UWorld #3

The nurse is reviewing administration technique with a student nurse who is preparing to give a prescribed dose of enoxaparin to a client. Which statement by the student nurse indicates an appropriate understanding of the technique?

"I should administer the medication subcutaneously into the lower lateral portion of the abdomen."

The nurse is discussing ways to decrease lead exposure with the parent of an infant living in a house built in 1948 with lead pipes. Which statement by the parent indicates a need for further education?

"I use warm water from the tap to mix formula, so I don't have to heat it in the microwave."

The precepting nurse and the graduate nurse (GN) are preparing to irrigate a facial laceration on a 6-year-old client. Which statement by the GN indicates a need for additional instruction?

"I will irrigate the wound from the most to least contaminated area."

The nurse preceptor is reviewing basic life support protocols with the graduate nurse (GN) and asks which actions the GN would take if an infant client becomes unresponsive. Which statement by the GN indicates a need for further teaching?

"I would palpate for a femoral pulse while assessing for the presence of respirations."

The clinic nurse is assessing a client with chronic lower back pain during a follow-up appointment. Which question by the nurse is most appropriate for evaluating the effectiveness of this client's pain management?

"What changes, if any, have you noticed in your ability to perform daily routines?"

The nurse is reinforcing education to a client with blepharitis about selfadministration of prescribed ophthalmic medications. Which of the following instructions by the nurse are appropriate? Select all that apply.

-"Administer the eye ointment after instilling the eye drops." -"Apply pressure over the inner corner of your eye with a finger after instillation." -"Avoid touching the tip of the medication applicator to your eye or eyelid." -"Wash your hands before administering the ophthalmic medications."

The nurse reinforces teaching for a client who has received two new prescriptions for eye drop medications. Which of the following client statements indicate that teaching has been effective? Select all that apply.

-"After putting in the eye drops, I will close my eyes gently and avoid rubbing my eyelids." -"Eye crusts should be wiped away from the inner corner to the outer corner of my eye." -"I should wait at least 5 minutes before putting the second eye medication into my eyes." -"I will be very careful not to touch my eye with the eyedropper." -"I will gently pull down on the skin below my lower eyelid to administer the eye drops."

The nurse is reinforcing discharge instructions with a client who received a prescription for a 24-hour urine test for creatinine clearance. Which of the following instructions should the nurse provide? Select all that apply.

-"Be careful not to spill any collected urine while pouring it into the collection container." -"Discard the urine from your first void, and then mark the time to begin the collection." -"Do not place toilet tissue in the urine collection container." -"Place a collection device in the toilet to help you collect the urine."

The nurse is teaching a health promotion class about sleep hygiene strategies to several clients with insomnia. Which of the following statements by the nurse are appropriate to include? Select all that apply.

-"Drinking a glass of warm milk or a cup of chamomile tea may help you fall asleep." -"Increasing physical activity promotes sleep, but avoid strenuous exercise near bedtime." -"Maintaining a dark and slightly cool bedroom provides an optimal sleeping environment." -"Using a fan or white noise machine may help with relaxation and mask distracting noises."

The nurse has attended a staff education program about providing end-of-life care for clients. Which of the following statements by the nurse would indicate a correct understanding of the program? Select all that apply.

-"I should ask if the client and family have a desire to speak with a chaplain." -"A soft tone and gentle voice should be used when speaking with the client." -"I will encourage family members to share their favorite memories of the client." -"Vivid dreams near the end-of-life indicate the client is experiencing emotional distress." -"Family conferences can help prepare the client's family members for changes the client may experience."

The nurse educator is teaching staff about preventing complications in clients receiving invasive mechanical ventilation and sedation. Which of the following statements by a staff nurse indicate a correct understanding of teaching? Select all that apply.

-"I should keep the head of the bed elevated 30-45 degrees to prevent aspiration." -"I should perform frequent oral care to reduce the risk for developing pneumonia." -"I will ensure venous thromboembolism prophylaxis is in effect for immobile, sedated clients." -"I will pause the sedation every shift to assess the client's readiness to wean from the ventilator." -"I will turn the client frequently to prevent skin breakdown and mobilize secretions."

The student nurse is preparing to administer an IM injection to an adult client and reviews the procedure with the registered nurse. Which of the following statements by the student nurse demonstrate a correct understanding of IM medication administration? Select all that apply.

