Fundamentals of Care

The nurse is told that an assigned client is suspected of having methicillin-resistant Staphylococcus aureus (MRSA). Which precautions should the nurse institute during the care of the client?

Wear a gown and gloves.

A client has had a set of arterial blood gases drawn. The results are pH, 7.34; Paco2, 37 mm Hg; Pao2, 79 mm Hg; and HCO3,- 19 mEq/L. The nurse interprets that the client is experiencing which acid-base imbalance?

Metabolic acidosis

The client has just undergone computed tomography (CT) scanning with a contrast medium. Which statement by the client demonstrates an understanding of postprocedure care?

"I should drink extra fluids for the remainder of the day."

The medication prescribed is prochlorperazine 5 mg intramuscularly, every 4 hours as needed. The medication label states prochlorperazine 10 mg/mL. The nurse prepares how much medication to administer the dose? Fill in the blank.

0.5mL

The nurse is planning to administer an oral glucose tolerance test (OGTT) to a client to rule out or confirm diabetes mellitus. The nurse knows that the client needs more information when the client makes which statements? Select all that apply.

"I can at least drink fluids during the test." "I have 30 minutes to drink the glucose load." "I will have blood drawn every 5 minutes for the next 3 hours."

A pregnant woman has tested positive for human immunodeficiency virus (HIV). The nurse reinforces information to the client about HIV and determines that the need for further teaching is necessary when the client makes which statement?

"I need to breastfeed my baby."

A client who has undergone barium enema is being readied for discharge. The nurse determines that the client has understood discharge instructions when the client makes which statement?

"I will be sure the barium passes and watch for my stools to return to normal."

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."

A client who had knee surgery 4 days ago reports to the home health nurse that he has not had a bowel movement since before the surgery. Which questions would assist the nurse in the collection of data regarding the client's problem? Select all that apply.

"What have you been eating and drinking since the surgery?" 5."Have you been experiencing any urge to move your bowels?" 6."What kind and how often have you been taking medications for pain?"

The nurse has reinforced instructions to a client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that there is a need for further teaching if the client makes which statement?

1. "I hope the incision from the test will heal quickly."

The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. Neutropenic precautions have been implemented. Which activity should the nurse question if observed while caring for this client?

1. The client orders lunch of soup, salad with tomatoes and cucumbers, and an apple.

Penicillin G procaine 1 million units intramuscularly, has been prescribed for the child with a throat infection. The child's weight is 62 pounds. The safe pediatric dosage for a child that weighs greater than 60 pounds is 600,000 to 1,200,000 units daily. Which should the nurse determine about the medication dosage?

1. The dosage is within the safe range.

A primary health care provider has prescribed phenobarbital sodium 25mg orally twice daily for a child with febrile seizures. The child's weight is 7.2 kg. The safe pediatric dosage is 1 to 6 mg/kg/day. What should the nurse determine about the medication dosage?

1. The dose is too high.

The nurse is asked to regulate the flow rate of an intravenous (IV) solution being administered to a client. The IV bag contains 50 mL of solution and the solution is to be administered over 30 minutes. The administration set has a drop factor of 10 drops (gtts)/mL. The nurse should regulate the roller clamp on the infusion set to deliver how many drops per minute? Fill in the blank. Round answer to the nearest whole number.

17 gtts/min

A licensed practical nurse (LPN) is asked to prepare an intravenous (IV) infusion of 1000 mL 5% dextrose in lactated Ringer's at 80 mL/hr to be administered to an assigned client. The LPN time-tapes the bag with a start time of 09:00. After making hourly marks on the time-tape, the LPN notes that which time would mark the completion time for the bag?

21:30

A client with diabetes mellitus has a blood sample drawn for the determination of a fasting blood glucose level. When reviewing the client's results, the nurse determines that which requires a call to the primary health care provider for intervention?

240 mg/dL (13.7 mmol/L)

Which is the most appropriate catheter for a male client with severe urinary retention, a history of urinary tract infections, and a stage 4 pressure injury on the coccyx.

3

The nurse is assigned to assist in caring for a client who is receiving parenteral nutrition with fat emulsion. The nurse is instructed to monitor the client for signs of fat overload. The nurse monitors for which signs and symptoms of this complication?

Fever and pruritic urticaria

The nurse is checking the remaining volume in a 1000-mL intravenous (IV) bag that is scheduled to infuse over 8 hours on an electronic infusion pump. The nurse has just noted at 11:00 am that the remaining IV fluid is at the 500-mL level. At 12:00 noon at which numerical level (mL) should the IV fluid be? Fill in the blank.

375 mL

The primary health care provider's prescription reads "phenytoin 0.2 g orally, twice daily." The medication label states 100-mg capsules. How many capsule(s) should the nurse plan to administer over a 24-hour period? Fill in the blank.

