150Q (2)

The nurse assesses a client with new onset diarrhea. It is most important for the nurse to question the client about recent use of which type of medication? Antibiotics Anticoagulants Antihypertensive Anticholinergics

Antibiotics

In assessing an older female client with complication associated with chronic obstructive pulmonary disease (COPD), the nurse notices a change in the client's appearance. Her face appears tense and she begs the nurse not to leave her alone. Her pulse rate is 100, and respirations are 26 per min. What is the primary nursing diagnosis?

Anxiety related to fear of suffocation.

A new member joins the nursing team spreads books on the table, puts items on two chairs, and sits on a third chair. The members of the group are forced to move closer and remove their possessions from the table what action should the nurse leader take? Move to welcome and accommodate a new person Ask the new person to move belonging to accommodate others Tell the new person to move belongings because of limited space Bring in additional chairs so that all staff members can be seated

Ask the new person to move belonging to accommodate others

An older male client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side. When entering the room, the nurse finds the client's wife tearful and trying unsuccessfully to give him a drink of water. What action should the nurse take?

Ask the wife to stop and assess the client's swallowing reflex

Which intervention should the nurse implement during the administration of vesicant chemotherapeutic agent via an IV site in the client's arm?

Assess IV site frequently for signs of extravasation

While receiving a male postoperative client's staples de nurse observe that the client's eyes are closed and his face and hands are clenched. The client states, "I just hate having staples removed". After acknowledgement the client's anxiety, what action should the nurse implement? Encourage the client to continue verbalize his anxiety Attempt to distract the client with general conversation Explain the procedure in detail while removing the staples Reassure the client that this is a simple nursing procedure.

Attempt to distract the client with general conversation

Which problem, noted in the client's history, is important for the nurse to be aware of prior to administration of a newly prescribed selective serotonin reuptake inhibitor (SSRI)?

Aural migraine headaches.

A male client, who is 24 hours postoperative for an exploratory laparotomy, complains that he is "starving" because he has had no "real food" since before the surgery. Prior to advancing his diet, which intervention should the nurse implement?

Auscultate bowel sounds in all four quadrants

A client with angina pectoris is being discharge from the hospital. What instruction should the nurse plan to include in this discharge teaching? Engage in physical exercise immediately after eating to help decrease cholesterol levels. Walk briskly in cold weather to increase cardiac output Keep nitroglycerin in a light-colored plastic bottle and readily available. Avoid all isometric exercises, but walk regularly.

Avoid all isometric exercises, but walk regularly. Rationale: Isometric exercise can raise blood pressure for the duration of the exercise, which may be dangerous for a client with cardiovascular disease, while walking provides aerobic conditioning that improves ling, blood vessel, and muscle function. Client with angina should refrain from physical exercise for 2 hours after meals, but exercising does not decrease cholesterol levels. Cold water cause vasoconstriction that may cause chest pain. Nitroglycerin should be readily available and stored in a dark-colored glass bottle not C, to ensure freshness of the medication.

The nurse should teach the client to observe which precaution while taking dronedarone?

Avoid grapefruits and its juice

The nurse is evaluating the diet teaching of a client with hypertension. What dinner selection indicates that the client understands the dietary recommendation for hypertension?

Baked pork chop, applesauce, corn on the cob, 2% milk, and key-lime pie

An adult male reports the last time he received penicillin he developed a severe maculopapular rash all over his chest. What information should the nurse provide the client about future antibiotic prescriptions?

Be alert for possible cross-sensitivity to cephalosporin agents.

A 13 years-old client with non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. The healthcare provider collects home aspirate specimens for culture and sensitivity and applies a cast to the adolescent's lower leg. What action should the nurse implement next? Administer antiemetic agents Bivalve the cast for distal compromise Provide high- calorie, high-protein diet Begin parenteral antibiotic therapy

Begin parenteral antibiotic therapy Rationale: The standard of treatment for osteomyelitis is antibiotic therapy and immobilization. After bond and blood aspirate specimens are obtained for culture and sensitivity, the nurse should initiate parenteral antibiotics as prescribed.

The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts? Express feelings of sadness and loneliness Neglects personal hygiene and has no appetite Lacks interest in the activity of the family and friends Begin to show signs of improvement in affect

Begin to show signs of improvement in affect Rationale: when a depressed client begins to show signs of improvement, it can be because the client has "figured out" how to be successful in committing suicide. Depressed clients, particularly those who have shown signs of potentially becoming suicidal, should be watched with care for an impending suicide attempt might be greater when the client appear suddenly happy, begin to give away possessions, or becomes more relaxed and talkative.

The mother of a child with cerebral palsy (CP) ask the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

Brain damage with CP is not progressive but does have a variable course

The mother of the 12- month-old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day, and has also experiences a loss of appetite. What instruction should the nurse provide? Perform CPT after meals to increase appetite and improve food intake. CPT should be performed more frequently, but at least an hour before meals. Stop using CPT during the daytime until the child has regained an appetite. Perform CPT only in the morning, but increase frequency when appetite improves.

CPT should be performed more frequently, but at least an hour before meals. Rationale: CPT with inhalation therapy should be performed several times a day to loosen the secretions and move them from the peripheral airway into the central airways where they can be expectorated. CPT should be done at least one hour before meals or two hours after meals.

A child with heart failure is receiving the diuretic furosemide (Lasix) and has serum potassium level 3.0 mEq/L. Which assessment is most important for the nurse to obtain? Cardiac rhythm and heart rate. Daily intake of foods rich in potassium. Hourly urinary output Thirst ad skin turgor.

Cardiac rhythm and heart rate.

When assessing a multigravida the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first? Massage the uterus to decrease atony Check for a destined bladder Increase intravenous infusion Review the hemoglobin to determined hemorrhage

Check for a destined bladder

The charge nurse in a critical care unit is reviewing clients' conditions to determine who is stable enough to be transferred. Which client status report indicates readiness for transfer from the critical care unit to a medical unit?

Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation

A male client is admitted for the removal of an internal fixation that was inserted for the fracture ankle. During the admission history, he tells the nurse he recently received vancomycin (vancomycin) for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which action should the nurse take? (Select all that apply.) Collect multiple site screening culture for MRSA Call healthcare provider for a prescription for linezolid (Zyrovix) Place the client on contact transmission precautions Obtain sputum specimen for culture and sensitivity Continue to monitor for client sign of infection.

