65Qw/exp *IMPORTANT contains Q from Q** pain questions

A nurse is preparing to administer aspirin 650 MGPO every 12 hours. The amount available is aspirin 325 MG tablets. How many tablets should the nurse administer? A) 1 tablet B) 2 tablets C) 4 tablets D) 6 tablets

B) 2 tablets

A nurse is preparing to administer acetaminophen 10 mg Dash kilograms Dash does to a child who weighs 28 pounds. The amount available is acetaminophen 120 mg Dash 5 mL. How many milliliters should the nurse administer?

5.3 mL

A nurse is preparing to administer heparin 2,000 units by IV bolus. Available heparin injections 5,000 units/mL. How many mL should the nurse administer?

0.4 mL

A nurse is preparing to administer meperidine 75 mg IM to a client who reports postoperative pain. Available is meperidine 100mg/mL. How many mL should the nurse administer?

0.8 mL

A nurse is assessing a client who reports acute pain the nurse should anticipate which of the following findings? A) increased HR B) decreased RR C) hyperactive bowel sounds D) decreased BP

A) increased HR Cute pain stimulates the sympathetic nervous system and can cause an increase in heart rate

A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor? A) confusion B) weakness C) increased intracranial pressure D) increased urinary output

B) weakness This can produce respiratory distress or predispose the client to respiratory infections are

A nurse is caring for a client who is receiving heparin by continuous IV fusion. Which of the following medications should the nurse plan to administer in the event of an overdose? A) iron B) glucagon C) protamine D) vitamin k

C) protamine This reversed the effects of heparin and is used in the event of an overdose

A nurse is teaching a client who takes acetaminophen daily to manage mild knee pain. The nurse should instruct the client to monitor for which if the following adverse reaction to this medication? A) tinnitus B) muscle pain C) hyperglycemia D) jaundice

D) jaundice Acetaminophen can cause hepatotoxicity. The client should monitor and report jaundice, abdominal pain, clay colored stools, and fever.

A nurse in an emergency department is preparing to administer naloxone 0.4mg IV bolus to client who has opioid induced respiratory depression. Available is naloxone injection 0.2mg/mL should the nurse administer per dose?

2

A nurse is caring for a client who has a deep vein thrombosis and is prescribed heparin by continuous IV infusion at 1,200 units/hr. Available is heparin 25,000 units in 500 mL D5W. The nurse should then set the pump to deliver how much mL/hr?

24mL/hr

A nurse is preparing to administer gabapenrin 900mg PO once daily for a client who is neuropathic pain. The amount available is gabapentin 300 mg/capsule. How many capsules should the nurse administer per dose?

3 doses

A nurse is preparing to administer valproic acid 400 mg PO be ID for migraine headaches. Available is Valproic acid 250mg/5 mL. How many milliliters should the nurse administer per dose?

8mL

A nurse is preparing to administer meperidine 35 MG IM to a client every six hours PRN for pain. Available is Memperidine injection 75 mg/mL. How many milliliters should the nurse administer per dose?

0.5 mL IM

A nurse is planning to administer methylntrexone 12mg subcutaneously to a client who has opioid induced constipation. Available is methlytrexone 8 mg/0.4 ml. How many ml should the nurse administer?

0.6 mL

A nurse is monitoring a client who is post operative and unable to respond to questions. Which of the following nonverbal action should the nurse identify as an indication that the client has pain? Select all that apply A) restlessness B) grimacing C) clenching D) drowsiness E)Moaning

A restlessness Clients who have uncontrolled pain often become restless and anxious in response to the discomfort B) grimacing Facial movements such as grimacing tightening closing of the eyes inviting the lower lip or behavioral indicators of pain C) clenching Clenching the teeth and biting the lower lip or common findings in patients who have pain

A nurse is providing information about pain control for a client who has acute pain following a subtotal gastric resection . Which of the following client statement indicates an understanding of pain control? A) I will call for pain medication before the previous dose wears off B) I will call for pain medication as my pain starts to increase again C) I will wait for you at evaluate my pain before asking for more medication D) I will ask for less pain medication to avoid addiction