-"I will administer the injection into the ventrogluteal muscle." -"I will insert the needle at a 90-degree angle to the skin." -"I will select a 1-in (2.5 cm), 22-gauge needle for injection."

A student nurse is caring for an adult client with a prescription for a cleansing enema. Which of the following statements by the student nurse indicate a correct understanding of the procedure? Select all that apply.

-"I will apply a water-soluble lubricant to the tip of the tubing prior to insertion." -"I will insert the tip of the tubing 3-4 inches (7.6-10.2 cm) into the rectum." -"The client should be placed in the left side-lying position with the right knee flexed."

The nurse is reviewing the procedure for administration of a rectal suppository with a student nurse who is preparing to administer a promethazine suppository to an adult. Which of the following statements by the student nurse indicate a correct understanding of the procedure? Select all that apply

-"I will assess for hemorrhoids before administrating the suppository." -"I will assist the client into the Sims position and drape for privacy." -"I will insert the suppository past the anal sphincter and into the rectum." -"I will lubricate the tapered end of the suppository before inserting it."

The home health nurse visits a client who was recently prescribed home oxygen therapy. Which of the following findings in the client's home demonstrate safe use of home oxygen equipment? Select all that apply.

-A "No Smoking—Oxygen in Use" sign is present on the front door -Fire extinguishers are present in the kitchen and hallway -No aerosol products are present throughout the house -There is a cotton blanket present on the client's bed

The nurse is caring for an actively dying client receiving hospice care. On assessment, the nurse finds that the client has rapid respirations with noisy expiratory sounds and appears to be short of breath. Which of the following actions are appropriate for the nurse to take? Select all that apply.

-Administer IV morphine sulfate for comfort -Check the client's mouth for retained secretions -Elevate the head of the client's bed -Initiate PRN supplemental O via nasal cannula

The unit-based nurse educator is preparing in-service training on parenteral medication administration. Which of the following teaching points are appropriate to include in the teaching? Select all that apply.

-Administer subcutaneous injections at a 90-degree angle in obese clients -Avoid massaging the injection site after administering an intradermal medication -Withdraw medication from a glass ampule using a blunt filter needle

A nurse is preparing for a staff education conference on improving outcomes for mechanically ventilated clients. Which of the following interventions are appropriate for the nurse to teach during the conference? Select all that apply.

-Apply sequential compression devices or antiembolism stockings -Maintain the elevation of the head of the client's bed at 30-45 degrees -Promote early mobility and range-of-motion exercises -Provide frequent oral care with antiseptic solution and moist sponges -Suspend sedation routinely and assess readiness to be weaned from the ventilator

The nurse is caring for a 72-year-old client on the medical-surgical unit. Nurses' Notes Medical Surgical Unit 0815: The nurse provides the client with soap, water, and washcloths for a partial bed bath. 0900: The peripheral IV dressing site on the left forearm is damp and loose following the client's bath. The IV is patent with no pain, swelling, or erythema at the insertion site. Drag the appropriate interventions that the nurse should take when changing an IV dressing to the box on the right.

-Apply skin protectant prior to applying the IV dressing -Label the new IV dressing with the date, time of change, and initials -Flush the IV with 0.9% sodium chloride following placement of the new dressing -Stabilize the IV catheter and apply countertraction to the skin during dressing removal

The nurse is caring for a disoriented client who is trying to remove IV tubing and an indwelling urinary catheter. The nurse has obtained a prescription for bilateral soft wrist restraints. Which of the following are the appropriate nursing actions? Select all that apply.

-Assess skin integrity and neurovascular status frequently -Evaluate and document the ongoing need for restraints throughout the shift -Offer toileting, nutrition, and hydration as needed -Remove restraints periodically to promote range-of-motion exercises

The nurse prepares to collect a sputum culture and sensitivity sample from a client. Which of the following actions by the nurse are appropriate? Select all that apply.

-Assists the client to perform an oral water rinse prior to collection -Instructs the client to inhale deeply and then cough forcefully -Performs sputum collection in the morning after the client awakens -Positions the client in an upright, sitting position before collection -Provides the client with a sterile sputum container

The nurse is caring for a client with dysphagia who coughs vigorously after drinking water to swallow an oral medication. Which of the following nursing interventions are appropriate? Select all that apply.