Collect multiple site screening culture for MRSA Place the client on contact transmission precautions Continue to monitor for client sign of infection.

When evaluating a client's rectal bleeding, which findings should the nurse document?

Color characteristics of each stool.

An older male client with type 2 diabetes mellitus reports that has experiences legs pain when walking short distances, and that the pain is relieved by rest. Which client behavior indicates an understanding of healthcare teaching to promote more effective arterial circulation? Consistently applies TED hose before getting dressed in the morning. Frequently elevated legs thorough the day. Inspect the leg frequently for any irritation or skin breakdown Completely stop cigarette/ cigar smoking.

Completely stop cigarette/ cigar smoking.

A client with Alzheimer's disease (AD) is receiving trazodone (Desyrel), a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client's mood and sleep patterns are improved, but there is no change in cognitive ability. How should the nurse respond to this information? Explain that it may take several weeks for the medication to be effective Confirm the desired effect of the medication has been achieved. Notify the health care provider than a change may be needed. Evaluate when and how the medication is being administered to the client.

Confirm the desired effect of the medication has been achieved.

A preeclamptic client who delivered 24h ago remains in the labor and delivery recovery room. She continues to receive magnesium sulfate at 2 grams per hour. Her total input is limited to 125 ml per hour, and her urinary output for the last hour was 850 ml. What intervention should the nurse implement? Discontinue the magnesium sulfate immediately Decrease the client's iv rate to 50 ml per hour Continue with the plan of care for this client Change the client's to NPO status

Continue with the plan of care for this client Rationale: continue with the plan. Diuresis in 24 to 48h after birth is a sign of improvement in the preeclamptic client. As relaxation of arteriolar spasms occurs, kidney perfusion increases. With improvement perfusion, fluid is drawn into the intravascular bed from the interstitial tissue and then cleared by the kidneys

The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first?

Convey to the client that birth is imminent.

A client with hyperthyroidism is receiving propranolol (Inderal). Which finding indicates that the medication is having the desired effect? Decrease in serum T4 levels Increase in blood pressure Decrease in pulse rate Goiter no longer palpable

Decrease in pulse rate

An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. What effect is the nurse likely to note as a result of this increases in glaucoma surgeries?

Decrease prevalence of glaucoma in the population.

The nurse is preparing to administer a histamine 2-receptor antagonist to a client with peptic ulcer disease. What is the primary purpose of this drug classification?

Decreases the amount of HCL secretion by the parietal cells in the stomach

An elderly male client is admitted to the mental health unit with a sudden onset of global disorientation and is continuously conversing with his mother, who died 50 years ago. The nurse reviews the multiple prescriptions he is currently taking and assesses his urine specimen, which is cloudy, dark yellow, and has foul odor. These findings suggest that his client is experiencing which condition? Delirium Depression Dementia Psychotic episode

Delirium

A client arrives on the surgical floor after major abdominal surgery. What intervention should the nurse perform first?

Determine the client's vital sign.

Which assessment is more important for the nurse to include in the daily plan of care for a client with a burned extremity? Range of Motion Distal pulse intensity Extremity sensation Presence of exudate

Distal pulse intensity Rationale: Distal pulse intensity assesses the blood flow through the extremity and is the most important assessment because it provides information about adequate circulation to the extremity. Range of motions evaluates the possibility of long term contractures sensation. C evaluates neurological involvement, and exudate. D provides information about wound infection, but this assessment do not have the priority of determining perfusion to the extremity.

The nurse is preparing to administer 1.6 ml of medication IM to a 4 month old infant. Which action should the nurse include? Select a 22 gauge 1 ½ inch (3.8 cm) needle for the intramuscular injection Administer into the deltoid muscle while the parent holds the infant securely Divide the medication into two injection with volumes under 1ml Use a quick dart-like motion to inject into the dorsogluteal site.

Divide the medication into two injection with volumes under 1ml

The nurse is planning a class for a group of clients with diabetes mellitus about blood glucose monitoring. In teaching the class as a whole, the nurse should emphasize the need to check glucose levels in which situation?

During acute illness

In preparing a diabetes education program, which goal should the nurse identify as the primary emphasis for a class on diabetes self-management? Prepare the client to independently treat their disease process Reduce healthcare costs related to diabetic complications Enable clients to become active participating in controlling the disease process Increase client's knowledge of the diabetic disease process and treatment options

Enable clients to become active participating in controlling the disease process Rationale: The primary goal of diabetic self- management education is to enable the client to become an active participant in the care and control of disease process, matching levels of self- management to the abilities of the individual client. The goal is to place the client in a cooperative or collaborative role with healthcare professional rather than (A)

A male client's laboratory results include a platelet count of 105,000/ mm3 Based on this finding the nurse should include which action in the client's plan of care? Cluster care to conserve energy Initiate contact isolation Encourage him to use an electric razor Asses him for adventitious lung sounds

Encourage him to use an electric razor

A 12 year old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50 ml/hour. The client's urine specific gravity is 1.035. What action should the nurse implement? Evaluate postural blood pressure measurements Obtain specimen for uranalysis Encourage popsicles and fluids of choice Assess bowel sounds in all quadrants

Encourage popsicles and fluids of choice Rationale: specific gravity of urine is a measurement of hydration status (normal range of 1.010 to 1.025) which is indicative of fluid volume deficit when Sp Gr increases as urine becomes more concentrated.

A woman just learned that she was infected with Heliobacter pylori. Based on this finding, which health promotion practice should the nurse suggest?

Encourage screening for a peptic ulcer

The nurse note a depressed female client has been more withdrawn and non-communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client? Encourage the client's family to visit more often Schedule a daily conference with the social worker Encourage the client to participate in group activities Engage the client in a non-threatening conversation.

Engage the client in a non-threatening conversation.

In assessing a client twelve hours following transurethral resection of the prostate (TURP), the nurse observes that the urinary drainage tubing contains a large amount of clear pale pink urine and the continuous bladder irrigation is infusing slowly. What action should the nurse implement?

Ensure that no dependent loops are present in the tubing.

Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room? Ensure that the knot can be quickly released. Tie the knot with a double turn or square knot. Move the ties so the restraints are secured to the side rails. Ensure that the restraints are snug against the client's wrist.

Ensure that the knot can be quickly released.

A vacuum-assistive closure (VAC) device is being use to provide wound care for a client who has stage III pressure ulcer on a below-the- knee (BKA) residual limb. Which intervention should the nurse implement to ensure maximum effectiveness of the device?

