NCLEX 100 Questions

The nurse is preparing to care for a client with acquired immunodeficiency syndrome (AIDS). In planning infection control for this client, the nurse should implement which form of isolation to prevent the spread of the AIDS virus to others?

Blood and body fluid precautions

The nurse is caring for a client with heart failure (HF). Which signs and symptoms could indicate fluid overload? Select all that apply.

Bounding pulse Difficulty breathing Presence of dependent edema Neck vein distention in the upright position

The nurse has administered an injection to a client. After the injection, the nurse accidentally drops the syringe on the floor. What is the safe nursing action in this situation?

Carefully pick up the syringe from the floor and dispose of it in a sharps container.

The nurse is providing home care instructions to the parents of an infant who had a surgical repair of an inguinal hernia. What instruction should the nurse include to prevent infection at the surgical site?

Change the diapers as soon as they become damp.

The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The health care provider has now prescribed that the nasogastric tube be removed. What is the priority nursing assessment prior to removing the tube?

Checking for the presence of bowel sounds in all 4 quadrants Rationale: Distention, vomiting, and abdominal pain are a few of the symptoms associated with intestinal obstruction. Nasogastric tubes may be used to remove gas and fluid from the stomach, relieving distention and vomiting. Bowel sounds return to normal as the obstruction is resolved and normal bowel function is restored. Discontinuing the nasogastric tube before normal bowel function may result in a return of the symptoms, necessitating reinsertion of the nasogastric tube. Serum electrolyte levels, pH of the gastric aspirate, and tube placement are important assessments for the client with a nasogastric tube in place, but would not assist in determining the readiness for removing the nasogastric tube.

The nurse is providing care to a client with the following arterial blood gas results: pH of 7.50 (7.50), Pao2 of 90 mm Hg (90 mm Hg), Paco2 of 40 mm Hg (40 mm Hg), and bicarbonate of 35 mEq/L (35 mmol/L). When the nurse notifies the health care provider about these levels, the nurse should anticipate receiving from the HCP which prescription for this client?

Discontinue nasogastric suctioning.

A client who had abdominal surgery is receiving epidural analgesia. The nurse monitors the client closely, knowing that which is a potential complication of this therapy?

Dislodgment of the epidural catheter because the catheter is not sutured in place

The nurse is providing instructions to the client scheduled for magnetic resonance imaging. Which instruction should the nurse provide to the client?

Lying still in a flat position for 45 to 60 minutes may be necessary.

The nurse is monitoring the nutritional status of a client receiving enteral nutrition. Which intervention should the nurse implement to determine the effectiveness of the tube feedings?

Obtain a daily weight.

The nurse is giving client instructions over the telephone about preparing for a mammography. The nurse should make which statement to the client?

"Avoid using underarm deodorant on the day of the test."

An adolescent is diagnosed with conjunctivitis, and the nurse provides information to the adolescent about the use of contact lenses. Which statement by the client would indicate the need for further information?

"My contact lenses can be worn if they are cleaned properly."

The health care provider prescribes 0.075 g of a medication orally daily. The label on the medication bottle reads 25-mg tablets. How many tablet(s) will the nurse administer to the client? Fill in the blank.

3

A client is scheduled for a test to detect kidney tumors or cysts. What test is considered safest for the client?

Ultrasonography

Which interventions are appropriate when administering a tepid bath to a child with a fever? Select all that apply.

Use a water toy to distract the child during the bath. Place lightweight pajamas on the child after the bath. Squeeze water over the child's body, using the washcloth.

The school nurse prepares a list of home care instructions for the parents of schoolchildren diagnosed with pediculosis capitis. Which instruction should the nurse include in the list?

Vacuum floors, play areas, and furniture to remove any hairs that might carry live nits.

The nurse has a written prescription to discontinue an intravenous (IV) line. The nurse obtains which item from the unit supply area for use in applying pressure to the site after removing the IV catheter?

sterile 2 x 2 gauze

The nurse is caring for a client with respiratory failure related to Guillain-Barré syndrome. The nurse plans care knowing that what other extrapulmonary causes can lead to respiratory failure? Select all that apply.

stroke Sleep apnea Myasthenia gravis Opioid analgesics, sedatives, anesthetics

The nurse is caring for a client admitted with a diagnosis of systemic lupus erythematosus (SLE). A highly sensitive C-reactive protein (hsCRP) blood test is prescribed. What other blood test is often used along with the hsCRP?