4 capsules

The primary health care provider's (PHCP's) prescription reads acetaminophen 240 mg orally every 6 hours as needed for relief of pain, for a 5-year-old child. The medication label reads "acetaminophen 160 mg per 5 mL." How many mL per dose should the nurse administer to the child? Fill in the blank.

7.5 mL

The nurse is obtaining the report for a group of assigned clients. The nurse plans to monitor the serum potassium levels in which clients at risk for hyperkalemia? Select all that apply.

A client with a new burn injury A client diagnosed with acute kidney injury (AKI)

The nurse is assigned to assist with caring for a client with esophageal varices who had a Sengstaken-Blakemore tube inserted because other treatment measures were unsuccessful. The nurse should check the client's room to ensure that which priority item is at the bedside?

A pair of scissors

A client's arterial blood gases reveal a pH of 7.51 and a bicarbonate level of 31 mEq/L. The nurse prepares for the administration of which medication that should be prescribed to treat this acid-base disorder?

Acetazolamide

When performing a surgical dressing change of a client's abdominal dressing, the nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse should plan to take which action in the initial care of the wound?

Apply a sterile dressing soaked with normal saline.

Which nursing action would avoid pressure on the popliteal nerve when applying the safety strap across the client's legs on the operating table?

Apply the safety strap 2 inches above the knees.

A client will undergo a barium swallow to confirm a diagnosis of a hiatal hernia. In preparation for the test, which instruction should the nurse provide the client?

Avoid eating or drinking after midnight before the test.

The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse should tell the client that which food item is least likely to contain calcium?

Butter

A client states that he has removed all dairy foods from his diet because he is lactose intolerant. The nurse plans care for the client knowing which information?

Calcium and protein are valuable nutrients and need to be supplemented in some form.

The nurse is assigned to care for a client who is traditional Chinese. The nurse enters the room and following a greeting and introduction to the client, the nurse begins to discuss the plan of care for the day. During the discussion, the client turns away from the nurse. The nurse should take which action?

Continue with the discussion.

The nurse is caring for an African-American client admitted for a planned surgery. The nurse enters the room and after a greeting and introduction to the client describes the routine for preparing for surgery. The client looks away from the nurse. Which nursing action is appropriate?

Continue with the explanation.

A 3-year-old child is hospitalized because of persistent vomiting. Which conditions should the nurse expect this child to be high risk for? Select all that apply.

Dehydration Metabolic alkalosis

A client with hypertension has been prescribed a low-sodium diet. The nurse reinforcing instructions about foods that are allowed should include which foods in a list provided to the client? Select all that apply.

Fresh tomato Summer squash

A client has a nasogastric tube in place that is attached to suction. The client is at risk for developing which electrolyte imbalances with prolonged suction? Select all that apply.

Hypokalemia Hyponatremia Hypomagnesemia

The nurse is instructed to complete a medication reconciliation form on a newly admitted client. Why is it important for the nurse to ensure that this process is completed accurately?

It helps to avoid medication errors.

The nurse is collecting data from a client with a suspected diagnosis of gastric ulcer. The client tells the nurse that oral antacids are taken frequently throughout the day. The nurse continues to collect data from the client, understanding that the client is at risk for which acid-base disturbance?

Metabolic alkalosis

A primary health care provider (PHCP) has written a prescription for a preoperative client to have "enemas until clear." The nurse has administered three enemas and the client is still passing brown liquid stool. Which action should the nurse take next?

Notify the primary health care provider.

A client presents in the emergency department reporting severe nausea, vomiting, and diarrhea for 5 days. The client is weak, has 2+ tenting skin turgor, and states a weight loss of 7 pounds in the last week. At this time, which action would the nurse take?

Obtain orthostatic vital signs.

A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 9%. On the basis of this test result, the nurse plans to reinforce teaching the client about the need for which measure?

Preventing and recognizing hyperglycemia

The nurse is caring for a homebound older postoperative cardiovascular client. The caregiver's daughter says to the nurse, "My mother has fallen out of bed three times." Which actions should the nurse reinforce to prevent falls? Select all that apply.

Provide adequate lighting. Ensure that frequently used items are easily accessible. Have the bedside stand and overbed tray table within reach.

A 1-year-old infant is admitted to the hospital for control of tonic-clonic seizures. The nurse helps minimize the infant's risk for injury by implementing which interventions? Select all that apply.

Removing any toy with bright blinking lights. Keeping the sides rails of the child's bed padded. Turning the infant on the side during any seizure. Having oxygen and suction available at the bedside.

The nurse is caring for a client with a diagnosis of chronic obstructive pulmonary disease (COPD). The nurse should monitor the client for which acid-base imbalance?

Respiratory Acidosis

A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, "No speak English, need interpreter." Which action should the nurse take?

Seek an interpreter from the hospital's interpreter services.

The nurse should recognize that which type of enema has the highest risk of water intoxication?

Tap water

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client?

