204 Exam 3

Upon review of four clients' urinalysis reports, which client's results support the nurse's suspicion that the client may be developing kidney disease? Client A Serum creatinine: 1.1 mg/dL Client B Blood urea nitrogen: 18 mg/dL Client C Serum creatinine: 2.5 mg/dL Client D Blood urea nitrogen: 20 mg/dL

Client C

a patient who has suffered a stroke is unable to maintain his position while seated in a chair without sliding down. his physician has ordered him to be up in a chair for part of the day. what does the nurse recognize as the patients greatest risk factor for development for pressure injuries? a. moisture from incontinence b. nutritional deficiencies c. pressure and shear d. aging

C

A client is scheduled for a kidney ultrasound. Which instructions would be given by thenurse? Select all that apply. One, some, or all responses may be correct. a. "Drink plenty of fluids." b. "Eat foods rich in fiber." c. "Do not urinate before the examination." d. "Lie flat and perfectly still during the test." e. "A urinary catheter may be needed temporarily for the test."

A, C, D

The appropriate needle size for insulin injection is: a. 18G, 1 ½" long b. 22G, 1" long c. 22G, 1 ½" long d. 25G, 5/8" long

d. 25G, 5/8" long

Which activity can the nurse delegate to unlicensed assistive personnel (UAP): Select all that apply. One, some, or all responses may be correct. a. Voiding urine specimen collection b. Obtaining a throat culture c. Blood glucose testing d. Collecting a stool specimen e. Testing stool for occult blood

a c d e

Most oral medications take effect in blank________ to 60 minutes.

30

The nurse is caring for a patient who reports nausea and vomiting. The nurse finds increased bilirubin levels and decreased urobilinogen levels in the patient's laboratory reports. Which clinical manifestation does the nurse expect to find in the patients assessment a. Steatorrhea b. Glycosuria c. Ketonuria d. Hematuria

A

Which enzyme level does the nurse monitor in a patient with bone disease? a. Alkaline phosphatase (ALP) b. Alanine aminotransterase(ALI) c. Aspartate aminotransferase (AST) d. Gamma-glutamyltransteraseGG

A

Which prescribed diagnostic test would the nurse expect to confirm a tentative urinary tractinfection diagnosis in a client recovering from deep, partial-thickness burns who developschills, fever, flank pain, and malaise? a. Cystoscopy and bilirubin level b. Specific gravity and pH of the urine c. Urinalysis and urine culture and sensitivity d. Creatinine clearance and albumin/globulin (A/G) ratio

C

four days after abdominal surgery, the patient is getting out of bed and feels something "pop" in his abdominal wound. an increase in the amount of drainage from the wound is seen, and further examination shows that the sutured incision is now partially open, with tissue protruding from the wound. which are the priority nursing interventions (select all that apply) a. apply steri-strips to close the wound edges b. cover the wound with saline-moistened guaze c. apply a binder to pull the wound edges together and provide support to the edges d. notify the surgeon e. allow the area to be exposed to air until all of the drainage has stopped

B, D

the nurse who recognizes and analyzes clues among laboratory results should immediately report which of the following to the primary care provider (PCP)? (select all that apply.) a. hemoglobin: 15.6 g/dL b. hematocrit: 31% c. red blood cells: 5.3 × 106/μL d. White blood cells: 2,000 cells/mm3 e. Platelets 230,000 cells /mm3

B, D

Which result does the nurse expect to find in the laboratory report of a patient who has abiliary tract obstruction? Select all that apply. One, some, or all responses may be correct. a. Increased albumin levels b. Increased bilirubin levels c. Increased serum creatinine levels d. Increased serum alkaline phosphatase levels e. Increased serum alanine aminotransferase levels

B, D, E

A female patient is receiving furosemide (Lasix), 40 mg P.O. b.i.D. in the plan of care, the nurse should emphasize teaching the patient about the importance of consuming

Bananas and oranges

which features are characteristics of a closed drainage system, such as a jackson-pratt (JP) drain? (select all that apply) a. works by gravity b. provides for early discharge c. usually is inserted in surgery d. reduces the amount of antibiotics required e. allows for accurate measurement of wound drainage