Erythrocyte sedimentation rate (ESR)

A client is admitted to the hospital 24 hours following an aspirin (acetylsalicylic acid) overdose. The nurse assesses this client for which signs/symptoms indicating the acid-base disturbance that could occur in the client?

Headache, nausea, vomiting, and diarrhea

The nurse collects a 24-hour urine specimen for catecholamine testing from a client with suspected pheochromocytoma. The results of the catecholamine test are reported as epinephrine 20 mcg (109 nmol) and norepinephrine 100 mcg (590 nmol). The nurse should make which interpretation about this result?

Higher than normal, indicating pheochromocytoma

A client has been on total parenteral nutrition (TPN) for 8 weeks at home. The health care provider prescribes that the TPN be weaned by 50 mL per hour per day until discontinued. The client asks the nurse why the TPN cannot just be stopped. The nurse explains that unless the TPN infusions are tapered gradually, the client is at risk for developing which complication?

Hypoglycemia

The nurse is providing instructions to a client who has had a bone scan. The nurse should instruct the client to take which measure?

Increase fluid intake for the next 24 to 48 hours.

The nurse is caring for a non-English-speaking client and is attempting to integrate the client's cultural practices into Western medicine. What are some other aspects of culturally competent care the nurse can employ? Select all that apply.

Increasing client safety Using spiritual practices Reducing health disparities Increasing client satisfaction Preventing misunderstandings between the nurse and the client

The clinic nurse is caring for a client who has been prescribed fentanyl, a potent opioid, for chronic pain. In what forms is it available for chronic pain administration in the at-home setting? Select all that apply.

Intranasal spray Oral transmucosal lozenge 72-hour transdermal patch Effervescent buccal oralets

A client's laboratory test results reveal an increased transferrin level and a decreased iron-binding capacity. The nurse interprets that these laboratory results are compatible with anemia because of which problem?

Iron deficiency

A female client seen in the ambulatory care clinic has a history of syphilis infection. The nurse assessing the client for reinfection would expect to observe a lesion on the labia that has which characteristic?

Is painless and indurated

Which clients have a high risk of obesity and diabetes mellitus? Select all that apply.

Latino American man Native American man Hispanic American man African American woman

The nurse is implementing the complementary therapy of therapeutic touch when caring for clients. The nurse should implement which action when performing therapeutic touch?

Position hands 2 to 4 inches (5 to 10 cm) from the body.

The nurse is reviewing the arterial blood gas values of a client and notes that the pH is 7.31 (7.31), Paco2 is 50 mm Hg (50 mm Hg), and the bicarbonate (HCO3) level is 26 mEq/L (26 mmol/L). The nurse concludes that which acid-base disturbance is present in this client?

Respiratory acidosis

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg (90 mm Hg), and HCO3- is 22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition?

Respiratory acidosis without compensation

The nurse is assisting the health care provider with a bedside liver biopsy. When the procedure is complete, the nurse assists the client into which position?

Right side-lying, with a small pillow or towel under the puncture site Rationale: Following a liver biopsy, the client is assisted to assume a right side-lying position with a small pillow or folded towel under the puncture site for at least 3 hours. This helps to immobilize the area and provides pressure to minimize bleeding in this vascular organ. The other options are incorrect.

The nurse is admitting a client who has a cough, dyspnea, and abnormal chest x-ray who is otherwise healthy. The client has an elevated serum angiotensin-converting enzyme (SACE) level. Based on this result, what condition is the client at risk for?

Sarcoidosis

A client is about to undergo a lumbar puncture (LP). Which position should the nurse tell the client will be used during the procedure?

Side-lying position, with legs pulled up and head bent down onto the chest

A client is about to undergo a lumbar puncture (LP). The nurse should tell the client that which position will be used during the procedure?

Side-lying with the legs pulled up and the head bent down onto the chest

The nurse is providing dietary instructions to a client about the food items that are high in vitamin K. Which food item does the nurse recommend as being highest in vitamin K?