A) I will call for pain medication before the previous dose wears off This helps with it become to severe to quick

A nurse is caring for a client who has an expressive aphasia following a cerebrovascular accident CVA. Which of the following parameters should the nurse use first in order to assess the clients pain level? A) pulse and blood pressure findings B) behavioral indicators and effect C) scheduled treatments and clients illness D) a self report pain rating scale

A) a self reporting pain rating scale Expressive aphasia results from damage to an area of the frontal lobe and is a motor speech problem. The client who has expressive aphasia is able to understand what I said but is unable to communicate verbally. However, this does not necessarily mean that the client is unable to rely report pain. Evidence-based practice indicates that nurses should first attempt to obtain the client self report of pain. When assessing a client for pain, the nurse should utilize the hierarchy of pain measures which begin with self report. It is always better to use objective method, such as the clients report, instead of an objective method, such as something that is observable by the nurse, which is much less reliable.

A nurse is caring for a child who suspected diagnosis of bacterial meningitis. Which of the following actions is the nurses priority? A) administer antibiotics when available B) reduce environmental stimuli C) document intake and output D) maintain seizure precautions

A) administer antibiotics when available The priority nursing action is to administer antibiotics when available. Bacterial meningitis is an acute inflammation of the Mindys in the central nervous system. Antibiotic therapy has a marked effect on the course in the prognosis of the illness.

A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take? A) apply the bag for 30 min at a time B) reapply the bag 30 mins after removing it C) allow room for some air inside the bag D) place the bag directly on the skin

A) apply the bag for 30 mins at a time The nurse should leave the bag in place for 30 minutes, but should check the client skin after 15 minutes to make sure there is no adverse effects

A nurse is assessing a clients cranial nerves. Which of the following method should the nurse use to assess cranial nerve two? A) ask the client to read a smeller chart B) listen to the clients speech C) ask the client to identify scented aromas D) ask the client to clench his teeth

A) as the client to read a shelled chart Cranial nerve to control central and peripheral vision. The Snellen chart is used to assess visual acuity and dysfunctions of cranial nerve two which is the optic nerve

A nurse is caring for a client who has difficulty swallowing medications as prescribed and transit coated aspirin PO once daily. The client asked if the medication can be crushed to make it easier to swallow. Which of the following responses should the nurse provide? A) crushing the medication might cause you to have a stomach ache or indigestion B) crushing the medication is a good idea and it can be mixed with some ice cream if you would like C) crushing the medication would release the medication at once versus over a period of time D) crushing is unsafe and it destroys ingredients in the medication

A) crashing the medication might cause you to have a stomach ache or indigestion

A nurse suspect that a coworker is diverting opioid analgesics. Which of the following is an adverse effect of opioid medications? A) euphoria B) rhinorrhea C) hallucinations D) dilates pupils

A) euphoria An adverse effect of opioids analgesics and is due to activation of MU receptors

A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following action should the nurse take first? A) evaluate the clients neurological status B) preform a complete blood count C) check the clients temperature D) administer an oral analgesic

A) evaluate the clients neurological status Manifestations of a headache and stiff neck are indications that the client might have meningitis. The greatest rest to the client is injury from increased in a cranial pressure, which can lead to brain and ration and death. Therefore, the nurse should complete inner logical assessment at a baseline. If the client does not have meningitis neurological check should be completed every 2 to 4 hours

A nurse is caring for a three-year-old child whose parents reports that she has intense fear of painful procedures such as injections. Which of the following strategies should the nurse add to the child's plan of care select all that apply A) have the parent stay with the child during he procedure B) cutler procedures whenever possible C) preform procedure as quickly as possible D) allow the child to keep a toy from home with them E) use mummy restraints during painful procedures