-Avoid providing thin liquids -Collaborate with the speech therapist -Eliminate the use of straws -Raise the head of the bed to 90 degrees during meals

The supervising nurse is observing a graduate nurse who is preparing a sterile field for a dressing change. Which of the following actions require the supervising nurse to intervene? Select all that apply.

-Before donning sterile gloves, holds a bottle of solution over the center of the field to pour it into a sterile receptacle -Drops sterile scissors onto the field within ¼ inch (0.64 cm) of the field's edge

The nurse is caring for a client with an indwelling urinary catheter. Which of the following actions by the nurse are appropriate? Select all that apply.

-Checks for kinks in the catheter tubing after repositioning the client -Empties the urine collection bag frequently to prevent overfilling -Stabilizes the catheter tubing near the urinary meatus while cleaning the tubing -Uses the sampling port on the drainage tubing to obtain a urine specimen

A male client is preparing to collect a clean-catch urine specimen for culture and sensitivity. Which of the following instructions should the nurse provide for this client? Select all that apply.

-Cleanse the urinary meatus with single-use antiseptic wipes after performing perineal care -Do not touch the inside of the collection container or lid -Place the lid back on the container tightly after the sample is collected -Retract the foreskin if uncircumcised before cleaning and during specimen collection -Void a small amount of urine into the toilet before collecting the sample

A nurse reinforces teaching about the proper care of newly fitted hearing aids and then asks the client for return demonstration. Which of the following client actions indicate understanding of the instructions? Select all that apply.

-Clears debris off the hearing aids with a soft, dry cloth -Repositions earmold when a whistling feedback sound is heard -Stores hearing aids in a container after removing batteries

The nurse is providing postmortem care for a client. Which of the following actions should the nurse take? Select all that apply

-Close the client's eyes and mouth. -Leave the client's dentures in the mouth.

A client with terminal cancer who was receiving hospice care has just died. No family members are present at the bedside. Which of the following actions by the nurse are appropriate? Select all that apply.

-Contact the family to ask about any religious rites related to death -Perform oral care and place the client's dentures in the mouth -Place a pillow under the client's head and close the client's eyes -Wash the client's body and change the bed linens

A nurse prepares to present information at a nursing conference about promoting cognitive function in older adults. Which of the following strategies should the nurse include in the presentation? Select all that apply.

-Determine the need for eyeglasses, magnifying glasses, or hearing aids -Help the client develop mnemonic devices to remember necessary information -Review the client's medications to check whether drug interactions may be impacting cognition -Work with the client to develop realistic expectations for learning and retaining information

The home health nurse is caring for a 46-year-old client. The client was recently diagnosed with rheumatoid arthritis and r pain in the knees and hands that has made it difficult to perform daily living. The pain is worse at the beginning of the day and im several hours after waking. Sitting for extended periods worsens The client takes an NSAID and an immunosuppressant

-Instruct the client to use distraction techniques -Instruct the client to perform range-of-motion exercises -Provide the client with information about rheumatoid arthritis support groups -Demonstrate the use of ice cubes for a 10-minute joint massage

The nurse is caring for a 72-year-old male client on the medical-surgical unit. Nurses' Notes Medical-Surgical Unit 1432: The nurse is at the bedside assisting the client to ambulate to the bathroom. On standing, the client reports dizziness and lightheadedness. Drag the appropriate steps that the nurse should perform to the box on the right.

-Measure the client's vital signs -Ensure the call light is within reach -Encourage the client to use a urinal at this time -Instruct the client to sit on the bed

The nurse implements seizure precautions for a newly admitted client. Which of the following actions by the nurse are appropriate? Select all that apply.

-Places suction supplies at the client's bedside -Places the bed in the lowest position -Removes excess equipment from the client's room -Secures padding to the side rails of the bed

A nurse is caring for a client who requires instruction on the use of an incentive spirometer following a recent open cholecystectomy. Place the instructions in the correct order. All options must be used.

1. "Sit as upright as possible and brace your abdomen with a pillow." 2. "Exhale normally and then close your lips tightly around the mouthpiece." 3. "Inhale as slowly and deeply as possible through your mouth." 4. "Hold your breath for at least 2-3 seconds." 5. "Remove your lips from the mouthpiece and exhale slowly."