Spinach

The nurse is preparing to suction the airway of a client who has a tracheostomy tube and gathers the supplies needed for the procedure. In order of priority, which actions should the nurse take to perform this procedure? Arrange the actions in the order that they should be performed. All options must be used.

1) Place the client in a semi Fowler's position. 2) Turn on the suction device and set the regulator at 80 mm Hg. 3) Attach the suction tubing to the suction catheter. 4) Hyperoxygenate the client. 5) Insert the catheter into the tracheostomy until resistance is met, and then pull it back 1 cm. 6) Apply intermittent suction and slowly withdraw the catheter while rotating it back and forth.

A health care provider prescribes morphine sulfate 4 mg, intravenously (IV) stat, for a postoperative client in pain. The medication label states morphine sulfate 2 mg/mL. How many milliliters will the nurse prepare to administer to the client? Fill in the blank.

2

The health care provider prescribes digoxin 0.25 mg orally daily for a client with heart failure. The medication label states 0.125 mg per tablet. The nurse should administer how many tablet(s) to the client? Fill in the blank.

2

A registered nurse (RN) is providing instructions to an unlicensed assistive personnel (UAP) assigned to give a bed bath to a client who is on contact precautions. The RN instructs the UAP to use which protective item when giving the bed bath?

A gown and gloves

The prescription for an infusion of parenteral nutrition reads: Infuse 1800 mL bag over 24 hours. At what rate will the nurse set the infusion pump? Fill in the blank.

75

The nurse is assigned to care for a client who is experiencing episodes of postural hypotension. Which action should the nurse take to ensure safety while transferring the client from the bed to the chair?

Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair.

A clinic nurse is providing instructions to a client who is scheduled for a glucose tolerance test. Which instruction should the nurse provide to the client in preparation for the test?

Avoid alcohol, coffee, and tea for 36 hours before and during the test.

A client with liver cancer receiving chemotherapy tells the nurse that some foods on the meal tray taste bitter. The nurse should try to limit which food that is most likely to cause this taste for the client?

Beef

Which finding in a postoperative client would be of concern to the nurse?

Blood pressure of 88/52 mm Hg

The nurse has a prescription to hang a crystalloid intravenous solution of lactated Ringer's on a newly admitted client. The nurse notices that the client has a history of alcoholic cirrhosis. What action should the nurse take first?

Contact the health care provider (HCP).

The nurse is caring for a client with suspected kidney failure. A 24-hour urine specimen is prescribed. What value measures overall kidney function?

Creatinine clearance levels

The nurse is preparing an intravenous (IV) set before starting the infusion. After removing the cap from the IV tubing port on the IV bag, the nurse removes the cover from the tubing insertion spike but then touches the spike with a finger. What should the nurse do next?

Discard the IV tubing and use a new set for the infusion.

The nurse is caring for an abdominal surgical client who has a Jackson-Pratt drain in place. Which interventions should the nurse include in the plan of care for this drain? Select all that apply.

Make sure suction is maintained. Check that the drains are sutured in place. Compress the reservoir to restore suction after emptying. Record the amount and color of drainage according to agency protocol or health care provider's orders. Rationale: Interventions include making sure suction is maintained, checking that the drains are sutured in place, compressing the reservoir to restore suction after emptying, and recording the amount and color of drainage according to agency protocol or health care provider's orders. The other interventions are not appropriate.

The nurse is providing care to a Puerto Rican-American client who is terminally ill. Numerous family members are present most of the time, and many of the family members are very emotional. What is the most appropriate nursing action for this client?

Make the necessary arrangements so that family members can visit.

The nurse is reviewing a client's laboratory report and notes that the total serum calcium level is 6.0 mg/dL (1.66 mmol/L). The nurse understands that which condition most likely caused this serum calcium level?

Prolonged bed rest Rationale: The normal serum calcium level is 9.0 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A client with a serum calcium level of 6.0 mg/dL (1.66 mmol/L) is experiencing hypocalcemia. Prolonged bed rest is a cause of hypocalcemia. Although immobilization initially can cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia. End-stage renal disease, rather than renal insufficiency, is a cause of hypocalcemia. Hyperparathyroidism and excessive ingestion of vitamin D are causative factors associated with hypercalcemia.