Ensure the transparent dressing has no tears that might create vacuum leaks

After receiving the first dose of penicillin, the client begins wheezing and has trouble breathing. The nurse notifies the healthcare provider immediately and received several prescriptions. Which medication prescription should the nurse administer first?

Epinephrine Injection, USP IV

A community health nurse is concerned about the spread of communicable diseases among migrant farm workers in a rural community. What action should the nurse take to promote the success of a healthcare program designed to address this problem?

Establish trust with community leaders and respect cultural and family values

Two clients ring their call bells simultaneously requesting pain medication. What action should the nurse implement first?

Evaluate both client's pain using a standardized pain scale

In monitoring tissue perfusion in a client following an above the knee amputation (aka), which action should the nurse include in the plan of care? Evaluate closet proximal pulse. Asses skin elasticity of the stump. Observe for swelling around the stump. Note amount color of wound drainage.

Evaluate closet proximal pulse. Rationale: A primary focus of care for a client with an AKA is monitoring for signs of adequate tissue perfusion, which include evaluating skin color and ongoing assessment of pulse strength.

An adult male is admitted to the emergency department after falling from a ladder. While waiting to have a computed tomography (CT) scan, he requests something for a severe headache. When the nurse offers him a prescribed does of acetaminophen, he asks for something stronger. Which intervention should the nurse implement?

Explain the reason for using only non-narcotics.

Diagnostic studies indicate that the elderly client has decreased bone density. In providing client teaching, which area of instruction is most important for the nurse to include?

Fall prevention measures.

The nurse is evaluating a client's symptoms, and formulates the nursing diagnosis, "high risk for injury due to possible urinary tract infection." Which symptoms indicate the need for this diagnosis?

Fever and dysuria.

A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h are prescribed. What action should the nurse include in this client's plan of care? Fingerstick glucose assessment q6h with meals Mix bedtime dose of insulin glargine with insulin aspart sliding scale dose Review with the client proper foot care and prevention of injury Do not contaminate the insulin aspart so that it is available for iv use Coordinate carbohydrate controlled meals at consistent times and intervals Teach subcutaneous injection technique, site rotation and insulin management

Fingerstick glucose assessment q6h with meals Review with the client proper foot care and prevention of injury Coordinate carbohydrate controlled meals at consistent times and intervals Teach subcutaneous injection technique, site rotation and insulin management

A neonate with a congenital heart defect (CHD) is demonstrating symptoms of heart failure (HF). Which interventions should the nurse include in the infant's plan of care? Give O2 at 6 L/nasal cannula for 3 repeated oximetry screens below 90% Administer diuretics via secondary infusion in the morning only Evaluate heart rate for effectiveness of cardio tonic medications Use high energy formula 30 calories/ounce at Q3 hours feeding via soft nipples Ensure Interrupted and frequent rest periods between procedures.

Give O2 at 6 L/nasal cannula for 3 repeated oximetry screens below 90% Evaluate heart rate for effectiveness of cardio tonic medications Use high energy formula 30 calories/ounce at Q3 hours feeding via soft nipples Ensure Interrupted and frequent rest periods between procedures.

When development a teaching plan for a client newly diagnosed type 1 diabetes, the nurse should explain that an increase thirst is an early sing of diabetes ketoacidosis (DKA), which action should the nurse instruct the client to implement if this sign of DKA occur? Resume normal physical activity Drink electrolyte fluid replacement Give a dose of regular insulin per sliding scale Measure urinary output over 24 hours.

Give a dose of regular insulin per sliding scale

Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis media. An antipyrine and benzocaine-otic also prescribed for pain and inflammation. What instruction should the nurse emphasize concerning the installation of the antipyrine/benzocaine otic solution? Place the dropper on the upper outer ear canal and instill the medication slowly. Warm the medication in the microwave for 10 seconds before instilling. Keep the medication refrigerated between administrations. Have the child lie with the ear up for one to two minute after installation.

Have the child lie with the ear up for one to two minute after installation.

The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn's survival? Heat loss Hypoglycemia Fluid balance Bleeding tendencies

Heat loss

The healthcare provider prescribes acarbose (Precose), an alpha-glucosidase inhibitor, for a client with Type 2 diabetes mellitus. Which information provides the best indicator of the drug's effectiveness?

Hemoglobin A1C (HbA1C) reading less than 7%

A 60-year-old female client asks the nurse about hormones replacement therapy (HRT) as a means preventing osteoporosis. Which factor in the client's history is a possible contraindication for the use of HRT?

Her mother and sister have a history of breast cancer

The nurse is auscultating a client's lung sounds. Which description should the nurse use to document this sound? High pitched or fine crackles. Rhonchi High pitched wheeze Stridor

High pitched or fine crackles.

After six days on a mechanical ventilator, a male client is extubated and place on 40% oxygen via face mask. He is awake and cooperative, but complaining of a severe sore throat. While sipping water to swallow a medication, the client begins coughing, as if strangled. What intervention is most important for the nurse to implement?

Hold oral intake until swallow evaluation is done.

A group of nurse-managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organization's budget. Which question is most important to consider when analyzing the cost-benefit for this piece of equipment? How many departments can use this equipment? Will the equipment require annual repair? Is the cost of the equipment reasonable? Can the equipment be updated each year?

How many departments can use this equipment?

When implementing a disaster intervention plan, which intervention should the nurse implement first? Initiate the discharge of stable clients from hospital units Identify a command center where activities are coordinated Assess community safety needs impacted by the disaster Instruct all essential off-duty personnel to report to the facility

Identify a command center where activities are coordinated

An older male client with history of diabetes mellitus, chronic gout, and osteoarthritis comes to the clinic with a bag of medication bottles. Which intervention should the nurse implement first?

Identify pills in the bag

A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the client to perform a series of movements that require use of the facial muscles. What symptoms suggest that the client has most likely experience a Bell's palsy rather than a stroke?

Inability to close the affected eye, raise brow, or smile

The nurse is developing the plan of care for a client with pneumonia and includes the nursing diagnosis of "Ineffective airway clearance related to thick pulmonary secretions." Which intervention is most important for the nurse to include in the client's plan of care?

