Week 2: Technical Skills

The nurse is caring for a newborn that has been prescribed naloxone hydrochloride. The newborn weighs 2.5 kg. The order states to give 0.1 mg/kg now. How many milligrams will the nurse administer to the newborn? Record your answer using two decimal places.

0.25 2.5 kg × 0.1 mg = 0.25 mg

After an intravenous pyelogram (IVP), the nurse should include which measure in the client's plan of care?

Encourage adequate fluid intake. After an IVP, the nurse should encourage fluids to decrease the risk of renal complications caused by the contrast agent. There is no need to place the client on bed rest or administer a laxative. An IVP would not cause hematuria.

The nurse is preparing to suction a tracheostomy for a client with methicillin-resistant Staphylococcus aureus (MRSA) (see figure). What should the nurse do next?

Proceed to suction the client's tracheostomy. The nurse is wearing protective personnel equipment appropriate for suctioning the client: goggles, gown, and respirator mask. It is not necessary to wear a PAPR face shield to suction a tracheostomy. A surgical mask does not provide maximum protection.

A nurse is assessing a 4-year-old child's peripheral IV line, observing that it is not infusing. What is the first action the nurse should take to correct this situation?

Reposition the child's extremity. The most likely reason for difficulty running an IV in this age group is a positional issue of the child or extremity because of the child's activity level.

The nurse is evaluating an electrocardiogram (ECG) tracing. Which graphic shows the QT interval?

The QT interval extends from the beginning of the QRS complex to the end of the T wave. It measures the time needed for ventricular depolarization and repolarization. Option B shows the PR interval, which is measured from the beginning of the P wave to the beginning of the QRS complex. It tracks the atrial impulse from the sinus node through the atrioventricular (AV) node. Option C shows the ST segment, which represents the end of ventricular depolarization. Option D shows the QRS duration and represents impulse conduction through the ventricles.

A nurse is preparing a client with a pleural effusion for a thoracentesis. The nurse should

assist the client to a sitting position on the edge of the bed, leaning over the bedside table A physician usually performs a thoracentesis when the client is sitting in a chair or on the edge of the bed, with the legs supported and the arms folded and resting on a pillow or on the bedside table. Raising an arm, lying supine, or raising the head of the bed won't allow the physician to easily access the thoracic cavity.

A client is scheduled for a cardiac catheterization. The nurse should do which preprocedure tasks? Select all that apply.

Verify the client has stopped taking anticoagulants if instructed by the health care provider. Check for iodine sensitivity. Verify that written consent has been obtained. Withhold food and oral fluids before the procedure. For clients scheduled for a cardiac catheterization, it is important to assess for iodine sensitivity, verify written consent<glicon>, and instruct the client to take nothing by mouth for 6 to 18 hours before the procedure. If the client is taking anticoagulant drugs, the nurse should ask the client if the health care provider has given instructions to withhold these medications. Oral medications are withheld unless specifically prescribed. A urinary drainage catheter is rarely required for this procedure.

When evaluating the effectiveness of airway suctioning, the nurse should use which criterion?

breath sounds clear on auscultation Auscultating for clear breath sounds is the most accurate way to evaluate the effectiveness of tracheobronchial suctioning. Auscultation should also be done to determine whether or not the client needs suctioning.Assessing for labored respirations is not as accurate in evaluating the effectiveness of tracheobronchial suctioning. A client may have labored breathing that is not affected by the presence or absence of tracheobronchial secretions.Percussion of the chest is useful for detecting masses or dense consolidation of lung tissue. It is not an accurate method for assessing the effectiveness of suctioning.Suctioning clears mucus but does not decrease its production.

A client with a nasotracheal tube needs to be suctioned. What is the length of time the nurse should apply the suction for each pass of the catheter?

10 to 15 seconds Suction should be applied for 10 to 15 seconds for each pass of the catheter. Suctioning for longer than 15 seconds removes oxygen from the respiratory tract and cause hypoxemia. Suctioning less than 10 seconds would not be adequate to remove the secretions.

