AHI - Module 1-6

A nurse is preparing to administer 250 mg of antibiotic IM. Available is 3g/5mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

0.4 mL

A nurse is caring for a client who has heart failure and a prescription for digoxin 125 mcg PO daily. Available is digoxin PO 0.25 mg/tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

0.5 tablet

A nurse is preparing to administer heparin 3,000 units by IV bolus. Available is heparin injection 5,000 units/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if applicable. Do not use a trailing zero.)

0.6 mL

A nurse is preparing to administer clindamycin 300 mg by intermittent IV bolus over 30 min to a client who has a staphylococci infection. Available is clindamycin premixed in 50 mL 0.90% sodium chloride (NaCl). The nurse should set the IV pump to deliver how many mL/hr? ( Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

50 mL/hr

A nurse is caring for a client who has the following arterial blood gas results: HCO3 18 mEq, PaCO2 28 mm Hg and pH 7.30. The nurse recognizes the client is experiencing which of the following acid base imbalances? A. metabolic acidosis B. respiratory acidosis C. metabolic alkalosis D. respiratory alkalosis

A A client experiencing metabolic acidosis would have a decreased pH, a decreased HCO3 and a decreased PaCO2.

A nurse is caring for a school-age child who has acute glomerulonephritis with peripheral edema and is producing 35 mL of urine per hour. The nurse should place the client on which of the following diets? A. Low-sodium, fluid-restricted B. Regular diet, no added salt C. Low-carbohydrate, low-protein diet D. Low-protein, low-potassium diet

A A low-sodium, fluid-restricted diet will prevent complications.

A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO2 48 mm Hg and the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate of which of the following acid base balances? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

A A number of conditions can lead to respiratory acidosis, including COPD and pneumonia. In the presence of respiratory acidosis, the client's blood gas values meet the following criteria: a pH less than 7.35, a PaCO2 greater than greater 45 mg/Hg, and a HCO3 that is normal or slightly elevated (22 to 26 mEq/mL).

A nurse is planning care for a client who has acute glomerulonephritis. Which of the following interventions should the nurse include in the plan? A. Administer antibiotics B. Encourage increased fluid intake C. Obtain weight weekly D. Encourage frequent ambulation

A Acute glomerulonephritis related to a streptococcal infection is treated with antibiotic therapy, including penicillin and erythromycin

A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make? A. "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level." B. "I will call the provider to get a prescription for discontinuing the IV heparin today." C. "Both heparin and warfarin work together to dissolve the clots." D. "The IV heparin increase the effects of the warfarin and decreases the length of your hospital stay."

A Heparin and warfarin are both anticoagulants that decrease the clotting ability of the blood and help prevent thrombosis formation in the blood vessels. However, these medications work in different ways to achieve therapeutic coagulation and must be given together until therapeutic levels of anticoagulation can be achieved by warfarin alone, which is usually within 1 to 5 days. When the client's PT and INR are within therapeutic range, the heparin can be discontinued.

A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first? A. Check the client's vital signs B. Request a dietitian consult C. Suggest that the client rests before eating the meal D. Request an order for an antiemetic

A It is possible that the client's nausea is secondary to digoxin toxicity. By obtaining vital signs, the nurse can assess for bradycardia, which is a symptom of digoxin toxicity. The nurse should withhold the medication and call the provider if the client's heart rate is less than 60 bpm.

The nurse is caring for a client who has heart failure and a history of asthma. The nurse reviews the provider's orders and recognizes that clarification is needed for which of the following medications? A. carvedilol B. fluticasone C. captopril D. isosorbide dinitrate

A Medications that block beta-2 receptors, such as carvedilol, are contraindicated in clients with asthma.

A nurse is admitting a client who is having an exacerbation of his asthma. When reviewing the provider's orders, the nurse recognizes that clarification is needed for which of the following medications? A. Propranolol B. Theophylline C. Montelukast D. Prednisone

A Medications that block beta-2 receptors, such as propanolol, are contraindicated in clients with asthma.

