Physiological Aspects of Care

The physician orders 7,500 units erythropoietin (Procrit) to be administered subcutaneously weekly. The vial reads 10,000 units per milliliter. How much erythropoietin will the nurse give for each weekly dose? Include a leading zero if applicable. Record your answer using two decimal places. _____ mL

0.75 mL

A client asks the nurse, "Should I tell my partner that I just found out I'm human immunodeficiency virus (HIV) positive?" What is the nurse's most appropriate response? 1."This is a decision you alone can make." 2."Do not tell your partner unless asked." 3."You are having difficulty deciding what to say." 4."Tell your partner that you don't know how you became sick."

3."You are having difficulty deciding what to say."

A nurse is transcribing a practitioner's orders for a group of clients. Which order should the nurse clarify with the practitioner? 1.Discharge in am 2.Blood glucose monitoring ac and bedtime 3.Erythropoietin (Procrit) 6000 units subcutaneously TIW 4.Dalteparin (Fragmin) 5000 international units Sub-Q BID

3.Erythropoietin (Procrit) 6000 units subcutaneously TIW

The nurse manager of the unit comes to work obviously intoxicated. The staff nurse's ethical obligation is to: 1.Call the security guard 2.Tell the nurse manager to go home 3.Have the supervisor validate the observation 4.Offer the nurse manager a large cup of coffee

3.Have the supervisor validate the observation

A client is being discharged from the hospital with an indwelling urinary catheter. The client asks about the best way to prevent infection and keep the catheter clean. Which would be appropriate for the nurse to include in the client teaching? 1.Once a day, clean the tubing with a mild soap and water, starting at the drainage bag and moving toward the insertion site. 2.After cleaning the catheter site, it is important to keep the foreskin pushed back for 30 minutes to ensure adequate drying. 3.Clean the insertion site daily using a solution of one part vinegar to two parts water. 4.Change the drainage bag at least once a week as needed.

4.Change the drainage bag at least once a week as needed.

A nurse assesses a client's serum electrolyte levels in the laboratory report. What electrolyte in intracellular fluid should the nurse consider most important? 1.Sodium 2.Calcium 3.Chloride 4.Potassium

4.Potassium

The count of hydrocodone (Vicodin) is incorrect. After several minutes of searching the medication cart and Physiological Aspects of Care records, no explanation is found. Who should the primary nurse notify about the discrepancy? 1.Nursing unit manager 2.Hospital administrator 3.Quality control manager 4.Health care provider prescribing the medication

1.Nursing unit manager

A client is admitted for surgery. Although not physically distressed, the client appears apprehensive and withdrawn. What is the nurse's best action? 1.Orient the client to the unit environment. 2.Have a copy of hospital regulations available. 3.Explain that that there is no reason to be concerned. 4.Reassure the client that the staff is available if the client has questions.

1.Orient the client to the unit environment.

A nurse understands that the primary purpose for a client to undergo reconstructive surgery is to: 1.Restore function and/or appearance. 2.Replace an organ or tissue. 3.Relieve or reduce symptoms. 4.Remove or excise an organ or tissue

1.Restore function and/or appearance.

A client is scheduled to receive conscious sedation during a colonoscopy. The client asks the nurse, "How will they 'knock me out' for this procedure?" Which answer by the nurse correctly describes the route of administration for conscious sedation? 1."You will receive the anesthesia through a face mask." 2."You will receive medication through an intravenous catheter." 3."We will give you an oral medication about one hour before the procedure." 4."The nurse anesthetist will inject the medication into the epidural space of your spine."

2."You will receive medication through an intravenous catheter."

A client with Type I Diabetes complains of hunger, thirst, tiredness, and frequent urination. Based on these findings, the nurse should take what action? 1.Notify the physician immediately about the client's symptoms. 2.Determine the client's blood glucose level. 3.Administer the client's prescribed insulin. 4.Give the client a peanut butter and graham cracker snack

2.Determine the client's blood glucose level.

What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess? 1.Rapid, thready pulse 2.Distended jugular veins 3.Elevated hematocrit level 4.Increased serum sodium level

2.Distended jugular veins

A client's intravenous (IV) infusion infiltrates. The nurse concludes that what is most likely the cause of the infiltration? 1.Excessive height of the IV bag 2.Failure to secure the catheter adequately 3.Contamination during the catheter insertion 4.Infusion of a chemically irritating medication

2.Failure to secure the catheter adequately

A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L and a potassium level of 3.6 mEq/L. Based on the lab results and symptoms, what is the client experiencing? 1.Hypernatremia 2.Hyponatremia 3.Hyperkalemia 4.Hypokalemia

2.Hyponatremia

What are the desired outcomes that the nurse expects when administering a nonsteroidal antiinflammatory drug (NSAID)? (Select all that apply.) 1.Diuresis 2.Pain relief 3.Antipyresis 4.Bronchodilation 5.Anticoagulation 6.Reduced inflammation

2.Pain relief 3.Antipyresis 6.Reduced inflammation

The nurse is caring for a client that is hyperventilating. The nurse recalls that the client is at risk for: 1.Respiratory acidosis 2.Respiratory alkalosis 3.Respiratory compensation 4.Respiratory decompensation

2.Respiratory alkalosis

A client that is scheduled for a surgical resection of the colon and creation of a colostomy for a bowel malignancy asks why preoperative antibiotics have been prescribed. The nurse explains that the primary purpose is to: 1.Decrease peristalsis. 2.Minimize electrolyte imbalance. 3.Decrease bacteria in the intestines. 4.Treat inflammation caused by the malignancy

3.Decrease bacteria in the intestines.