A) have the parent stay with the child during he procedure Supportive interventions for preschoolers and toddlers C) preform procedure as quickly as possible Supportive intervention for children D) allow the child to keep a toy from home with them Therapeutic intervention for children

A nurse is providing teaching to a client who takes opioid pain medication and has a new prescription for Docusate sodium. Which of the following statements by the client indicates an understanding of teaching? A)it might take up to 3 days for the medication to work B) i will take the medication for diarrhea C) I should drink 4 ounces of water when I take the medication D) I can take this medication along with mineral oil

A) it might take up to 3 days for the medication to work The client understands docsate sodium is a stool softener and that the therapeutic effect might take up to three days to fully achieve

A nurse is caring for a client who is withdrawing from opioids. Which of the following medication should the nurse prepare to administer? A) methadone B) disulfiram C) risperidone D) lithium carbonate

A) methadone Methadone is a synthetic opiate that blocks the cravings for and the effects of narcotics. It is widely used to assist with detoxification and maintenance of those who have had dependency to opioids. Methadone reduces withdrawal symptoms but it does not cause a high. The medication must be taken every day. The client requires close monitoring because methadone is highly addictive. Methadone is approved for the treatment of women who are pregnant and addicted to opioids.

A nurse is caring for a client who is post operative following a cholecystectomy and reports pain. Which of the following actions should the nurse take? Select all that apply A) offer the clients a back rub B) remind the client to use incisional splinting C) identify the clients pain level D) assist the client to ambulated E) chance the clients position

A) offer the clients a back rub For comfort measures to improve pain B) remind the client to use incisional splinting Self management for pain C) identify the clients pain level Helps determine the severity if the pain E) chance the clients position Non pharmacological measure to manage pain

A nurse is caring for a client who has right sided acoustic neuroma resulting in impaired meant of cranial nerves 9 and 10 which of the following action should the nurse take? A)place auction equipment on the clients bedside B)apply an eyepatch to the clients right eye C)avoid using warm water to wash a clients face D)provide range of motion exercises to the clients neck and shoulders

A) place suctions equipment at the clients bedside Cranial nerve nine gloss and cranial nerve 10 the Vagus nerve the muscles of the soft palate, larynx, pharynx. Impairment of these nerves places a client at risk for aspiration, making it necessary for the nurse to have access to sections for the client

A nurse suspects a client who has myasthenia Gracie is experiencing a myasthenia crisis. Which of the following intervention should the nurse take? A) prepare the client for mechanical ventilation B) administer an anticholinsterase medication C) instruct the client to preform the purses lip breathing D) prepare to administer a vasoconstriction

A) prepare the client for mechanical ventilation The client who is experiencing this crisis is at risk for loss of inadequate respiratory function. The nurse should closely monitor the clients respiratory status and prepare for possible mechanical ventilation

A nurse is assessing a client who has meningitis. Which of the following should the nurse expect? A) severe headache B) bradycardia C) blurred vision D) oriented to person, place and year

A) severe headache The nurse should expect. A client who has meningitis to manifest a severe headache due to meningeal inflammation

A nurse is caring for a client with myasthenia gravis who is experiencing dysphasia. The nurse should recommend a referral to which if the following members I'd health care team? A) speech therapist B) social worker C) respiratory therapist D) occupational therapist

A) speech therapist Helps a client experiencing speech, language and swallowing difficulties

A nurse is assessing a client who Has diabetes Mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? Select all that apply A) bradycardia B) an increase in neutrophils C) an increase in RBC's D) an increase in platelets E) localized edema

B) an increase in neutrophils during the inflammatory stage of wound healing, neutrophils move into the intestinal spaces. About 24 hours later, macrophages replace them in just in destroy micro organisms. E) localized Edema Edema develops in the first stage of inflammation, when vascular and cellular responses cause fluid, white blood cell count, and protein to pour into the interestrial spaces at the site of invasion of micro organisms. The accumulated fluid appears as look less swelling or edema

A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurses priority? A) The client reports weakness in the lower extremities B) blood pressure 80/56MMHG C)temperature of 38.2°C or 100.8°F D) the client reports profuse itching

