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November 11 clinical assignment. Questions, Interventions, and Rationales.

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Questions/Answers
1. A nurse is admitting a patient with a diagnosis of Parkinson’s disease. Which signs and symptoms that the client is experiencing helps support this diagnosis?
a. Blood glucose level of 240
b. Skin that appears yellow
c. Concentrated urine
d. Pill-rolling movements of the fingers
Answer d.
2. A nurse is explaining the medication regimen for Baclofen (Lioresal). What statement by the patient alerts the nurse that the patient has not understood the teaching provided by the nurse?
a. I can stop taking Baclofen if it upsets my stomach.
b. I need to taper off of baclofen before I stop taking it over a period of 2 weeks.
c. This medicine will help relax my muscles.
d. This medicine can make me dizzy.
Answer a.
3. A patient is scheduled for a hip replacement and a nurse is doing post-operative teaching. What should the nurse include in her teaching? Select all that apply.
a. Turning, cough, and deep breathing after surgery.
b. Explaining how to operate a PCA pump to help alleviate pain.
c. Movements to avoid preventing dislocation the hip.
d. Instructions for the client to remain in bed for 3 days after surgery.
Answer a. b. c.
4. A patient diagnosed with multiple sclerosis is having problems ambulation and performing activities of daily living. A nurse plans to refer the client to which of the following for assistance?
a. Local YMCA
b. Occupational therapist
c. Speech therapist
d. Respiratory therapist
Answer b.
5. A nurse is teaching a patient with Rheumatoid Arthritis about the side effects of Prednisone. What is the priority teaching?
a. The medicine can make you hungry
b. The medicine can make you have insomnia
c. The medicine will make you immunocompromised
d. The medicine will make you thirsty.
Answer c.

Risks for decreased cardiac tissue perfusion
Intervention Monitor for chest, neck and jaw pain, SOB, diaphoresis, N/V.
Rationale These symptoms are signs of decreased cardiac perfusion and heart attack according to the America Heart Association.
Intervention If chest pain is present administer oxygen per nasal cannula as ordered.
Rationale Maintaining a SaO2 of 90% or more will decrease the pain associated with myocardial ischemia by increasing the amount of oxygen delivered to the cardiac heart muscles.
Intervention Give client an aspirin tablet if ordered and not contraindicated.
Rationale Aspirin inhibits platelet aggregation to help stop clotting and also inhibits vasoconstriction.

Gas Exchange/Cellular regulation
Intervention Monitor oxygen continuously using pulse oximetry.
Rationale Oxygen saturation less than 90 or partial pressure oxygen less than 80mmHg indicates significant oxygenation problems.
Intervention Observe for cyanosis of the skin especially note the color of the tongue and oral membranes.
Rationale Central cyanosis of the tongue and oral mucosa is indicative of serious hypoxemia and is a medical emergency.
Intervention Position in a semi-fowler position with an upright posture of 45 degrees if possible.
Rationale Research done on clients on a ventilator demonstrated that being in a 45 degree upright position increased oxygenation and ventilation.

A patient with an INR of 4 is most likely taking Warfarin. INR of 4 will put this patient at risk for bleeding.
Intervention Before administering warfarin check INR. Hold medicine and notify physician if the INR is outside the recommended parameters.
Rationale Target INR for Warfarin should be between 2.0 – 3.0.
Intervention Notify the dietary department when client is receiving Warfarin.
Rationale Insure consistency and amount of vitamin K in the diet.
Intervention Monitor lab test for H&H, PT, and INR.
Rationale H&H are late determinates of bleeding but are more objective than visual assessments of blood loss.

Interventions and rationales from
Nursing Diagnosis Handbook
Evidence Based Guide to Planning
Authors: Betty J. Ackley and Gail B. Ladwig

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I love your NCLEX questions. I wish you could make up the real NCLEX! Maybe I wouldn't worry as much. Smile You have the same evidence based practice book that I have. I love that book. It has helped me a lot over the past year. I don't know what else to say except keep up the good work!

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Guest
I absolutely agree with Kim, you make AWESOME NCLEX questions. Great job! Also your interventions and rationales are very good! They highlight the most important parts! You’re going to make a great Nurse!

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