C, E

The nurse is teaching a patient to prepare a syringe with 40 units of U-100 NPH insulin for self-injection. The patient's first priority concerning self-injection in this situation is to

Check the syringe to verify that the nurse has removed the prescribed insulin dose

While reviewing the urinalysis report of a patient with cardiac disease, the nurse finds increased levels of sodium in the urine. The patient also has an increase in urinary output. Which finding in the patient's blood results does the nurse correlate with the results from the patient's urinalysis report? a. Increased homocysteine levels b. Increased myoglobin protein levels c. Increased c-reactive protein (CRP) level d. Increased brain natriuretic peptide (BNP)

D. Increased brain natriuretic peptide (BNP)

How should the nurse prepare an injection for a patient who takes both regular and NPH insulin?

Draw up the regular insulin, then the NPH insulin, in the same syringe

A patient has just received 30 mg of codeine by mouth for pain. Five minutes later he vomits. What should the nurse do first?

Observe the emesis.

After having an I.V. line in place for 72 hours, a patient complains of tenderness, burning, and swelling. Assessment of the I.V. site reveals that it is warm and erythematous. This usually indicates:

Phlebitis

A male client blood test results are as follows: white blood cell (WBC) count, 100ul; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 40%. Which goal would be most important for this client?

Prevent infection

What are the 6Rs of medication administration

Right medication Right dose Right patient Right route Right time Right documentation

A patient must receive 50 units of Humulin regular insulin. The label reads 100 units = 1 ml. How many milliliters should the nurse administer?

0.5ml

Which information about common expected responses to computed tomography (CT) scan contrast material would the nurse include in preprocedure teaching? Select all that apply. One, some, or all responses may be correct. a. Visual disturbances b. Flushing of the face c. Sensation of warmth d. Lemony taste in the mouth e. Small petechiae on the arms

B, C

After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient begins to exhibit fatigue, muscle cramping, and muscle weakness. These symptoms probably indicate that the patient is experiencing: a. Hypokalemia b. Hyperkalemia c. Anorexia d. Dysphagia

a. Hypokalemia

You have administered a sublingual medication to a patient. You know that sublingual/buccal medications take effect in blank________ minutes or less.

15 minutes

When a client with chronic dyspnea is scheduled tor computed tomograpny (C 1) using contrast, which assessment information would the nurse communicate to the health care provider before the procedure? Select all that apply. One, some, or all responses may be correct. a. Metformin taken today b. Hematocrit 38% c. Serum creatinine 2.1 mg d/L (185.6 umol/L) d. Coronary artery disease history e. Shellfish allergy f. Respiratory rate 22 breaths per minute

A, C, E

Which condition is associated with an increased serum bilirubin level? Select all that apply. One, some, or all responses may be correct. a. Hepatitis b. Cholecystitis c. bone tumors d. Anemic conditions e. Biliary obstruction

A, D, E

on initial assessment of a patient , the nurse notices an area of redness over the right trochanter that, when pressed lightly, does not blanch. What does this assessment cue indicate to the nurse? a. the presence of an infection in the area b. the presence of a stage 1 pressure injury c. an allergic reaction to the sheets d. the need to apply a cold compress to reduce inflammation

B

A client reports a loss of 20 pounds (9 kg) in 3 months and black, tarry stools. A colonoscopy is scheduled. Which instructions would the nurse give to prepare the client for this test? a. The nurse instructs the client that a bland diet will be prescribed for the night before the test. b. The nurse tells the client not to eat or drink anything the morning of the test. c. The nurse administers an oil-retention enema just before the test. d. The nurse explains that the pretest laxative will cause diarrhea after the test.

