Fundamentals Exam 3

Which nursing intervention is most important in preventing postoperative complications?

early ambulation

A client reports being allergic to amoxicillin even though the medication administration record and armband do not indicate medication allergies. What should the nurse do about administering the drug to the client

Withhold the medication

The nurse is teaching a client about using topical gentamicin sulfate. Which comment by the client indicates the need for additional teaching? "I should stop applying it once the infected area heals." "I should apply it to large open areas."

"I should apply it to large open areas."

Which statement indicates that the client understands the home care of a colostomy?

"I should be able to establish a regular pattern of elimination with my colostomy."

What is one disadvantage of using the rectal route

It can result in incomplete drug absorption

Using Abraham Maslow's hierarchy of human needs, the nurse assigns highest priority to which client need?

inserting a Foley catheter

Three days after surgery, a client continues to take hydrocodone 7.5 mg and acetaminophen 500 mg for postoperative pain. What should the nurse ask the client before administering the pain medication?

"When did you last have a bowel movement?"

What is the maximum amount of medication (in milliliters) that can be administered into the deltoid muscle? Record your answer using a whole number. 3 2

2

A client is admitted to the health care facility with bowel obstruction secondary to colon cancer. The nurse obtains a health history, measures vital signs, and auscultates for bowel sounds. Which step of the nursing process is she performing?

Assessment

The nurse manager on a pediatric floor is updating safety recommendations for the unit. Which strategy would help reduce pediatric medication errors? Select all that apply

Avoid using parenteral syringes when administering liquid oral medications. Limit the size of IV fluid bags that can be hung on small children. Reduce the available concentrations or dose strengths of high-alert medications to the minimum.

A client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, the nurse notes that the client's stoma appears dusky. How should the nurse interpret this finding?

Blood supply to the stoma has been interrupted

The nurse is using the Z-track method of intramuscular (IM) injection to administer iron dextran to a client with iron-deficiency anemia. Which techniques should the nurse use to give this injection? Select all that apply

Confirm the client's identity before administering the iron dextran. Change the needle after drawing up the iron dextran. Before inserting the needle, displace the skin laterally by pulling it away from the injection site. Inject the iron dextran after aspirating for a blood return

The nurse is preparing to administer the last dose of ceftriaxone before discharge to a 1-year-old but finds the IV has occluded. What should the nurse do/?

Contact the prescriber to request a prescription change

A physician orders hourly urine output measurement for a postoperative client with an indwelling catheter. The nurse records these amounts of output for 2 consecutive hours: 8 a.m. (0800): 50 ml; 9 a.m. (0900): 60 ml. Based on these amounts, which action should the nurse take?

Continue to monitor and record hourly urine output

A client is diagnosed with acute pyelonephritis. What should the nurse instruct the client to do?

Empty the bladder every 2 to 3 hours

A client has a patient a controlled analgesia (PCA) infusion to manage postoperative pain. In spite of receiving a dose of pain medication, the client rates the pain at 8 on a 0 to 10 pain scale. What should the nurse do first?

Inspect the infusion

What is the priority action that a nurse should take after omitting an ordered medication?

Notify the prescrib

A child is admitted with constipation and a diagnosis of possible appendicitis. The child is in acute pain. Which nursing interventions would be appropriate prior to surgery to decrease pain? Select all that apply

Offer an ice pack. Assume a position of comfort. Limit the child's activity

A registered nurse (RN) and licensed practical nurse (LPN) are administering medications on the neurologic floor. The LPN prepares to administer phenytoin to a client with a history of seizures. The LPN walks into the room and hands the medication to a nursing assistant. The LPN asks the nursing assistant to give the client the medication after completing the client's morning care. What should the registered nurse do?

Remind the LPN that it is the LPN's duty to administer the medications

A client has requested to have patient-controlled analgesia (PCA) after surgery? When is it appropriate for a client to receive PCA?

The client has the ability to self-administer

The nurse notes that a client's blood glucose level is increased. The nurse plans to inform the physician by phone. Which technique should the nurse use to communicate verbally to the physician?

SBAR

The physician orders docusate sodium 100 mg at bedtime for a primiparous client after vaginal delivery of a term neonate after a midline episiotomy. The nurse instructs the client to expect which of the following results from taking the medication?

Softening of the stool

The nurse is teaching the client how to use a metered-dose inhaler (MDI) to administer a corticosteroid. Which observations indicates that the client is using the MDI correctly? Select all that apply.

The inhaler is held upright. The client rinses the mouth with water following administration.

A medication order reads, "Meperidine 1 ml I.M. stat." A nurse responsible for administering the drug should base the next action on which understanding?

The nurse should clarify the order with the physician.

The nurse is observing a new graduate nurse instill eyedrops into a client's eyes. The nurse evaluates that the new graduate is using appropriate technique when which step is incorporated into the procedure?

The nurse's hand is stabilized on the client's forehead while instilling the drops.

A physician's order for a client states the administration of a medication "b.i.d." How many times should the nurse administer the medication to the client?

