med and IV

The client is admitted for a myocardial infarction and has a heparin drip infusing. Which signs and symptoms would prompt the nurse to stop the infusion and notify the prescribing health care provider?

New onset bleeding from client's rectum

A nurse is caring for a client who is vomiting. The physician has ordered oral dimenhydrinate. What is the most appropriate action by the nurse to help the client?

Notify the physician of the vomiting, and obtain a new medication order.

Which statement indicates that a client understands discharge instructions about propranolol? Correct response: "I will assess my heart rate before I take my medication."

Correct response: "I will assess my heart rate before I take my medication."

Sodium polystyrene sulfonate is prescribed for a client following a crush injury. Which finding indicates the drug has been effective?

The serum potassium is 4.0 mEq/L (4.0 mmol/L).

A client is brought to the emergency department unconscious. An empty bottle of aspirin was found in the car, and a drug overdose is suspected. Which medication should the nurse have available for further emergency treatment?

activated charcoal powder

Small air bubbles adhering to the interior surface of the syringe might have which effect on parenteral administration?

altered drug dose

A client is receiving warfarin for newly diagnosed atrial fibrillation. Which laboratory result would indicate that the nurse should withhold the medication and contact the health care provider?

an INR of 4.8

A client is to be discharged with a prescription for an analgesic that is a controlled substance. Which comment by the client indicates to the nurse that further teaching is needed?

"I know I can titrate the dose according to the pain level."

A nurse has just received report on four clients. Which client should the nurse see first?

A client who underwent a thyroidectomy and has new onset hoarseness.

While attempting to obtain a blood sample from a peripherally inserted central catheter (PICC) line with a nonocclusive dressing, the nurse inadvertently dislodges the catheter. The catheter did not come all the way out and is still partially inserted. What should the nurse do first?

Secure the catheter and call the health care provider.

The client was admitted to the hospital with the diagnosis of iron overload. Over time, an excess of iron can damage the liver and cause heart problems. Which medication does the nurse anticipate the healthcare provider to order?

deferoxamine

While providing palliative care to a client in the home setting, the client's family expresses concern that the client is receiving "too much narcotic medication." Which statement is the most therapeutic response by the nurse?

"You are concerned that the client is receiving too much narcotic medication?"

The health care provider has prescribed ciprofloxacin for a client who takes warfarin. What should the nurse instruct the client to do? Select all that apply. Correct response: Avoid exposure to sunlight. Report unusual bleeding.

Correct response: Avoid exposure to sunlight. Report unusual bleeding.

The nurse administers an intradermal injection to a client. Proper technique has been used if the injection site has which appearance?

evidence of a bleb

A client's intravenous catheter has become occluded. The nurse knows that the reason for the occlusion is:

thrombosis at the site.

A physician orders an I.V. bolus injection of diltiazem hydrochloride for a client with uncontrolled atrial fibrillation. What should the nurse do before administering an I.V. bolus?

Gently aspirate the I.V. catheter to check for a blood return.

The nurse is instructing the client who is taking gentamicin to monitor renal function. The nurse determines that the client needs additional instruction when the client makes which statement? "I should call you if:

I have a fever."

The surgeon prescribes cefazolin 1 g to be given IV at 0730 when the client's surgery is scheduled at 0800. What is the primary reason to start the antibiotic exactly at 0730?

The antibiotic is most effective in preventing infection if it is given 30 to 60 minutes before the operative incision is made.

Which category of medications would the nurse expect to administer for a client with myasthenia gravis?

cholinesterase inhibitors and corticosteroids

What therapeutic outcome does the nurse expect for a client who has received a premedication of glycopyrrolate?

decreased secretions

Methylphenidate hydrochloride has been prescribed for a child with attention deficit hyperactivity disorder. The nurse should make which statements to the child's parents? Select all that apply.

"If discontinued, methylphenidate hydrochloride must be tapered off slowly." "If the symptoms do not improve, the medication may need to be adjusted."

Which statement by a student nurse demonstrates that further instruction about cytotoxic drugs is needed?

"Nurses who are pregnant must wear gloves during administration of cytotoxic drugs."

A nurse is to administer 10 mg of morphine sulfate to a client with three fractured ribs. The available concentration for this drug is 15 mg/mL. How many milliliters should the nurse administer? Record your answer using one decimal place.