A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Saturation 80% Bicarbonate 26 mEq/L A. Respiratory acidosis B. Metabolic acidosis C. Metabolic alkalosis D. Respiratory alkalosis

A Respiratory acidosis occurs when there is retention of CO2 due to an impairment of respiratory function. It can be the result of respiratory depression, seen with anesthesia or opioid administration; inadequate chest expansion, due to a weakness of the respiratory muscles or constriction to the thorax; an obstruction of the airway, seen in aspiration, bronchoconstriction, or laryngeal edema; or from an inability of the lungs to adequately diffuse gases (O2 and CO2), resulting from conditions such as pneumonia, COPD, chest trauma, or pulmonary emboli. Arterial blood gases will reveal a pH that is lower than the normal reference range (7.35 - 7.45) and a CO2 level that is higher than the normal reference range (35 - 45 mm Hg).

The nurse asks a client who is about to have a cardiac catheterization about any allergies. The client states, "I always get a rash when I eat shellfish." Which of the following is the priority nursing action? A. notify the provider of the client's allergy B. attach a wrist band indicating the client's allergy C. ask the client if any other foods cause such a reaction D. notify the dietary department of the client's allergy

A The greatest risk to the client is an allergic reaction to the iodine-containing contrast agent the client will receive IV for the procedure, because shellfish also contains iodine. A steroid and/or antihistamine will be given to a client with an iodine allergy to prevent or minimize a reaction.

A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse plan to implement? A. Vitamin B12 injections B. Iron supplements C. Blood transfusions D. Vitamin B6 supplements

A The nurse should administer vitamin B12 injections to treat pernicious anemia when diet fails to improve the anemia due to poor absorption.

A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect? A. Fatigue B. Hypertension C. Bradycardia D. Diarrhea

A The nurse should identify that the client who has anemia due to blood loss following surgery will experience fatigue. This is due to the body's decreased ability carry oxygen to vital tissues and organs.

A nurse is planning care for a client who has deep vein thrombosis of the lower leg. Which of the following interventions should the nurse include in the plan of care? A. Keep the client's affected leg elevated while in bed B. Have the client ambulate prior to applying antiembolic stockings C. Apply ice packs to affected leg D. Massage the client's affected leg twice a day

A The nurse should keep the client's leg elevated when he is in bed to decrease edema.

A nurse is preparing to administer a pre-packaged oral medication to a client and complete the final medication check. At which of the following times or places should the nurse perform this final check? A. at the client's bedside before administration B. in the area where the nurse obtained the medication C. at the time of documentation D. at the nurses' station while reviewing the provider's prescription

A The nurse should perform the final medication check at the client's bedside while reviewing the package's label.

A nurse is reviewing the laboratory results of a client who takes furosemide. Which of the following results should the nurse identify as the priority finding? A. Potassium 2.9 mEq/L B. Phosphorus 4.5 mEq/L C. Sodium 145 mEq/L D. Calcium 8.2 mg/dL

A Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is the client's potassium level. The client's level is below the expected reference range of 3.5 to 5.0 mEq/L. Hypokalemia can be a life-threatening condition if left untreated. Potassium is the primary electrolyte vital for cell metabolism and cardiac and neuromuscular function.

A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of personal protective equipment (PPE) should the nurse remove last? A. mask B. gloves C. gown D. goggles

A With a client who requires airborne precautions, the nurse will continue to need the protection of the mask while removing other contaminated PPE.

A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see? A. pH below 7.35 B. HCO3 above 26 mEq/L C. PaO2 below 70 mm Hg D. PaCO2 above 45 mm Hg

A With acidosis, the pH is below 7.35. However, the pH alone does not indicate whether the problem is metabolic or respiratory. A pH above 7.45 indicates alkalosis.

