fundamentals

A health care provider prescribes a 24-hour urine collection for vanillylmandelic acid (VMA). The nurse instructs the client in the procedure for the collection of the urine. Which statement by the client would indicate a need for further teaching?

"I can take any medications if I need to before the collection."

A client is having trouble remembering his prescribed medication regimen. Which statement by the nurse is therapeutic?

"Let me go over your prescribed medications with you again."

Which laboratory results indicate a therapeutic drug level? Refer

1 3 5

A client has a history of mild renal insufficiency. Which serum creatinine level should the nurse determine is consistent with this problem?

1.9 mg/dL

A health care provider has prescribed a liquid oral suspension of amoxicillin (Amoxil). The prescription reads 0.25 gram (g) orally 3 times daily. How many milliliters (mL) should the nurse administer to the client per dose? Refer to the figure. Fill in the blank.

10ml

A client is to receive 1000 mL of 5% dextrose in water (D5W) at a rate of 100 mL/hr. The drop (gtt) factor is 10 drops (gtt) per mL. The nurse adjusts the flow rate to deliver how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

17

A health care provider prescribes digoxin (Lanoxin) 0.5 mg orally daily for a client with heart failure. The medication label states, 0.25 mg per tablet. How many tablet(s) will the nurse administer to the client? Fill in the blank.

2

A health care provider prescribes 1000 mL of 0.9% normal saline (NS) to run over 8 hours. The drop (gtt) factor is 10 drops (gtt) per 1 mL. The nurse adjusts the flow rate to run at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

21

A health care provider prescribes 2000 mL of 5% dextrose in water to run over 24 hours. The drop (gtt) factor is 15 gtt/mL. The nurse plans to adjust the flow rate at how many drops per minute? Fill in the blank. Round answer to the nearest whole number.

21

The nurse should plan to reinforce instructions to which client's about the risk for transmission of disease through blood and sexual contact? Select all that apply.

A client diagnosed with hepatitis B virus A client diagnosed with hepatitis C virus A client diagnosed with human immunodeficiency virus (HIV)

The nurse is obtaining the intershift report for a group of assigned clients. The nurse plans to monitor which client for signs of hyperkalemia because of the physiology associated with the health problem?

A client with a new burn injury

The nurse is caring for a client with respiratory insufficiency. The arterial blood gas results indicate a pH of 7.50 and a PCo2 of 30 mm Hg, and the nurse is told that the client is experiencing respiratory alkalosis. Which additional laboratory value should the nurse expect to note?

A potassium level of 3.2 mEq/L

Which of these clients are most likely to develop fluid (circulatory) overload? Select all that apply.

A premature infant A 101-year-old man A client on renal dialysis A client with heart failure

The nurse is told that a client will be admitted to the hospital for a radiation implant for bladder cancer. The nurse is asked to prepare for the admission of the client and plans which measure for this client?

Admit the client to a private room.

A client has a prescription to receive purified protein derivative (PPD) 0.1 mL intradermally (tuberculin skin test). The nurse prepares to administer the PPD and obtains a tuberculin syringe with a 26-gauge, 5/8-inch needle. Which technique should the nurse use to insert the needle?

Almost parallel to the skin with bevel side up

The nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse tells the client that which food provides the least amount of potassium?

Apple

The nurse is changing the abdominal dressing on a client following abdominal surgery. The nurse notes that the incision line is separated and the appearance of underlying tissue is noted. Wound dehiscence is suspected. Which is the appropriate initial nursing action?

Apply a sterile dressing soaked with sterile normal saline to the wound.

The nurse is assisting in performing an arterial blood gas (ABG) analysis on a client. The nurse initially implements which intervention after the blood gas is drawn to minimize the risk for uncontrolled bleeding?

Applying pressure to the site

The nurse has just confirmed that a client has been scheduled for a mammogram for the following week. The nurse reinforces that the client should take which action? Select all that appl

Avoid applying skin lotion on the day of the test. Remove any necklaces before presenting for the procedure

The nurse reinforces teaching a client on how to administer enoxaparin (Lovenox) subcutaneously. The nurse determines that the client understands the correct procedure if the client does which on a return demonstration?

Bunches the skin before injection

The nurse prepares to administer a prescribed dose of scopolamine (Transderm-Scōp). The nurse should monitor for which side effect of this medication?

Dry mouth

The nurse is reinforcing instructions to a client about complete/high quality protein foods. Which food choice should indicate the client understood the teaching?

Eggs

A client is admitted to a long-term care facility with the diagnosis of weight loss secondary to anorexia. The health care provider inserts a nasogastric tube and prescribes a tube feeding of a standard formula feeding to run at 50 mL/hr. The nurse plans care, knowing that which is true regarding enteral feedings?

Enteral feedings require the normal digestive capabilities of the gastrointestinal (GI) tract.

The nurse is caring for a client who has hand restraints. How often should the nurse assess the skin integrity of the restrained hands?

Every 30 minutes

Which statement made by the nursing student indicates a need for further teaching by the nursing instructor on the concept of ethnocentrism

It is imposing one's beliefs on individuals from another culture.

The nurse is caring for a client following a total hip replacement. The client has been diagnosed with iron deficiency anemia. The nurse instructs the client to increase intake of which foods?

Lean beef and chicken liver

The nurse is turning a postoperative client who had extensive spinal surgery on the previous day. Which turning intervention or position would be best for repositioning this client?