The nurse is caring for a client who requires suture removal after a knee replacement. Which of the following actions is appropriate as the nurse removes sutures from the incision? Select all that apply.

1. Avoid pulling the exposed portion of the suture through the incision 3. Count and document the total number of sutures removed 5. Use sterile suture scissors and forceps for the removal procedure

The nurse prepares to draw up intermediate-acting insulin and rapid-acting insulin into one syringe. Place in order the steps the nurse should take when mixing the insulins into 1 syringe. All options must be used.

1. Clean the tops of both vials with antiseptic wipes 2. Inject air into the intermediate-acting insulin vial 3. Inject air into the rapid-acting insulin vial 4. Withdraw rapid-acting insulin into the syringe 5. Withdraw intermediate-acting insulin into the syringe 6. Verify that the total amount of insulin in the syringe is correct

The nurse is preparing to administer an IM injection of a medication contained in a glass ampule. Place in order the steps the nurse should take when preparing the medication. All options must be used.

1. Grasp the top of the ampule firmly with a barrier device 2. Snap the neck of the ampule with the glass breaking away from the body 3. Withdraw the medication from the ampule using a filter needle and syringe 4. Remove the filter needle from the syringe and place in the sharps container 5. Attach the IM injection needle to the medication-filled syringe

A nurse prepares to administer 2 mg morphine IV push to a client who has a peripheral IV with a saline lock. Place the steps for medication administration in the correct sequence. All options must be used.

1. Perform hand hygiene, don gloves, and dilute morphine per facility protocol 2. Clean port with antiseptic swab, flush IV with normal saline, and assess for blood return 3. Clean port with antiseptic swab, and inject morphine slowly over 5 minutes 4. Clean port with antiseptic swab, and use saline to flush IV over 5 minutes 5. Dispose of used syringes, needles, and medication vials in sharps container

The health care provider prescribes a continuous argatroban infusion at 2 mcg/kg/min for a client who weighs 198 lb and who has heparin-induced thrombocytopenia. The infusion bag contains 250 mg of argatroban in 250 mL of D W. At what rate in milliliters per hour (mL/hr) should the nurse set the IV infusion pump? Record your answer using one decimal place.

10.8 (mL/hr)

A pediatric client diagnosed with bilateral otitis media is prescribed amoxicillin. The medication is available as a 200 mg/5 mL suspension. The client weighs 50 lb. How many milliliters should the client receive with each dose (mL/dose)? Record the answer using two decimal places. Click on the exhibit button for more information. Exhibit: Health care provider's prescription Amoxicillin: 45 mg/kg/day PO divided every 12 hr

12.78 (mL/dose)

A student nurse is caring for a client with hemolytic anemia with the precepting nurse. A new prescription for 2 units of packed red blood cells is received. Which statement by the student nurse shows a correct understanding of the transfusion procedure?

"An informed consent will need to be signed by the client before transfusion."

The clinic nurse is teaching methods to improve sleep hygiene to a client who has been diagnosed with insomnia. Which statement by the client indicates that the teaching has been effective?

"I need to get out of bed to read books at bedtime."

The charge nurse is preparing for several client admissions to the pediatric unit. Which of the following clients require airborne isolation precautions? Select all that apply.

-Client with high fever and suspected rubeola infection -Client with varicella and open, vesicular lesions

The nurse is assessing the IV insertion site of a client receiving a continuous infusion of 5% dextrose in 0.45% normal saline (D W ½ normal saline). The site is leaking slightly, and the surrounding area feels cool to the touch and appears edematous. Which of the following actions should the nurse perform? Select all that apply.

-Discontinue use of the IV catheter -Elevate the affected extremity

The nurse is preparing to discharge a client who suddenly becomes pulseless. Resuscitation efforts are not successful, and the client is declared deceased. The health care provider requests an autopsy to determine the cause of death. Which of the following actions by the nurse are appropriate? Select all that apply.

-Discusses the client's religious background and spiritual considerations with the client's next of kin -Educates the client's family on the purpose and benefits of autopsy, including establishing a clinical diagnosis -Ensures that the client's wishes regarding organ and tissue donation are documented 4. -Witnesses the health care provider obtain informed consent prior to the autopsy

The nurse is preparing to transfuse a unit of packed red blood cells to a client. Which of the following actions demonstrate the correct procedure for a blood transfusion? Select all that apply.