Increase fluid intake to 3,000 ml/daily

An older adult female admitted to the intensive care unit (ICU) with a possible stroke is intubated with ventilator setting of tidal volume 600, PlO2 40%, and respiratory rate of 12 breaths/minute. The arterial blood gas (ABG) results after intubation are PH 7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To normalize the client's ABG finding, which action is required? Report the results to the healthcare provider. Increase ventilator rate. Administer a dose of sodium carbonate. Decrease the flow rate of oxygen.

Increase ventilator rate. Rationale: This client is experience respiratory acidosis. Increasing the ventilator rate depletes CO2 a, which returns the PH toward normal. Report findings is important but only after increasing ventilator rate.

A client experiencing withdrawal from the benzodiazepines alprazolam (Xanax) is demonstrating severe agitation and tremors. What is the best initial nursing action? Administer naloxone (Narcan) per PNR protocol Initiate seizure precautions Obtain a serum drug screen Instruct the family about withdrawal symptoms.

Initiate seizure precautions

What is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PCA) pump? Initiate the dosage lockout mechanism on the PCA pump Instruct the client to use the medication before the pain becomes severe Assess the abdomen for bowel sounds. Assess the client ability to use a numeric pain scale

Initiate the dosage lockout mechanism on the PCA pump

If the nurse is initiating IV fluid replacement for a child who has dry, sticky mucous membranes, flushed skin, and fever of 103.6 F. Laboratory finding indicate that the child has a sodium concentration of 156 mEq/L. What physiologic mechanism contributes to this finding? The intravenous fluid replacement contains a hypertonic solution of sodium chloride Urinary and Gastrointestinal fluid loss reduce blood viscosity and stimulate thirst Insensible loss of body fluids contributes to the hemoconcentration of serum solutes Hypothalamic resetting of core body temperature causes vasodilation to reduce body heat

Insensible loss of body fluids contributes to the hemoconcentration of serum solutes Rationale: Fever causes insensible fluid loss, which contribute to fluid volume and results in hemoconcentration of sodium (serum sodium greater than 150 mEq/L). Dehydration, which is manifested by dry, sticky mucous membranes, and flushed skin, is often managed by replacing lost fluids and electrolytes with IV fluids that contain varying concentration of sodium chloride. Although other options are consistent with fluid volume deficit, the physiologic response of hypernatremia is explained by hem concentration.

The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective signs of depression? (Select all that apply)

Interacts with a flat affect. Avoids eye contact. Has a disheveled appearance.

The nurse is caring for a client who is taking a macrolide to treat a bacterial infection. Which finding should the nurse report to the healthcare provider before administering the next dose? Jaundice Nausea Fever Fatigue

Jaundice

The nurse is teaching a client how to perform colostomy irrigations. When observing the client's return demonstration, which action indicated that the client understood the teaching?

Keeps the irrigating container less than 18 inches above the stoma

The nurse inserts an indwelling urinary catheter as seen in the video what action should the nurse take next? Remove the catheter and insert into urethral opening Observe for urine flow and then inflate the balloon. Insert the catheter further and observe for discomfort. Leave the catheter in place and obtain a sterile catheter.

Leave the catheter in place and obtain a sterile catheter. Rationale: the catheter is in the vaginal opening.

An adult male client is admitted to the emergency room following an automobile collision in which he sustained a head injury. What assessment data would provide the earliest that the client is experiencing increased intracranial pressure (ICP)? Lethargy Decorticate posturing Fixed dilated pupil Clear drainage from the ear.

Lethargy Rationale: Lethargy is the earliest sign of ICP along with slowing of speech and response to verbal commands. The most important indicator of increase ICP is the client's level or responsiveness or consciousness. B and C are very late signs of ICP.

When providing diet teaching for a client with cholecystitis, which types of food choices the nurse recommend to the client? High protein Low fat Low sodium High carbohydrate.

Low fat Rationale: A client with cholecystitis is at risk of gall stones that can be move into the biliary tract and cause pain or obstruction. Reducing dietary fat decrease stimulation of the gall bladder, so bile can be expelled, along with possible stones, into the biliary tract and small intestine.

A client is admitted with metastatic carcinoma of the liver, ascites, and bilateral 4+ pitting edema of both lower extremities. When the client complains that the antiembolic stocking are too constricting, which intervention should the nurse implement?

Maintain both lower extremities elevated on pillows.

A client at 30 week gestation is admitted due to preterm labor. A prescription of terbutaline sulfate 8.35 mg is gives subcutaneously. Based on which finding should the nurse withhold the next dose of this drug?

Maternal pulse rate of 162 beats per min

Ten years after a female client was diagnosed with multiple sclerosis (MS), she is admitted to a community palliative care unit. Which intervention is most important for the nurse to include in the client's plan of care?

Medicate as needed for pain and anxiety.

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? (Select all that apply.) Monitor abdominal girth. Increase oral fluid intake to 1500 ml daily. Report serum albumin and globulin levels. Provide diet low in phosphorous. Note signs of swelling and edema.

Monitor abdominal girth. Report serum albumin and globulin levels. Note signs of swelling and edema. Rationale: monitoring for increasing abdominal girth and generalized tissue edema and swelling are focused assessments that provide data about the progression of disease related complications. In advanced cirrhosis, liver function failure results in low serum albumin and serum protein levels, which caused third spacing that results in generalized fluid retention and ascites. Other options are not indicated in end stage liver disease.

While monitoring a client during a seizure, which interventions should the nurse implement? (Select all that apply)

Move obstacle away from client Monitor physical movements Observe for a patent airway Record the duration of the seizure

A client with a history of cirrhosis and alcoholism is admitted with severe dyspnea and ascites. Which assessment finding warrants immediate intervention by the nurse? Jaundice skin tone Muffled heart sounds Pitting peripheral edema Bilateral scleral edema

Muffled heart sounds Rationale: Muffled heart sounds may indicative fluid build-up in the pericardium and is life- threatening. The other one are signs of end stage liver disease related to alcoholism but are not immediately life- threatening.