The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

The nurse is reading the primary health care provider's (PHCP's) progress notes in the client's record and sees that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." Which client is at risk for this loss?

The client with a fast respiratory rate

The nurse is developing a nutritional plan for an assigned client. Which is the most critical piece of data to collect before formulating the plan?

The presence of food allergies.

A client is recovering from abdominal surgery and has a large abdominal wound. The nurse encourages the client to eat foods from which nutrient categories to promote wound healing? Select all that apply.

1. Protein 2. Vitamin C

The nurse is caring for a client at risk for postpartum endometritis. Which nursing intervention would minimize the risk following delivery?

1. Reviewing hand-washing techniques and pericare with the client.

Abdominal ultrasonography is prescribed for a client who is pregnant. The nurse provides information to the client regarding the procedure and makes which statement?

"You will be positioned on your back and turned slightly to one side with your head elevated."

A primary health care provider prescribes morphine 6 mg intramuscularly for a client in pain. The medication label states, morphine 10 mg per mL. How many milliliters will the nurse administer to the client? Fill in the blank. Record the answer to one decimal place.

0.6mL

A primary health care provider prescribes an intramuscular (IM) dose of 250,000 units of penicillin G benzathine. The label on the 10-mL ampule sent from the pharmacy reads penicillin G benzathine 300,000 units/mL. How much medication will the nurse prepare to administer the correct dose? Fill in the blank. Record your answer to one decimal place.

0.8 mL

The nurse educator is providing an in-service education to the nursing staff regarding transcultural nursing care. A staff member asks the nurse educator to describe the concept of acculturation. Which response is appropriate?

1. "It is a process of learning a different culture to adapt to a new or changing environment."

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

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

The nurse is preparing to deliver a food tray to a client whose religion is Judaism and follows Kosher preferences. The nurse checks the food on the tray and notes that the client has received a roast beef dinner with whole milk as a beverage. Which action should the nurse take?

1. Call the dietary department and ask for a new meal tray without the milk.

The nurse is preparing to administer a medication through a nasogastric (NG) tube that is connected to suction. Which interventions should be included to accurately administer the medication?

1. Clamp the NG tube for 30 minutes after medication administration. 2. Before medication administration, verify correct placement of tube. 3. Flush the NG tube with saline before and after medication administration. 4. Discontinue the suction from the tube during administration of medication.

The nurse considers the universal protocol for preventing wrong site, wrong procedure, and wrong person surgery. Which are correct about this protocol?

1. The surgeon is the person that marks the area of the operative procedure. 2. The site marking is done before the client is brought to the surgical suite in the operating room.

The ultrasound of the gallbladder is scheduled for the client with a suspected diagnosis of cholecystitis. Which should the nurse explain to the client about the test?

1. The test requires the client to lie still for short intervals.

A client arrives to the surgical nursing unit after surgery. What should be the initial nursing action after surgery?

Assess patency of the airway.

The nurse is caring for a postoperative client who has a Jackson-Pratt drain inserted into the surgical wound. Which actions should the nurse take in the care of the drain? Select all that apply.

Check the drain for patency. Check that the drain is decompressed. Observe for bright red, bloody drainage. Maintain aseptic technique when emptying. Empty the drain when it is half full and every 8 to 12 hours.

The nurse is preparing to administer an intermittent tube feeding to a client with a nasogastric (NG) tube. The nurse checks the residual and obtains an amount of 200 mL. Which actions should the nurse take? Select all that apply.

Listen to the client's bowel sounds. Question the client regarding nausea. Determine whether the client has abdominal distension. Hold the feeding after flushing the tubing with 30 mL saline.

When positioning for a surgical procedure, the nurse understands that the client's respiratory system is most at risk for dysfunction in which position?

Lithotomy

A client with diabetes mellitus has a blood glucose level of 596 mg/dL on admission. The nurse anticipates that this client is at risk for which type of acid-base imbalance?

Metabolic acidosis

The nurse monitors the 3-day postoperative client who underwent abdominal surgery. Vital signs are:temperature: 37.9° C (100.2° F), pulse 104 beats per minute, respirations 22 breaths per minute, blood pressure 128/74 mm Hg. Oxygen saturation is 93% on room air. The client feels tired and has a productive cough. Fine crackles are audible in the bases of the lungs posteriorly. The nurse considers the client has developed which postoperative problem?

Pneumonia

A client with new onset migraine headaches is being seen in the clinic. The client has a history of hypotension and diabetes mellitus. The nurse understands the client is at risk for cardiac side effects if the primary health care provider prescribes which medications? Select all that apply.

Verapamil Propranolol Sumatriptan

A client with ascites is scheduled for a paracentesis. The nurse is assisting the primary health care provider (PHCP) with performing the procedure. Which position should the nurse assist the client into for this procedure?

Upright

The nurse is planning to reinforce dietary teaching about following a diet that is low in potassium to a client receiving a potassium-retaining (sparing) diuretic. The nurse should be sure to include which strategies to avoid foods high in potassium in the diet? Select all that apply.