B

A complete blood count (CBC), urinalysis, and x-ray examination of the chest are prescribed for a client before surgery. The client asks why these tests are done. Which reply by the nurse is best? a. "Don't worry, these tests are routine" b. "They are done to identify other health risks" c. "they determine whether surgery will be safe" d. "I don't know, your HCP prescribed them"

B

A patient is on a fluid restriction. When giving oral medications, which of the following considerations are needed? a. Use a commercial liquid thickener b. Allow the patient to take medications with a small amount of water and document the amount on the patient's record c. Allow the patient to take medications with water. The amount consumed does not affect fluid restriction d. Avoid giving the patient any liquid. Crush the medications and offer them in applesauce

B

A patient is prescribed furosemide and is at risk of hypokalemia. Which food choice would be beneficial to manage this potential side effect? a. applesauce b. oranges c. cauliflower d. blueberries

B

The nurse instructs a patient with renal failure who is receiving hemodialysis about the type of diet needed to be consumed. the nurse determines that a patient understands the education if the patient selects which diet? a. high in calories b. low in sodium, phosphorus, and protein c. low in fiber d. high in potassium

B

The nurse is administering medication through a patient's feeding tube. The nurse poured the liquid medication into the syringe, but it is not flowing freely into the patient. What action should the nurse take at this time? a. Notify the health care provider of this change in patient condition. b. Raise the height of the syringe or have the patient change position. c. Lower the height of the syringe and ask the patient to cough. d. Add the plunger to the syringe and forcefully push the plunger.

B

The nurse is preparing to initiate antibiotic therapy for a client who developed an incisional infection. Which task would the nurse ensure has been completed before starting the first dose of intravenous antibiotics? a. Red blood cell count b. Wound culture c. Knee x-ray d. Urinalysis

B

the patient is taking an oral anticoagulant (wafarin). which of the following laboratory results should the nurse recognize as being the most clinically significant for this patient? a. Platelets: 400,000 cells/mm3 b. INR: 5.9 c. Activated partial thromboplastin time: 30 seconds d. Fibrinogen: 350 mg/dL

B

After reviewing the lipid profile results for a patient, the nurse concludes that the patienthas a borderline risk of developing cardiovascular disease. Which triglyceride level in the patient's report supports the nurse's conclusion? a. 120 mg/dL b. 140 mg/dL c. 180 mg/dL d. 200 mg/dL

C

The nurse evaluates the nutritional education for a patient on a clear liquid diet has been effective when the patient selects which food item to comply with this order? a. pudding b. ice cream c. chicken broth d. rice

C

Which blood test would the nurse expect to be elevated in a patient which chronic renal failure? a. creatine kinase b. triglycerides c. creatinine d. alkaline phosphatase

C

Which client finding would the nurse document as a pulse deficit? a. Blood pressure of 130/70 mm Hg indicating pulse deficit of 60 b. Capillary refill greater than 3 seconds indicating pulse deficit c. Apical pulse 86 and radial pulse 78 indicating pulse deficit of 8 d. Radial pulse 80 and pedal pulse 70 indicating pulse deficit of 10

C

The health care provider instructs the nurse to prepare a patient with a cardiac disorder fora magnetic resonance imaging (MRI) procedure. Which condition would the nurse check for in the patient's medical records? a. History of a heart attack b. History of bypass surgery c. History of a heart transplant d. History of a pacemaker insertior

D

The nurse is administering medication to a patient when the patient accidentally drops the tablet on the floor. What should the nurse do? a. Allow the patient to take the tablet if it appears clean b. Quickly remove the tablet from the floor and wipe off the tablet with a gloved hand. Administer the tablet because medications are costly c. Ask the patient whether he would like for the nurse to obtain a new tablet or take the one that fell on the floor d. Discard the tablet and get another one

D

The nurse is teaching a patient with diverticulitis about increasing fiber intake. Which of the following foods should the nurse recommend? a. white bread b. cream of wheat c. carrots d. bananas

D

which of the following nutrients is most helpful in preventing birth defects and should be taken by women of childbearing age? a. folic acid b. magnesium c. calcium d. selenium

A

What patient specimens should collected by nurse using sterile technique in a sterile container? (select all that apply) a. clean-catch urine b. stool for occult blood c. wound drainage d. sputum e. urine from a foley catheter