B) blood pressure 80/56 mm Hg When using the airway breathing circulation approach to client care the nurses priority finding is the blood pressure of 80/56 which indicates hypertension. The clients blood pressure is not adequate to sustain uteroplacental perfusion and oxygen to the fetus which can lead to respiratory distress and possible death

A nurse is planning care for a client who is post operative. Which of the following statements about pain management should the nurse consider when implementing care? Select all that apply A) the use of analgesic will eventually lead to addiction B) each clients expressions of pain may be different and individualized C) patient controlled and logistics offers a constant level of opioid and therapeutic range D) the pain level and pain tolerance can be assessed using a scale of 0 to 10 E) The client will express feelings of pain both verbally and nonverbally

B) each clients expression of pain may be different and individualized D) the pain level and pain tolerance can be assessed using a scale of 0 to 10

A nurse is caring for a client who is at a six week of gestation and has ammonia. While the nurse is obtaining the clients history, the client tells the nurse that she has to take the herb feverfew for migraine headaches. Which of the following actions should the nurse take? A) tell the client that she should take an over the counter and analgesics instead B) explain to the client that she should not take this herb while she is pregnant C) ask the client why she would take an herb during pregnancy D) suggest that the client ask her herbalist within the next few weeks about taking it while pregnant

B) explain to the client that she should not take this her while she is pregnant The nurse should explain that feverfew interferes with platelet actions and can therefore cause bleeding. It is unsafe for the client to take during pregnancy

A nurse is assessing a client who has a suspected diagnosis of Gillian barre (GBS) which of the following questions should the nurse ask the client? A) do you have a history of chronic alcohol abuse B) have you had a recent influenza infection C) have you traveled overseas recently D) are you taking a multivitamin?

B) have you had a recent influenza infection The nurse should ask about haemophilus influenzas infection. The cause of the GSB is unknown but it is usually following a viral infection

A nurse is providing teaching to a client who is post operative following a coronary artery bypass graft CABG surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medication should the nurse identify as most important for the clients recovery? A) decreased clients level of anxiety B) it facilities the clients deep breathing C) it enhances the clients ability to sleep D) it reduces the clients blood pressure

B) it facilitates the clients deep breathing When using the airway, breathing, circulation approach to client care, the nurse should identify facilitation of deep breathing such as the most important desired effect of opioids aside from pain relief. Following the thoracic type surgeries, the client has the increased pain with moving, deep breathing and coughing. Opioid medications help minimize the discomfort experience with deep breathing and coughing which prevents the development of postoperative ammonia. The nurse should also encourage the client to splint his incisions to help minimize pain

A nurse is caring for a client with myasthenia gravis and observes the client experiencing severe dysphasia. The nurse notifies the provider which of the following nutritional therapies will likely be prescribed? A) NPO until dysphasia subsides B) supplements via nasogastric tube C) initiation of total parental nutrition D) soft residue diet

B) supplements via nasogastric tube Supplement via nasal gastric tube provide enteral nutrition for clients who are at risk for aspiration caused by diminished gag reflex or difficulty swallowing. This nutritional therapy will likely be prescribed

A nurse is teaching a client who has a new prescription for ibuprofen to treat hip pain. Which of the following instruction should the nurse include in the teaching? A) expect ringing in your ears B) take the medication with food C) store the medication in the refrigerator D) monitor for weight loss

B) take the medication with food This minimizes gastric irritation, the client should take ibuprofen with food or immediately after a meal

A nurse is caring for a client who is post operative. The nurse should base pain management interventions primarily on which of the following methods of determining the intensity of a clients pain? A) viral sign measures B) the clients self report and pain severity C) visual observation for nonverbal signs of pain D) the nature and invasiveness of the surgical procedure

B) the clients self report of pain severity Because nurses cannot measure pain objectively, it is standard practice to except that pain is what the client says it is into intervene accordingly

