place the emergency cart bedside. What is the next action the nurse should implement?	Notify the laboratory of the transfusion reaction.
Which nursing intervention best promotes effective communication by the charge nurse?	Review blood transfusion interventions with the nurse.
What action by the nurse would indicate a breech of duty.	Initial blood transfusion rate 10 mL/min for the first 15 minutes.
Which focused assessment finding warrants intervention by the nurse?	Confused to surroundings.
Which of the client's serum laboratory values requires immediate intervention by the nurse?	Hematocrit 28 % (0.28)
While the client is awaiting transport to the operating room, which nursing staff member should be assigned to his care?	A PN who has worked on the unit for 3 years.
The nurse is monitoring the client and preparing client for surgery. Which task is within the scope of practice for the PN to complete?	Prepare a client with renal failure for a scheduled dialysis treatment.
Which nursing intervention best promotes effective communication while teaching the client about contracting pelvic floor muscles?	Squeeze as if stopping the flow of urine.
Which nursing intervention best promotes effective communication regarding follow up care?	Provide the client with written information explaining the need for yearly rectal exams and PSA screenings.

Which assessment finding warrants immediate intervention by the nurse COPD?

Which assessment finding warrants immediate intervention by the nurse? Kussmaul respirations are a deep, rapid repiration that occurs when the lungs are trying to compensate for the respiratory acidosis.

Which assessment is most important for the nurse to complete?

The initial nursing assessment is an essential part of the patient care process. It is used by nurses to gather information about an individual before using that data to prepare a care plan and ensure the patient's needs are met.

Which is the most important intervention for the PN to implement for Dan's priority nursing diagnosis?

Which is the most important intervention for the PN to implement for Dan's priority nursing diagnosis? Monitor rate and depth of respirations.

Which focused assessment finding warrants immediate intervention by the nurse?

hesi remediation case study 1

Which assessment finding warrants immediate intervention by the nurse COPD?

Which assessment is most important for the nurse to complete?

Which is the most important intervention for the PN to implement for Dan's priority nursing diagnosis?

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