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Morphine sulfate is being administered to a client with cancer. The nurse is monitoring the client for signs of overdose related to this medication therapy. Which finding noted in the client would require the need to notify the registered nurse?
Respirations of 10 breaths per minute
Meperidine hydrochloride is prescribed for a client with pain. Which would the nurse monitor as a side effect of this medication
urinary retention
Which of the following drugs will the nurse be prepared to administer to a client who is receiving morphine and is experiencing respiratory depression?
Naloxone
The nurse evaluates a client's voiding patterns, to detect potential issues. Which questions should the nurse ask?
"Do you frequently need to get up to urinate at night" "Does your bladder feel empty after voiding?" "Do you void at least every 8 hours?" "Has the appearance of your urine changed?"
The home health nurse is visiting a client with a diagnosis of multiple sclerosis. The client has been taking oxybutyin. Which statement would indicate that the medication has not been effective?
"I still get up during the night to urinate"
Of the following, which size IV catheter would be best for the nurse to place in an adult client receiving routine IV therapy?
20 gauge
The client needs to receive an IV bolus of 1L normal saline over 30 minutes. The nurse will set the infusion rate to ____ ml/hour
2000
Dobutamine is currently running at 7.5ml/hr. The pharmacy has provided it as 800mg in 250mls of 0.9% normal saline. The client is receiving ____ mg/hr of dobutamine.
24
Heparin 1,200 units/hr is ordered for the client. Pharmacy provides Heparin available at 25,000 units/hr/500ml. The nurse should start the infusion at ___ml/hr
24
Dobutamine is currently running at 5ml/hr. The pharmacy has provided Dobutamine 800 mg in 250 mls of 0.9% normal saline. The client is receiving ____mcg/minute of dobutamine
267
Heparin 2,700 units/hr is ordered for the client. Pharmacy provides Heparin available as 25,000 units/500ml. The nurse should start the infusion at ____ ml/hr
54
the client is ordered an anitibiotic of 1 gram in 250mls that needs to infuse over 3 hours. The nurse will set the infusion pump for ___ ml/hr.
83
The nurse is providing directions to the assistive personnel regarding clients' hygiene needs. Based on the clients needs, the nurse instructs the AP to bathe which client first?
A confused client who is incontinent of stool and urine
A nurse is assessing a patient's skin. Which patient is at most risk for impaired skin integrity?
A patient who is diaphoretic
A nurse is assessing a client on lorazepam who exhibits drowsiness, lethargy, confusion, and has respirations of 11/minute. The nurse recognizes these signs and symptoms and should prepare to administer which drug as ordered by the provider?
Atropine Epinephrine FLumazenil Naloxone
The nurse is reviewing an elderly client's A1c result of 8. The last office visit demonstrated A1c of 5.5. What question should the nurse ask the client to confirm a possible cause of increased blood glucose levels?
Can you demonstrate to me how to pull up 6 units of insulin?
The nurse cares for a client with peripheral venous disease and an open ulcer on the left ankle. Which interventions are appropriate for this client? SATA
Elevate the legs above the heart intermittently throughout the day wear compression stockings during the day and night avoid prolonged sitting or standing prevent client from crossing their legs
The nurse is caring for a client with anxiety prescribed alprazolam. Which of the following will the nurse monitor the client for?
Excessive sedation
A nurse is assisting a patient in making dietary choices that promote healthy bowel elimination. Which menu option should the nurse recommend?
Grape and walnut chicken salad sandwhich on whole weat bread
The nurse is preparing to infuse an antibiotic IV piggyback through the primary intravenous (IV) line. How should the nurse correctly attach the medication bag?
Hanging the antibiotic bag higher than the primary IV bag
A client is about to receive a morning dose of digoxin has an apical pulse of 50 beats/minute. What nursing action is appropriate?
Hold the dose and notify the healthcare provider?
A client with a nasogastric suctioning is experiencing diarrhea. The client has an order for a morning dose of Lasix 20mg IV. The client's potassium is 3.0. What is the priority nursing intervention?
Hold the dose of Lasix and notify the doctor for further orders
The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding would the nurse expect to note as a result of this long-term use?
Increased specific gravity of urine
The nurse is monitoring a client receiving levothyroxine sodium for hypothyroidism. Which findings indicate the presence of a side effect associated with this medication?
Insomnia Weight loss Mild heat intolerance
The nurse is completing a medication reconcillation for a new client who was admitted an hour ago. The nurse discovers 15 different prescriptions for multiple over the counter medications. What is the priority when managing the client's care?