Use eggs as a source for protein. Avoid eating lunch meats and bolognas. Eat salads with cabbage and lettuce and avoid spinach.

A postoperative client has been receiving morphine sulfate every 3 to 4 hours for pain. The nurse should be sure to implement which measures to reduce the risk of adverse effects from this medication? Select all that apply.

1. Encourage fluids when not NPO. 2. Encourage coughing and deep breathing. 3. Monitor the number of bowel movements.

A client has a diagnosis of hyperphosphatemia. The nurse reinforces instructions by telling the client to eliminate which items from the diet?

1. Fish 2. Chicken

A client is having problems with blood clotting. Which food item should the nurse encourage the client to eat?

1. Green, leafy vegetables.

A primary health care provider is caring for a client who is human immunodeficiency virus (HIV) positive and has delivered a newborn baby. The nurse anticipates which interventions should be employed for the newborn to decrease the risk of HIV.

1. HIV testing of the newborn within 48 hours. 2. Antiretroviral prophylaxis for newborns testing HIV positive. 3. Periodic testing for HIV at set intervals until the age of 6 months.

The nurse is assigned to care for a group of clients on the clinical nursing unit. Which client is least likely to develop third spacing of fluids?

1. Hypertension

Which cardiovascular sign should the nurse expect to note in a client with a diagnosis of hypocalcemia?

1. Hypotension

A surgeon is performing an abdominal hysterectomy. Before the surgery is completed, the operating room nurse counts the sponges and notes that the sponge count is not correlating with the preoperative count. Which action by the nurse is important?

1. Informing the surgeon of the situation.

The nurse is preparing to set up a sterile field using the principles of aseptic technique to perform a dressing change. Which should the nurse include in the preparations?

1. Open the distal flap of a sterile package first. 2. Prepare the sterile field just before the planned procedure. 3. Avoid planing items within 1 inch of any area surrounding the outer edge of the sterile field.

The nurse has conducted dietary teaching with the client diagnosed with iron deficiency anemia. The nurse determines that the client understands the information if the client states the intention to increase intake of which foods?

1. Oysters 2. Spinach 2. Kidney beans

The nurse is preparing to suction a client through a tracheostomy tube. The nurse should perform which actions when performing this procedure? Select all that apply.

1. Preoxygenating the client before suctioning 2. Moistening the catheter tip in sterile saline solution before suctioning. 3. Introducing the catheter into the tracheostomy tube using a sterile gloved hand.

The nurse is reinforcing instructions to a client about the use of an incentive spirometer in the postoperative period. The nurse should include which information in discussions with the client?

1. Use the incentive spirometer 5 to 10 breaths every hour while awake. 2. The best results are achieved when sitting at least halfway or fully upright.

The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history and determines it is necessary to consult with the registered nurse if the client is also taking which medications?

1. Warfarin 2. Glimepiride 3. Amlodipine

A caregiver of a client with an advanced case of acquired immune deficiency syndrome (AIDS) asks the nurse to review instructions in order to take care of the client. Which instructions would be appropriate for the nurse to reinforce?

1. Wash soiled clothes in hot water. 2. Use gloves when handling body fluids. 3. Soak cleaning rags, sponges and mops in a 1:10 bleach solution for 5 minutes.

The nurse has given dietary instructions to a client to minimize the risk of osteoporosis. The nurse determines that the client understands the recommended changes if the client verbalizes the intention to increase intake of which foods?

1. Yogurt 2. Cottage cheese

The nurse assists the primary health care provider in performing a lumbar puncture on a 3-year-old child with leukemia suspected of central nervous system (CNS) disease. In which position should the nurse place the child during this procedure?

Lateral recumbent with the knees flexed to the abdomen and head bent with the chin resting on the chest

The insulin drip (continuous insulin infusion) is infusing at 1.5 mL per hour. There are 100 units of regular insulin in 100 mL of 0.9% NaCl. How many units of insulin will the client receive per hour? Fill in the blank. Record the answer to one decimal place.

1.5 units/hr

The nurse is reinforcing instructions to a client following mastectomy who will be discharged with an axillary drain in place. The client will be receiving home care visits from the nurse to monitor drainage and perform dressing changes. Which client statement indicates a need for further teaching?

"I need to begin full range-of-motion (ROM) exercises to my upper arm as soon as I get home."

The nurse evaluates that there is a need for further teaching on bowel elimination when the client makes which statement?

"I need to decrease fiber in my diet."

A licensed practical nurse is precepting a student assigned to care for a client with chronic pain. Which statement, if made by the student, indicates the need for further teaching regarding pain management?

"I will be sure to cue in to any indicators that the client may be exaggerating their pain."

Intravenous (IV) lactated Ringer's (LR) solution is prescribed for a postoperative abdominal surgery client. A nursing student is caring for the client, and the nursing instructor asks the student about why this IV solution is prescribed. Which student response is correct?