A physician prescribes penicillin potassium oral suspension 56 mg/kg/day in four divided doses for a client with anorexia nervosa who weighs 25 kg. The medication dispensed by the pharmacy contains a dosage strength of 125 mg/5 mL. How many milliliters of solution should the nurse administer with each dose? Record your answer using a whole number.

14 To determine the total daily dosage, set up this proportion: 25 kg/X = 1 kg/56 mg X = 1,400 mg. Next, divide the daily dosage by four doses to determine the dose to administer every 6 hours: X = 1,400 mg/4 doses X = 350 mg/dose. The adolescent should receive 350 mg every 6 hours. Lastly, calculate the volume to give for each dose by setting up this proportion: X/350 mg = 5 mL/125 mg X = 14 mL.

A nurse is assessing the injection site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation?

15-mm induration A 10-mm induration strongly suggests a positive response in this tuberculosis screening test; a 15-mm induration clearly requires further evaluation. A reddened area, 5-mm induration, and a blister aren't positive reactions to the test and require no further evaluation

The client is to receive digoxin 0.25 mg. Available are 0.125-mg scored tablets. How many tablets should the nurse administer?

2 tablets 0.25 mg/x tablets = 0.125 mg/1 tablet.x = 2 tablets.

The nurse receives a physician's order to administer 1,000 mL of intravenous (I.V.) normal saline solution over 8 hours to a client who recently had a stroke. What should the drip rate be if the drop factor of the tubing is 15 gtt/mL? Record your answer using a whole number.

31 The drip rate is calculated using the following formula: Volume of infusion (in milliliters)/Time of infusion (in minutes) × drip factor (in drops/milliliter) = drops/minute. Therefore, 1,000 mL/480 minutes × 15 drops/mL = 31 gtt/minute.

A client is admitted to the hospital with lower gastrointestinal bleeding. The client's hemoglobin on admission to the emergency department is 7.3 g/dl. The healthcare provider prescribes two units of packed red blood cells (RBCs) to infuse over one hour each. Each unit of packed RBCs contains 250 ml. The blood administration set has a drip factor of 10 gtt/ml. What is the flow rate in drops per minute? Record your answer using a whole number.

42 Each unit of packed RBCs contains 250 ml. Each unit is to infuse over one hr. Use the following equation: (250 ml)/(60 minutes)= 4.16 ml/minute. Multiply by the drip factor: 4.16 ml/minute x 10 gtt/ml = 41.6 gtt/minute which rounds to 42 gtt/minute.

A client is admitted with a diagnosis of diabetic ketoacidosis. An insulin drip is initiated with 50 units of insulin in 100 ml of normal saline solution. The I.V. is being infused via an infusion pump, and the pump is currently set at 10 ml/hr. How many units of insulin each hour is this client receiving? Record your answer using whole number.

5 To determine the number of insulin units the client is receiving per hour, the nurse must first calculate the number of units in each milliliter of fluid: (50 units)/(100 mL)= 0.5 units/mL 0.5 units x 10 mL/hour=5 units/hour

A nurse is preparing to administer phenytoin to a 99-lb (45-kg) client with a seizure disorder. The medication administration record documents phenytoin 5 mg/kg/day to be administered in three divided doses. How many milligrams of phenytoin should be administered in the first dose? Record your answer as a whole number.

75 First, convert the client's weight to kilograms:99 lb ÷ 2.2 lb/kg = 45 kg.Then calculate the total daily dosage:45 kg X 5 mg/kg/day = 225 mg/day.Finally, divide the total daily dosage into three parts:225 mg/day ÷ 3 doses/day = 75 mg/dose.

The nurse is observing a client with cerebral edema for evidence of increasing intracranial pressure and monitors the blood pressure for signs of widening pulse pressure. The client's current blood pressure is 170/80 mm Hg. What is the client's pulse pressure? Record your answer using a whole number.