-Infuses the packed red blood cells through a 20-gauge IV catheter -Primes a Y-type tubing with an in-line filter with 0.9% sodium chloride -Remains with the client during the first 15 minutes of the infusion

A client at a nursing home accidentally starts a small fire in a common area. The nurse escorts all the clients from the area while another employee obtains a fire extinguisher. Place the nurse's actions in the correct order. All options must be used.

1. Activates the nursing home fire alert system 2. Removes the safety pin of the extinguisher 3. Points the nozzle at the base of the fire 4. Squeezes the handle of the extinguisher 5. Sweeps the nozzle from side to side

The nurse is preparing to irrigate impacted cerumen (ie, earwax) from a 1- year-old client's right ear. Which actions illustrate proper technique for ear irrigation? Select all that apply.

1. Allow the irrigation solution to warm to body temperature 2. Avoid aiming the stream directly at the eardrum 5. Prepare the ear by pulling the pinna down and back

The nurse is demonstrating proper instillation of ofloxacin ear drops to the parents of a 2-year-old client with otitis externa. Place the steps for medication administration in the correct sequence. All options must be used.

1. Assist the client to a side-lying position with the affected ear positioned up 2. Straighten the ear canal by pulling down and back on the auricle 3. Instill ear drops by holding the dropper ½ inch (1.3 cm) above the ear canal 4. Apply gentle pressure to or massage the tragus with a finger 5. Loosely place a cotton ball in the outermost part of the meatus of the ear

The nurse is caring for a 1-year-old client who sustained partial-thickness (second-degree) burns covering approximately 10% of the body. The client weighs 22 lb (10 kg). Using the Parkland formula, how many mL of IV fluid resuscitation should the nurse administer to the client during the first 8 hours? Click the exhibit button for additional client information. Record your answer using a whole number. Exhibit Parkland formula protocol 24-hr fluid requirement calculation: 4 mL × body weight (kg) × total body surface area burned (%) First 8-hr fluid administration: 50% total fluid requirement Remaining 16-hr fluid administration: 50% total fluid requirement

200 (mL)

The nurse is caring for a client who is prescribed a continuous IV infusion of heparin 25,000 units in 500 mL of D W at 1300 units/hr. After 6 hours, the client's PTT is 74 seconds. The nurse must adjust the infusion rate according to the heparin drip protocol (shown in the exhibit). According to the heparin drip protocol, at what rate in milliliters per hour (mL/hr) should the nurse set the IV infusion pump? Click on the exhibit button for additional information. Record your answer using a whole number. Exhibit Heparin infusion protocol PTT (seconds): 71-85 Hold infusion: No Infusion: ↓ by 100 units/hr

24 (mL/hr)

An IV infusion of dopamine at 10 mcg/kg/min is prescribed for a 176-lb client with advanced heart failure. The concentration of dopamine is 400 mg in 250 mL D W. At what rate in milliliters per hour (mL/hr) should the nurse program the IV infusion pump? Record your answer using a whole number.

30 (mL/hr)

The nurse is caring for a 52-year-old client. Nurses' Notes Emergency Department 1845: The client arrived at the emergency department with a stab wo 2-inch (4.4-cm) laceration in the right upper quadrant of the abd bleeding profusely. The client is difficult to arouse and appears Vital signs: T 98 F (36.6 C), P 121, RR 12, BP 98/60, SpO 93 Laboratory Results Blood Type AB positive Prescriptions Infuse 2 units of packed RBCs Drag the blood types that are compatible with the client's blood type to the box on the right.

A positive B positive A negative B negative O positive O negative AB positive AB negative

A nurse is preparing to teach a client to perform wound care for a painful venous leg ulcer. For teaching to be effective, which nursing intervention is most important?

Administer prescribed ibuprofen 30 minutes prior to dressing change

A client with a sacral stage 2 pressure injury is being prepared for a dressing change. Which action should the nurse perform first?

Administer the prescribed analgesic medication

The graduate nurse (GN) is performing closed (in-line) suctioning on a client with an established tracheostomy who is mechanically ventilated. Which action by the GN would cause the supervising nurse to intervene?