A, C, D, E

A primary health care provider schedules a bone scan for a client with osteoporosis. Which nursing action is beneficial for the client? Select all that apply. One, some, or all responses may be correct. a. Placing the client in the supine position b. Verifying presence or absence of a shellfish allergy c. Ensuring the client does not have metal on their clothing d. Instructing the client to empty their bladder before the scan e. Informing the client that the post procedure headache resolves in 2 days

A, D

A physician orders heparin, 7,500 units, to be administered subcutaneously every 12 hours. The vial reads 10,000 units per milliliter. The nurse should anticipate giving how much heparin for each dose? A) 1¼ ml B) ¾ ml C) ½ ml D) ¼ ml

B) ¾ ml The nurse solves the problem as follows: 1 mL/10,000 units X 7,500 units = 0.75 mL or 3/4 mL

The nurse is caring for a patient after a lumbar puncture to obtain a cerbrospinal fluid specimen. Which are appropriate postprocedure interventions? (select all that apply) a. position the patient with the head of the bed up at least 90 degrees for hours b. assess the puncture site for drainage or bleeding c. encourage oral fluids d. maintain NPO until the gag reflex returns e. encourage ambulation immediately after the test is complete

B, C

A patient's cholesterol level is 240 mg/dL. Which complication does the nurse expect in the patient? Select all that apply. One, some, or all responses may be correct. a. Chronic anemia b. Hyperlipidemia c. Atherosclerosis d. Nephrotic syndrome e. Acquired immunodeficiency syndrome (AIDS)

B, C, D

When performing a focused assessment on a client with a possible diagnosis of irondeficiency anemia, which locations would the nurse examine? Select all that apply. One,some, or all responses may be correct a. Sclera b. Nail beds c. Conjunctivae d. Palms of hands e. Bony prominences

B, C, D

A patient states that she has difficulty swallowing pills and asks the nurse to crush them. Which of the following medications would it be okay to crush? a. Enteric coated aspirin. b. Cardizem CD (diltiazem). c. A scored tablet of Lanoxin (digoxin) d. Entex LA (guaifenesin).

C

which patient is at highest risk for impaired wound healing? a. a 22 year old with a pelvic fracture incurred in a motor vehicle accident b. a 49 year old with a history of smoking two packs a day who just had abdominal surgery c. a 72 year old with diabetes and cardiovascular disease who had surgical repair of a broken hip d. a 90 year old who no chronic health conditions with a small blistered burn on the hand

C

The nursing student is administering oral medications to her patient. The student has verified the patient's identity and checked the medications against the MAR for the third time as she removes them from their wrappers. The patient states she "takes them all at once." The student nurse hands the medicine cup full of pills to the patient and as the patient is putting them in her mouth, one of the pills falls to the floor. What is the nursing student's best action? a. Notify the prescriber and get an order for another pill. b. Pick up the pill, wipe it with a tissue, and give it to the patient if it has been on the floor less than 5 seconds. c. Pick up the pill, identify it, discard it appropriately and get the patient a new one. d. Ask the patient if she wants to take the pill or skip this dose. Document the patient's decision in the chart.

C (The student nurse will have to identify which pill it is, document the dropped pill as wasted (according to agency policy), discard of the pill appropriately, and get the patient a new one.)

Which test requires prior administration of a radionuclide agent into the patient's vein? a. Endoscopy b. Electrocardiogram c. Magnetic resonance imaging d. Positron emission tomography (PET)

D

which technique is used to collect an aerobic culture specimen from a wound? a. collect the specimen immediately after removing the old dressing b. apply sterile gloves, then open the culture tube c. always be sure to culture any necrotic tissue d. irrigate the wound before collecting the culture material

D

Which finding indicates that a patient has a pseudomonal urinary tract infection? a. Bluish or greenish color of the urine b. Dark yellow to amber color of the urine c. Light yellow to amber color of the urine d. A very pale yellow color of the urine

A

Which laboratory test is important for the nurse to monitor when a client is admitted with acute coronary syndrome? a. Troponin b. Myoglobin c. Homocysteine d. Creatine kinase (CK)