90 Pulse pressure is the difference between the systolic blood pressure and the diastolic blood pressure. For this client, pulse pressure is 170 - 80 = 90.

Which intervention is most effective in minimizing the risk of seizure activity in a client who is undergoing diagnostic studies after having experienced several episodes of seizures?

Administer carbamazepine 200 mg PO, twice per day. Carbamazepine is an anticonvulsant that helps prevent further seizures and is the most effective intervention for preventing seizure risk while the client is undergoing diagnostic tests for seizures. Bed rest, sedation, and providing privacy do not minimize the risk of seizures.

A physician orders triamcinolone and salmeterol for a client with a history of asthma. What action should the nurse take when administering these drugs?

Administer the salmeterol and then administer the triamcinolone A client with asthma typically takes bronchodilators and uses corticosteroid inhalers to prevent acute episodes. Triamcinolone is a corticosteroid; Salmeterol is an adrenergic stimulant (bronchodilator). If the client is ordered a bronchodilator and another inhaled medication, the bronchodilator should be administered first to dilate the airways and to enhance the effectiveness of the second medication. The client may not choose the order in which these drugs are administered because they must be administered in a particular order. Monitoring the client's theophylline level isn't necessary before administering these drugs because neither drug contains theophylline.

The nurse is discontinuing an intravenous catheter on a 10-year-old client with hemophilia. What would be the most important intervention for this client?

Apply firm pressure on the site for 5 minutes after removal. The most important intervention for this client is to hold pressure on the wound for 5 minutes due to the bleeding disorder. Wearing gloves is important, but protects the nurse not the client. Heat will make the wound bleed more and infection is important, but not the most important with this client.

A client has a sucking stab wound to the chest. Which action should the nurse take first?

Apply a dressing over the wound and tape it on three sides. The nurse should immediately apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line.

The nurse is making rounds and observes the client receiving oxygen (see figure). What should the nurse do next?

Confirm that the flow rate is set to deliver oxygen at 6 to 10 L/min. The client is receiving oxygen using a partial rebreathing mask which is positioned correctly. The correct flow rate for this type of oxygen mask is 6 to 10 L of oxygen per minute. To be effective, the mask must cover the client's face. The elastic band must be tight enough to secure the mask. When used correctly, the reservoir bag should inflate during the inspiratory phase.

While assessing a client's spine for abnormal curvatures, a nurse notes kyphosis. Using a picture diagram to instruct the client about kyphosis, in which location would the nurse note the structural abnormality?

Kyphosis is characterized by an accentuated forward curve of the thoracic area of the spine, which leads to a hunchback or slouching position. In adults, kyphosis can be caused by degenerative joint disease, fractures, trauma, and spondylolisthesis. Symptoms stem from the location of the deformity and include mild back pain, rounded back appearance, tenderness and stiffness in the spine, and, in extreme cases, difficulty breathing.

The nurse is administering insulin to a 9-year-old child and has completed the medication rights and hand hygiene. Place the actions in the order the nurse will take to administer this injection. All options must be used.

Select an appropriate injection site with the child. Clean the site with an alcohol pad; loosen the needle cover. Pinch the skin around the injection site. Uncover the needle; insert at a 45- to 90-degree angle. Release the skin, and give the injection. Cover the site with an alcohol pad. To give a subcutaneous injection of insulin to a child, the nurse should first select an appropriate injection site, being sure to discuss the selection with the child to ensure that injection sites are rotated. The nurse should then clean the injection site with an alcohol pad and loosen the needle cover. The next step is to pinch the skin around the site. The nurse should then uncover the needle and insert the needle at a 45- to 90-degree angle, release the skin, and give the injection. When finished, the nurse should cover the injection site with an alcohol pad and avoid rubbing the site.

A 4-year-old child is brought to the emergency department in cardiac arrest. The staff performs cardiopulmonary resuscitation (CPR). Identify the area where the child's pulse would be checked.