A client is to receive 1000 mL of 5% dextrose in water at a rate of 125 mL/hour. The drop factor is 10 drops (gtt) per mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

Rationale: The first step is to determine how many hours the solution will take to infuse. This requires simple division of the total volume of milliliters to be infused (1000 mL) by the total milliliters per hour (125 mL). The solution will take 8 hours to infuse. Convert 8 hours to minutes, which is 480 minutes. Next, use the formula to calculate the flow rate. Total volume × Drop factor -------------------------- = gtt/min Time in minutes 1000 mL × 10 gtt 10,000 ---------------- = ------ = 20.8 gtt/min 480 minutes 480 = 21 gtt/min (rounded)

A client with hypertension has been told to maintain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food item in a list provided to the client?

Summer squash

The ambulatory care nurse is preparing to assist the health care provider in performing a liver biopsy on a client. The client is receiving a local anesthetic for the procedure. The nurse should assist the client into which position for this test to be performed?

Supine with the right hand under the head

The school nurse is providing a nutritional counseling session to a group of adolescents. The school nurse should instruct the adolescents that which item is a good source of vitamin C?

Sweet potatoes

The nurse is providing preoperative teaching to a client scheduled for a cholecystectomy. Which intervention would be of highest priority in the preoperative teaching plan?

Teaching coughing and deep breathing exercises

The nurse is teaching a client who had a stroke how to use a walker for ambulation. Which level of prevention is the nurse implementing?

Tertiary level

The nurse has instructed a client in the foods that are best to consume on a low-fat diet. The nurse determines that the client understands this diet if the client indicates which food item is lowest in fat?

dry toast and strawberry jelly

The nurse provides information to a client scheduled for a dual x-ray absorptiometry (DEXA) test. Which information should the nurse provide to the client? Select all that apply.

it is a painless test Metallic objects such as jewelry or belt buckles may interfere with the test and need to be removed. Rationale: The most commonly used screening and diagnostic tool for measuring bone mineral density is the dual x-ray absorptiometry (DEXA) test. It is a painless test that emits less radiation than a chest x-ray. A height is taken before the start of the test. The client stays dressed but is asked to remove any metallic objects such as belt buckles, coins, keys, or jewelry because they may interfere with testing. No special follow-up care for the test is necessary.

The ambulatory care nurse is preparing a client who is scheduled for a liver biopsy. The nurse reviews the client's record and expects to note which laboratory results documented in the client's chart?

Prothrombin time

The nurse is providing medication instructions to a parent. Which statement by the parent indicates a need for further instruction?

"I should mix the medication in the baby food and give it when I feed my child." Rationale: The nurse would teach the parent to avoid putting medications in foods because it may give an unpleasant taste to the food, and the child may refuse to accept the same food in the future. In addition, the child may not consume the entire serving and would not receive the required medication dosage. The mother should provide comfort measures immediately after medication administration, such as touching, holding, cuddling, and providing a favorite toy. The mother should offer juice, a soft drink, or a frozen juice bar to the child after the child swallows the medication. If the taste of the medication is unpleasant, the child should pinch the nose and drink the medication through a straw.

A staff nurse is precepting a new graduate nurse and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management?

"I will be sure to cue in to any indicators that the client may be exaggerating their pain."

The unlicensed assistive personnel (UAP) is assigned to care for a client who is of Asian heritage. The UAP tells the nurse, "I think that my assignment needs to be changed. Every time I try to talk, the client turns away." Which statement is the most appropriate teaching response from the nurse?

"If the client turns away, continue with the discussion."

The nurse is preparing to administer 30 mEq of liquid potassium chloride (KCl) to an adult client. The label on the medication bottle reads 40 mEq of KCl per 15 mL. The nurse should prepare how many milliliters of KCl to administer the correct dose of medication? Fill in the blank. Round your answer to the nearest whole number.

11

Amoxicillin/clavulanate potassium 500 mg orally every 6 hours is prescribed for a child with an upper respiratory infection. The medication is supplied as 200 mg/5 mL. How many milliliters will be administered in each dose? Fill in the blank.