0.7

A nurse is preparing a continuous insulin infusion for a child with diabetic ketoacidosis and a blood glucose level of [800 mg/dl (44.4 mmol/L)]. Which solution is the most appropriate at the beginning of therapy?

100 units of regular insulin in normal saline solution

A physician orders an infusion of 2,400 ml of I.V. fluid over 24 hours, with half this amount to be infused over the first 10 hours. During the first 10 hours, a client should receive how many milliliters of I.V. fluid per hour?

120 ml/hour

A client who weighs 207 lb (94.1 kg) is to receive 1.5 mg/kg of gentamicin sulfate IV three times each day. How many milligrams of medication should the nurse administer for each dose? Round to the nearest whole number.

141

The physician has ordered an I.V. of 3000 mL of 0.9% sodium chloride to be infused over the next 24 hours. The nurse uses I.V. tubing that has a drip factor of 10. Calculate the drops per minute needed to deliver the correct amount of I.V. fluid. Record your answer using a whole number.

21

A client returns to the room from the postanesthesia care unit after undergoing a right hemicolectomy. The health care provider orders 1 L of dextrose 5% in half-normal saline solution to infuse at 125 ml/hour. The drop factor of the available intravenous tubing is 15 gtt/ml. What is the drip rate in drops per minute? Round your answer to the nearest whole number. (For example: 62)

31

The emergency department nurse is caring for a client having a STEMI. The health care provider has prescribed a weight-based heparin bolus of 40 units/kg, with a maximum dose of 4000 units. The client weighs 250 lb (113.64 kg). How many units of heparin will the nurse give?

4000

The client is admitted to the medical/surgical unit for treatment of acute thrombophlebitis of the right calf. The client is administered 5000 units of heparin IV, followed by 1000 units of IV heparin per hour. Which action by the nurse is most appropriate if the client receives too much heparin?

Administer protamine sulfate.

A client is upset to learn that corticosteroids need to be taken to control symptoms of systemic lupus erythematosus (SLE). While the nurse is preparing to administer medication, the client refuses to take it, stating, "This is turning me into an old woman before my time." What is the best response by the nurse?

Ask about the medication side effects that are a concern and explain why suddenly stopping the drug can cause problems.

The nurse is caring for a client who has been prescribed a benzodiazepine medication for acute anxiety. What information is most important for the nurse to include when teaching the client about the medication? Correct response: "Take the medication as prescribed as there is risk for addiction."

Correct response: "Take the medication as prescribed as there is risk for addiction."

The nurse should advise which client who is taking lithium to consult with the health care provider regarding a potential adjustment in lithium dosage? Correct response: a client who is beginning training for a tennis team

Correct response: a client who is beginning training for a tennis team

After abdominal surgery 3 days ago the client continues to have pain every 4 to 6 hours ranging from 3 to 7 on a 10-point scale. The client has prescriptions for morphine 10 mg IM every 3 to 4 hours and acetaminophen with codeine 30 mg every 3 to 4 hours as needed for pain. The client has been taking the morphine every 4 hours for the past 3 days but tells the nurse that the morphine is no longer lasting 4 hours and wants to receive pain medication every 3 hours. The nurse reviews the progress notes that indicate the client has obtained pain relief for 5 to 6 hours after receiving the morphine. What should the nurse do to help the client manage the pain?

Suggest that the client take the acetaminophen with codeine every 3 hours.

To prevent development of peripheral neuropathies associated with isoniazid administration, what should the nurse teach the client to do?

Supplement the diet with pyridoxine (vitamin B6).

A client's serum ammonia level is elevated, and the health care provider (HCP) prescribes 30 mL of lactulose. Which effect is common for this drug?

increased bowel movements

Which action is a priority when a nurse is preparing to administer a transfusion of platelets?

obtaining a written informed consent

A health care provider prescribes gentamicin for a client with peritonitis. The client has preexisting impaired vision and hearing. The nurse should:

question the prescription because gentamicin could cause further hearing impairment.

The client in preterm labor is admitted to the hospital. To stop the client's uterine contractions, the nurse anticipates administering which medication?

terbutaline

Which instruction should a nurse give a client with prostatitis who is receiving co-trimoxazole double strength?

"Drink 6 to 8 glasses of fluid daily while taking this medication."

A health care provider prescribes intravenous normal saline solution to be infused at a rate of 150 ml/hour for a client. How many liter(s) of solution will the client receive during an 8-hour shift? Record your answer using one decimal place (For example: 6.2).