A nurse is caring for a client who is beginning to breast-feed her newborn after delivery. The new mother states, "I don't want to take anything for pain because I am breast-feeding." which of the following statements should the nurse make? A)You need to take pain medication so you are more comfortable B) we can take your pain medication so you have an hour or two before the next feeding C) all medications are found in breastmilk to some extent D) you have the option of not taking pain medication if you are concerned

B) we can take your pain medication so that you have an hour or two before the next feeding This answer provides a client an option that allows for administration of pain medication but minimizes the effect it will have on the newborn while breast-feeding

A nurse in the emergency department is caring for a client who has an acute toxicity from acetaminophen overdose. The nurse should prepare to administer which of the following medications? A) through minerals B) a sister A nurse in the emergency department is caring for a client who has an acute toxicity from acetaminophen overdose. The nurse should prepare to administer which of the following medications? A) Flumazenil B)Acetylcysterine C)Atropine D)Viramin K

B)Acerylcysterine

A nurse is teach the partner of a client with guillain barre about manifestations of dysphasia. Which if the following statements by the clients partner indicates the need for furthering teaching? A) I will monitor my husband for coughing while he is eating B) I will monitor for a change in my husband voice after he swallows C) I will monitor my husband for tilting his head forward when he swallows D) I will monitor my husband for pocketing food in his mouth

C) I will monitor my husband for titling his head forward when he swallows This reduces the risk for dysphasia

A client who has a history of myocardial infraction MI is prescribed aspirin 325 MG. The nurse recognizes that the aspirin is given due to which of the following actions of medication? A) Analegestics B) anti inflammatory C) anti platelets aggregate D) antipyretic

C) anti platelets aggregate Aspirin is used to decrease the likelihood of blood clotting it also is used to reduce the risk of a second heart attack or stroke by inhibiting platelet aggregation and reducing thrombus formation in an artery vein or the heart

A nurse is reviewing the medical record of a client who reports drinking 3 to 4 glasses of wine each night and taking 3000 mg of acetaminophen daily. Which of the following laboratory values is the priority of the nurse to assess? A) amylase B) cretinine C) aspartame aminotransferase (AST) D) anriduretic hormone (ADH)

C) aspartame aminotransferase (AST) The greatest rest to the client is liver injury from the combined adverse effects of alcohol and acetaminophen. Therefore, the priority lab value for the nurse to evaluate is that a AST because an evaluated level is an indication of liver damage

A nurse is caring for a client with sever visual impairments due to myasthenia gravis. When the clients food tray arrives which of the following interventions should the nurse take to promote independence in eating? A) assign an assistive personnel to feed the client B) explain to the client the location of the food in the tray C) describe the client the location of the food on the tray D) ask the client if she would prefer a liquid diet

C) describe to the client the location of the food in the tray Provides the client with the necessary information for her to feed herself, promoting independence

A nurse is caring for a client who request prescription pain medication. Which if the following actions should the nurse preform first? A) reposition the client B) administer the medication C) determine the location of Pain D) review the effects of pain medication

C) determine the location of pain The first action the nurse should take using the nursing process is to assess the client. By determining the location of pain, the nurse can take necessary steps to alleviate the client pain, such as administering pain medication, repositioning the client, and teaching the client about the effects of the medication.

A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous IV infusion. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which if the following responses should the nurse give? A) it usually takes heparin at least 2-3 days to reach therapeutic blood level B) a pharmacist is the person to answer that question C) heparin does not dissolve clots. It stops new clots from forming D) the Iran medication you will take after this IV will dissolve the clot

C) heparin does not dissolve clots. It stops new clots from forming

A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache? A) administer pain medication B) darken the clients room and close the door C) increased fluid intake D) elevate the head of bed to 30°

C) increase fluid intake The client who has a lumbar puncture is at risk for continued leaking of CSF from the puncture site. This results in a decreased amount of circulating CSF. Increasing fluids is helpful and quickly replacing the cerebral spinal fluid that was removed during the procedure and increasing fluids well then facilitate resolution of the headache. The client should also be instructed to remain in a prone position for six hours to prevent leaking of CSF fluid