12.5

A health care provider's prescription reads potassium chloride 30 mEq to be added to 1000 mL normal saline (NS) and to be administered over a 10-hour period. The label on the medication bottle reads 40 mEq/20 mL. The nurse prepares how many milliliters of potassium chloride to administer the correct dose of medication? Fill in the blank.

15

The nurse has a prescription to infuse 100 mL of antibiotic solution by the intravenous (IV) route over 1 hour. The tubing administration set has a drop factor of 10 drops (gtt) per mL. The nurse would regulate the roller clamp on the infusion set to deliver how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

17

A health care provider's prescription reads 200 mcg orally daily. The medication label reads 0.1 mg per tablet. The nurse administers how many tablet(s) to the client? Fill in the blank.

2

The nurse is administering an acetaminophen suppository to a child with a fever. The nurse inserts the suppository into the rectum a distance of no more than how many centimeters?

2

The nurse is reviewing the results of the electrolyte panel for a client seen in the health care clinic. The nurse determines that the client's potassium level is normal if which value is noted?

4.0 mEq/L (4.0 mmol/L)

An adult male client admitted to the hospital with shock has received fluid volume replacement. The nurse should determine that the client has had adequate fluid resuscitation if the client's repeat hematocrit level has decreased to which value in the normal range?

48% (0.48)

The nurse is monitoring the laboratory results of a client receiving an antineoplastic medication by the intravenous route. The nurse plans to initiate bleeding precautions if which laboratory result is noted?

A platelet count of 50,000 mm3 (50 × 109/L)

The nurse is caring for an Appalachian client. The nurse makes sure to have frequent contact with the client and to initiate many different conversations. What is the best reason why the nurse uses this approach?

The Appalachian client may prefer personal relationships with health care providers and a desire for frequent communication.

Morphine sulfate, 2.5 mg intravenous piggyback, is prescribed for a child with cancer. The safe pediatric dose is 0.05 to 0.1 mg/kg/dose. The child weighs 50 kg. The nurse determines which concerning the dose prescribed?

The dose prescribed is within the safe dosage range.

The nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client?

Wearing a gown and gloves Rationale: Gowns and gloves are required if the nurse anticipates contact with soiled items such as those with wound drainage, or is caring for a client who is incontinent with diarrhea or a client who has an ileostomy or colostomy. Masks are not required unless droplet or airborne precautions are necessary. Regardless of the amount of wound drainage, a gown and gloves must be worn.

The nurse is providing discharge instructions to a Chinese American client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. The nurse should implement which best action?

continue with instructions, verifying client understanding

The nurse reviews a client's arterial blood gas results and notes that the pH is 7.30 (7.30), the Paco2 is 52 mm Hg (50 mm Hg), and the HCO3 is 22 mEq/L (22 mmol/L). The nurse interprets these results as indicating which condition?

respiratory acidosis, uncompensated

A client treated for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client states a need to perform which action?

resume full activity level

The nurse has been giving a client furosemide intravenously for an exacerbation of heart failure. The nurse monitors what potential abnormal blood levels that frequently occur when this medication is administered? Select all that apply.

serum potassium serum sodium

The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function?

the passage of flatus

The nurse is teaching a client who has iron deficiency anemia about foods she should include in the diet. The nurse determines that the client understands the dietary modifications if which items are selected from the menu?

oranges and dark green leafy vegetables

The nurse is teaching a client with acquired immunodeficiency syndrome (AIDS) how to avoid food-borne illnesses. The nurse should instruct the client that which food can cause a food-borne illness?

raw oysters

The nurse purchases a cup of coffee, a bottle of water, and a bagel in the hospital cafeteria and then returns to the nursing unit to take a morning break in the staff lounge. On entering the lounge, the nurse notes that the cushion of a chair is on fire. What should the nurse's first action be?

Activate the fire alarm. Rationale: The initial nursing action in the event of a fire would be to remove any clients from the vicinity of the fire. The next step would be to activate the fire alarm. The nurse would then contain the fire, followed by extinguishing the fire. In the situation described in the question, the initial nursing action would be to activate the fire alarm. Pouring water or coffee onto the fire or attempting to extinguish the fire with the use of a fire extinguisher can delay obtaining life-saving assistance from the fire department.