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.) A. increased heart rate B. increased blood pressure C. increased respiratory rate D. increase hematocrit E. increased temperature

A, B, C Increased heart rate is correct. The nurse should expect the client who has fluid volume excess to have tachycardia and increased cardiac contractility in response to the excess fluid. Increased blood pressure is correct. The nurse should expect the client who has fluid volume excess to have increased blood pressure and bounding pulse in response to the excess fluid. Increased respiratory rate is correct. The nurse should expect the client who has fluid volume excess to have increase in respiratory rate and moist crackles heard in lungs. Increased hematocrit is incorrect. The nurse should expect the client who has fluid volume deficit to have an elevated hematocrit because of hemoconcentration. Increase temperature is incorrect. The nurse should expect the client who has fluid volume deficit to have an increase in temperature due to fluid loss.

A nurse is assessing an older adult client who is receiving IV therapy. The nurse should recognize that which of the following findings indicates fluid volume excess? (Select all that apply.) A. Bounding pulse B. Pitting edema C. Swelling at the IV site D. Urine-specific gravity greater than 1.030 E. Crackles upon auscultation

A, B, D Bounding pulse is correct. Fluid volume excess is due to excessive fluid intake or inadequate fluid excretion. Manifestations include increased blood pressure, pulse, and respirations. With fluid volume excess, the pulse is full and bounding. Pitting edema is correct. Excess extracellular fluid can lead to pitting edema in dependent areas of the body. Swelling at the IV site is incorrect. Edema at the IV site indicates a localized accumulation of fluid due to infiltration. Although this is a concern, this finding does not suggest fluid volume excess. This finding would suggest infiltration. The nurse should discontinue the IV and restarted at another site. Urine specific gravity greater than 1.030 is incorrect. Urine-specific gravity measures the concentration of all chemical particles in the urine. A therapeutic range is 1.005 to 1.030. A urine-specific gravity greater than 1.030 indicates dehydration, and a gravity of less than 1.010 indicates fluid volume excess. Crackles upon auscultation is correct. Pulmonary edema can occur with fluid volume excess.

A nurse is caring for a client who just had a cardiac catheterization. Which of the following nursing interventions should the nurse include in the client's plan of care? (Select all that apply.) A. check peripheral pulses in the affected extremity B. place the client in high-Fowler's position C. measure the client's vital signs every 4 hours D. keep the client's hip and leg extended E. have the client remain in bed up to 6 hours

A, D, E Check peripheral pulses in the affected extremity is correct. The nurse should check pulse points plus skin temperature and color in the affected extremity as prescribed by the facility, which is commonly every 15 min for 1 hr, every 30 min for 1 hr, and hourly for 4 hr. Place the client in high-Fowler's position is incorrect. The client should remain flat or with the head of the bed elevated no more than 30° for 2 to 6 hr after the procedure. Measure the client's vital signs every 4 hr is incorrect. The nurse should measure the client's vital signs frequently, with each check of the affected extremity. Keep the client's hip and leg extended is correct. The nurse should keep the client from flexing the knee or hip and can use a knee brace to prevent bending the affected leg. Have the client remain in bed up to 6 hr is correct. Clients who had manual or mechanical pressure after catheter removal require 6 hr of bed rest. Those who had a closure device or patch only need 2 hr of bed rest.

A nurse is preparing to administer oral medications to a client. Which of the following should the nurse recognize as an acceptable client identifier? (Select all that apply.) A. Client's full name B. Facility room number C. Partner's full name D. Provider's name E. Facility-assigned identification number