The carotid artery would be used to check for a pulse when performing CPR on children and adults. The brachial pulse would be used when performing CPR on an infant.

A client with acute bronchitis is admitted to the healthcare facility and is receiving supplemental oxygen via nasal cannula. When monitoring this client, the nurse suddenly hears a high-pitched whistling sound. What is the most likely cause of this sound?

The oxygen tubing is pinched. Pinching of the tubing used to deliver oxygen causes a high-pitched whistling sound. When the water level in the humidifier reservoir is too low, the oxygen tubing appears dry but doesn't make noise. A client with a nasal obstruction becomes more uncomfortable with nasal prongs in place and doesn't experience relief from oxygen therapy; the client's complaints, not an abnormal sound, would alert the nurse to this problem. A nasal cannula can't deliver oxygen concentrations above 44%.

A client who had a transurethral resection of the prostate (TURP) 1 day earlier has a three-way Foley catheter inserted for continuous bladder irrigation. Which of the following statements best explains why continuous irrigation is used after TURP?

To keep the catheter free from clot obstruction. Continuous irrigation, usually consisting of sterile normal saline, is used after TURP to keep blood clots from obstructing the catheter and impeding urine flow. Antibiotics may be instilled in the bladder with the use of an irrigating solution, but this is not the primary reason for using continuous irrigation in TURP. The irrigating solution may secondarily help prevent bladder distention because it keeps the catheter from becoming obstructed.

When administering an oral medication to an infant, the nurse should take which action to decrease the risk of aspiration?

Use an oral syringe to place the medication beside the tongue, and administer the medication slowly. Using an oral syringe is the best way to prevent aspiration because it allows controlled administration of a small amount of medication. Administering the medication too quickly may cause aspiration. Putting the drug in a bottle of formula isn't preferred because the infant may not take the entire dose of medication and the contents of the bottle could interfere with drug absorption or action. Blocking the nasal passages could cause aspiration.

The client in acute renal failure has an external cannula inserted in the forearm for hemodialysis. Which nursing measure is appropriate for the care of this client?

Use the unaffected arm for blood pressure measurements. The unaffected arm should be used for blood pressure measurement. The external cannula must be handled carefully and protected from damage and disruption. In addition, a tourniquet or clamps should be kept at the bedside because dislodgment of the cannula would cause arterial hemorrhage. The arm with the cannula is not used for blood pressure measurement, IV therapy, or venipuncture. Patency is assessed by auscultating for bruits every shift. Heparin is not injected into the cannula to maintain patency. Because it is part of the general circulation, the cannula cannot be heparinized.

A client is to receive peritoneal dialysis. What should the nurse do to prepare the client for the procedure?

Warm the dialysis solution in the warmer. Solution for peritoneal dialysis should be warmed to body temperature in a warmer or with a heating pad; do not use the microwave. Cold dialysate increases discomfort. Assessment for a bruit and thrill is necessary with hemodialysis when the client has a fistula, graft, or shunt. An indwelling urinary catheter is not required for this procedure. The nurse should position the client in a supine or low Fowler's position.

The nurse is caring for an older adult male who had open reduction internal fixation of the right hip 24 hours ago. The client is now experiencing shortness of breath and reports having "tightness in my chest." The nurse reviews the recent lab results. The nurse should report which lab results to the health care provider?

troponin: 1.4 mcg/L (1.4 µg/L) Troponin is a cardiac biomarker and is normally almost undetectable in the blood. A level of 1.4 means there has likely been some damage to the heart muscle. Though serum glucose (normal 60 to 100 mg/dL [3.3 to 5.5 mmol/L]) and ESR (normal is less than 20 for males greater than 50 years old) are slightly elevated, this could be explained by normal stress and inflammatory response to surgery. The hematocrit is low (normal 40% to 45% [0.4 to 0.5] for men) but also not unexpected for a client following surgery.

The nurse is flushing a peripheral intravenous access device. Place the steps in the order that the nurse should perform them. All options must be used.