1.2

The health care provider has ordered ondansetron 0.15 mg/kg IV to a pediatric client who weighs 40 lb (18.1 kg). The dose on hand is 2 mg/mL. How many milliliters will the nurse administer to the client? Round the answer to the nearest tenth.

1.4

After laparoscopic cholecystectomy, a 43-year-old client reports pain and nausea. The nurse is preparing meperidine hydrochloride 75 mg and promethazine hydrochloride 12.5 mg to be administered I.M. in the same syringe. If the label on the meperidine reads 50 mg/ml and the label on the promethazine reads 25 mg/ml, how many milliliters should the nurse have in the syringe after the correct doses are drawn up? Record your answer using a whole number.

2

The nurse is to administer chloramphenicol 50 mg IV in 100 mL of dextrose 5% in water over 30 minutes. The infusion set administers 10 gtt/mL. At what flow rate (in drops per minute) should the nurse set the infusion? Round to the nearest whole number.

33

After undergoing small-bowel resection, a client is prescribed metronidazole 500 mg intravenously. The mixed solution is 100 ml. The nurse is to administer the drug over 30 minutes. The drop factor of the available intravenous tubing is 15 gtt/ml. What is the drip rate in drops per minute? Record your answer using a whole number. (For example: 62)

50

The nurse is preparing to administer a chemotherapy infusion to a client with esophageal cancer. The client has an implanted port that was last accessed 7 days ago. The insertion site is clean and dry and without erythema. Which is the appropriate action by the nurse?

Access the port using a Huber needle.

The nurse is administering an IV antibiotic to a client in the emergency department (ED). Within 15 minutes, the client reports itching, shortness of breath, and difficulty swallowing. Which interventions should the nurse implement? Select all that apply.

Administer epinephrine per order. Discontinue the medication. Apply oxygen.

A client in the intensive care unit has a critically low potassium level of 1.9 mEq/l (mmol/l). What would be the best way to replace this client's potassium?

Administer two potassium chloride 10 mEq (10 mmol) in 100 ml 0.9% sodium chloride IVPB, over 1 hour each

The nurse used a secure access code to obtain a morphine 2 mg/ml vial from the computerized automated dispensing cabinet (ADC). Before exiting the system, the nurse is prompted to count the remaining vials. The nurse counts 10 remaining vials, but the system reads 9 remaining vials. What is the next action by the nurse?

Ask another nurse to assist with following the procedure to resolve the discrepancy.

After having a total hip replacement, a client receives morphine sulfate by patient-controlled analgesia (PCA) pump. The client says, "This pump doesn't help my pain at all." What should the nurse do in response to this statement?

Assess the client's understanding of the PCA pump.

Which instruction is most important for the nurse to include in the teaching plan for a client who is taking phenelzine?

Avoid foods high in tyramine.

The nurse is caring for four clients who will all be undergoing moderate sedation procedures today. The health care provider (HCP) has ordered midazolam to be given to all four clients. The nurse notifies the HCP to clarify the prescription for which client? Correct response: a 30-year-old client who is pregnant

Correct response: a 30-year-old client who is pregnant

The nurse is obtaining blood from a central venous access device (CVAD) using aseptic technique and during the procedure soils the CVAD dressing with blood. After the sample is obtained and sent to the laboratory, what should the nurse do next? Correct response: Change the soiled dressing per facility policy.

Correct response: Change the soiled dressing per facility policy.

A nurse is caring for a 3-year-old child admitted to the pediatric unit with acetaminophen poisoning. The nurse administers acetylcysteine every 4 hours for 72 hours. Which laboratory findings confirm the effectiveness of the drug therapy? Correct response: alanine aminotransferase and aspartate aminotransferase

Correct response: alanine aminotransferase and aspartate aminotransferase

When developing a teaching plan for a client taking hormonal contraceptives, a nurse should ensure that the client knows she must have which vital sign monitored regularly? Correct response: blood pressure

Correct response: blood pressure

Which baseline laboratory data should be established before a client is started on tissue plasminogen activator or alteplase recombinant? Correct response: hemoglobin level, hematocrit, and platelet count

Correct response: hemoglobin level, hematocrit, and platelet count

The nurse learns that a client who is scheduled for a tonsillectomy has been taking 40 mg of oral prednisone daily for the last week for poison ivy on the leg. What should the nurse do first?