A, D, E Client's full name is correct. To prevent medication errors, it is essential to perform the six rights of medication administration which includes the "correct client." The Joint Commission requires the use of two separate client identifiers to identify the correct client. Facility room number is incorrect. To prevent medication errors, it is essential to perform the six rights of medication administration which includes the "correct client." The Joint Commission requires the use of two separate client identifiers to identify the correct client. These can include the client's full name, an identification number assigned by the facility, and a telephone number. Partner's full name is incorrect. To prevent medication errors, it is essential to perform the six rights of medication administration which includes the "correct client." The Joint Commission requires the use of two separate client identifiers to identify the correct client. These can include the client's full name, an identification number assigned by the facility, and a telephone number. Provider's name is incorrect. To prevent medication errors, it is essential to perform the six rights of medication administration which includes the "correct client." The Joint Commission requires the use of two separate client identifiers to identify the correct client. These can include the client's full name, an identification number assigned by the facility, and a telephone number. Facility-assigned identification number is correct. To prevent medication errors, it is essential to perform the six rights of medication administration which includes the "correct client." The Joint Commission requires the use of two separate client identifiers to identify the correct client.

A nurse is teaching a client who has urolithiasis (renal calculi). The nurse should explain that which of the following conditions can increase the risk for renal calculi? A. Protein in the urine B. Dehydration C. Iron deficiency D. Obesity

B Dehydration can cause hypercalcemia which increases the risk for renal stone formation. Inadequate fluid intake can result in urinary stasis and promote the formation of calculi.

A nurse is reviewing a client's laboratory results and finds the hemoglobin is 10 g/dL and the hematocrit is 30%. The nurse recognizes that the client is at risk for which of the following? A. Prolonged bleeding B. Cellular hypoxia C. Impaired immunity D. Fluid retention

B The client's laboratory results indicated anemia, which places the client at risk for cellular hypoxia

A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first? A. call the client's provider B. assess the client C. notify the nurse manager D. complete an incident report

B The first action the nurse should take using the nursing process is to assess the client. The nurse must first determine whether or not the error has caused the client any harm and also provide any relevant interventions.

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse? A. observe client's respiratory status B. elevate the head of the client's bed 30 deg to 45 deg C. monitor intake and output every 8 hr D. check residual volume every 4 to 6 hr

B A client who has a decreased level of consciousness and an inability to swallow is at risk for aspiration. Lying flat also increases this risk. The priority action by the nurse is to keep the head of the bed elevated 30o to 45o to promote gastric emptying and reduce the risk of aspiration.

A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority? A. increase the oxygen flow to 3 L/min B. assess the client's respiratory status C. call emergency services for the client D. have the client cough and expectorate secretions

B The first action the nurse should take using the nursing process is to collect data from the client. The nurse should immediately assess the client's respiratory status before determining the appropriate interventions.

A nurse is planning care for a client who has leukemia and a platelet count of 130,000/mm3. Which of the following interventions should the nurse include in the plan of care? A. check the IV site for bleeding every 8 hr B. limit IM injections C. obtain a rectal temperature every 8 hr D. check the client for proteinuria

B The nurse should plan to limit IM injections or venipunctures to prevent harm to the client. If venipuncture is necessary, the nurse should hold pressure to the site for 10 min afterward.

A nurse is caring for a client who has an indwelling urinary catheter and a prescription for a urine specimen for culture and sensitivity. Which of the following actions should the nurse take? A. insert the needle into the needless port at a 60 deg angle B. withdraw 3 to 5 mL of urine from the port C. wipe the area of needless port with sterile water D. don sterile gloves

B The nurse should withdraw the required amount of urine which would be approximately 3 to 5mL for a urine culture or 30 mL for a routine urinalysis.

A nurse is preparing an in-service program about preventing medication errors when transcribing a prescription. The nurse is using a dosage example of two tenths a milligram. Which of the following examples should the nurse use to show appropriate transcription of this dosage? A. .2 mg B. 0.2 mg C. 0.20 mg D. 2.0 mg

B The use and placement of a decimal point can cause a medication error. A zero should precede a decimal point, but should not follow a decimal point unless a whole number follows the zero, as in 1.05 mg.