"LR is isotonic to plasma and contains electrolytes"

An antihypertensive medication has been prescribed for a client with hypertension. The client tells the nurse that she would like to take an herbal substance to help lower her blood pressure. Which statement by the nurse is most important to provide to the client?

"You will need to talk to your primary health care provider (PHCP) before using an herbal substance."

A primary health care provider's prescription reads atenolol 0.025 grams orally daily. The medication bottle reads atenolol 50-mg tablets. The nurse prepares how many tablet(s) to administer the dose? Fill in the blank. Record the answer to one decimal place.

0.5 tablet

The primary health care provider's prescription reads "levothyroxine, 100 mcg orally daily." The medication label reads "levothyroxine, 0.1 mg/tablet." The nurse prepares to administer how many tablet(s) to the client? Fill in the blank.

1 tablet

Which laboratory results indicate a therapeutic drug level? Refer to chart. Select all that apply.

1, 3 & 5

The nurse is reinforcing teaching with a client who is having difficulty sleeping. Which bedtime snacks will help the client achieve a restful night's sleep?

1. A glass of warm milk. 2. A cube of Swiss cheese. 3. A cup of caffeine-free tea.

A low-sodium diet has been prescribed for a client with hypertension. Which food selected form the menu by the client indicates an understanding of this diet?

1. Baked turkey

A primary health care provider's prescription reads "meperidine hydrochloride 125 mg by the intramuscular route stat." The medication vial reads 100 mg/mL. How many milliliters of the medication should the nurse draw into the syringe for injection? Fill in the blank. Record answer to two decimal places.

1.25 mL

The intravenous prescription is 3000 mL of 5% dextrose in water (D5W) to run over a 24-hour period. The drop factor is 10 gtts/1 mL. The nurse plans to adjust the flow rate to how many gtts/minute? Fill in the blank and record the answer to the nearest whole number.

21 gtts/min

The primary health care provider prescribes ibuprofen 5 mg per kg for a child who weighs 13 pounds. How many milligrams (mg) should the nurse administer to the child? Fill in the blank. Record your answer using one decimal place.

29.5 mg

A primary health care provider prescribes gabapentin 0.9 g three times by mouth daily. The label on the medication bottle states gabapentin 300-mg tablets. How many tablets will the nurse administer to the client for one dose? Fill in the blank.

3 tablets

The primary health care provider prescribes 1000 mL of 0.45% NaCl to run over 8 hours. The drop (gtt) factor is 15 gtt/mL. The nurse plans to adjust the flow rate to how many gtt/min? Fill in the blank. Round your answer to the nearest whole number.

31 gtt/min

A client is receiving an enteral feeding that delivers 1.5 calories/mL. The feeding is infusing at 30 mL/hr via a feeding pump. What is the maximal amount of calories the client should receive in an 8-hour period if the tube feeding is not interrupted? Fill in the blank.

360 calories

A licensed practical nurse (LPN) asks an unlicensed assistive personnel (UAP) to gather supplies in preparation for administering a tepid bath to a child with an elevated temperature. The LPN intervenes if the UAP obtains which unnecessary item(s)?

A bottle of alcohol.

Why should the nurse who is focusing on facilitating positive outcomes regarding health care services become familiar with the cultural beliefs and practices of a childbearing woman?

A culturally diverse woman may have beliefs that impact the delivery of health care services.

A client has a prescription to take sodium polystyrene sulfonate for several days. The client also needs to make some dietary changes. Which foods should the client avoid? Select all that apply.

Cabbage Mushrooms Strawberries

The nurse reviews the client's laboratory results. Which abnormal findings should the nurse report? Select all that apply.

Calcium 8.2 mg/dL Potassium 6 mEq/L Magnesium 2.9 mg/dL Phosphorus 5.2 mg/dL

The nurse is caring for a child following a cleft palate repair who has elbow restraints in place. The nurse assists in preparing a plan of care and determines that which nursing intervention should receive highest priority regarding the restraints?

Checking color, sensation, and pulses distal to the restraints

The nurse is providing dietary instructions to a client with a diagnosis of ulcerative colitis. The client is prescribed to follow a low residue diet during episodes of diarrhea. Which food should the nurse instruct the client to avoid?

Fresh corn on the cob

The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which sign/symptom would be an indication of this electrolyte imbalance?

Generalized muscle weakness

A client is determined to be in respiratory alkalosis by blood gas analysis. The nurse should monitor this client for signs of which electrolyte disorder that could accompany the acid-base imbalance?

Hypokalemia

The nurse is observing a client who is independently performing the application of an ostomy appliance for the first time. Which actions observed demonstrate the need for further teaching? Select all that apply.

Lightly scrub the stoma with soap and water. Cut the opening on the appliance ½ inch larger than stoma.