Applies suction while inserting the catheter

The nurse preceptor observes a student nurse applying a client's newly prescribed graduated compression stockings. Which action by the student nurse would cause the preceptor to intervene?

Applies the stockings while the legs are in a dependent position

The nurse receives a prescription to obtain orthostatic blood pressure measurements on a client with a history of syncope. What action should the nurse take first?

Assist the client to lie quietly in the supine position for 3-5 minutes

The nurse is caring for a client with an indwelling urinary catheter. Nurses' Notes Medical-Surgical Unit 1700: The client reports lower abdominal pain and the urge to urinate. Intake and Output Record Intake: 180 mL 170 mL 160 mL Output: 150 mL 175 mL 50 mL Complete the following sentence by choosing from the list of options. The nurse should first:

Check the drainage tubing for kinks

The nurse is preparing to change the injection caps on a triple-lumen central venous access device. Which action by the nurse is most important?

Clamping the catheter lumens before removing the caps

The nurse and the unlicensed assistive personnel (UAP) are caring for a client who is sedated and mechanically ventilated with an oral endotracheal tube. Which action by the UAP requires the nurse to intervene?

Cleans the client's face and around the oral endotracheal attachment device with a chlorhexidine bath wipe

The nurse prepares to administer 2 mg of morphine to a client. The morphine is available as a 1-mL prefilled syringe with a concentration of 4 mg/mL. The nurse calculates that the dose will be 0.5 mL. Which action by the nurse is appropriate?

Waste 0.5 mL of morphine from the prefilled syringe with a second nurse as witness before leaving the medication room

The nurse auscultates the heart sounds of a client with chronic aortic regurgitation. Which action by the nurse is appropriate to facilitate the auscultation of aortic regurgitation?

Instruct the client to sit on the side of the bed and lean forward slightly

The nurse plans care for a client with hepatitis A who is admitted with dehydration. Which infection control measure is the priority for the nurse to implement?

Instruct the client to wash hands well with soap and water after toileting

The nurse is caring for a 52-year-old client. Nurses' Notes Nurses' Notes The client reports to the clinic for a tuberculin skin test. Complete the diagram by dragging from the choices below to specify what type of injection is required, 2 methods the nurse should use to appropriately administer the injection, and 2 client statements that demonstrate correct understanding.

Intradermal; Insert the needle at a 5- to 15-degree angle, Inject the medication just below the epidermis; I may feel a raised bump at the insertion site. I need to return to 38-72 hours so the nurse can examine the site to determine the result

The nurse is providing care to a 24-year-old client. Nurses' Notes Admission 1730: The client is brought to the emergency department after being struck by a car while riding a bicycle. The client is in respiratory distress, anxious, and not oriented to person, place, or time. When the client sees the trauma team preparing supplies for intubation, the client says, "No! No tube!" However, soon afterward, the client loses consciousness while resuscitative efforts are ongoing. The health care provider instructs the team to proceed with intubation. Vital signs are P 130, RR 28, BP 84/54, and SpO 84% on 100 nonrebreather mask. Vital signs are P 130, RR 28, BP 84/54, and SpO 84% on 100 nonrebreather mask. Which action by the nurse is appropriate at this time?

Proceed with preparing the client for intubation

The nurse is removing personal protective equipment after caring for a client who requires droplet precautions. Which of the following actions should the nurse take first?

Remove the protective gown and gloves

The nurse is providing end-of-life care for a client who has dysphagia and is scheduled to receive oral morphine. Which of the following actions should the nurse take?

Request a prescription for IV morphine.

The nurse receives handoff of care report on a client who is receiving enteral feeding via a nasogastric tube. After reviewing the offgoing nurse's notes from the prior shift, which action should the nurse perform next? Click the exhibit button for additional information. Exhibit 1 Progress notes 1900 Nasogastric tube (NGT) placed this shift at 1845 for enteral feeding. NGT measured and marked prior to insertion. Placement markings at the naris insertion site. Tube is secured to nasal bridge. Positive auscultation of air bubbles. Abdominal x-ray pending. Enteral feeding initiated at 45 mL/hr, with 30 mL flush q4h. Goal is 80 mL/hr. ____________________________________, RN Exhibit 2 Vital signs Temperature: 97.5 F (36.4 C) Blood pressure: 165/90 mm Hg Heart rate: 105/min Respirations: 20/min SpO2: 97%

Stop the enteral tube feeding

The nurse is teaching a client how to ambulate using crutches. Which of the following actions by the client requires the nurse to intervene?