A nurse is caring for an antepartum client who has iron-deficiency anemia. When teaching the client about nutrition, the nurse should emphasize the need for an increased intake of which of the following foods? A. milk and cheese B. red meat and organ meat C. fresh fruits D. whole grain breads

B This client has a deficiency in iron and needs instruction about foods that are rich sources of iron. A diet rich in red and organ meat provides iron, which is what the client needs to improve anemia.

A nurse is reviewing laboratory findings for four clients. Which of the following clients has manifestations of acute kidney injury? A. BUN 15mg/dL B. Serum creatinine 6 mg/dL C. Hemoglobin 16 g/dL D. Serum potassium 4.5 mEq/L

B This finding is above the expected reference range. The expected reference range for creatinine is 0.5 mg/dL to 1.3 mg/dL depending on the client's gender and age. An elevated serum creatinine is a manifestation of impaired kidney function, such as with acute kidney injury.

A nurse is caring for a client who has active pulmonary (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take the transport the client safely to the radiology department for a chest x-ray? A. ask the x-ray technician to come to the client's room to obtain a portable x-ray B. have the client wear a mask C. notify the x-ray department that the client requires airborne precautions D. wear a filtration mask and gloves during transport

B When a client who has a communicable disease must leave his room, it is important to protect everyone with whom the client comes in contact. Having the client wear a mask protects others from airborne particles should the client cough.

A nurse in a provider's office is assessing a client. The nurse should identify that which of the following findings are manifestations of pulmonary tuberculosis? (Select all that apply) A. night sweats B. low-grade fever C. weight gain D. flushed cheeks E. blood in the sputum

B, D, E Night sweats is correct. Night sweats are a manifestation of tuberculosis. Low-grade fever is correct. Low-grade fever is a manifestation of tuberculosis. Weight gain is incorrect. Weight loss, not weight gain, is a manifestation of tuberculosis. Flushed cheeks is incorrect. Flushed cheeks are a manifestation of pneumonia, not tuberculosis. Blood in the sputum is correct. Blood-streaked sputum is a manifestation of tuberculosis.

A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider requires clarification? A. morphine sulfate 2 mg IV bolus every 2 hr PRN pain B. laboratory testing of serum potassium upon admission C. 0.9% normal saline IV at 50 mL/hr continuous D. bumetanide 1 mg IV bolus every 12 hr

C 0.9% sodium chloride is isotonic and will not cause the fluid shift needed in this client to reduce circulatory overload. This prescription requires clarification.

A nurse is caring for a male client who has chronic glomerulonephritis. Which of the following findings should the nurse expect? A. urine specific gravity 1.035 B. creatinine clearance 120 mL/min C. serum creatinine 7 mg/dL D. BUN 15 mg/dL

C A serum creatinine of 7 mg/dL is a critical value that indicates serious impairment of renal function. Clients who have chronic glomerulonephritis usually develop the disease over 20 to 30 years. Gradual changes occur in the kidney resulting in atrophy and a decreased number of functioning nephrons.

A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider immediately? A. Serosanguineous drainage from the puncture site B. Discomfort at the puncture site C. Increased heart rate D. Decreased temperature

C Clients are at risk for developing pulmonary edema or cardiovascular distress due mediastinal content shift after the aspiration of a large amount of fluid from the client's pleural space. Therefore, the client may experience an increase in heart and respiratory rate, along with coughing with blood-tinged frothy sputum, and tightness in the chest. These findings require notification of the provider immediately.

A nurse is providing discharge instructions for a client who has congestive heart failure. Which of the following client statements indicates to the nurse that the teaching was effective? A. "I will read food labels and limit my sodium to 4 grams per day." B. "I should use naproxen to manage discomfort. C. "I plan to slow down if I am tired the day after exercising." D. "I will take my diuretic before sleep and drink fluids during the day."

C Clients who experience chest pain or dyspnea while exercising or experience fatigue the next day are probably advancing the activity too quickly and should slow down.