Cleanse the end cap with an antimicrobial swab. Insert the saline flush syringe into the cap on the extension tubing. Pull back on saline flush syringe to aspirate the catheter for blood return. Instill saline solution over 1 minute. Remove the syringe and reclamp the extension tubing. Remove gloves and perform hand hygiene. The first step is to cleanse the end cap with an antimicrobial swab to reduce the risk for contamination. The second step is to insert the saline flush syringe into the cap on the extension tubing to prepare to flush the intravenous site. The third step is to pull back on saline flush syringe to aspirate the catheter for blood return to confirm patency. The fourth step is to instill saline solution over 1 minute to maintain patency of the peripheral intravenous access device site. The fifth step is to remove the syringe from the peripheral intravenous access device because the normal saline has been administered and reclamp the extension tubing to prevent air from entering the peripheral intravenous access device. The sixth step is to remove gloves and perform hand hygiene to reduce the risk of transmission of microorganisms.

The nurse is caring for a client during a prolonged hospital stay for congestive heart failure. The client has a prescription for thigh high antiembolism stockings. In regard to the antiembolism stockings, what is the priority action by the nurse?

Remeasure the client's legs routinely. Using the correct size of antiembolism stockings is critical to their effectiveness. If a stocking is not tight enough, it will not improve venous return effectively. If the stocking is too tight, it may impair circulation. In a client who has had a prolonged hospitalization for congestive heart failure, the potential for changes in leg circumference related to increases or decreases in the amount of lower extremity edema requires the legs be remeasured routinely to ensure the appropriate sized stocking. Laundering the stockings every day is recommended, but not a priority. Lightly dusting the legs with talcum powder may ease the application of the stocking, but is not required. Documenting the size of the stockings used is important to provide a baseline, but remeasuring the legs routinely is the nurse's priority.

A nurse must apply an elastic bandage to a client's ankle and calf. The nurse should apply the bandage beginning at the client's

lower foot. An elastic bandage should be applied from the distal area to the proximal area. This method promotes venous return. In this case, the nurse should begin applying the bandage at the client's foot. Beginning at the ankle, lower thigh, or knee will not promote venous return.

What liquid does the nurse recommend the parents of a 1½-month-old infant with hypothyroidism use to administer levothyroxine with?

small amount of formula or breast milk Placing the dissolved pill in a small amount of formula or expressed breast milk would be acceptable for this infant because doing so helps to ensure that the infant will take all the medication.Mixing medications in large amounts of fluid such as water is not recommended because the infant may not take all the liquid. Thus, the parents would not know if the child received the correct dose.Mixing the medication with milk, juice, or cereal is contraindicated for this infant, who would not be taking these foods yet.

The nurse is preparing to administer I.V. insulin to a client diagnosed with diabetic ketoacidosis (DKA). What will the nurse monitor while the client is receiving this intervention?

hypokalemia and hypoglycemia The nurse should monitor for decreased potassium and decreased glucose. Hypoglycemia might occur if too much insulin is administered, or insulin is administered too quickly. Intravenous insulin forces potassium into cells, thereby lowering plasma levels of potassium. The client may have hyperkalemia prior to starting the insulin therapy, but hypokalemia will occur with insulin administration. Calcium and sodium levels should not be affected.

The nurse is performing a focused assessment on a client's gastrointestinal system. Which assessment is an expected finding?

high pitched gurgling noises in four abdominal quadrants High-pitched gurgles heard in four abdominal quadrants are a normal finding. Decreased bowel motility causes two or three bowel sounds per minute; increased bowel motility causes hyperactive bowel sounds. Abdominal cramping causes hyperactive, high-pitched tinkling bowel sounds and may indicate a bowel obstruction.

A client admitted to the hospital with diabetic ketoacidosis is receiving a continuous infusion of regular insulin. The physician orders an I.V. containing 1 liter of dextrose 5% in water at 150 ml/hour to be started when the client's blood glucose level reaches [250 mg/dl (13.9 mmol/L)]. The drip factor of the I.V. tubing is 15 gtt/ml. What is the drip rate for this I.V. infusion in drops per minute? Record your answer using one decimal place.