A

A patient is a newly diagnosed diabetic. The nurse prioritizes education focused on which of the following nutritional choices? a. limiting carbohydrates b. increasing simple sugars c. maintaining 2500 calories diet d. limiting sodium intake

A

The nurse administers a sublingual tablet and instructs the patient to avoid swallowing the tablet but rather to allow it to dissolve. The patient asks why. The nurse's best response is: a. "It is designed to be absorbed through the vessels of the undersurface of the tongue, and if it is swallowed, the medication will be destroyed by the gastric juices." b. "It will work quicker this way than waiting until it is digested." c. "It is a safer method of taking the medication because it dissolves rapidly under your tongue and bypasses the liver so the drug won't become toxic." d. "It will cause gastric irritation and may upset your stomach if it is swallowed."

A

The nurse is caring for a patient who has undergone a cystoscopy. Which action will the nurse take when the patient expresses concern about passing pink-colored urine? a. Explain to the patient that it is a normal finding. b. Send the patient's urine sample for examination. c. Administer the prescribed antibiotic to the patient. d. Notify the health care provider immediately.

A

Which action would be appropriate to implement when collecting a 24-hour urine test? a. Start the time of the test after discarding the first voiding. b. Discard the last voiding in the 24-hour period for the test. c. Insert a urinary retention catheter to promote the collection of urine. d. Strain the urine after each voiding before adding the urine to the container.

A

Which finding does the nurse expect when reviewing the mean corpuscular volume for patient with thalassemia major. a. 70 cells/mm b. 88 cells/mm c. 100 cells/mm d. 108 cells/mm?

A

The registered nurse is evaluating the performance of a student nurse who is collecting a urine sample through an indwelling Foley catheter. Which action made by the student nurse needs correction? a. The student nurse empties any urine that is present in the tubing into the drainage bag. b. The student nurse inserts a blunt needleless cannula at g90-degree angle into the port. c. The student nurse places a waterproof pad under the catheter close to the injection port. d. The student nurse removes the clamp from the catheter tubing after obtaining the urine sample.

B

Which laboratory test provides evidence consistent with a client having renal impairment?Select all that apply. One, some, or all responses may be correct. a. Serum albumin: 4.7 g/dL(6.815 umol/L) b. Serum creatinine: 2.0 mg/dL (176.8 umol/L) c. Serum potassium: 5.9 mEg/L (5.9 mmol/L) d. Serum cholesterol: 120 mg/dL (3.108 mmol/L) e. Blood urea nitrogen (BUN): 32 mg/dL (11.424 mmol/L)

B, C, E

Which purpose is served by a cystoscopy ordered for a client experiencing decreased anddifficult urination? a. To ascertain the size of the kidneys b. To ascertain the protein content in urine c. To ascertain the presence of urethral wall abnormalities d. To ascertain the total amount of catecholamines excreted

C

While reviewing the coagulation results for a patient, the nurse notices that the international normalized ratio (IN) is 3.5 and documents it as normal. Which rationale explains the nurse's action? a. The patient has acquired hemolytic anemia. b. The patient takes diuretic medications. c. The patient has an artificial heart valve. d. The patient has developed venous thrombi.

C

You are teaching the patient how to care for his poison oak and demonstrate the application of calamine lotion. The patient asks you, "Why do you always wash it first, when you're just going to cover it up again with the lotion?" What is your best response? a. "It helps the lotion to adhere better." b. "It prevents the poison oak from spreading and will reduce the itching sensation." c. "It removes microorganisms and debris that block penetration of the medicated lotion to the skin." correct answer d. "I need to cleanse the area to prevent drug toxicity."