An older client is admitted to the intensive care unit with severe abdominal pain, abdominal distention, and absent bowel sound. The client has a history of smoking 2 packs of cigarettes daily for 50 years and is currently restless and confused. Vital signs are: temperature 96`F, heart rate 122 beats/minute, respiratory rate 36 breaths/minute, mean arterial pressure(MAP) 64 mmHg and central venous pressure (CVP) 7 mmHg. Serum laboratory findings include: hemoglobin 6.5 grams/dl, platelets 6o, 000, and white blood cell count (WBC) 3,000/mm3. Based on these findings this client is at greatest risk for which pathophysiological condition? Multiple organ dysfunction syndrome (MODS) Disseminated intravascular coagulation (DIC) Chronic obstructive disease. Acquired immunodeficiency syndrome (AIDS)

Multiple organ dysfunction syndrome (MODS)

Which problem reported by a client taking lovastatin requires the most immediate fallow up by the nurse? Diarrhea and flatulence Abdominal cramps Muscle pain Altered taste

Muscle pain

A male client who was diagnosed with viral hepatitis A 4 weeks ago returns to the clinic complaining of weakness and fatigue. Which finding is most important for the nurse to report to the healthcare provider?

New onset of purple skin lesions.

A client is admitted to the emergency department with a respiratory rate of 34 breaths per minute and high pitched wheezing on inspiration and expiration, the medical diagnosis is severe exacerbation of asthma. Which assessment finding, obtained 10 min after the admission assessment, should the nurse report immediately to the emergency department healthcare provider?

No wheezing upon auscultation of the chest.

An older adult client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant, heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement? Observe neck for jugular vein distention Notify healthcare provider to prepare for pericardiocentesis Asses for paradoxical blood pressure Monitor oxygen saturation (Sp02) via continuous pulse oximetry

Notify healthcare provider to prepare for pericardiocentesis

A mother brings her 3-year-old son to the emergency room and tells the nurse the he has had an upper respiratory infection for the past two days. Assessment of the child reveals a rectal temperature of 102 F. he is drooling and becoming increasingly more restless. What action should the nurse take first?

Notify the healthcare provider and obtain a tracheostomy tray

A male client with a long history of alcoholism is admitted because of mild confusion and fine motor tremors. He reports that he quit drinking alcohol and stopped smoking cigarettes one month ago after his brother died of lung cancer. Which intervention is most important for the nurses to include in the client's plan of care? Determine client's level current blood alcohol level. Observe for changes in level of consciousness. Involve the client's family in healthcare decisions. Provide grief counseling for client and his family.

Observe for changes in level of consciousness. Rationale: Based on the client's history of drinking, he may be exhibiting sing of hepatic involvement and encephalopathy. Changes in the client's level of consciousness should be monitored to determine if he able to maintain consciousness, so neurological assessment has the highest priority.

An older male client arrives at the clinic complaining that his bladder always feels full. He complains of weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating his urine stream. Which action should the nurse implement? Obtain a urine specimen for culture and sensitivity Palpate the client's suprapubic area for distention Advise the client to maintain a voiding diary for one week Instruct in effective technique to cleanse the glans penis

Palpate the client's suprapubic area for distention

In early septic shock states, what is the primary cause of hypotension? Peripheral vasoconstriction Peripheral vasodilation Cardiac failure A vagal response

Peripheral vasodilation Rationale: Toxins released by bacteria in septic shock create massive peripheral vasodilation and increase microvascular permeability at the site of the bacterial invasion.

A client is admitted to the hospital after experiencing a brain attack, commonly referred to as a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding? Abnormal responses for cranial nerves I and II Persistent coughing while drinking Unilateral facial drooping Inappropriate or exaggerated mood swings

Persistent coughing while drinking

A client with rheumatoid arthritis (RA) starts a new prescription of etanercept (Enbrel) subcutaneously once weekly. The nurse should emphasize the importance of reporting problem to the healthcare provider? Headache Joint stiffness Persistent fever Increase hunger and thirst

Persistent fever Rationale: Enbrel decrease immune and inflammatory responses, increasing the client's risk of serious infection, so the client should be instructed to report a persistent fever, or other signs of infection to the healthcare provider.

When entering a client's room, the nurse discovers that the client is unresponsive and pulseless. The nurse initiate CPR and Calls for assistance. Which action should the nurse take next? Prepare to administer atropine 0.4 mg IVP Gather emergency tracheostomy equipment Prepare to administer lidocaine at 100 mg IVP Place cardiac monitor leads on the client's chest.

Place cardiac monitor leads on the client's chest. Rationale: Before further interventions can be done, the client's heart rhythm must be determined. This can be done by connecting the client to the monitor. A or C are not a first line drug given for any of the life threatening, pulses dysrhythmias

In caring for the body of a client who just died, which tasks can be delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Place personal religious artifacts on the body. Attach identifying name tags to the body. Follow cultural beliefs in preparing the body.

A client who underwent an uncomplicated gastric bypass surgery is having difficult with diet management. What dietary instruction is most important for the nurse to explain to the client? Chew food slowly and thoroughly before attempting to swallow Plan volume-controlled evenly-space meal thorough the day Sip fluid slowly with each meal and between meals Eliminate or reduce intake fatty and gas forming food

Plan volume-controlled evenly-space meal thorough the day Rationale: It is most important for the client to learn how to eat without damaging the surgical site and to keep the digestive system from dumping the food instead of digesting it. Eating volume-control and evenly-space meals thorough the day allows the client to fill full, avoid binging, and eliminate the possibility of eating too much one time. Chewing slowly and thoroughly helps prevent over eating by allowing a filling of fullness to occur. Taking sips, rather than large amounts of fluids keeps the stomach from overfilling and allow for adequate calories to be consumed. Gas forming foods and fatty foods should be avoiding to decrease risk of dumping syndrome and flatulence.

The nurse is caring for a one week old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which findings are an indication of a postoperative complication? Poor feeding and vomiting Leakage of CSF from the incisional site Hyperactive bowel sound Abdominal distention WBC count of 10000/mm3

Poor feeding and vomiting Leakage of CSF from the incisional site Abdominal distention

The nurse is teaching a postmenopausal client about osteoporosis prevention. The client reports that she smokes 2 packs of cigarettes a day and takes 750 mg calcium supplements daily. What information should the nurse include when teaching this client about osteoporosis prevention?

Postmenopausal women need an intake of at least 1,500 mg of calcium daily.

Following an esophagogastroduodenoscopy (EGD) a male client is drowsy and difficult to arouse, and his respiration are slow and shallow. Which action should the nurse implement? Select all that apply. Prepare medication reversal agent Check oxygen saturation level Apply oxygen via nasal cannula Initiate bag- valve mask ventilation. Begin cardiopulmonary resuscitation

Prepare medication reversal agent Check oxygen saturation level Apply oxygen via nasal cannula

A client with coronary artery disease who is experiencing syncopal episodes is admitted for an electrophysiology study (EPS) and possible cardiac ablation therapy. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? Prepare the skin for procedure. Identify client's pulse points Witness consent for procedure Check telemetry monitoring

Prepare the skin for procedure.