Logrolling

A client is scheduled for blood to be drawn from the radial artery for an arterial blood gas (ABG) determination. The nurse assists with performing Allen's test before drawing the blood to determine the adequacy of which?

Ulnar circulation

The nurse is preparing to provide mouth care to an unconscious client. The nurse collects which items to perform this procedure? Select all that apply

Mouthwash A soft toothbrush Oral suction catheter Bite stick or a padded tongue blade

During a surgical procedure, the nurse prevents a client's extremities from dangling over the sides of the table, knowing that this action may cause what?

Nerve and muscle damage

Which action should the nurse include in the plan of care for a client following a renal scan?

No special precautions are needed except to wear gloves if coming into contact with the client's urine.

The registered nurse is preparing to insert a nasogastric (NG) tube in a client and asks the licensed practical nurse (LPN) to obtain supplies needed for the procedure. Which supply obtained by the LPN indicates a need for further teaching regarding this procedure?

Oil-soluble lubricant

The nurse is caring for a client who is on airborne precautions. The nurse notes that the client is scheduled for a magnetic resonance imaging (MRI) test. Which nursing action would be most appropriate in preparing the client for the test?

Place a surgical mask on the client for transport and for contact with other individuals.

The nurse is instructing a client on how to decrease the intake of magnesium in the diet. The nurse tells the client that which food item contains the least amount of magnesium?

Processed drinking water

The nurse reviews a client's serum sodium level and notes that the level is 150 mEq/L. The health care provider prescribes dietary instructions for the client based on the sodium level. Which food item should the nurse instruct the client to avoid?

Processed oat cereals

The nurse is reinforcing instructions to a client with chronic vertigo. The nurse stresses the importance of which safety measure to prevent injury or exacerbation of symptoms?

Removing throw rugs and clutter in the home

A client who has fallen from a roof and fractured his ribs has arterial blood gas results of: pH 7.48, PaCO2 32 mm Hg, PaO2 89 mm Hg, and HCO3- 22 mEq/L. How does the nurse interpret the client's blood gas results?

Respiratory alkalosis

Which equipment should the nurse plan to have at the bedside when initiating a clear liquid diet in a postoperative client who has had general anesthesia?

Suction equipment

The chart describes characteristics of various types of enemas. Which type of enema has the highest risk of complications? Refer to chart.

Tap water

A client with chronic pain has been taught how to operate a transcutaneous electrical nerve stimulation (TENS) unit. Which action by the client shows understanding of the appropriate use of the device when the level of stimulation is uncomfortable?

The client adjusts the setting downward slightly

A client with tuberculosis (TB) who is being prepared for discharge to home should be instructed to follow which practice to decrease the possibility of spreading the infection?

Wear a mask when in contact with people outside of the family until medications are effective.

A client is seen in the clinic for a physical examination. Laboratory studies are performed and reveal that the hemoglobin and hematocrit are low, indicating the need for further diagnostic studies and a blood transfusion. The client is a Jehovah's Witness and refuses to have a blood transfusion. Which should be an appropriate action by the clinic nurse?

upport the client's decision not to receive a blood transfusion

The nurse is caring for a Jewish client who follows a kosher diet. Which foods should the nurse use in planning meals for the client? Select all that apply.

Tuna Chicken Potatoes Apples

A licensed practical nurse (LPN) is providing follow-up teaching after a client underwent an upper gastrointestinal (GI) series with Gastrografin used for contrast. The nurse instructs the client that which may occur from the Gastrografin?

Diarrhea

A client has had a bone scan procedure. The nurse determines that the client understands the elements of follow-up care if the client states which postprocedural care?

Drink plenty of water for a day or two following the procedure.

Diphenhydramine hydrochloride (Benadryl), 25 mg orally every 6 hours, is prescribed for a child with an allergic reaction. The child weighs 25 kg. The safe pediatric dosage is 5 mg/kg/day. Which conclusion should the nurse infer?

The dose is within the safe dosage range.

A child with leukemia is hospitalized and is receiving chemotherapy. Laboratory results indicate that the child is neutropenic, and protective isolation procedures are initiated. The grandmother of the child visits and brings a fresh bouquet of flowers picked from her garden and asks the nurse for a vase for the flowers. Which response by the nurse is appropriate?

The flowers from your garden are beautiful, but they should not be placed in the child's room at this time.

A client was transferred to the nursing unit from the coronary care unit after experiencing a myocardial infarction (MI). When reviewing the client's serum creatinine phosphokinase (CPK) levels recorded in the chart, the nurse knows that an elevation of which enzyme was due to the MI?

MB

The nurse is discharging a postoperative female client who had a urinary tract infection (UTI) after surgery. Which essential issues about UTIs should the nurse reinforce in the discharge instructions? Select all that apply.

Maintain adequate fluid intake. Avoid vaginal douches and/or harsh soaps, bubble baths, powders, and sprays in the perineal area. Take all discharge medication as prescribed including antibiotics, and notify your health care provider if symptoms or signs of a UTI reappear Use good hygiene including cleaning the perineum by separating the labia, cleaning with warm soapy water after a bowel movement, and wiping from front to back after urinating.

An Appalachian family has brought a toddler to the emergency department with a fractured arm. The nurse knows that nonverbal communication is important to evaluate with assessing the family. Which factors are involved in non-verbal communication? Select all that apply.

Touch Body posture Use of space Eye behavior Facial expressions