The nurse is assisting in the care of a client with pheochromocytoma who has been experiencing clinical manifestations of hypermagnesemia. When evaluating the client, the nurse should determine that the client's status is returning to normal if which is no longer exhibited?

Areflexia

The nurse has a prescription to give 30 mL of an antacid to a client through a feeding tube. Which is the priority nursing action?

Assess tube placement.

A client is being transferred to the nursing unit after receiving a radiation implant for bladder cancer. The nurse should take which priority action in the care of this client?

Assign the client to a private room.

The nurse is caring for a client who is receiving immunosuppressant therapy, including corticosteroids, after renal transplantation. The nurse should plan to carefully monitor results of which laboratory test for this client?

Blood glucose level

The health care provider (HCP) writes a prescription for acetylsalicylic acid, or aspirin, for a client who was admitted to the hospital with joint pain from rheumatoid arthritis. The nurse contacts the HCP to verify the prescription if which finding is noted in the assessment data?

Gastric ulceration

The ambulatory care nurse is seeing a client for a follow-up visit after treatment for toxic shock syndrome (TSS). To assess the client's recovery from TSS, the nurse should ask whether which signs and symptoms have resolved?

High fever, abdominal pain, vomiting, and diarrhea

A client states to the home health nurse that she has not had a bowel movement since coming home from the hospital after surgery 4 days ago. The nurse instructs the client to follow which diet at this time?

High-fiber diet

The nurse is preparing to test a client's blood glucose level with a glucometer. Which steps would facilitate obtaining an accurate result? Select all that apply.

Hold the finger in a dependent position during the test. Use gentle pressure to obtain an adequate amount of blood. Obtain the blood specimen by puncturing the lateral side of the finger.

A client is receiving oral anticoagulant therapy with warfarin. The result of a newly drawn prothrombin time (PT) is 40 seconds. The nurse should anticipate which prescription to be prescribed for this client?

Hold the next dose of warfarin.

The nurse is monitoring the client with a serum calcium level of 6.2 mg/dL (1.55 mmol/L). Which findings should the nurse assess for in the client? Select all that apply.

Irritability Muscle cramps Tingling sensations Hyperactive reflexes Memory impairment Rationale: Begin by recalling the normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L) to determine that the client is experiencing hypocalcemia. Signs of hypocalcemia include tingling sensations, hyperactive reflexes, and a positive Trousseau's or Chvostek's sign. Other signs include increased neuromuscular excitability, muscle cramps, tetany, seizures, insomnia, irritability, memory impairment, and anxiety. Severe muscle weakness is seen in hypercalcemia, not hypocalcemia.

The nurse is assisting the health care provider during a colonoscopy procedure. The nurse helps the client to assume which position for the procedure?

Left Sims'

The nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of which food?

Legumes

The nurse orientee is preparing to insert a nasogastric tube, and the nurse educator is observing the procedure. Which item, if obtained by the nurse orientee, would indicate a need for further teaching regarding this procedure?

Oil-soluble lubricant

A client is recovering from abdominal surgery and has a large abdominal wound. The nurse should encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing?

Oranges

The nurse is preparing a plan of care for a client who will be hospitalized for insertion of an internal cervical radiation implant. Which nursing intervention should the nurse implement in preparation for the arrival of the client?

Prepare a private room at the end of the hallway.

The nurse is reading a computer printout of the results of a cerebrospinal fluid (CSF) analysis performed on an adult client who has undergone lumbar puncture. The nurse determines that which is an abnormal finding?

Protein 100 mg/dL (1 g/L)

The nurse is caring for a client with impaired mobility that occurred as a result of a stroke. The client has right-sided arm and leg weakness. Which assistive device should the nurse suggest that the client use to provide the best stability for ambulating?

Quad cane

Ampicillin sodium 500 mg in 100 mL of normal saline (NS) is to be administered over a period of 45 minutes. The delivery rate (drop factor) is 10 drops (gtt) per mL. The nurse should set the flow rate at how many drops per minute? Fill in the blank. Round your answer to the nearest whole number.

Rationale: Use the formula for calculating intravenous (IV) line flow rates. Total volume × Drop factor -------------------------- = gtt/min Time in minutes 100 mL × 10 gtt --------------- = 22.2 gtt/min 45 minutes = 22 gtt/min (rounded)