Notify the anesthesiologist of the prednisone administration.

The nurse understands that assessment of blood pressure in clients receiving antipsychotic drugs is important. What is a reason for this assessment?

Orthostatic hypotension is a common side effect.

The client was found not breathing and was transported to the hospital. A family member states the client may have taken too much pain medication because the client frequently forgets if the medication was taken. Which observation(s) by the nurse indicates therapeutic effect of naloxone hydrochloride in the client? Select all that apply.

Reverses decreased respiratory rate of 10. Reverses decreased level of consciousness. Reverses blood pressure of 90/58.

The nurse received an order to administer intravenous fluids with potassium for a client receiving intravenous fluids. What step(s) are included in the process? Select all that apply.

Review the client's laboratory values. Obtain correct ordered intravenous fluids. Identify client with two methods. Review the label of the intravenous tubing.

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

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

The health care provider (HCP) has prescribed nitroglycerin to a client with angina. The client also has closed-angle glaucoma. The nurse should contact the HCP to discuss the potential for which drug interaction?

increased intraocular pressure

What should a nurse expect to find while assessing the vital signs of a client who has abruptly stopped taking beta-adrenergic blocker?

irregular pulse

In the first 12 hours after starting a patient-controlled analgesia (PCA) infusion to administer an opioid, what should the nurse monitor every 1 to 2 hours? Select all that apply.

level of sedation oxygen saturation vital signs

A client who has been taking furosemide has a serum potassium level of 3.2 mEq/L. Which assessment findings by the nurse would confirm an electrolyte imbalance?

muscle weakness and a weak, irregular pulse

Which is most critical for the nurse to communicate to the health care provider (HCP) prior to placing an epidural analgesia catheter? The client:

received enoxaparin 40 mg subcutaneously 1 hour ago.

The nurse has administered aminophylline to a client with emphysema. Which indicates the medication has been effective?

relaxation of smooth muscles in the bronchioles

A client is taking acetylsalicylic acid (ASA) for pain control. Which finding should the nurse report to the healthcare provider immediately?

ringing in the ears

During gentamicin therapy, the nurse should monitor a client's

serum creatinine level.

A nurse is developing a teaching plan for a client who has just been diagnosed with breast cancer. The nurse should include information about

tamoxifen.

The nurse is instructing the client with hypothyroidism who takes levothyroxine 100 mcg, digoxin, and simvastatin. The nurse judges that the teaching regarding the use of these medications is effective if the client will take:

the levothyroxine before breakfast and the other medications 4 hours later.

A nurse is to give a client a 325-mg aspirin suppository. The client has diarrhea and is in the bathroom. The best nursing approach at this time would be to

withhold the suppository and notify the client's physician.

The emergency department nurse is caring for a client having a STEMI. The health care provider has prescribed a weight-based heparin bolus of 40 units/kg, with a maximum dose of 4000 units. The client weighs 250 lb (113.64 kg). How many units of heparin will the nurse give? Correct response: 4000

Correct response: 4000

A nurse must monitor a client receiving chloramphenicol for adverse drug reactions. What is a toxic reaction to chloramphenicol?

bone marrow suppression

The nurse should instruct a client who is taking dexamethasone and furosemide to report which symptom?

muscle weakness

A client is receiving chemotherapy that has the potential to cause pulmonary toxicity. Which signs or symptoms indicates a toxic response to the chemotherapy?

cough and shortness of breath

An older adult is taking eight medications to manage hypertension, diabetes, and arthritis and reports having nausea, diarrhea, tremors, and unusual thoughts. When investigating the cause of these symptoms, the nurse should consider which reason for underestimating adverse drug reactions in older adults?

Physical or psychological symptoms are attributed to the effects of aging.

A student nurse is reviewing physician orders written on a client's chart. Which entry is written incorrectly because it contains material from the "do not use" list of the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission)?

epoetin alfa 6500 U SQ daily.

Clients who are receiving parenteral nutrition (PN) are at risk for development of which complication?

fluid imbalances

A physician orders a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance?

hypokalemia

A nurse has inserted a peripheral intravenous catheter. Which type of dressing is most appropriate to use to cover the insertion site?

transparent

A client is taking iron supplements. What information should the nurse give the client? Correct response: The stools will become darker.

Correct response: The stools will become darker.