C

a male patient with heat disease asks the nurse what his ideal numbers should be for cholesterol and triglycerides. which of the following is the recommended level for lipids? a. Total cholesterol: >200 mg/dL b. LDL: >100 mg/dL c. HDL: >45 mg/dL d. Triglycerides: >160 mg/dL

C

a patient has a stage 3 pressure injury on the coccyx. which food will be most beneficial in improving the healing process? a. food high in vitamin D b. whole-grain carbohydrates c. high-calorie, high-protein drink d. food high in fat and water content

C

for which patient is magnetic resonance imagine (MRI) contraindicated? a. a patient with an allergy to latex b. a patient with an infection c. a patient with an inner ear implant d. a patient with a head injury

C

the nurse has placed a nasogastric tube for a patient requiring enteral feeding. the nurse validates placement through pH measurement and using clinical judgment. what gold standard should be used to confirm placement prior to using the tube? a. auscultation b. presence of bowel sounds c. X-ray d. patient affirmation

C

Which of the following are contraindications to oral medication administration? (Select all that apply.) a. Confusion b. Inability to swallow c. Nausea/vomiting d. Postoperative after gastrointestinal surgery e. Continuous gastric suction d. Fluid restriction.

b, c, d, e

The nurse is caring for a patient who has difficulty swallowing due to a cerebrovascular accident (stroke) and receives her medications and continuous enteral feeding through a feeding tube. The patient's respiratory rate was 15 an hour ago and is now 22 breaths per minute. The pulse oximetry reading was 95% earlier and is now 90%. The patient is coughing occasionally. What is the nurse's priority action? a. Document the findings b. Notify the health care provider c. Reassess the patient in 15 minutes d. Stop the feeding

D

The nurse is reviewing medication administration through a feeding tube with the caregiver. Which of the following statements indicates further instruction is needed? a. "I will flush the tube with 15 to 30 mL of water between each dose of medication. b. "After all of the medications are administered, I will flush the tube with 60 mL of water." c. "I will return aspirated gastric contents to the stomach unless the gastric residual volume is greater than 250 mL." d. "I will crush the medications into a fine powder and add them directly to the feeding tube."

D

Which nursing action would be included in the plan of care when a client is admitted withthrombocytopenia? Select all that apply. One, some, or all responses may be correct. a. Avoid intramuscular injections. b. Institute neutropenic precautions. c. Monitor the white blood cell (WBC) count. d. Administer prescribed anticoagulants. e. Examine the skin for ecchymotic areas.

A, E

A client has a low hemoglobin level that is attributed to a nutritional deficiency. Which foods should the nurse teach the client to increase in the diet? Select all that apply. One,some, or all responses may be correct. Some correct answers were not selected a. Liver b. Apples c. Carrots d. Cheese e. Spinach

A, E

Which prescribed action would the nurse perform first when caring for a client with hemodynamically stable sepsis who complains of abdominal pain? a. Draw peripheral blood cultures from two different sites. b. Administer levofloxacin 500 mg intravenously over 30 minutes. c. Administer 1 L intravenous bolus of Ringer's lactate over 30 minutes. d. Take the client to x-ray for an abdominal computed tomography (CT) scan.

A

Which response would the nurse give when a client is admitted with chest pain and a family member asks about the purpose of the prescribed 12-lead electrocardiogram (ECG)? a. Indicates whether a heart attack is occurring b. Detects changes in the structures in the heart c. Shows whether the heart muscle is pumping d. Evaluates for prognosis after heart attack

A

While collecting a specimen for a throat culture, the nurse swabs quickly and does not place the swab in the center of the throat. Which rationale justifies this intervention? a. To prevent the patient from gagging b. To prevent any cross-contamination c. To obtain a large enough specimen d. To visualize the throat and oral cavity

A

The doctor orders dextrose 5% in water, 1,000 ml to be infused over 8 hours. The I.V. tubing delivers 15 drops per milliliter. The nurse in charge should run the I.V. infusion at a rate of: 1. 15 drops/minute 2. 21 drops/minute 3. 32 drops/minute 4. 125 drops/minute

3. 32 drops/minute. RATIONALES: Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes). Find the number of milliliters per minute as follows:125/60 minutes = X/1 minute60X = 125 = 2.1 ml/minuteTo find the number of drops per minute:2.1 ml/X gtt = 1 ml/15 gttX = 32 gtt/minute, or 32 drops/minute

based on knowledge of areas at greatest risk for development of a pressure injury in the bedridden patient, the nurse identifies which position to minimize this risk? a. 30-degree side-lying b. sitting with the head of the bed elevated 75 degrees c. 90-degree side-lying d.. lying supine with the bed flat at all times

