Nursing 1202 Unit 2

A nurse is caring for a client who is prescribed warfarin therapy for an artificial heart valve. Which of the following laboratory values should the nurse monitor for a therapeutic effect of warfarin?

Prothrombin time (PT) ----------This test is used to monitor warfarin therapy. For a client receiving full anticoagulant therapy, the PT should typically be approximately two to three times the normal value, depending on the indication for therapeutic anticoagulation.

A nurse is preparing to instill ear-drops to a 5-year-old child. Which of the following techniques should the nurse use?

Pull the auricle up and out.--------The nurse should pull the auricle up and out to instill eardrops to a 5-year-old child. This technique is used for children 4 years of age and older, and adults.

A nurse is caring for a client who has difficulty swallowing medication as is prescribed enteric-coated aspirin PO once daily. The client asks if the medication can be crushed to make it easier to swallow. which of the following responses should the nurse provide?

"Crushing the medication might cause you to have a stomachache or indigestion." -----The pill is enteric-coated to prevent breakdown in the stomach and decrease the possibility of GI distress. Crushing the pill destroys that protection.

A nurse is caring for a client who is taking naproxen following an exacerbation of rheumatoid arthritis. Which of the following statements by the client requires further discussion by the nurse?

"I've been taking an antacid to help with indigestion." -------NSAIDs, like naproxen, can cause serious adverse gastrointestinal reactions such as ulceration, bleeding, and perforation. Warning manifestations such as nausea or vomiting, gastrointestinal burning, and blood in the stool reported by the client require further investigation by the nurse. The client might be taking an antacid because he is experiencing one or more of these manifestations.

A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy via nasal cannula. Which of the following should the nurse include in the teaching? ( select All that apply)

1. Check the cannula position on a regular basis. 2. Check the tops of the ears for skin breakdown. 3. Post "no smoking" signs in a prominent location in the home.

A nurse is preparing to administer oral medications to a client. Which of the following should the nurse recognize as a acceptable client identifier?

1. Client's full name 2. Facility-assigned identification number

A nurse is reviewing a medical record for a client who has Hypertension and a new prescription for metoprolol. Which of the following findings should the nurse investigate further?

A history of Left-sided heart failure --- The nurse should further investigate the client's history of heart failure. Although metoprolol can be used to treat heart failure, it can also cause heart failure, so this medication should be used with great caution with a client who has a history of heart failure. The nurse should teach the client to watch for signs of increasing left-sided heart failure, such as shortness of breath and weight gain indicating fluid retention, and report these findings to the provider.

A provider prescribes a sublingual medication for a client who has a NG tube in place. Which of the following actions should the nurse take?

Administer the medication under the client's tongue.--------The nurse should administer the sublingual medication under the client's tongue. Sublingual preparations work via direct absorption into the bloodstream. Swallowing it exposes it to gastric juices, which can inactivate the medication.

A nurse is caring for a client who has hypertension and asks the nurse about a prescription for propranolol. The nurse should inform the client that this medication is contraindicated in clients who have a history of which of the following conditions?

Asthma --------Propranolol, a beta-blocker, is contraindicated in clients who have asthma because it can cause bronchospasms. Propranolol blocks the sympathetic stimulation, which prevents smooth muscle relaxation.

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following action should the nurse take?

Attach a humidifier bottle to the base of the flow meter. ----Oxygen therapy can dry the mucous membranes. The nurse should attach humidification for a client receiving oxygen greater than 4 L/min via nasal cannula.

A nurse is providing dietary teaching for a client who takes furosemide. The nurse should recommend which of the following foods as the best source of potassium?

Bananas ---------The nurse should determine that bananas are the best food source to recommend because 1 cup of bananas contains 806 mg of potassium. In addition to the potassium supplements the provider might prescribe, the client should increase his daily intake of foods that have high potassium content, such as bananas, orange juice, and spinach.

A nurse is teaching a client who has a new prescription for aspirin to treat rheumatoid arthritis. The nurse should include to monitor for which of the following adverse effect of this medication?