37.5 Drip rate = 150 ml ÷ 60 minutes × 15 gtt ÷ 1 ml2,250 gtt ÷ 60 minutes = 37.5 gtt/minute

The nurse attempts to obtain a blood specimen from an implanted port. The port does not have blood return. What should the nurse do next?

Have the client change positions. If an implanted port does not have blood return, having the client change position, performing the valsalva maneuver, and raising or lowering the head of the bed can promote blood return. The port should not be removed; the access needle may need to be removed and reinserted depending on the facility policy. A chest x-ray may be required but is not what the nurse should do first. Changing the dressing may not help with blood return.

Indicate on the illustration where the nurse would place the other electrode of the automated external defibrillator on a victim who has collapsed and does not have a pulse.

One electrode is placed to the right of the upper sternum just below the right clavicle. The other is placed, as shown, over the fifth or sixth intercostal space at the left anterior axillary line

After gathering all necessary equipment and setting up the supplies, what should be the first step in performing endotracheal (ET) or tracheal suctioning in an infant?

Provide extra oxygen by using a ventilator or through manual bagging. Providing extra oxygen before suctioning is the first step because it helps prevent hypoxemia. Insertion of a suction catheter is performed after preoxygenation. Instilling a few drops of sterile saline solution is no longer part of routine suctioning. ET and tracheal suctioning require sterile technique and sterile gloves, not just clean gloves.

The nurse is caring for a client with a nasogastric tube who is receiving intermittent tube feedings by gravity every 4 hours. The nurse aspirates 75 mL of residual prior to the next feeding. What action should the nurse take next?

Return the residual and begin the feeding. The amount of residual is within normal limits, and the client should have the feeding started. The residual should be returned to help prevent electrolyte imbalances. The other options do not ensure adequate nutritional management for the client.

The nurse teaches the client how to instill nose drops. Which technique is correct?

The client blows the nose gently before instilling drops. The client should blow the nose before instilling nose drops. Instilling nose drops is a clean technique. The dropper should be cleaned after each administration, but it does not need to be changed. The client should assume a position that will allow the medication to reach the desired area; this is usually a supine position.

A client with a partial thickness burn injury has had Biobrane applied 2 weeks ago. The Biobrane is now separating from the wound. What nursing intervention is appropriate?

Trim away the Biobrane that has separated from the wound. It is normal for the Biobrane to separate as the wound heals. It should be trimmed away as it separates. There is no need to apply a new dressing to the healing skin. The Biobrane should not be forcibly removed. It will slowly release as healing occurs.

Which step should a nurse take first when administering a liquid medication to an infant?

Verify the physician order. The nurse should first verify the physician's order. Next, the nurse should verify the drug, dose, route, and time. The nurse should then verify the client by checking the infant's armband. After these steps, the nurse should hold the infant securely in the crook of the arm and raise the infant's head to about a 45-degree angle. Then, the nurse should place the dropper at the corner of the infant's mouth so the drug runs into the pocket between the infant's cheek and gum. Doing this keeps the infant from spitting out the drug and reduces the risk of aspiration.

A nurse is caring for a client with status asthmaticus. Which medication should the nurse prepare to administer?

an inhaled beta2-adrenergic agonist An inhaled beta2-adrenergic agonist helps promote bronchodilation, which improves oxygenation. Although an I.V. beta2-adrenergic agonist can be used, the client needs be monitored because of the drug's greater systemic effects. The I.V. form is typically used when the inhaled beta2-adrenergic agonist doesn't work. A corticosteroid is slow acting, so its use won't reduce hypoxia in the acute phase.

A client requires long-term ventilator therapy. The client has a tracheostomy in place and requires frequent suctioning. Which technique should the nurse use?

intermittent suction while withdrawing the catheter To prevent hypoxia, the nurse should use intermittent (not continuous) suction while withdrawing the catheter. Suctioning shouldn't last more than 10 seconds at a time. Neither intermittent nor continuous suctioning should be applied while the catheter is being advanced.