The nurse is teaching a group of clients with rheumatoid arthritis about the need to modify daily activities. Which goal should the nurse emphasize? Protect joint function Improve circulation Control tremors Increase weight bearing

Protect joint function

The nurse is planning preoperative teaching plan of a 12-years old child who is scheduled for surgery. To help reduce the child anxiety, which action is the best for the nurse to implement? Give the child syringes or hospital mask to play it at home prior to hospitalization. Include the child in pay therapy with children who are hospitalized for similar surgery. Provide a family tour of the preoperative unit one week before the surgery is scheduled. Provide doll an equipment to re-enact feeling associated with painful procedures.

Provide a family tour of the preoperative unit one week before the surgery is scheduled. Rationale: School age children gain satisfaction from exploring and manipulating their environment, thinking about objectives, situations and events, and making judgments based on what they reason. A tour of the unit allows the child to see the hospital environment and reinforce explanation and conceptual thinking.

A 56-years-old man shares with the nurse that he is having difficulty making decision about terminating life support for his wife. What is the best initial action by the nurse? Provide an opportunity for him to clarify his values related to the decision Encourage him to share memories about his life with his wife and family Advise him to seek several opinions before making decision Offer to contact the hospital chaplain or social worker to offer support.

Provide an opportunity for him to clarify his values related to the decision

A client with a cervical spinal cord injury (SCI) has Crutchfield tongs and skeletal traction applied as a method of closed reduction. Which intervention is most important for the nurse to include in the client's a plan of care? Provide daily care of tong insertion sites using saline and antibiotic ointment

Provide daily care of tong insertion sites using saline and antibiotic ointment

While assessing a client's chest tube (CT), the nurse discovers bubbling in the water seal chamber of the chest tube collection device. The client's vital signs are: blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation 88%. Which interventions should the nurse implement? Provide supplemental oxygen Auscultate bilateral lung fields Administer a nebulizer treatment Reinforce occlusive CT dressing Give PRN dose of pain medication

Provide supplemental oxygen Auscultate bilateral lung fields Reinforce occlusive CT dressing

A man expresses concern to the nurse about the care his mother is receiving while hospitalized. He believes that her care is not based on any ethical standards and ask what type of care he should expect from a public hospital. What action should the nurse take?

Provide the man and his mother with a copy of the Patient's Bill of Rights

While undergoing hemodialysis, a male client suddenly complains of dizziness. He is alert and oriented, but his skin is cool and clammy. His vital signs are: heart rate 128 beats/minute, respirations 18 breaths/minute, and blood pressure 90/60. Which intervention should the nurse implement first?

Raise the client's legs and feet

The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation?

Recommend weigh bearing physical activity

A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the nurse implement? Replace the IV site with a smaller gauge. Redress the abdominal incision Leave the lights on in the room at night. Apply soft bilateral wrist restraints.

Redress the abdominal incision Rationale: The abdominal incision should be redressed using aseptic-techniques. The IV site should be assessed to ensure that it has not been dislodged and a dressing reapplied, if need it. Leaving the light on at night may interfere with the client's sleep and increase confusion. Restraints are not indicated and should only be used as a last resort to keep client from self-harm.

A client with diabetic peripheral neuropathy has been taking pregabalin (Lyrica) for 4 days. Which finding indicates to the nurse that the medication is effective? Reduced level of pain Full volume of pedal pulses Granulating tissue in foot ulcer Improved visual acuity

Reduced level of pain

To evaluate the effectiveness of male client's new prescription for ezetimibe, which action should the clinic nurse implement?

Remind the client to keep his appointments to have his cholesterol level checked.

At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the client's medical record. Based on date contained in the record, what action should the nurse take before assisting the client with ambulation: Remove sequential compression devices. Apply PRN oxygen per nasal cannula. Administer a PRN dose of an antipyretic. Reinforce the surgical wound dressing.

Remove sequential compression devices. Rationale: Sequential compression devices should be removed prior to ambulation and there is no indication that this action is contraindicated. The client's oxygen saturation levels have been within normal limits for the previous four hours, so supplemental oxygen is not warranted.

The leg of a client who is receiving hospice care have become mottled in appearance. When the nurse observes the unlicensed assistive personal (UAP) place a heating pad on the mottled areas, what action should the nurse take? Remove the heating pads and place a soft blanket over the client's leg and feet. Advise the UAP to observe the client's skin while the heating pads are in place. Elevate the client's feet on a pillow and monitor the client's pedal pulses frequently. Instruct the UAP to reposition the heating pads to the sides of the legs and feet.

Remove the heating pads and place a soft blanket over the client's leg and feet.

During discharge teaching, the nurse discusses the parameters for weight monitoring with a client who was recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge?

Report weight gain of 2 pounds (0.9kg) in 24 hours

A client who had a below the knee amputation is experiencing severe phantom limb pain (PLP) and ask the nurse if mirror therapy will make the pain stop. Which response by the nurse is likely to be most helpful? Research indicates that mirror therapy is effective in reducing phantom limb pain You can try mirror therapy, but do not expect to complete elimination of the pain Transcutaneous electrical nerve stimulators (TENS) have been found to be more effective Where did you learn about the use of mirror therapy in treating in treating phantom limb pain?

Research indicates that mirror therapy is effective in reducing phantom limb pain

During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate first?

Respiratory apnea of 30 seconds

An older adult male is admitted with complications related to chronic obstructive pulmonary disease (COPD). He reports progressive dyspnea that worsens on exertion and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide? Limit the intake of high calorie foods. Eat meals at the same time daily. Maintain a low protein diet. Restrict daily fluid intake.

Restrict daily fluid intake. Rationale: the client is exhibiting signs of cor pulmonale, a complication of COPD that causes the right side of the heart to fail. Restricting fluid intake to 1000 to 2000 ml/day, eating a high-calorie diet at small frequent meals with foods that are high in protein and low in sodium can help relive the edema and decrease workload on the right-side of the heart.

