VN440: HW1

IV solution of 1000mL 5% Dextrose in water is to be infused at 125mL/hr to correct a pt's fluid imbalance. The infusion set delivers 15 drops/mL. To ensure that the solution will infuse over an 8-hr period, at how many drops per minute should the nurse set the rate of flow?

31 gtts/min

A nurse is assessing a pt experiencing a diabetic coma. What unique response associated with diabetic coma that is not exhibited with hyperglycemic hyperosmolar nonketotic syndrome *HHNS) should the nurse identify when assessing the pt?

Kussmaul respiration

A pt with hyperthyroidism has been treated with radioactive iodine to destroy overactive thyroid gland cells. To reduce radiation exposure, the nurse's principle for providing care should be based on:

Limiting distance & time spend with the client

A pt has seeds containing radium implanted in the pharyngeal area. What should the nurse include in the plan of care?

Maintain the client in an isolation room

A nurse is caring for a pt who is experiencing an underproduction of thyroxine (T4). Which pt response is associate with an underproduction of thyroxine?

Myxedema

A child is receiving 60mg of Phenytoin (Dilantin). This medication is available as an oral suspension that contains 125mg/5mL. How many millimeters should the nurse administer?

2.4mL

At the start of the nursing shift, there were 200mL in a pt's IV bag. The nurse took the bag down when there were 50mL still in the bag and hung a new 1000mL IV bag. The client received 2 IV piggybacks during the shift; each contained 100mL. When calculating the I&O at the end of the shift, the nurse looks at the IV bag, there is 600mL left. How many mL of IV fluid did the client receive during this shift?

950mL

A pt has undergone a subtotal thyroidectomy. The pt is being transferred from the post anesthesia care unit/recovery to the inpatient nursing unit. What emergency equipment is most important for the nurse to have available for the pt?

A tracheostomy tray

The nurse is caring for a pt that is hyperventilating. The nurse recalls that the pt is at risk for

Respiratory alkalosis

When performing a postoperative assessment, which parameter would alert the nurse to a common side effect of epidural anesthesia?

Decreased BP

A nurse is assessing a client & suspects DKA. What clinical findings support this conclusion?

Deep respirations & fruity odor to the breath

A pt is admitted to the hospital with a tentative dx of infectious pulmonary TB. What infection control measures should the nurse take?

Don a N95 respirator mask before entering the room

When caring for a pt who is receiving enteral feedings, the nurse should take which measure to prevent aspiration?

Elevate HOB 30-45 degrees

The nurse provides a pt with left-sided weakness with instructions on how to safely use a cane. The nurse should demonstrate proper use of the cane by holding it on

The right side

A pt is admitted to the hospital with DKA. The nurse identifies that the elevated ketone level present with this disorder is caused by the incomplete oxidation of

Fats

A primary nurse receives prescriptions or a newly admitted pt and has difficulty reading the health care provider's writing. Who should the nurse ask for clarification of this prescription?

Health care provider who wrote the prescription

A nurse caring for a postoperative pt with DM. Which is the most common cause of DKA that the nurse needs to consider when caring for this pt?

Presence of infection

A pt dx with DKA. Which insulin should the nurse expect the health care provider to prescribe?

Regular insulin (Novolin R)

A pt has a fractured mandible that is immobilized with wires. For which life-threatening postoperative problem should the nurse monitor this pt?

Vomiting

A pt expresses concern about being exposed to radiation therapy because it can cause cancer. What should the nurse emphasize when informing the pt about exposure to radiation?

Only a small part of the body is irradiated

A graduate nurse is preparing to apply to the State Board of Nursing for licensure to practice as a LVN. What group primarily is protected under the regulations of the practice of nursing?

The public

Which clinical findings should the nurse expect when assessing a pt with hyperthyroidism?

-Diarrhea -Weight loss

The nurse is providing teaching to a pt who recently has been dx with Type I DM. The nurse reinforces the importance of monitoring for ketoacidosis. What are the signs & sx of keotacidosis?

-Excessive thirst -Fruity-scented breath -Confusion

A pt who weighs 176lbs is receiving 8mg/kg Cyclosporine (Sandimmune) each day to prevent organ transplant rejection. How many milligrams should the nurse administer each day?

640mg

When suctioning a pt with a tracheostomy, an important safety measure for the nurse is to

Apply suction only as a catheter is being withdrawn

When providing care for a pt with a NG tube, the nurse should take measures to prevent what serious complication?

Aspiration pneumonia

A nurse is planning to teach facts about hyperglycemia to a pt with the dx of DM. What info should the nurse include in the discussion about what causes diabetic acidosis?

Breakdown of fat stores for energy

When changing the soiled bed linens of a pt with a wound that is draining seropurulent material, what PPE is most essential for the nurse to wear?

Clean gloves

A pt with an ABD wound infected with MRSA is scheduled for CT scan of ABD. To ensure pt and visitor safety during transport, the nurse should implement which precaution?

Cover the infected site with a dressing

A pt appears anxious, exhibiting 40 shallow respirations per minute. The pt complains of feeling dizzy and lightheaded & of having tingling sensations of the fingertips around the lips. The nurse concludes that the pt complaints probably are r/t

Hyperventilation

A pt is admitted to the hospital with a dx of DKA. What is the initial intervention that the nurse should expect the health care provider to prescribe for this pt?

IV fluids

As a nurse prepares an older adult pt for sleep, actions are taken to help reduce the likelihood of a fall during the night. What nursing action is most appropriate when targeting older adults' most frequent cause of falls?

Instructing the client to call the nurse before going to the bathroom

Pt with untreated type I DM may lapse into a coma because of acidosis. An increase in which component in the blood is a direct cause of this type of acidosis?

Ketones

Two nurses are planning to help a pt with one-sided weakness to move up in bed. What should the nurses do to conform to a basic principle of body mechanics?

Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the pt, turn toward the head of the bed, and then move the pt

A pt with a fractured tibia & fibula is to be d/c from the ED with a right leg cast & crutches. In addition to the technical aspects of crutch walking, the nurse should teach the pt to:

Remove loose rugs from the environment

A pt with COPD has a blood pH of 7.25 and PCO2: 60. These blood gases require nursing attention because they indicate

Respiratory acidosis

A nurse is caring for a pt admitted to the hospital for DKA. Which clinical findings r/t this event should the nurse document in the pt's clinical record?

-Acetone breath -Decreased arterial carbon dioxide level

When caring for a pt with varicella & disseminated herpes zoster, the nurse should implement which types of precautions?

-Airborne -Contact -Standard