A physician orders preoperative medications to be administered to a client by the I.M. route: meperidine, 50 mg; hydroxyzine pamoate, 25 mg; and glycopyrrolate, 0.3 mg. The medications are dispensed this way: meperidine, 100 mg/ml; hydroxyzine pamoate, 100 mg/2 ml; and glycopyrrolate, 0.2 mg/ml. How many milliliters in total should the nurse administer?

2.5 ml

A nurse is preparing to give an average-size 9-year-old child a preoperative I.M. injection. Which size needle should the nurse use?

22G, 1″

The surgeon prescribes cefazolin 1 g to be given IV at 0730 when the client's surgery is scheduled at 0800. What is the primary reason to start the antibiotic exactly at 0730? Correct response: The antibiotic is most effective in preventing infection if it is given 30 to 60 minutes before the operative incision is made.

Correct response: The antibiotic is most effective in preventing infection if it is given 30 to 60 minutes before the operative incision is made.

An older adult is taking eight medications to manage hypertension, diabetes, and arthritis and reports having nausea, diarrhea, tremors, and unusual thoughts. When investigating the cause of these symptoms, the nurse should consider which reason for underestimating adverse drug reactions in older adults? Correct response: Physical or psychological symptoms are attributed to the effects of aging.

Correct response: Physical or psychological symptoms are attributed to the effects of aging.

A 75-year-old client who has been taking furosemide regularly for 4 months tells the nurse about having trouble hearing. What should the nurse do? Correct response: Report the hearing loss to the health care provider.

Correct response: Report the hearing loss to the health care provider.

A nurse is to give a client a 325-mg aspirin suppository. The client has diarrhea and is in the bathroom. The best nursing approach at this time would be to Correct response: withhold the suppository and notify the client's physician.

Correct response: withhold the suppository and notify the client's physician.

When assessing a client's I.V. insertion site, a nurse notes normal color and temperature at the site and no swelling. However, the I.V. solutions haven't infused at the ordered rate; the flow rate is slow even with the roller clamp wide open. When the nurse lowers the I.V. fluid bag, no blood returns to the tubing. What should the nurse do first? Correct response: Check the tubing for kinks and reposition the client's wrist and elbow.

Correct response: Check the tubing for kinks and reposition the client's wrist and elbow.

A client has a nasogastric (NG) tube. How should the nurse administer oral medication to this client? Correct response: Crush the tablets and prepare a liquid form; then insert the liquid into the NG tube.

Crush the tablets and prepare a liquid form; then insert the liquid into the NG tube.

What information must a medication order include? Correct response: physician's signature

Correct response: physician's signature

Which statement indicates that a new graduate nurse understands central venous pressure (CVP) measurement when used on a client? Correct response: "The test will assess pressure and volume changes in the right atrium."

Correct response: "The test will assess pressure and volume changes in the right atrium."

During gentamicin therapy, the nurse should monitor a client's Correct response: serum creatinine level.

Correct response: serum creatinine level.

The nurse is caring for a client with an order for an intravenous infusion of dextrose with 5% normal saline at 1500 mL over 8 hrs. The drip administration is set at 10 drops/mL. How fast will the IV infuse (drops/minute)? Record your answer using a whole number. Correct response: 31

Correct response: 31

The health care provider has prescribed phenytoin sodium therapy for a client with seizures. What should the nurse explain to the client about stopping the drug suddenly? Correct response: Status epilepticus may occur.

Correct response: Status epilepticus may occur.

What should the nurse tell the client who is preparing for insertion of a nasoduodenal tube? Select all that apply. Correct response: The nose and throat will be numbed with a viscous anesthetic. X-rays with the use of a contrast dye will be used to verify placement. The client will be closely monitored for 30 minutes following the procedure. The tube will be taped to the nose.

Correct response: The nose and throat will be numbed with a viscous anesthetic. X-rays with the use of a contrast dye will be used to verify placement. The client will be closely monitored for 30 minutes following the procedure. The tube will be taped to the nose.

Which factors influence safe and effective medication administration for elderly clients? Correct response: There is less efficient absorption, detoxification, and elimination.

Correct response: There is less efficient absorption, detoxification, and elimination.