Twice a day "B.i.d." is a commonly used abbreviation that means twice a day. The abbreviation "q.d." indicates every day; "q.i.d" indicates four times a day; "q.o.d" indicates every other day

A child with rheumatic fever complains of painful joints. Which nonpharmacologic measures should the nurse use to reduce the child's pain?

Use a bed cradle to keep linens from pressing on the child's joints.

Which procedures can the nurse working on a pediatric floor safely delegate to the licensed practical/vocational nurse (LPN/VN)? Select all that apply

administering gastrostomy tube feedings inserting hearing aids

A nurse is developing a drug therapy regimen that won't interfere with a client's lifestyle. When doing this, the nurse must consider the drug's

adverse effects.

A client is receiving massage therapy to relieve pain. Which statement explains why massage is an effective way to relive pain?

blocks pain impulses from the spinal cord to the brain.

A nurse is inserting a urinary catheter into a client who is extremely anxious about the procedure. The nurse can facilitate the insertion by asking the client to:

breathe deeply

A hospitalized client fell on the floor and sustained a small laceration on the hand that requires stitches. The intern will suture the client's hand at the client's bedside and asks for bupivacaine with epinephrine and a suture kit in order to suture the laceration. Which issue should be resolved before proceeding with suturing?

bupivacaine with epinephrine used as the local anesthetic.

When planning pain control for a client with terminal gastric cancer, a nurse should consider that

clients with terminal cancer may develop tolerance to opioids

A 13-year-old client is being evaluated for possible Crohn's disease. The nurse expects to prepare the client for which diagnostic study

colonoscopy with biopsy

When a nurse tries to administer medication, the client refuses it, saying, "I don't have to take those pills if I don't want to." What intervention by the nurse would have the highest priority

exploring how the client's feelings affect the decision to refuse medication

A client requests medication at 9 p.m. (2100) instead of 10 p.m. (2200) so that the client can go to sleep earlier. Which type of nursing intervention is required? interdependen independent

independent

After teaching the parents about the urethral catheter placed after surgical repair of their son's hypospadias, the nurse determines that the teaching was successful when the mother states that the catheter in her child's penis accomplishes which goal?

keeps the new urethra from closing

A client with colon cancer is having a barium enema. The nurse should instruct the client to take which type of medication after the procedure is completed

laxative

A client's diagnosis of pneumonia requires treatment with antibiotics. The corresponding order in the client's chart should be written as

moxifloxacin 400 mg daily

The nurse transcribes the physician's order onto the client's medication record:September 15, 2012Administer 10 gtt of timolol maleate ophthalmic solution AU daily.John Bloom, MDWhich components of the medication order should the nurse question? Select all that apply:

number of drops route

The client is admitted with left lower leg pain, a positive Homans' sign, and a temperature of 100.4°F (38°C). What additional signs should the nurse assess?

p vein thrombosis (DVT) in the left leg.

gate-control theory

pain has emotinal and cognitive components in addition to physical sensation Closing gate basis for nonpharmacological

The SOAP note is a

progress note that relates to only one health problem.

The nurse manager is developing a "read-back" procedure to reduce medication administration errors. What are purposes of the "read-back" requirement? Select all that apply

to make sure that prescriptions and test results that are communicated verbally or by telephone are clear to the receiver of the information to make sure that prescriptions and test results that are communicated verbally or by telephone are confirmed by the individual giving the information

When assessing an 18-year-old primipara who gave birth under epidural anesthesia 24 hours ago, the nurse determines that the fundus is firm but to the right of midline. Based on this finding, the nurse should further assess for which complication?

urinary retention

During the preoperative interview, the nurse obtains information about the client's medication history. Which information is not necessary to record about the client?

use of all drugs taken in the last 18 months

The nurse is preparing to administer 4 units of regular insulin to a client with type 1 diabetes mellitus. Which equipment does the nurse need to perform the injection? Select all that apply.

Medication administration record 27-gauge, ½" needle

The client has been taking magnesium hydroxide to control hiatal hernia symptoms. The nurse should assess the client for which condition most commonly associated with the ongoing use of magnesium-based antacids?

diarrhea

The nurse is assessing a client who has benign prostatic hypertrophy (BPH). The nurse should determine if the client has which symptom

difficulty starting the urinary stream

A nurse is teaching a client what to expect following a barium enema. Which client statement indicates a need for further teaching?

"I should limit my fiber intake for 1 to 2 weeks following the procedure."

The charge nurse on a hematology/oncology unit is reviewing the policy for using abbreviations with the staff. The charge nurse should emphasize which information about why dangerous abbreviations need to be eliminated? Select all that apply.

to ensure efficient and accurate communication to prevent medication errors to ensure client safety

A nurse has administered one unit of glucose to the client as per order. What is the correct documentation of this information?

1 Unit of glucose

A client is using healing touch therapy to manage pain. What should the nurse tell the client about how healing touch can be effective in pain management?

directing the flow of energy fields

Which intramuscular (IM) sites are appropriate for the nurse to use in an adult client? Select all that apply

dorsogluteal muscle deltoid muscle vastus lateralis muscle rectus femoris muscle