Fallowing an outbreak of measles involving 5 students in an elementary school, which action is most important for the school nurse to take? Review the immunization records of all children in the elementary school Report the measles outbreak to all community health organizations Schedule a mobile public health vehicle to offer measles inoculations to unvaccinated children. Restrict unvaccinated children from attending school until measles outbreak is resolved.

Restrict unvaccinated children from attending school until measles outbreak is resolved.

An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasms when taking the blood pressure using the same arm. After confirming the presence of spams what action should the nurse take? Ask the UAP to take the blood pressure in the other arm Tell the UAP to use a different sphygmomanometer. Review the client's serum calcium level Administer PRN antianxiety medication.

Review the client's serum calcium level Rationale: Trousseau's sign is indicated by spasms in the distal portion of an extremity that is being used to measure blood pressure and is caused by hypocalcemia (normal level 9.0-10.5 mg/dl, so C should be implemented.

When assessing and adult male who presents as the community health clinic with a history of hypertension, the nurse note that he has 2+ pitting edema in both ankles. He also has a history of gastroesophageal reflex disease (GERD) and depression. Which intervention is the most important for the nurse to implement? Arrange to transport the client to the hospital Instruct the client to keep a food journal, including portions size. Review the client's use of over the counter (OTC) medications. Reinforce the importance of keeping the feet elevated.

Review the client's use of over the counter (OTC) medications. Rationale: Sodium is used in several types of OTC medications. Including antacids, which the client may be using to treat his GERD. Further evaluation is need it to determine the need for hospitalization (A) A food journal (B) may help over, but dietary modifications are needed now since edema is present. (C) May relieve dependent edema, but not treat the underlying etiology.

To reduce staff nurse role ambiguity, which strategy should the nurse manager implemented? Confirm that all the staff nurses are being assigned to equal number of clients. Review the staff nurse job description to ensure that it is clear, accurate, and recurrent. Assign each staff nurse a turn unit charge nurse on a regular, rotating basis. Analyze the amount of overtime needed by the nursing staff to complete assignments.

Review the staff nurse job description to ensure that it is clear, accurate, and recurrent. Rationale: Role ambiguity occurs when there is inadequate explanation of job descriptions and assigned tasks, as well as the rapid technological changes that produce uncertainty and frustration. A and D may be implemented if the nurse manager is concerned about role overload, which is the inability to accomplish the tasks related to one's role. C is not related to ambiguity.

A male client receives a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, what action should the nurse implement? Send stool sample to the lab for a guaiac test Observe stool for a day-colored appearance. Obtain specimen for culture and sensitivity analysis Asses for fatty yellow streaks in the client's stool.

Send stool sample to the lab for a guaiac test Rationale: Thrombolytic drugs increase the tendency for bleeding. So guaiac (occult blood test) test of the stool should be evaluated to detect bleeding in the intestinal tract.

A young adult client is admitted to the emergency room following a motor vehicle collision. The client's head hit the dashboard. Admission assessment include: Blood pressure 85/45 mm Hg, temperature 98.6 F, pulse 124 beat/minute and respirations 22 breath/minute. Based on these data, the nurse formulates the first portion of nursing diagnosis as " Risk of injury" What term best expresses the "related to" portion of nursing diagnosis? Infection Increased intracranial pressure Shock Head Injury.

Shock

A client refuses to ambulate, reporting abdominal discomfort and bloating caused by "too much gas buildup" the client's abdomen is distended. Which prescribed PRN medication should the nurse administer?

Simethicone (Mylicon)

When assessing a 6-month old infant, the nurse determines that the anterior fontanel is bulging. In which situation would this finding be most significant? Crying Straining on stool Vomiting Sitting upright.

Sitting upright. Rationale: The anterior fontanel closes at 9 months of age and may bulge when venous return is reduced from the head, but a bulging anterior fontanel is most significant if the infant is sitting up and may indicated an increase in cerebrospinal fluid. Activities that reduce venous return from the head, such as crying, a Valsalva maneuver, vomiting or a dependent position of the head, cause a normal transient increase in intracranial pressure.

Which assessment finding for a client who is experiencing pontine myelinolysis should the nurse report to the healthcare provider? Sudden dysphagia Blurred visual field Gradual weakness Profuse diarrhea

Sudden dysphagia

The nurse is assisting a new mother with infant feeding. Which information should the nurse provide that is most likely to result in a decrease milk supply for the mother who is breastfeeding? Supplemental feedings with formula Maternal diet high in protein Maternal intake of increased oral fluid Breastfeeding every 2 or 3 hours.

Supplemental feedings with formula Rationale: Infant sucking at the breast increases prolactin release and proceeds a feedback mechanism for the production of milk, the nurse should explain that supplemental bottle formula feeding minimizes the infant's time at the breast and decreases milk supply. B promotes milk production and healing after delivery. C support milk production. C is recommended routine for breast feeding that promote adequate milk supply.

A client with muscular dystrophy is concerned about becoming totally dependent and is reluctant to call the nurse to assist with activities of daily living (ADLs). To achieve maximum mobility and independence, which intervention is most important for the nurse to include in the client's plan of care?

Teach family proper range of motion exercises

A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan?

Teach tracheal suctioning techniques

A 350-bed acute care hospital declares an internal disaster because the emergency generators malfunctioned during a city-wide power failure. The UAPs working on a general medical unit ask the charge nurse what they should do first. What instruction should the charge nurse provide to these UAPs?

Tell all their assigned clients to stay in their rooms.

The fire alarm goes off while the charge nurse is receiving the shift report. What action should the charge nurse implement first?

Tell the staff to keep all clients and visitors in the client rooms with the doors closed

A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement?

The client's need for pain medication should be determined.

The nurse performs a prescribed neurological check at the beginning of the shift on a client who was admitted to the hospital with a subarachnoid brain attack (stroke). The client's Glasgow Coma Scale (GCS) score is 9. What information is most important for the nurse to determine? The client's previous GCS score When the client's stroke symptoms started If the client is oriented to time The client's blood pressure and respiration rate

The client's previous GCS score

The nurse is assessing an older adult with type 2 diabetes mellitus. Which assessment finding indicates that the client understands long- term control of diabetes? The fating blood sugar was 120 mg/dl this morning. Urine ketones have been negative for the past 6 months The hemoglobin A1C was 6.5g/100 ml last week No diabetic ketoacidosis has occurred in 6 months.