A client has sustained a head injury and is to receive mannitol by I.V. push. In evaluating the effectiveness of the drug, the nurse should expect to find: Correct response: decreased cerebral edema

Correct response: decreased cerebral edema

Which laboratory test should the nurse monitor when the client is receiving warfarin sodium therapy? Correct response: prothrombin time (PT)

Correct response: prothrombin time (PT)

A client is to receive a glycerin suppository. Which nursing action is appropriate when administering a suppository? Correct response: Applying a lubricant to the suppository

Correct response: Applying a lubricant to the suppository

The client is receiving an IV infusion of 5% dextrose in normal saline running at 125 ml/h. When hanging a new bag of fluid, the nurse notes swelling and hardness at the infusion site. The nurse should first: Correct response: discontinue the infusion.

Correct response: discontinue the infusion

A client who has been taking flunisolide nasal spray, two inhalations a day, for treatment of asthma has painful, white patches in the mouth. What should the nurse tell the client? Correct response: "You have developed a fungal infection from your medication. It will need to be treated with an antifungal agent."

Correct response: "You have developed a fungal infection from your medication. It will need to be treated with an antifungal agent."

The nurse is monitoring a client receiving oxytocin. What is one possible scenario in which this drug would be indicated and used? Correct response: Medically indicated induction of labor in client at 39 weeks' gestation

Correct response: Medically indicated induction of labor in client at 39 weeks' gestation

A client is prescribed heparin 6,000 units subcutaneously every 12 hours for deep vein thrombosis prophylaxis. The pharmacy dispenses a vial containing 10,000 units/1 ml. How many milliliter(s) of heparin would the nurse administer? Record your answer using one decimal place. (For example: 6.2) Correct response: 0.6

Correct response: 0.6

The nurse is preparing a client's preoperative medication. The prescription reads atropine 0.6 mg and meperidine hydrochloride 50 mg IM. The dosage of available atropine is 0.8 mg/mL, and the dosage of available meperidine is 100 mg/mL. What will be the total volume of medication the nurse will administer? Record your answer using two decimal places. Correct response: 1.25

Correct response: 1.25

A client is taking phenelzine 15 mg PO three times a day. The nurse is about to administer the next dose when the client tells the nurse about having a throbbing headache. Which action should the nurse do first? Correct response: Obtain the client's vital signs.

Correct response: Obtain the client's vital signs.

A client is upset to learn that corticosteroids need to be taken to control symptoms of systemic lupus erythematosus (SLE). While the nurse is preparing to administer medication, the client refuses to take it, stating, "This is turning me into an old woman before my time." What is the best response by the nurse? Correct response: Ask about the medication side effects that are a concern and explain why suddenly stopping the drug can cause problems.

Correct response: Ask about the medication side effects that are a concern and explain why suddenly stopping the drug can cause problems.

A client reports pain in the right heel and is requesting medication. The nurse assesses the client and administers an analgesic. The client experiences no pain relief and states that the heel pain is worse. What is an appropriate intervention by the nurse? Correct response: Call the physician to report the finding.

Correct response: Call the physician to report the finding.

The client was recently diagnosed with a hiatal hernia. The healthcare provider orders an antacid that has reduced adverse effects. What should the nurse include in the client's teaching about the side effects of antacids? Correct response: "The major side effect of an antacid is diarrhea."

Correct response: "The major side effect of an antacid is diarrhea."

After undergoing small-bowel resection, a client is prescribed metronidazole 500 mg intravenously. The mixed solution is 100 ml. The nurse is to administer the drug over 30 minutes. The drop factor of the available intravenous tubing is 15 gtt/ml. What is the drip rate in drops per minute? Record your answer using a whole number. (For example: 62) Correct response: 50

Correct response: 50

A client is prescribed an intravenous solution of 1,000 ml to be infused from 0800 to 2000. The nurse will use an infusion pump that delivers the solution in milliliters per hour. At what rate would the nurse set the pump to deliver the solution? Record your answer using a whole number. (For example: 62) Correct response: 83

Correct response: 83

A client who is 1 day postoperative is using a morphine patient-controlled analgesia (PCA) pump. The client is confused and disoriented. What is the priority intervention by the nurse? Correct response: Check respiratory rate and depth as well as oxygen saturation levels.

Correct response: Check respiratory rate and depth as well as oxygen saturation leve

A nurse is working in a clinic where a family member's spouse is treated for a sexually transmitted disease. The nurse is concerned about the risk to family members. What is the most appropriate action for the nurse to take? Correct response: Encourage the client to speak with the family member about the diagnosis if the client has not already done so.

Correct response: Encourage the client to speak with the family member about the diagnosis if the client has not already done so.