The client's body weight is supported with the crutch pads under the axillae when resting

The nurse is observing a client perform colostomy irrigation. The nurse should intervene if the client is observed

lubricating and inserting the tip of an enema tubing set into the stoma

The nurse is observing a client self-administer enoxaparin using a prefilled syringe. The nurse should intervene if the client is observed

massaging the injection site after withdrawing the needle

A client who was diagnosed with external hemorrhoids a month ago describes current self-care measures to the clinic nurse. Which client statement indicates a need for follow-up on self-care management of hemorrhoids?

"I apply hydrocortisone cream every day even if there is no itching."

The nurse is caring for a client with chronic venous insufficiency who is prescribed graduated compression stockings for the legs. Which of the following actions by the nurse are appropriate? Select all that apply.

-Assess for skin breakdown at least once per shift -Elevate the legs prior to applying the stockings -Remove the stockings if pallor in the toes develops -Smooth out creases or wrinkles along the stockings

The nurse is assessing an unlicensed assistive personnel (UAP) who is bathing an unconscious client. Nurses' Notes Medical-Surgical Unit The UAP performed a bed bath using warmed, prepackaged disposable washcloths. A separate disposable washcloth was used for each area of the body, and the face was cleansed with warm water. The UAP cleansed the vaginal area by spreading the labia and using a disposable washcloth to wipe from the pubic area to the anal area. The indwelling urinary catheter was cleansed by wiping from the distal area toward the urinary meatus. The client was placed in a side-lying position for oral care. The UAP performed oral care using chlorhexidine gluconate paste and used oral suction to remove secretions.

-separate disposable washcloth was used for each area of the body -wipe from the pubic area to the anal area -placed in a side-lying position for oral care -performed oral care using chlorhexidine gluconate paste

The nurse is caring for a client with gonorrhea who is prescribed IM ceftriaxone. The medication is available as a 500-mg vial for reconstitution. How many milliliters (mL) of ceftriaxone should the nurse administer? Click on the exhibit button for additional information. Record your answer using two decimal places. Exhibit 1 Medication package insert For IM route: Reconstitute medication with 1 mL of sterile 0.9% sodium chloride to produce an approximate total volume of 1.42 mL. Each 1 mL of solution has a concentration of approximately 350 mg/mL. Exhibit 2 Medication package insert For IM route: Reconstitute medication with 1 mL of sterile normal saline to produce an approximate total volume of 1.42 mL. Each 1 mL of solution has a concentration of approximately 350 mg/mL.

0.71 (mL/dose)

The nurse is preparing prescribed amoxicillin for a child who has bilateral otitis media and weighs 42 lb. The available medication is an oral suspension with a concentration of 125 mg/5 mL. How many milliliters (mL) should the child receive per dose? Click on the exhibit button for more information. Record your answer using a whole number. Exhibit Medication prescription Amoxicillin: 85 mg/kg/day PO divided every 12 hr

32 (mL/dose)

The nurse is caring for a client who has necrotizing pancreatitis and who is prescribed strict intake and output monitoring with calculation of net fluid balance each shift. Calculate the client's net fluid balance for the shift milliliters (mL). Click the exhibit button for additional information. Record your answer using a whole number. Exhibit Intake and output record Oral intake: 300 mL enteral feeding 100 mL free water flush Parenteral intake: 100 mL cefepime IV 1 L 0.9% sodium chloride IV 100 mL cefepime IV Output: 150 mL liquid stool 75 mL emesis 110 mL from closed-wound drainage device 925 mL from urinary drainage bag

340 (mL)

The nurse is calculating a client's intake and output after breakfast. The client has had the following intake: 240 mL of coffee with 30 mL of liquid creamer, 120 mL of whole milk, 1 pancake, 2 scrambled eggs, and 120 mL of grape-flavored gelatin. How many mL should the nurse record as the client's fluid intake? Record your answer using a whole number.