The correct landmark for obtaining an apical pulse is the

left fifth intercostal space, midclavicular line. The correct landmark for obtaining an apical pulse is the left fifth intercostal space in the midclavicular line. This area is the point of maximum impulse and the location of the left ventricular apex. The left second intercostal space in the midclavicular line is where the nurse auscultates pulmonic sounds. The apical pulse isn't obtained at the midaxillary line or the seventh intercostal space in the midclavicular line.

When teaching the mother of an infant diagnosed with congenital hypothyroidism about daily oral levothyroxine sodium therapy, which manifestation should the nurse include as possibly indicating an overdose?

sweating Sweating, insomnia, rapid pulse, dyspnea, irritability, fever, and weight loss are all signs indicating levothyroxine overdose.Diminished or absent appetite (anorexia), constipation, and fatigue and sleepiness would suggest thyroid insufficiency.

A client is scheduled to undergo percutaneous transluminal coronary angioplasty (PTCA). Which statement by the nurse best explains the procedure to the client?

"PTCA involves opening a blocked artery with an inflatable balloon located on the end of a catheter." PTCA is best described as insertion of a balloon-tipped catheter into the coronary artery to compress a plaque, thereby opening a stenosed or blocked artery.Cutting away blockages with a special catheter is an atherectomy.Passing a catheter through the coronary arteries to find blocked arteries is a cardiac catheterization.Inserting grafts to divert blood from blocked arteries describes coronary artery bypass graft surgery.

A client with a spinal cord injury has dexamethasone 16 mg ordered .IV. The drug vial contains 24 mg/ml. The nurse plans to use a tuberculin syringe to measure the dose. How much should the nurse draw up to give to this client? Record your answer using two decimal places.

0.67 X = (Dose Desired)/(Dose on Hand or Dose Available) X=(16 mg)/(24 mg/ml)=0.67 ml

The health care provider prescribes 0.4 mg of atropine sulfate and 75 mg of meperidine hydrochloride to be given intramuscularly to a client 1 hour before surgery. The stock ampule of atropine contains 0.8 mg/mL, and the stock ampule of meperidine contains 100 mg/mL. The two drugs are compatible and can be drawn up in one syringe. What is the combined volume of medication in the syringe?

1.25 mL The correct amount to administer is determined by using ratios, as follows:0.8 mg/1 mL = 0.4 mg/x mL0.8/x = 0.4x = 0.5 mL of atropine sulfate100 mg/1 mL = 75 mg/x mL100/x = 75x = 0.75 mL of meperidine hydrochloride0.5 mL of atropine + 0.75 mL of meperidine hydrochloride = 1.25 mL total

A client with deep vein thrombosis (DVT) has an IV infusion of heparin sodium infusing at 1,500 units/hr. The concentration in the bag is 25,000 units/500 ml. How many milliliters should the nurse document as intake from this infusion following an 8-hr shift? Record your answer using a whole number.

240 First, calculate how many units are in each milliliter of the medication: 25,000 units/500 ml = 50 units/ml. Next, calculate how many milliliters the client receives each hr: 1 ml/50 units × 1,500 units/hr = 30 ml/hr Lastly, multiply by 8 hr: 30 ml/hr × 8 hr = 240 ml.

A child with osteomyelitis is to receive nafcillin IV every 6 hours. Before administering the drug, the nurse calculates the appropriate dosage. The recommended dosage is 50 to 100 mg/kg daily; the child weighs 22 lb (10 kg). Which dosage is acceptable?

250 mg every 6 hours To determine the correct dose, multiply 10 kg by 50-100 mg/kg. If the nurse is multiplying 10 kg by 50 mg/kg, the daily dose would be 500 mg. To give every 6 hours, divide 500 mg by 4; each dose would be 125 mg. If using 100 mg, then multiply 100 mg/kg by 10 kg. The maxiimum daily dose would be 1,000 mg daily, or (when divided over 4 doses) 250 mg per dose.