The hemoglobin A1C was 6.5g/100 ml last week Rationale: A hemoglobin A1C level reflects he average blood sugar the client had over the previous 2 to 3 month, and level of 6.5 g/100 ml suggest that the client understand long-term diabetes control. Normal value in a diabetic patient is up to 6.5 g/100 ml.

During change of shift, the nurse reports that a male client who had abdominal surgery yesterday increasingly confused and disoriented during the night. He wandered into other clients rooms, saying that there are men in his room trying to hurt him. Because of continuing disorientation and the client's multiple attempts to get of bed, soft restrains were applied at 0400. In what order should the nurse who is receiving report implement these interventions? (Arrange from first action on top to last on the bottom). Evaluate the client's mentation to determine need to continue the restrains Assess the client's skin and circulation for impairment related to the restrains Contact the client's surgeon and primary healthcare provider Assign unlicensed assistive personnel to remove restrains and remain with client

1. Assess the client's skin and circulation for impairment related to the restrains 2. Evaluate the client's mentation to determine need to continue the restrains 3. Assign unlicensed assistive personnel to remove restrains and remain with client 4. Contact the client's surgeon and primary healthcare provider

The nurse is caring for a 4-year-old male child who becomes unresponsive as his heart rate decreases to 40 beats/minute. His blood pressure is 88/70 mmHg, and his oxygen saturation is 70% while receiving 100% oxygen by non-rebreather face mask. In what sequence, from first to last, should the nurse implement these actions? (Place the first action on top and last action on the bottom.) Apply pads and prepare for transthoracic pacing Administer epinephrine 0.01 mg/kg intraosseous (IO) Start chest compressions with assisted manual ventilations Review the possible underlying causes for bradycardia

1. Start chest compressions with assisted manual ventilations 2. Administer epinephrine 0.01 mg/kg intraosseous (IO) 3. Apply pads and prepare for transthoracic pacing 4. Review the possible underlying causes for bradycardia

An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full thickness burns to all surfaces of both lower extremities. What percentage of body surface area should the nurse document in the electronic medical record (EMR)? 9 % 18 % 36 % 45 %

36 %

The nurse is preparing a heparin bolus dose of 80 units/kg for a client who weighs 220 pounds. Heparin sodium injection, USP is available in a 3o ml multidose vial with the concentration of 1,000 USP units/ml. how many ml of heparin should the nurse administer? (Enter numeric value only)

8 Calculate the client's weigh in kg: 220 pounds divides by 2.2 pounds/kg ꞊100 kg Calculate the client's dose, 80 units x 100 kg ꞊ 8,000 units Use the formula, D / H X Q ꞊ 8,000 units / 1,000 units x 1ml ꞊ 8

Which client should the nurse assess frequently because of the risk for overflow incontinence?

A client Who is confused and frequently forgets to go to the bathroom

The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first?

A family member of a client with dementia who has been missing for five hours

The charge nurse is making assignment on a psychiatric unit for a practical nurse (PN) and newly license register nurse (RN). Which client should be assigned to the RN? An adult female who has been depress for the past several month and denies suicidal ideations. A middle-age male who is in depressive phase on bipolar disease and is receiving Lithium. A young male with schizophrenia who said voices is telling him to kill his psychiatric. An elderly male who tell the staff and other client that he is superman and he can fly.

A young male with schizophrenia who said voices is telling him to kill his psychiatric.

A client is scheduled to receive an IW dose of ondansetron (Zofran) eight hours after receiving chemotherapy. The client has saline lock and is sleeping quietly without any restlessness. The nurse caring for the client is not certified in chemotherapy administration. What action should the nurse take? Ask a chemotherapy-certified nurse to administer the Zofran Administer the Zofran after flushing the saline lock with saline Hold the scheduled dose of Zofran until the client awakens Awaken the client to assess the need for administration of the Zofran.

Administer the Zofran after flushing the saline lock with saline Rationale: Zofran is an antiemetic administered before and after chemotherapy to prevent vomiting. The nurse should administer the antiemetic using the accepter technique for IV administration via saline lock. Zofran is not a chemotherapy drug and does not need to be administered by a chemotherapy- certified nurse.

A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. What action should the nurse implement next?

Administer the analgesic as requested

A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at bedtime. What action should the nurse take?

Administer the medication as prescribed with a glass of water

The healthcare provider changes a client's medication prescription from IV to PO administration and double the dose. The nurse notes in the drug guide that the prescribed medication, when given orally, has a high first-pass effect and reduce bioavailability. What action should the nurse implement?

Administer the medication via the oral route as prescribed

A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide (Amphogel) is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention? Allopurinol (Zyloprim) Aspirin, low dose Furosemide (lasix) Enalapril (vasote)

Allopurinol (Zyloprim)

Based on principles of asepsis, the nurse should consider which circumstance to be sterile? One inch- border around the edge of the sterile field set up in the operating room A wrapped unopened, sterile 4x4 gauze placed on a damp table top. An open sterile Foley catheter kit set up on a table at the nurse waist level Sterile syringe is placed on sterile area as the nurse riches over the sterile field.

An open sterile Foley catheter kit set up on a table at the nurse waist level

An elderly client with degenerative joint disease asks if she should use the rubber jar openers that are available. The nurse's response should be based on which information about assistive devices?

They decrease the risk for joint trauma

A client in the postanesthesia care unit (PACU) has an eight (8) on the Aldrete postanesthesia scoring system. What intervention should nurse implement?

Transfer the client to the surgical floor.

The nurse plans to collect a 24- hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client? Clearance around the meatus, discard first portion of voiding, and collect the rest in a sterile bottle Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours. For the next 24 hours, notify the nurse when the bladder is full, and the nurse will collect catheterized specimens. Urinate immediately into a urinal, and the lab will collect specimen every 6 hours, for the next 24 hours.

Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours.

The public nurse health received funding to initiate primary prevention program in the community. Which program the best fits the nurse's proposal? Case management and screening for clients with HIV. Regional relocation center for earthquake victims Vitamin supplements for high-risk pregnant women. Lead screening for children in low-income housing.

Vitamin supplements for high-risk pregnant women.

A client is being discharged home after being treated for heart failure (HF). What instruction should the nurse include in this client's discharge teaching plan? Weigh every morning Eat a high protein diet Perform range of motion exercises Limit fluid intake to 1,500 ml daily

Weigh every morning

The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply)

Weigh the client and report any weight gain. Report any client complaint of pain or discomfort. Note and report the client's food and liquid intake during meals and snacks.