Loo for duplicate prescriptions
The nurse cares for a client who is confused, and consistently pulls at their nasogastric tube. Which type of restraint would the nurse try first?
Mittens
The nurse cares for a severely anemic client. which blood product should the nurse anticipate administering?
Packed red blood cells
The nurse is administering a medication to the client with a history of renal impairment. The medication is known to be excreted through the kidneys. To monitor the client for adverse reactions, the nurse would monitor which of the following?
Serum blood urea nitrogen BUN and creatine
The nurse is teaching a client with mysathenia gravis about the prevention of masthenic an cholinenergic crisis. Which client activity suggests that teaching is most effective?
Space out activities throughout the day
The nurse in a long term care facility is observing a nursing student provide foot care to a client with diabetes mellitus. Which action by the nurse would indicate a need for further teaching?
The nursing student applies lotion to the dorsal and plantar surfaces of the feet and in between the toes
The nurse obtains a prescription to restrain a client using a belt (safety) restraint and instructs the assistive personnel to apply the restraint. Which observation, if made by the nurse, indicates unsafe application of the restraint.
The restraint straps are safely secured to the side rails.
The nurse conducts discharge education with a client who is taking phentoynin for control of seizures. Which client statement indicates that the teaching has been effective?
"I will use an additional form of birth control when on this medication"
The nurse is educating the client about their change in captopril dosage from 5mg to 10mg PO daily. Which of these responses from the client indicates that the teaching has been effective?
"It will take 20 to 60 minutes before a meal"
The nurse is teaching a client who is beginning antiviral therapy for influenza. Which statement indicates a need for additional teaching?
"once I begin the medication, I will no longer be contagious"
The client is ordered Dopamine 5mcg/kg/minute. Pharmacy sends you Dopamine 800mg in 250ml saline. The client weighs 253 pounds. The nurse will set the infusion rate at ___ ml/hour.
11
The client is ordered an antibiotic of 1 gram in 250mls that needs to infuse over 120 minutes. The nurse will set the infusion pump for _____ ml/hr
125
The client needs to receive an. IV bolus of 1 liter normal saline over 3 hours. The nurse will set the infusion rare to ____ ml/hour
333
The nurse cares for a client in acute abdominal pain rated 10/10. The client has been advised to incorporate various nonpharmacological pain interventions such as applying heat or cold to the abdomen, meditation, and imagery. Which finding is the best indicator of a successful outcome of those interventions.
Client states they are "more comfortable"
A client who had a cast applied to their right lower arm two days ago presents to the emergency department with burning pain, paraesthesia and cool and pale skin to the extremity. Which condition should the nurse suspect?
Compartment syndrome
A patient is being discharged home on an around-the-clock opioid for postoperative pain. Because of this order, the nurse anticipates an additional order for which class of medication?
Stool softeners
Alendronate is prescribed for a client with osteoporosis, and the nurse is providing instructions on administration of the medication. Which instructions should the nurse provide?
Take the medication with a full glass of water after rising in the morning
The nurse cares for a group of clients. Which client is at the highest risk of skin breakdown.
The 34-year old wheelchair-bound client
The nurse is caring for a client with severe back pain, an codeine sulfate has been prescribed for the client, which would the nurse include in the plan of care while the client is taking this medication?
monitor bowel activity
The nurse is having a conversation with an adolescent regarding the need for sleep. The adolescent states that it is common to stay up with friends several nights a week. Which action should the nurse take next?
Discuss with the adolescent sleep needs and the effects of excessive daytime sleepiness
The nurse applies wrist restraints, prescribed to prevent a client from pulling out a nasogastric tube. How would the nurse determine that the restraints are not too constrictive?
Place two fingers under the restraint to determine snugness
The nurse is assigned to care for a child who is in skeletal traction. The nurse needs to avoid which action when caring for the child?
Placing the bed linens on the traction ropes
A client has fallen and is sitting on the floor. Which guideline should the nurse follow, when assisting the client off the floor?
Position the feet shoulder-width apart
The nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hard veins. The nurse suspects hyponatremia. Which additional s&s would the nurse expect to see in this client if hyponatremia is present?
Postural blood pressure changes
The nurse cares for a client who is currently unable to move on their own, and its positioned on their back, Which guideline should be folllowed, to achieve proper body alignment of the client?
Prevent hyperflexiation of the neck
The nurse should tell the client who is taking levothyroxine to notify the pcp if which problem occurs?
Tremors
The nurse cares for a client in skeletal traction. What is the priority assessment?
Verify that the skin at the pin site is free of signs of infection
The nurs is teaching a client with diabetes mellitus how to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the client, indicates the need for further teaching?
Withdraws the NPH insulin first
