Nurse performance

The health care provider prescribed t-PA, a thrombolytic agent. The order is for 0.9 mg/kg over 1 hour. The client weighs 110 lb (50 kg). What is the total dose in milligrams the client will receive? Record your answer using a whole number.

45 Explanation: 0.9 mg/kg × 50 kg = 45 mg

Which hormone deficiency should the nurse suspect as the underlying cause of diabetes insipidus in a postoperative craniotomy client?

Antidiuretic hormone (ADH) Explanation: A client with diabetes insipidus has a deficiency of antidiuretic hormone. TSH, FSH, and LH hormone levels are not affected.

A client is diagnosed with a brain tumor. As the nurse is assisting the client from the bed to the chair, a generalized seizure occurs. Which action should the nurse perform first?

Assist the client to the floor, and place the client in a side-lying position. Explanation: The nurse should protect the client from injury by assisting the client to the floor and placing the client in a side-lying position. There is no need to initiate the code team response and CPR because seizures are self-limiting. The client's cardiopulmonary status is not affected as long as the airway is protected. The nurse should not force anything into the mouth of a client during a seizure; doing so may cause injury. Documenting seizure activity is important, but it does not take priority over client safety.

A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to:

Carefully move him to a flat surface and turn him on his side. Explanation: When caring for a client experiencing a tonic-clonic seizure, the nurse should take steps to ensure that the client can breathe and to protect the client from injury. In this situation, the nurse should help the client to a flat nonelevated surface and then position him on his side. These steps help reduce the risk of injury from falling or hitting surrounding objects. They also help establish an open airway. The client shouldn't be restrained during the seizure. Also, nothing should be placed in his mouth; anything in the mouth could impair ventilation and damage the inside of his mouth.

The nurse is reinforcing education for the family of a child with seizures. When should the nurse inform them to call emergency medical services in the event of a seizure?

Continuous vomiting for 30 minutes after the seizure Explanation: Continuous vomiting after a seizure has ended can be a sign of an acute problem and indicates that the child requires an immediate medical evaluation. All of the other body responses to seizure are normally present in various types of seizure activity and don't require immediate medical evaluation.

The nurse educator presents an in-service on how to formulate a nursing diagnosis of Risk for imbalanced body temperature for a client who suffers a stroke after surgery. The expected outcomes incorporate assessment of the client's temperature to detect abnormalities. The educator will include in the lecture that the thermoregulatory centers are located in which part of the brain?

Hypothalamus Explanation: The hypothalamus contains the body's thermoregulatory centers. The pons, cerebellum, and temporal lobe don't regulate body temperature.

A client with amyotrophic lateral sclerosis (ALS) tells the nurse, "Sometimes I feel so frustrated. I can't do anything without help!" This comment best supports which nursing diagnosis?

Powerlessness Explanation: This comment best supports a nursing diagnosis of Powerlessness because ALS may lead to locked-in syndrome, characterized by an active and functioning mind locked in a body that can't perform even simple daily tasks. Although Anxiety and Risk for disuse syndrome may be diagnoses associated with ALS, the client's comment specifically refers to an inability to act autonomously. A diagnosis of Ineffective denial would be indicated if the client didn't seem to perceive the personal relevance of symptoms or danger.

A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes highest priority?

Risk for injury related to neurologic deficit Explanation: Because a cerebral contusion causes altered cognition, the nurse should identify Risk for injury as the primary nursing diagnosis and focus on interventions that promote client safety and prevent further injury. The other options are pertinent, but they don't take precedence over client safety.

The nurse is reinforcing instruction with a female client regarding collection of a urine culture. Which instruction will the nurse include?

Separate the labia, one at a time clean from front to back with the three wipes provided in the kit, and then start to void in the toilet. Stop voiding, then continue to void into the sterile container. Explanation: The statement describes the correct method for obtaining a clean-catch urine specimen from a female. The statement describes the correct method for obtaining a clean-catch urine specimen from a male. Women should never wipe from back to front as this will increase the risk of infection. Soap/water is not used to cleanse the urinary meatus. Usually three cleaning wipes are provided in the clean-catch kit

A client had cataract surgery. Which sign or symptom should the nurse tell the client to report immediately to the health care provider?

eye pain Explanation: Pain shouldn't be present after cataract surgery. Pain may be an indication of hyphema or clouding in the anterior chamber and infection. The client should be told that the other symptoms might be present.