An assessment of the client on total parenteral nutrition (TPN) reveals a bounding pulse, distended jugular veins, dyspnea, and cough. What is the priority nursing intervention? 1.Ask the registered nurse start the client's infusion at a peripheral site 2.Slow the rate of the client's infusion of the TPN 3.Interrupt the client's infusion and notify the charge nurse or health care provider 4.Obtain the vital signs and continue monitoring the client's status

3.Interrupt the client's infusion and notify the charge nurse or health care provider

A nurse is providing care to a client eight hours after the client had surgery to correct an upper urinary tract obstruction. Which assessment finding should the nurse report to the charge nurse or surgeon? 1.Incisional pain 2.Absent bowel sounds 3.Urine output of 20 mL/hour 4.Serosanguineous drainage on the dressing

3.Urine output of 20 mL/hour

A client with a history of ulcerative colitis is admitted to the hospital because of severe rectal bleeding. The client engages in angry outbursts and places excessive demands on the staff. One day an unlicensed assistive personnel (UAP) tells the nurse, "I've had it. I am not putting up with that behavior. I'm not going in there again." What is the best response by the nurse? 1."You need to try to be patient. The client is going through a lot right now." 2."I'll talk with the client. Maybe I can figure out the best way for us to handle this." 3."Just ignore it and get on with your work. I'll assign someone else to take a turn." 4."The client's frightened and taking it out on the staff. Let's think of approaches we can take."

4."The client's frightened and taking it out on the staff. Let's think of approaches we can take."

A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client? 1.Skin turgor 2.Intake and output results 3.Client's report about fluid intake 4.Blood lab results

4.Blood lab results

A health care provider prescribes simvastatin (Zocor) 20 mg daily for elevated cholesterol and triglyceride levels for a female client. Which is most important for the nurse to teach when the client initially takes the medication? 1.Take the medication with breakfast. 2.Have liver function tests every six months. 3.Wear sunscreen to prevent photosensitivity reactions. 4.Inform the health care provider if the client wishes to become pregnant.

4.Inform the health care provider if the client wishes to become pregnant.

The nurse is assessing a group of older adults. Which should the nurse consider to be least likely to be affected by aging? 1.Sense of taste or smell 2.Gastrointestinal motility 3.Muscle or motor strength 4.Strategies to handle stress

4.Strategies to handle stress

A nurse reinforces teaching a client about Coumadin (warfarin) and concludes that the teaching is effective when the client states, "I must not drink: 1.apple juice 2.grape juice 3.orange juice 4.cranberry juice

4.cranberry juice

At the start of the nursing shift, there were 200 mL in a client's intravenous (IV) bag. The nurse took the bag down when there were 50 mL still in the bag and hung a new 1000 mL IV bag. The client received two intravenous piggybacks (IVPBs) during the shift; each contained 100 mL. When calculating the intake and output at the end of the shift, the nurse looks at the IV bag. Refer to the illustration.(The bad is on number 6) How many mL of IV fluid did the client receive during the shift? Record the answer as a whole number. ______ mL

950 mL

A nurse addresses the needs of a client who is hyperventilating to prevent what complication? 1.Cardiac arrest 2.Carbonic acid deficit 3.Reduction in serum pH 4.Excess oxygen saturation

2.Carbonic acid deficit

A client reports nausea, vomiting, and seeing a yellow light around objects. A diagnosis of hypokalemia is made. Upon a review of the client's prescribed medication list, the nurse determines that what is the likely cause of the clinical findings? 1.Digoxin (Lanoxin) 2.Furosemide (Lasix) 3.Propranolol (Inderal) 4.Spironolactone (Aldactone)

1.Digoxin (Lanoxin)

A client with limited mobility is being discharged. To prevent urinary stasis and formation of renal calculi, the nurse should instruct the client to: 1.Increase oral fluid intake to 2 to 3 L per day. 2.Maintain bed rest after discharge. 3.Limit fluid intake to 1 L/day. 4.Void at least every hour

1.Increase oral fluid intake to 2 to 3 L per day.

The nurse assesses an edematous client and recalls that edema occurs in what extracellular fluid compartment? 1.Interstitial 2.Intercellular 3.Intravascular 4.Intracellular

1.Interstitial

A child is to receive 60 mg of phenytoin (Dilantin). The medication is available as an oral suspension that contains 125 mg/5 mL. How many milliliters should the nurse administer? Record the answer using one decimal place. ______ mL

2.4 mL