A nurse in a provider's office is assessing a client who reports dyspnea and fatigue. Physical assessment reveals tachycardia and weak peripheral pulses. The nurse should recognize these findings as manifestations of which of the following conditions? A. asthma B. aortic valve regurgitation C. heart failure D. aortic stenosis

C Fatigue and tachycardia are early manifestations of heart failure. Other manifestations include dyspnea and weak peripheral pulses.

A nurse is assessing a client who has a fluid volume deficit. The nurse should expect which of the following findings? A. decreased urine specific gravity B. decreased Hgb C. increased BUN D. increased urine ketones

C Increased BUN is an expected finding of fluid volume deficit due to the hemoconcentration of substances in the blood from excessive water loss.

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions? A. encourage the client to ambulate frequently B. encourage coughing and deep breathing C. encourage to client to increase fluid intake D. encourage regular use of the incentive spirometer

C Increasing fluid intake to 1,500 to 2,500 mL/day promotes liquefaction and thinning of pulmonary secretions, which improves the client's ability to cough and remove the secretions.

A nurse is reviewing the laboratory report of a client a identifies a serum potassium level of 6.8 mEq/L. Which of the following medications should the nurse plan to administer? A. Lactulose B. Sevelamer C. Sodium polystyrene D. Darbepoetin alfa

C Sodium polystyrene is used for the treatment of hyperkalemia., It removes excess potassium by ion exchange through the bowel. The client's serum potassium level of 6.8 mEq/L is significantly above the reference range of 3.5 - 5.0 mEq/L.

A nurse is administering an oral medication to an older adult client. The client states, "The pill I always take is green. I don't take an orange pill." Which of the following responses should the nurse make? A. "Sometimes the same pill comes in a different color." B. "Let me explain the purpose of the medication." C. "I will check your medication order again." D. "This is the medication that your doctor wants you to take."

C The appropriate nursing response is to check the provider's original medication order to avoid a medication error.

A nurse is teaching a client who has angina pectoris about starting therapy with SL nitroglycerin tablets. The nurse should include which of the following instructions regarding how to take the medication? A. "Take this medication after each meal and a bedtime." B. "Take one tablet every 15 min during an acute attack." C. "Take one tablet at the first indication of chest pain." D. "Take this medication with 8 oz of water."

C The client should take nitroglycerin as soon as he feels pain, pressure, or tightness in his chest and not wait until his chest pain is severe.

A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction. Which of the following prescriptions should the nurse take first? A. Attach the leads for a 12-lead ECG B. Obtain a blood sample C. Initiate oxygen therapy D. Insert the IV catheter

C The greatest risk to the client's safety is myocardial ischemia and cellular death; therefore, the priority action the nurse should take is to administer oxygen to help minimize this possibility.

A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction? A. Check the client's blood pressure. B. Auscultate heart tones. C. Perform a 12-lead ECG D. Determine if pain radiates to the left arm.

C The nurse should perform a 12-lead ECG when a client complains of chest pain to determine if the client is experiencing a myocardial infarction.

A nurse is preparing to administer heparin subcutaneously to a client who has a deep vein thrombosis. Which of the following techniques should the nurse use? A. Cleanse the skin with an alcohol swab, insert the needle, aspirate, and inject the heparin. B. Cleanse the skin with an alcohol swab, insert the needle, aspirate, and inject the heparin, and massage the site. C. Cleanse the skin with an alcohol swab, insert the needle, inject the heparin, and observe for bleeding. D. Cleanse the skin with an alcohol swab, insert the needle, inject the heparin, aspirate, and observe for bleeding.

C This is the correct technique for the nurse to use to inject heparin.

A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect? A. slow B. not palpable C. irregular D. bounding

C With atrial fibrillation, multiple ectopic foci stimulate the atria to contract. The AV node is unable to transmit all of these impulses to the ventricles, resulting in a pattern of highly irregular ventricular contractions and thus an irregular pulse.