A client has just undergone a gastroscopy. Which action should be taken by the nurse as the essential postprocedure nursing intervention?

Monitoring for the gag reflex

Which instructions should be included in the teaching plan for a mother whose newborn is human immunodeficiency virus (HIV) positive?

Instruct the mother and family to provide meticulous skin care to the newborn and to change the newborn's diaper after each voiding or stool.

The nurse is reading a client's urinalysis report. The nurse interprets which item found on the report to be considered abnormal? Select all that apply.

Positive protein Leukocyte esterase positive. White blood cells, 10 per high power screen

The nurse is caring for a group of clients on a clinical nursing unit. The nurse interprets that which assigned clients are at risk for excess fluid volume? Select all that apply.

The client with renal failure The client with chronic cirrhosis

Which types of nourishment should the nurse include when initiating a prescribed clear liquid diet for a postoperative client who has a gag reflex after surgery under general anesthesia?

1. Coffee 2. Ice chips 3. Beef broth 4. Lemon flavored gelatin.

A client who has calcium phosphate kidney stones tells the nurse, "Tell me what I can do , so that I never have this pain again." Which instructions should the nurse plan to include in the reinforcement of dietary instructions?

1. Decrease sodium intake. 2. Limit the intake of whole grains. 3. Limit protein to 5 to 7 servings per week.

A client is seen in the urgent care center for complaints of chest pain 2 days ago. Since that time, the client has not been feeling well and fatigues easily. The nurse reviews the results of the laboratory tests. An elevation of which laboratory test indicates a myocardial infarction occurred at the time of chest pain 2 days ago?

1. Troponin I

Which are the most important interventions that can help reduce the incidence of hospital-acquired urinary catheter infections?

1. Use indwelling catheters judiciously. 2. Remove indwelling catheters when no longer needed. 3. Use strict aseptic technique when inserting all urinary catheters.

A 3-year-old child is hospitalized because of persistent vomiting. Which conditions should the nurse expect this child to be high risk for?

1. Dehydration 2. Metabolic alkalosis

The metabolic panel of a client reveals a calcium level of 6.5 mg/dL (1.6 mmol/L). Based on this laboratory finding, which additional data specific to this calcium level should the nurse collect? Select all that apply.

Presence of Chvostek's sign. Presence of electrocardiogram abnormalities. Presence of tingling in the fingertips and around the mouth. Presence of carpal spasm when blood pressure cuff is inflated above systolic blood pressure for a few minutes.

The nurse is caring for a client scheduled for magnetic resonance imaging (MRI). Which instruction does the nurse reinforce to the client?

1. Earplugs can be worn if the noise from the machine is uncomfortable.

The nurse is reviewing the preoperative prescriptions of a client with a colon tumor who is scheduled for abdominal perineal resection. The nurse notes that the primary health care provider has prescribed Neomycin sulfate orally for the client. Which is the rationale for prescribing this medication?

1. To decrease the bacteria in the bowel.

A client enters the emergency department confused, twitching, and having seizures. Upon assessment, flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor is noted. The serum sodium level is 172 mEq/L (172 mmol/L). Which interventions should the primary health care provider (PHCP) likely prescribe? Select all that apply.

Monitor vital signs. Monitor intake and output. Increase water intake orally. Monitor electrolyte levels. Provide a sodium-reduced diet.

A client is admitted to the hospital with a diagnosis of malnutrition. The nurse is told that blood will be drawn to determine whether the client has a protein deficiency. Which laboratory data indicate that the client is experiencing a protein deficiency?

1. Albumin 2.2 g/dL 2. Transferrin 90 mg/dL 3. Prealbumin 10 mg/dL

A client scheduled for a pulmonary angiography is fearful about the procedure and asks the nurse if the procedure involves significant pain and radiation exposure. The nurse gives a response to the client that provides reassurance, based on which understanding?

Discomfort may occur with needle insertion, and there is minimal exposure to radiation.

The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates 90 mL of residual from the tube. What should the nurse do? Select all that apply.

Document the amount of residual. Reinstill the residual and administer the feeding.

The nurse administers scopolamine as prescribed to a client in preparation for surgery. The nurse monitors the client for adverse/side effects related to the administration of this medication. Which should the nurse determine is an expected side effect of this medication?

Client complaints of a dry mouth

The nurse initiates a prescription from the primary health care provider and restrains a client who has a chest tube connected to suction. The client is confused and continues to remove the dressing around the tube and pulls at the tube. Which information should the nurse document in the client's medical record regarding restraints? Select all that apply.

Adequacy of circulation in the body area that is restrained. Type of restraint and body area where the restraint was applied. Communication with client and family member about need for restraint. The alternative measures that were attempted before restraints were applied.

A client is scheduled to receive digoxin 0.125 mg by mouth. The licensed practical nurse (LPN) reads the medication label and notes that each tablet contains 0.25 mg. The LPN should perform which action?

Administer half of a medication tablet.