A nurse is planning care for a six-year-old child who has a bacterial meningitis. Which of the following nursing interventions is a necessary in the clients plan of care? A) place the client in semi Fowler's position B) admit the client to a private room C) measure head circumference every shift D) implement seizure precautions

C) measure the head circumference every shift The head circumference of a six-year-old can a crease since the frontals and structures have been close since a child was 18 months old therefore it is unnecessary to measure the child's head circumference

A nurse is preparing to administer heparin to a client who is at risk for developing a DVT due to gullaim barre. Which of the following action should the nurse plan to take? A) use a 22 gauge needle to object the medication B) use a 1 inch needle to inject medication C) inject the medication into the abdomen above the level of iliac crest D) massage the injection site after administration of the medication

C) object the medication into the abdomen abound the level of iliac crest The nurse should inject the medication into the abdomen above the level of the iliac crest, at least 2 inches from the umbilicus

A nurse is teaching a client who has a new prescription for sumatriptan tablets to treat migraine headaches. Which of the following instruction should the nurse include? A) take daily to prevent headaches B) chew tablets well before swallowing C) report swelling of eyelids after dosage D) repeat dose in 1 hour for unrelieved headache

C) report swelling of eyelids after dosage Report swelling of eyelids and lips to provider which can indicate an allergic reaction to this medication

A nurse is teaching a female client who has a new prescription for transdermal sumatriptan to treat migraine headaches. Show the following should the nurse include? A) take this medication daily to prevent headaches B) activate the patch 30 mins after application C) use contraception while taking this medication D) you can bathe with the patch in place

C) use contraceptive while taking this medication Sumatriptan can cause teratogenesis and should not be used during pregnancy

A nurse is assessing a client who has meningitis and notices when passively flexing the clients neck there is an involuntary flexion in both legs. Which of the following conditions is the client displaying? A)kernigs signs B)nuchal rigidity C)brudzinski sign D)Bradykinsia

C)brudzinski sign This client is manifesting a positive brudzinski sign which indicates when the hips and knees flexed when the neck is flexed. A positive brudzinski sign is a common sign of meningitis

A nurse in the emergency room is assessing a client who has brought in following a seizure. The nurse suspects the client may have Meningococcal meningitis when assessment findings include nuchal rigidty and petechial rash. After implementing droplet precautions, which of the following action should the nurse initiate next? A) completed vascular assessment B)administer an antipyretic C)decrease environmental stimuli D) assess the cranial nerves

D) assess the cranial nerves The greatest rest of the client is from increased intercranial pressure which may lead to herniation of the brain and death. The nurse should perform neurological assessment including evaluation of the cranial nerves at least every four hours. Early neurological changes to be monitoring for include a decrease in the level of consciousness, the developing of Cushing triad(severe hypertension, why didn't pulse pressure, and bradycardia), and changes in pupillary reaction

A nurse suspects that a client is admitted for treatment of bacterial meningitis is experiencing increased intercranial pressure (ICP). Which of the following assessment findings by the nurse supports the suspicion? A) photophobia B)nuchal rigidity C)positive Kernigs sign D)blood pressure 134/67

D) blood pressure 134/67 Clients who have meningitis can be at risk for developing increased ICP. The nurse should monitor the clients vital signs and neurological status for at least four hours. Indications of increased intercranial pressure include increased restlessness and confusion, a decreased level of consciousness, in the presence of Cushing's Triad open parentheses widened pulse pressure, breed a piña and bradycardia). A normal pulse pressure is 40 to 60 MMHG. This patient has a pulse pressure of 88.