Bleeding -------Aspirin can cause bleeding, tinnitus, gastric ulceration, nausea, and heartburn. The client should monitor and report manifestations of bleeding, such as black tarry stools.

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?

Cleanse the skin with an alcohol swab, insert the needle, inject the heparin, and observe for bleeding. --------

A nurse is caring for a client who is receiving oxygen therapy via a nasal cannula. The nurse explains to the client that this method of oxygen delivery does which of the following?

Delivers a low concentration of oxygen ---------A nasal cannula delivers a relatively low concentration of oxygen (24% to 44%).

A charge nurse is observing a newly licensed nurse administer medications to a client. Which of the following actions by the newly licensed nurse should prompt the charge nurse to intervene?

Documents medication administration prior to administering it.----------The nurse should document administering medications after they are given to reduce the risk of error.

A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toe nails. The nurse should apply the pulse oximeter probe to which of the following locations?

Earlobe -------The earlobe is rarely edematous, is the least affected by decreased blood flow, and has greater accuracy when measuring oxygen saturation.

A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication?

Hypotension ------Verapamil, a calcium channel blocker, can be used to control supraventricular tachyarrhythmias. It also decreases blood pressure and acts as a coronary vasodilator and antianginal agent. A major adverse effect of verapamil is hypotension; therefore, blood pressure and pulse must be monitored before and during parenteral administration.

A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?

Raise the head of the bed. -----------Elevating the head of the bed uses gravity to reduce pressure on the diaphragm from the abdominal organs and allows for increased expansion of the lungs. The head and neck can be extended, which promotes a patent airway. This is the first action the nurse should take and is the least invasive.

A nurse is preparing to administer a rectal suppository to a client. In which of the following positions should the nurse place the client for insertion of the suppository?

Sim's position --------The nurse should assist the client to the Sim's position by lying on the left side, left hip and lower extremity straight, and right hip and knee bent. This position exposes the anus and helps the client relax the external sphincter, allowing for easier insertion of the suppository.

A nurse is assessing a client who is taking lisinopril to treat hypertension. Which of the following findings is a priority to report?

Swelling of the tongue------------When using the urgent vs non-urgent approach to client care, the nurse determines that the priority finding is swelling of the tongue, which is a manifestation of angioedema. The nurse should withhold the medication and notify the provider immediately if the client reports swelling of the tongue or throat. Other manifestations include giant wheals and edema of the tongue, glottis, and pharynx. Severe reactions are treated with subcutaneous epinephrine. If angioedema develops, ACE inhibitors are discontinued.

A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect?

Tachycardia ----The nurse should expect the client who has hypoxia to manifest tachycardia.

A nurse is caring for a client who requires a medication that is packaged in a single does glass ampule. Which of the following techniques should the nurse use when opening the glass ampule?

Tap the top of the ampule, place a sterile gauze pad around the ampule neck, and break off the top by bending it toward the body. -------The nurse should tap the top of the ampule, place a sterile gauze pad around the ampule neck, and break off the top by bending it toward the body. The sterile gauze prevents broken glass coming in contact with the fingers, and bending the ampule top toward the body allows glass fragments to spray away from the nurse.

A nursing is providing teaching to a client who has a new prescription for lisinopril. Which of the following statements by the nurse indicates an understanding of the teaching?

"I should report a cough to my provider." ---------The client should report a cough to the provider. The provider should discontinue the medication for a persistent, irritating cough.

A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect as result of long-term inadequate oxygenation?

Clubbing of the fingers - ------The nurse should expect the client who has chronic hypoxia or respiratory insufficiency to display clubbing of the fingers and toes. The base of the nail becomes swollen and the ends of the fingers and toes can increase in size.

A nurse is providing discharge teaching for a client who has a new prescription for warfarin. Which of the following instructions should the nurse include in the teaching?

Use an electric razor while on this medication. ---------Warfarin, an anticoagulant, increases the client's risk for bleeding. The nurse should teach the client safety measures, such as using an electric razor, to decrease the risk for injury and bleeding.