A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances? A. metabolic acidosis B. metabolic alkalosis C. respiratory acidosis D. respiratory alkalosis

C With uncompensated respiratory acidosis, the pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg.

A nurse in an emergency department is assessing a client who is having a suspected acute myocardial infarction (MI). Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI? (Select all that apply) A. orthopnea B. headache C. nausea D. tachycardia E. diaphoresis

C, D, E Orthopnea is incorrect. Orthopnea is a manifestation of heart failure, which can develop from an MI but is not a common manifestation of an acute MI. A client experiencing an MI typically manifests dyspnea. Headache is incorrect. Chest pain and sometimes jaw, back, and shoulder pain are manifestations of an acute MI. Nausea is correct. Nausea and vomiting are manifestations of an acute MI. Tachycardia is correct. Tachycardia and dysrhythmias are manifestations of an acute MI. Tachycardia can also occur as a result of the client's anxiety. Diaphoresis is correct. Profuse sweating and anxiety are manifestations of an acute MI.

A nurse is discussing laboratory values associated with the renal system with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the values? A. Potassium levels are increased in clients who have polyuria B. Specific gravity is decreased in clients who have hypovolemia C. BUN is decreased in clients who have dehydration D. Creatinine levels are increased in clients who have acute kidney injury

D Increased creatinine levels are associated with renal failure.

A nurse in an emergency department is planning care for a client who is having an acute myocardial infarction (MI). The nurse should plan to administer which of the following medications after the initial acute phase to manage the client's pain and anxiety? A. nitroglycerin B. aspirin C. oxygen D. morphine

D Morphine is the medication of choice for managing the pain and anxiety of an acute MI. By reducing preload and afterload, it decreases the work of the heart.

A nurse is teaching a client who has angina about nitroglycerin sublingual tablets. Which of the following statements should the nurse include in the teaching? A. "Place one tablet under your tongue every 5 min for 30 min to relieve chest pain." B. "Nitroglycerin decreases chest pain by dissolving blood clots that are occluding the arteries." C. "You can store the bottle of tablets in your bathroom medicine cabinet." D. "Nitroglycerin dilates cardiac blood vessels to deliver more oxygen to the heart."

D Nitroglycerin is a nitrate medication that increases collateral blood flow, redistributes blood flow toward the subendocardium, and dilates the coronary arteries.

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan? A. restrict the client's fluid intake to less than 2 L/day B. provide the client with a low-protein diet C. have the client use the early-morning hours for exercise and activity D. instruct the client to use pursed-lip breathing

D Pursed-lip breathing lengthens the expiratory phase of respiration and also increases the pressure in the airway during exhalation. This action reduces airway resistance and decreases trapped air for clients who have COPD.

A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority? A. initiating oxygen therapy B. providing immediate rest for the client C. positioning the client in high-Fowler's D. administering a nebulized beta-adrenergic

D The greatest risk to the client's safety is airway obstruction. Beta-adrenergic medications act as bronchodilators. They provide prompt relief of airflow obstruction by relaxing bronchiolar smooth muscle and are the initial priority intervention when a client has an acute asthma exacerbation.

A nurse is planning care for a client who has urolithiasis. Which of the following actions should the nurse take? A. apply cold compress to the client's flank area B. restrict protein intake to 2 servings per day C. discourage ambulation D. encourage intake of at least 3 L of fluids per day

D The nurse should encourage the client to consume at least 3,000 mL of fluids per day to dilute the urine, increase hydrostatic pressure behind the stone, and move the calculi down the urinary tract.

A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take? A. mix the three medications together prior to administering B. dilute each medication with 10 mL of tap water C. maintain the head of the bed in a flat position for 30 min following medication administration D. flush the NG feeding tube with 30 mL of water immediately following medication administration

D The nurse should flush the NG feeding tube with 15 to 60 mL of sterile water following medication administration to ensure the feeding tube is cleared of the medications.