Quiz #2 passpoint

A school-age child who has received burns over 60% of his body is to receive 2,000 mL of IV fluid over the next 8 hours. At what rate (in milliliters per hour) should the nurse set the infusion pump?

2,000 / 8 = 250 mL/hr

During inspiration, which action occurs???

diapraghm descends

What education should the nurse give to a male client older than age 50 to help ensure early identification of prostate cancer????

have a digital rectal exam and prostate-specific antigen done yearly

A physician orders albuterol for a client with newly diagnosed asthma. When teaching the client about this drug, the nurse should explain that it may cause.....

nervousness

Which would be MOST important to teach a client older than 65 years to prevent a recurrence of bacterial pneumonia????

obtain flu and pneumococcal vacc

The nurse has asked the unlicensed assistive personnel to help with admitting an elderly client who has been diagnosed with bacterial pneumonia. Which activity is appropriate for the nurse to ask the UAP to perform????

obtain height and weight

What instruction should the nurse's discharge teaching plan for the client with heart failure include????

obtaining daily wts at the same time every day

A client tells the nurse that "the hospital food is horrible." What should the nurse tell the client???

would you like to speak with the dietitian about the food and meal selection???

A client with Alzheimer's disease tells the nurse, "I'm so afraid. Where am I? Where is my family?" What is the best response by the nurse????

youre in the hospital, and youre safe here. your family will return at 10 oclock, which is one hour from now

A client with acute renal failure has a serum potassium level of 6.5 mEq/L (6.5 mmol/L). The nurse should monitor the client for which potential complication???

cardiac arrest

A client with lung cancer has developed an intractable, nonproductive cough that is unrelieved by non-opioid antitussive agents. The physician orders codeine, 10 mg P.O. every 4 hours. Which statement accurately describes codeine????

centrally-acting antitussive and can cause dependence

The nurse is caring for an older adult who has been bedridden for an extended period. Which symptom indicates that the client has hypoxia????

confusion

To assess the client's renal status, the nurse should monitor which of the following laboratory tests? Select all that apply

-serum blood urea nitrogen -creatinine levels

The nurse is starting a peripheral intravenous line. Place the steps in the order that the nurse should perform them. All options MUST be used

...

A client must take streptomycin for tuberculosis. Before therapy begins, the nurse should instruct the client to notify the physician if which health concern occurs????

decreased hearing acuity

Which finding in a clients history would be the most likely to increase the client's risk for renal calculi????

drinking only 1-2 glasses of fluid a day

A nurse is planning care for a client after a tracheostomy. One of the client's goals is to overcome verbal communication impairment. Which intervention should the nurse include in the care plan????

encourage client communication, allowing time to select or write words out

Which statement by the client demonstrates understanding of advance directives, living wills, and health care power of attorney???

guide what you want to do in certain health circumstances/situations

The nurse is giving a 40 year old client with limited English language skills printed info about post-op dressing care. The nurse is using the interpreter to explain the printed information. What should the nurse do to determine that the client understands the procedure????

having patient demonstrate after

A nursing supervisor notices that a previously effective nurse has been preoccupied and distant for several days and is having difficulty focusing on clients' needs. What statement will the supervisor use to explore the change in the nurse's behavior????

i have noticed you seem to be preoccupied. would you like to talk???

A client who is about to undergo gastric bypass surgery calls the nurse into the room. The client expresses concern that friends will learn about the upcoming surgery and asks the nurse not to share the reason for the surgery. Which response by the nurse is best????

im not at liberty to discuss your case with anyone except those directly involved in your care, unless you authorize me to do so

A nurse is caring for a client who had a prostatectomy for prostate cancer. The nurse is reviewing the client's vital signs and intake and output as documented by a nursing assistant. Which documented finding requires immediate action?

intake and output

Which mental status change may occur when a client with pneumonia is first experiencing hypoxia????

irritability

A nurse is caring for a client who suffered a stroke. The family reports that the nurse on the previous shift failed to administer medications properly or maintain client privacy. What is the best action by the nurse????

notify unit manager/charge nurse of family's concerns

A nurse who is not assigned to care for a client may access the client's electronic health record in which circumstance????

nurse is reporting lab results to the code blue team during resuscitation

Which technique for administering the TB skin test is correct????

parellel with the skin

Which client should receive a shingles vaccine????

person over 50 years of age

A client newly diagnosed with tuberculosis (TB) is being admitted with a prescription for "isolation precautions for tuberculosis." The nurse should assign the client to which type of room????

private room to implement airborne precautions

The nurse is on the telephone with the health care provider to share the stat potassium result on a client. The health care provider gives the nurse a telephone order for potassium chloride 60 mEq oral every 6 hours for 2 days. What should the nurse do first????