A nurse is assessing a clients cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve three? A)Testing visual acuity B)Observing for facial symmetry C) Eliciting the gag reflex D)Checking the pupillary response to light

D) checking the pupillary response to light Cranial nerve three is the aqua motor nerve that is responsible, along with cranial nerves 4 trochlear and six abducens for eye-movement and people every response to light. If the cranial nerve is functioning properly, the expected reaction is people construction in response to light

A nurse is planning care for a five month old infant who is scheduled for a lumbar puncture to rule out meningitis. Which of the following action should the nurse include in the plan of care? A) keep the infant NPO for six hours prior to the procedure B)Apply an euthectic mixture of lidocaine and priolocaine cream tropically 15 minutes prior to the procedure. C) placed the infant in an infant seat for two hours following the procedure. D) hold the infants chin to his chest and his knees to his abdomen during the procedure

D) hold the infants chin to his chest and knees to his abdomen during the procedure During the procedure, the infant is positioned on her side in a fetal position (knees curl to abdomen and chin tuck to chest) to open up the subarachnoid space

A nurse is caring for a client who has opioid toxicity and has a respiratory rate of 6 beats per min. Which if the following medications should he nurse plan to administer? A) epinephrine B) protamine C) flumaznil D) naloxone

D) naloxone It's an I plate antagonist what competes with opioids at oplate receptor sites making the opioid ineffective

A nurse is implementing a plan of care for a client who has myasthenia gravis with recurring pneumonia. Which of the following actions should the nurse take? A) encourage fluid intake of 1500mL/day B) position head of bed at 10 degrees C) cough and deep breathe every 8 hours D) obtain a sputum culture

D) obtain a sputum culture This determines which antibiotic is needed for the organism that is causing the pneumonia

A nurse is caring for a client who has suspected diagnosis of bacterial meningitis. Which of the following actions is the nurses priority? A)prepare the child for lumbar puncture B)administer an intravenous antibiotic C)obtain blood cultures D)place the child in isolation

D) place the child in isolation Bacterial meningitis is highly contagious. Therefore, the nurse should protect others from infection by placing the child in isolation.

A nurse is caring for a client who has meningitis, a temperature of 39.7°C or 103.5°F and is prescribed a hypothermia blanket. While using this therapy, the nurse will know that the client must carefully be observed for which of the following complications? A) dehydration B) seizures C) burns D) shivers

D) shivers The hypothermia blanket, if. Used improperly open parenthesesat inappropriate low temperatures, or without skin protection) can cause a client to cool too fast, leaving to shivering to prevent heat loss from the skin, the body becomes peripherally Basil constricted in an attempt to reduce heat loss. The body will also try to increase heat production by shivering, which can lead to metabolic rate by 2 to 5 times and in doing so greatly raise oxygen consumption

A nurse is admitting a young client who has suspected bacterial meningitis. The nurse should closely monitor the client for increased in a cranial pressure ICP as indicated by which of the following findings? A) nuchal rigidity B) pupils reactive to light C) head turns to follow light D) slow respiration's

D) slow respiration's Cushing's Triad is a hallmark sign of ICP. Cushing's Triad includes increased pulse pressure, bradycardia and bradypnea

A hospice nurse is caring for a client who has terminal cancer and takes PO morphine for pain relief. The client reports that he has had to increase the dose of morphine this week to obtain pain relief. Which of the following scenarios should the nurse document as an explanation for the situation? A) The client not been taking medication properly B) the client is experiencing episodes of confusion C) the client has become addicted to the medication D) the client develop a tolerance to the medication

D) the client has developed a tolerance to the medication The nurse should document that the client has developed a tolerance to the medication. Morphine is a narcotic analgesic used for the treatment of severe pain. Tolerance is an adverse effect of narcotic analgesic in which a large dose is needed to produce the same response

A nurse is monitoring a client who took an overdose of acetaminophen 72 hours ago. The nurse should identify which of the following findings as manifestation of acetaminophen poisoning? A) constipation B) Xerostomia C) tinnitus D) vomiting

D) vomiting The nurse should expect a client who has acetaminophen poisoning to have early manifestations of nausea, vomiting, abdominal distress, diarrhea, and sweating