The nurse is caring for a Hispanic client who reports that she is a practicing Roman Catholic. Which actions by the nurse demonstrate spiritual and cultural sensitivity? Select all that apply.

Allow the client to observe communion daily if requested. Facilitate anointing of the client by a priest if requested.

The nurse is caring for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On data collection, the nurse notes that the client is severely dysphagic. The nurse should include which in the plan of care? Select all that apply.

Allowing the client sufficient time to eat. Providing oral hygiene after each meal. Maintaining a suction machine at the bedside.

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, ⅝-inch needle. Which technique should the nurse use to insert the needle?

Almost parallel to the skin with bevel side up

When reinforcing dietary instructions to a client with irritable bowel syndrome whose primary symptom is alternating constipation and diarrhea, the nurse should tell the client that which foods are best to include in the diet for this disorder? Select all that apply.

Apples & Whole-grain bread

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 actions? Select all that apply.

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

The nurse reinforces what information to a client who is scheduled for an electromyogram (EMG)?

Electrodes will be inserted into the skeletal muscles.

The nurse is reviewing the serum electrolyte laboratory results of a client and finds that the client has an elevated magnesium level. Which part of the client's history is likely associated with this problem?

History of chronic laxative use

Which information should the nurse include when reinforcing client teaching regarding ostomy care? Select all that apply.

Empty pouch when ⅓ to ½ full. The stoma should be moist and pink to red. The skin barrier should be within 1⁄16 to ⅛ inch of the stoma. Change the appliance about every 3 days, or sooner, if it is leaking effluent.

The nurse is working in a long-term care facility and is observing a new unlicensed assistive personnel (UAP) caring for a client who requires a security device (wrist restraints). The nurse determines that the UAP is providing safe care if the nurse observes the UAP checking skin integrity by completely removing the client's wrist restraints at which time interval?

Every 2 hours

A 0.9% intravenous (IV) solution is prescribed for a client. The IV is to run at 100 mL/hr. The nurse prepares the solution, understanding that which are characteristics of this type of solution? Select all that apply.

Is the same solution as sodium chloride 0.9% Is used to administer red blood cell transfusion. Is used to treat hypotension due to fluid volume deficit.

A pulmonary angiography is scheduled for a client suspected of having a pulmonary embolism. The nurse understands that which actions are an appropriate preprocedure care intervention? Select all that apply.

Obtain a signed informed consent form. Prepare the anticipated entry site for local anesthesia. Inquire whether the client has any allergies to shellfish. Ask whether client has ever experienced an allergy to any contrast media.

The nurse is preparing to set up a sterile field using the principles of aseptic technique to perform a dressing change. Which should the nurse include in the preparations? Select all that apply.

Open the distal flap of a sterile package first. Prepare the sterile field just before the planned procedure. Avoid placing items within 1 inch of any area surrounding the outer edge of the sterile field.

The nurse is caring for a client who has been prescribed cold pack applications to the right lower extremity. The nurse plans to collect which data specifically associated with this therapy before the initiation of therapy? Select all that apply.

Pedal pulses Capillary refill Color of the extremity Temperature of the skin Presence of numbness

The nurse is monitoring a client who is attached to a cardiac monitor and notes the presence of U waves. The nurse checks the client and then reviews the results of the client's recent electrolyte results. The nurse expects to note which electrolyte value?

Potassium 3.0 mEq/L

The nurse is reinforcing instructions to a client on how to decrease the intake of potassium in the diet. The nurse determines the need for further teaching if the client selects which foods to include in the diet? Select all that apply.

Potatoes Avocados Salt substitute

The nurse reinforces dietary instructions to a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse determines the client has understood if the client plans to include which foods in the diet? Select all that apply.

Raisins Kiwifruit Bananas

The nurse is preparing a client for a magnetic resonance imaging (MRI) examination. Which action by the nurse is important?

Remove metal objects from the client.

The nurse enters the room to find that the client's trash can is in flames. The client is in bed and the edge of the gown is smoking. The nurse should take which action first?

Remove the gown from the client and remove the client from the room.

A nurse about to give a daily dose of digoxin and notes that a serum digoxin level drawn earlier in the day measured 2.7 ng/mL. The nurse should take which actions? Select all that apply.

Report the finding to the registered nurse. Gather data from the client related to signs of toxicity.

The nurse just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit after abdominal surgery. The client has an indwelling urinary catheter in place. The vital signs are temperature 99.6° F (37.6° C), pulse 104 beats per minute, respirations 16 breaths per minute, and blood pressure (BP) 100/70 mm Hg. Urinary output is 20 mL for the past hour. Based on this data, which actions should the nurse take before notifying the registered nurse? Select all that apply.

Review vital signs from previous hour. Observe the urinary catheter for patency and flow. Observe the IV site for patency and correct flow rate. Review when the client last received pain medication.