repeat the KCl order back to the HCP

After undergoing a thoracotomy, a client is receiving epidural analgesia. Which assessment finding indicates that the client has developed the most serious complication of epidural analgesia????

resp depression

After a client has had a bronchoscopy under local anesthesia, the nurse should.....

restrict oral intake under gag reflex returns

The nurse is assisting another member of the health care team who is placing a peripherally inserted central catheter in a 10-year-old with peritonitis from a ruptured appendix. The family is present in the treatment room to support the child. The nurse observes that the other team member has contaminated a sterile glove. What should the nurse do next?

sims left lateral

The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1 inch × 1 inch (3 cm x 3 cm) area on the sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the medical record????

stage 2

Parents bring their infant to the clinic, seeking treatment for vomiting and diarrhea that has lasted for 2 days. On assessment, the nurse detects dry mucous membranes and lethargy. What other finding suggests a fluid volume deficit

sunken frontanel

A nurse is caring for a client on a four-medication regimen to treat tuberculosis. The nurse discovers that the client isn't taking all medications. What is appropriate for the nurse to say to the client???

taking several medications can be difficult, tell me about the problems youre havig

The nurse is assisting another member of the health care team who is placing a peripherally inserted central catheter in a 10-year-old with peritonitis from a ruptured appendix. The family is present in the treatment room to support the child. The nurse observes that the other team member has contaminated a sterile glove. What should the nurse do next????

tell the provider the glove is now contaminated

A nurse is assisting an anesthetist during the intubation of a client. The anesthetist visualizes the vocal cords with the laryngoscope and says to the nurse, "This is an easy one, so why don't you give it a try?," indicating that the nurse should insert the endotracheal tube. What would be the most appropriate response by the nurse????

this is not in my scope of practice

A seriously ill client asks the nurse "Am I dying?" What is the best response the nurse can give to enhance therapeutic communication with this client????

this must be difficult for you, what is on your mind

Which statement demonstrates a safe practice for taking a telephone prescription from a health care provider????

verify prescription by reading it back

A healthy client presents to the clinic for a routine examination. When auscultating the client's lower lung lobes, the nurse should expect to hear which type of breath sound???

vesicular

A client recovering from a pulmonary embolism is receiving warfarin. To counteract a warfarin overdose, the nurse should administer....

vit k1

The nurse is caring for a client with influenza. The most effective way to decrease the spread of microorganisms is:

washing the hands freq

A client has presented to the emergency department with symptoms of appendicitis. The client admits to the nurse, "I am very nervous because I am in the country illegally and have been for several years." What is the nurse's best response????

we are going to give you treatment you need regardless of your immigration status

After reading the vaccine information sheets, the parent of a 2 month old infant is hesitant to consent to the recommended vaccinations. What should the nurse ask the parent first????

what concerns do you have about the vaccinations

For a client with an acute pulmonary embolism, the physician orders heparin 25,000 units in 500 ml of dextrose 5% in water (D5W) at 1,100 units/hour. The nurse should administer how many milliliters per hour???

22

When instructing clients on how to decrease the risk of chronic obstructive pulmonary disease (COPD), the nurse should emphasize which instruction????

abstain from smoking

During a routine physical examination on a 75-year-old female client, a nurse notes that the client is 5 feet, 3/8 inches (1.6 m) tall. The client states, "How is that possible? I was always 5 feet and 1/2 inches (1.7 m) tall." Which statement is the best response by the nurse????

after menopause, the body's bone density declines, resulting in a gradual loss of height

The nurse on the adolescent unit delegates a task to the nursing assistant. After delegating the task, the nurse should...

allow adequate time for the nursing assistant to complete the task, then follow up with the nursing assitant

When assessing a 17-year-old client with depression for suicide risk, which question would be best???

are you thinking about killing yourself??

A nurse working on the respiratory floor is preparing to administer medications using the computerized med-dispensing system. The nurse's password is not working. What is the appropriate action by the nurse????

ask computer support to reset password

The nurse is caring for a group of clients on a pulmonary unit. The nurse can delegate which task to unlicensed assistive personnel

assisting a client w adjusting his/her NC

A client with end-stage pulmonary hypertension tells the physician they don't want any heroic measures should their heart stop, and doesn't want to be placed on a ventilator. The physician enters a do-not-resuscitate order into the hospital's computer system. Which ethical principle is the nurse upholding by supporting the client's decision????

autonomy

The nurse is assessing a client with chronic obstructive pulmonary disease. The client weighs 200 lb (90.7 kg) and is 6 feet tall. Using the diagram shown here, how should the nurse describe the client's chest in the record in the health history????

barrel-shaped