The client was found not breathing and was transported to the hospital. A family member states the client may have taken too much pain medication because the client frequently forgets if the medication was taken. Which observation(s) by the nurse indicates therapeutic effect of naloxone hydrochloride in the client? Select all that apply. Correct response: Reverses decreased respiratory rate of 10. Reverses decreased level of consciousness. Reverses blood pressure of 90/58.

Correct response: Reverses decreased respiratory rate of 10. Reverses decreased level of consciousness. Reverses blood pressure of 90/58.

A 36-month-old child weighing 20 kg (44 lb) is to receive ceftriaxone 2 g IV every 12 hours. The recommended dose of ceftriaxone is 50 to 75 mg/kg per day in divided doses. How should the nurse proceed? Correct response: Withhold administering the ceftriaxone, and notify the child's health care provider (HCP).

Correct response: Withhold administering the ceftriaxone, and notify the child's health care provider (HCP).

A nurse overhears this conversation between coworkers: "Older people have lost many friends and family and also have health problems. Their anxiety and worries can be so severe that they need higher doses of benzodiazepines than most people." What is the most appropriate response for the nurse to make to the coworkers? Correct response: "That's not right. Older people need lower doses than most people because of reduced liver and kidney function."

Correct response: "That's not right. Older people need lower doses than most people because of reduced liver and kidney function."

After surgery, the client is receiving epidural pain management. The client wants to get out of bed and walk to the bathroom. The nurse should base the decision to ambulate on which information? Correct response: A low concentration of analgesia is used with the catheter.

Correct response: A low concentration of analgesia is used with the catheter.

The health care provider has prescribed a saline lock for a client. In which order from first to last should the nurse implement this prescription? All options must be used. Correct response: Apply clean gloves, and locate and clean the venipuncture site. Use the nondominant hand to stabilize the vein by pulling the skin taut. Insert an over-the-needle catheter, advancing the catheter once flashback is observed. Stabilize the catheter and apply dressing to secure the saline lock.

Correct response: Apply clean gloves, and locate and clean the venipuncture site. Use the nondominant hand to stabilize the vein by pulling the skin taut. Insert an over-the-needle catheter, advancing the catheter once flashback is observed. Stabilize the catheter and apply dressing to secure the saline lock.

The nurse is changing the subclavian dressing of a client who is receiving total parenteral nutrition. When assessing the catheter insertion site, the nurse notes the presence of yellow drainage from around the sutures that are anchoring the catheter. What should the nurse do first? Correct response: Obtain a culture specimen of the drainage.

Correct response: Obtain a culture specimen of the drainage.

The nurse is reviewing laboratory values on a client with heart failure and atrial fibrillation. The client has a potassium level of 2.8 mEq/L (2.8 mmol/L). The client is scheduled to receive their 0900 dose of digoxin. What is the nurse's best action? Correct response: Withhold the dose of digoxin and notify the healthcare provider.

Correct response: Withhold the dose of digoxin and notify the healthcare provider.

A client is receiving opioid epidural analgesia. The nurse should notify the health care provider (HCP) if the client has which findings? Select all that apply. Correct response: blood pressure of 80/40 mm Hg and baseline blood pressure of 110/60 mm Hg report of crushing headache minimal clear drainage on the dressing

Correct response: blood pressure of 80/40 mm Hg and baseline blood pressure of 110/60 mm Hg report of crushing headache minimal clear drainage on the dressing

A client who has been taking furosemide has a serum potassium level of 3.2 mEq/L. Which assessment findings by the nurse would confirm an electrolyte imbalance? Correct response: muscle weakness and a weak, irregular pulse

Correct response: muscle weakness and a weak, irregular pulse

A nurse is about to administer a medication and notices that the medication and dosage are unrelated to the client's diagnosis. Which interventions should the nurse take? Select all that apply. Correct response: Double check the physician's order. Refuse to administer the medication until the order can be clarified. Request a current medical drug reference to research the dose.

Correct response: Double check the physician's order. Refuse to administer the medication until the order can be clarified. Request a current medical drug reference to research the dose.

The nurse is admitting a client with glaucoma. The client brings prescribed eye drops from home and insists on using them in the hospital. What should the nurse do? Correct response: Explain to the client that the health care provider (HCP) will write a prescription for the eye drops to be used at the hospital.

Correct response: Explain to the client that the health care provider (HCP) will write a prescription for the eye drops to be used at the hospital.