510 (mL)

The nurse is completing the intake and output record for a client who is receiving continuous bladder irrigation at 150 mL/hr. The nurse empties 2570 mL of urine from the urinary drainage bag at the end of the 12-hour shift. How many mL should the nurse document as the client's net urine output for the shift? Record your answer using a whole number.

770 (mL)

The nurse is preparing to administer oral acetaminophen to a 5-year-old client with a fever. Acetaminophen is available as a 160 mg/5 mL oral solution. How many milliliters per dose (mL/dose) of acetaminophen should the nurse administer? Click the exhibit button for additional information. Record your answer using a whole number. Exhibit Medication administration record Allergies: None Admission Weight: 58 lb Medication: Acetaminophen: 10 mg/kg/dose PO Instructions: Administer q6h PRN for temperature >101 F (38.3 C).

8 (mL/dose)

The nurse is caring for a 72-year-old client. Nurses' Notes Postanesthesia Care Unit 1815: The client is being transferred to the medical-surgical unit 2 ho open bowel resection. The client is unable to transfer from the bed independently. Weight is 236 lb (107 kg). The nurse is caring for a 72-year-old client. Nurses' Notes Postanesthesia Care Unit 1815: The client is being transferred to the medical-surgical unit 2 ho open bowel resection. The client is unable to transfer from the bed independently. Weight is 236 lb (107 kg).

Appropriate -Position the bed ½ inch (1.3 cm) lower than the stretcher -Ensure both the stretcher and the bed wheels are locked -Instruct the client to cross the arms across the chest during the transfer -Place a transfer-assist device under the client using a log-rolling technique Not Appropriate -Bend the lumbar spine and twist 45 degrees when transferring the client -Place the feet 4-8 inches (10-20 cm) apart before assisting the client to transfer

The student nurse prepares to insert a nasogastric tube for a client who has been prescribed enteral tube feedings. Which action by the student nurse would cause the nurse preceptor to intervene?

Measures the length of the tube from the tip of the nose, to the earlobe, to the umbilicus

The nurse on the medical-surgical unit is caring for a 72-year-old client. Nurses' Notes Medical-Surgical Unit Total hip arthroplasty 3 days ago. Reports abdominal pain, bloating, and nausea. Abdomen distended and tender to palpation. Normal bowel sounds in all quadrants. Receiving hydrocodone/acetaminophen PRN for pain. No bowel movement since surgery; passing flatus.

Expected -Administer a laxative to the client -Assist the client with frequent ambulation. Develop a toileting schedule for the client. Recommend a diet high in fruits, vegetables, and grains for the client. Not Expected -Encourage the client to consume caffeinated beverages with meals.

The nurse is caring for a 24-year-old client. Nurses' Notes 0200: The client enters the emergency department appearing extremely agitated and disheveled. The client states, "I am in so much pain. The provider would not prescribe my pain medications again." The client has stable vital signs, and the physical assessment is normal. 0400: The client shouts, "Find someone to give me the medication!" The client appears angry and irritable, pacing around the room. The nurse enters room to assess the client's vital signs, but the client refuses to comply. The client sits in the corner with a tense posture and clenched fists. For each potential intervention, click to specify if the intervention is expected or not expected for the care of the client at this time.

Expected: -Use verbal deescalation techniques -Avoid direct eye contact with the client -Offer the client something to eat or drink -Assign staff to continuously observe the client Not Expected: -Obtain a prescription for physical restraints -Offer the client the option to be discharged against medical advice

The nurse is caring for a 62-year-old client. Nurses' Notes Preoperative Unit 0700: The client is scheduled for right knee arthroplasty. The client has hypertension, type 2 diabetes mellitus, osteoarthritis of the right knee, and gastroesophageal reflux disease. The client is wearing contact lenses. The client has an allergy to penicillin that causes urticaria. The client last ate solid food yesterday at 2300. The client took home medications, including an antihypertensive, antacid, NSAID, and insulin, 0600 this morning with a sip of water. The client states, "I am nervous about the procedure."

Indicated -Obtain a finger-stick blood glucose level -Review the client's preoperative platelet count -Place an allergy alert band on the client's wrist -Ask the client to provide an explanation of the procedure -Notify the health care provider that an NSAID was taken 1 hour ago -Ask the client to explain the expectations regarding pain after the procedure -Identify who will assist the client with activities of daily living after discharge Not Indicated -Allow the client to wear contact lenses during surgery