A

which best describes a fresh surgical wound that has been closed with sutures or staples, making the two edges of the wound meet? a. approximated b. proliferated c. debrided d. tertiary intention

A

Which topic will the nurse include when teaching a group of clients about risk factors forheart disease? Select all that apply. One, some, or all responses may be correct. a. Obesity b. Hypertension c. Diabetes insipidus d. Asian-American ancestry e. Increased high-density lipoprotein (HDL)

A, B

the nurse is preparing a patient for a barium swallow test. which statements by the patient indicate that the patient has understood the nurses teaching? (select all that apply) a. "The doctor will be able to view my stomach and intestines during the test." b. "I should increase fluids after the test." c. "I will have to drink a contrast agent." d. "Barium can cause constipation and I may need a mild laxative." e. "I will be NPO for 8 hours after the test." f. "My stools may turn black for a few days afterward."

A, B, C, D

the nurse is instructed the patient in selecting food items that contain common sources of protein in the diet. which of the following food choices can be included in the teaching as examples (select all that apply) a. fish b. beans c. eggs d. apples e. avocado

A, B, C, E

put the following steps in the correct sequence for obtaining a capillary blood glucose. a. cleanse the site with alcohol and allow to dry b. ensure the hands are washed c. select the site and put on gloves d. quickly puncture the skin with the lancet e. cover the test strip with full blood sample f. wipe away the first drop of blood with guaze

A, B, C, E, F

Which of the following actions should be taken by the nurse when caring for a patient receiving total parenteral nutrition (hyperalimentation)? (select all that apply) a. change the IV tubing every 24 hours according to facility protocol b. monitor patient blood glucose levels every 6 hours c. weigh the patient weekly d. administer through a peripheral IV line e. use an infusion pump administration f. use routinely with intact GI tract

A, B, E

Upon reviewing a patient's urinalysis report, the nurse notices proteinuria. Which condition would the nurse anticipate from these findings? a. Alcoholic cirrhosis b. Trauma to the kidneys c. acute tubular necrosis d. Glomerulonephritis

D

Which action would the nurse take after having difficulty in palpating the pedal pulse of aclient with venous insufficiency? a. Count the pulse at another site. b. Notify the primary health care provider. c. Lower the legs to increase blood flow. d. Verify the pulse by using a Doppler.

D

Which condition would the nurse instruct a client to report immediately to the health care provider? a. Pelvic pain immediately after colposcopy b. Rectal bleeding for 48 hours after prostate biopsy c. Light vaginal bleeding for 24 hours after a hysterosalpingogram d. Body temperature of 102°F (38.9°C) 48 hours after cervical biopsy

D

Which of the following actions made by you is an evaluation measure? a. You remove the previous dosage paper and wipe off residual medication with a tissue. b. You write the date, time, and initials on the application paper. c. You document the procedure. d. You ask the patient what the medication is for and to list the possible side effects.

D

While reviewing the urinalysis report of a patient with cardiac disease, the nurse finds increased levels of sodium in the urine. The patient also has an increase in urinary output.Which finding in the patient's blood results does the nurse correlate with the results from the patient's urinalysis report? a. Increased homocysteine levels b. Increased myoglobin protein levels c. Increased c-reactive protein (CRP) level d. Increased brain natriuretic peptide (BNP)

D

a patient has a 24hr urine specimen ordered for creatinine clearance. which education should be provided by the nurse? a. "Collect all urine from the time the collection begins until it ends." b. "Save only a sample from each voiding." c. "Clean the perineal area three times before beginning to urinate." d. "Discard the first urine specimen, and then collect all urine until the time period expires."

D

the nurse is reviewing discharge instructions for a patient on a low-fat diet. the nurse determines that the patient understands the dietary instructions if the patient selects which of the following food choices containing unsaturated fat? a. beef b. hydrogenated oil c. ice cream d. almonds

D