The nurse is caring for a client with pneumonia who is to receive oxygen via nasal cannula at 2L. To provide a safe delivery of the oxygen the nurse should avoid which actions? Select all that apply.

Securing the oxygen tubing to the client's bottom sheet. Positioning the nasal prongs in the nares and adjusting the plastic slide on the cannula so that the cannula fits as tight as possible.

The nurse reviews an assigned client's laboratory report and notes a serum potassium level of 5.5 mEq/L (5.5 mmol/L). The nurse should determine that this is an expected finding if the client had which health problems? Select all that apply.

Severe burn injury Untreated ketoacidosis

The client is having a lumbar puncture (LP) performed. The nurse should place the client in which position for the procedure?

Side-lying, with legs pulled up and chin to the chest

The nurse is caring for a postoperative client who is wearing an abdominal binder following abdominal surgery. Which interventions should the nurse include in relationship to prescribed dressing change? Select all that apply.

Sit up for coughing while splinting the incision. Remove the binder to change the abdominal dressing as prescribed and reapply.

Which fluids are identified as insensible fluid losses? Select all that apply.

Sweat & Sputum

A licensed practical nurse is explaining the appropriate methods for measuring an accurate temperature to an unlicensed assistive personnel (UAP). Which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching?

Taking an oral temperature for a client with a cough and nasal congestion

A client who has undergone a barium enema is being readied for discharge from the ambulatory care unit. Which instruction should the nurse include in instructions to the client?

The barium will cause the stools to be clay colored, but then the stool becomes normal colored.

A client with diabetes mellitus calls the clinic nurse to report that the blood glucose level is 150 mg/dL. After obtaining further data from the client, the nurse determines that the client ate lunch approximately 2 hours ago. How should the nurse interpret the data?

The blood glucose level is slightly higher than the normal value.

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for a potassium deficit?

The client receiving nasogastric suction

Penicillin V 250 mg orally every 8 hours, is prescribed for a child with a respiratory infection. The child's weight is 45 pounds. The safe pediatric dosage is 25 to 50 mg/kg/day. Which statement accurately describes the prescribed dosage for this child?

The dosage is within the safe dosage range.

The nurse obtains a prescription to restrain a client using a belt (safety) restraint and instructs the unlicensed assistive personnel (UAP) to apply the restraint. Which observation, if made by the nurse, indicates unsafe application of the restraint?

The restraint straps are safely secured to the side rails.

The registered nurse (RN) and a licensed practical nurse (LPN) are discussing total parenteral nutrition (TPN) with a client who is receiving TPN through a peripherally inserted central catheter (PICC). The client asks why the solution is being infused through a central catheter IV. The nurses explain that TPN is preferably infused through a central line for which reason?

There is greater blood flow with a central line IV to dilute the TPN, which is a concentrated solution and needs to be diluted to avoid damage to the blood vessel.

The nurse needs to increase the calcium in the diet of a client who is lactose intolerant. Which food items should the nurse encourage? Select all that apply.

Tofu, Broccoli, Sardines, Mustard Greens.

Which electrocardiogram changes would the nurse note on the cardiac monitor with a client whose potassium (K+) level is 2.7 mEq/L (2.7 mmol/L)?

U waves

The nurse is reviewing laboratory results and notes that the client's international normalized ratio (INR) is 2.2. The nurse should realize this test is performed to monitor the effectiveness of which medication?

Warfarin

The registered nurse (RN) and a licensed practical nurse (LPN) are discussing total parenteral nutrition (TPN) with a client who is receiving TPN though a peripherally inserted central catheter (PICC). The client asks why the solution is being infused through a central catheter IV. The nurses explain that TPN is preferably infused though a central line for which reason?

1. There is greater blood flow with a central line IV to dilute the TPN, which is a concentrated solution and needs to be diluted to avoid damage to the blood vessel.

A client is transferred from the special care unit to the medical-surgical unit. The nurse receives report and plans to calculate the fall risk. The client is a male, aged 61, admitted to the hospital after being injured in a motor vehicle crash. He has no history of falling. He has no vision or hearing deficits. He has a peripheral continuous intravenous infusion, an indwelling urinary catheter, and sequential compression devices (SCD) while in bed. His gait is steady. He needs supervision when ambulating and uses the call light to contact the nurse for assistance. His prescribed medications include furosemide, penicillin, and ibuprofen. He has received ibuprofen twice in the last 24 hours. He is oriented and cooperative. Which score should the client receive based on the fall risk tool? Refer to figure.

9 total points (moderate risk)

The nurse is checking postoperative prescriptions and planning care for a 110-pound child after spinal fusion. Morphine sulfate, 8 mg subcutaneously every 4 hours as needed (PRN) for pain, is prescribed. The pediatric drug reference states that the safe dosage is 0.1 to 0.2 mg/kg/dose every 2 to 4 hours. What should the nurse determine about the medication dosage?

The dosage is within the safe range.