A woman who has preeclampsia is receiving magnesium sulfate 20 grams per 500 mL of lactated Ringers via infusion pump. The prescribed rate of infusion is 2 grams/hour. How many mL/hour should the nurse set the infusion pump for? Record your answer using a whole number.

50 X = 500mL/20grams x 2grams/hour.X = 50 mL/hour.

A 15-month-old child with an IV line in place is prescribed to receive a total of 200 mL over the next 3 hours. The infusion set delivers 1 mL per 60 drops. At what rate (in drops/min) should the nurse run the infusion? Record your answer using a whole number.

67 The drop rate is determined as follows:Rate = (200 mL/3 h) x (1 h/60 min) x (60 drops/1 mL) = 67 drops/min.200 ml fluid/3 hours = 67 ml (rounded from 66.67) fluid/1 hour 67 ml x 60 drops/ml = 4020 drops 4020 drops divided by 60 minutes = 67 drops/minute.

The nurse is to administer a bolus starting dose of heparin to a child who is taking penicillin. What should the nurse do? Select all that apply.

Check that the dose is appropriate for the child's weight. Note that the onset of the medication will be immediate. Monitor partial thromboplastin time (PTT). Heparin dosage in children is based on the child's weight. A bolus of heparin is administered by the IV route, and the onset of action is immediate. The PTT is an indicator of the effectiveness of heparin. Following the heparin with a continuous infusion of heparin would cause life-threatening anticoagulation in this child. Penicillin and cephalosporins potentiate the effects of heparin, so the heparin must be carefully titrated to obtain maximum effect without causing an overdose. However, the antibiotic should not be discontinued.

When cleaning the skin around an incision and drain site, what should the nurse do?

Clean the incision and drain site separately. When cleaning the skin around an incision and drain, the nurse should clean the incision and drain separately to avoid contaminating either wound. This is applying the principle of working from the least contaminated area to the most contaminated area. In this case, both areas are fresh wounds and should be kept separate.

A client is scheduled to undergo a bronchoscopy. Which nursing interventions would be included on the care plan? Select all that apply.

Keep suction equipment available. Assess cough and gag reflexes after the procedure. Report hemoptysis, stridor, or dyspnea immediately. Suctioning equipment should be kept available to clear the airway and prevent aspiration. Preoperative sedation and local anesthesia depress the gag and cough reflexes, so the nurse must assess for the return of these reflexes after bronchoscopy. Hemoptysis, stridor, or dyspnea should be reported immediately, because these findings indicate respiratory distress possibly caused by a pneumothorax, a complication of bronchoscopy. The client should not eat immediately after the procedure. Food and fluid are withheld until the gag reflex returns. The client is sedated for the procedure. A bronchoscopy involves inserting a fiberoptic endoscope into the bronchi, not the stomach.

A client had a total hip replacement today. How should the nurse position the client when the client is transferred from the transport cart to the bed?

Maintain the affected extremity in slight abduction using an abduction splint or pillows placed between the thighs. After total hip replacement, proper positioning by the nurse prevents dislocation of the prosthesis. The nurse should place the client in a supine position and keep the affected extremity in slight abduction using an abduction splint or pillows or Buck's extension traction. The client must not abduct or flex the operated hip because this may produce dislocation.

The nurse is giving care to an infant with a brain tumor. The nurse observes the infant arches the back (see figure). What action should the nurse take first?

Notify the health care provider (HCP). The infant has opisthotonos, an indication of brain stem herniation; the nurse should notify the HCP immediately and have resuscitation equipment ready. Stroking the back will not relieve the herniation or release the arching. Although the infant may also have a seizure, and padded side rails will prevent injury, the first action is to notify the HCP. Placing the child in a prone position will not relieve the herniation or release the arching.

After a laminectomy, a client has a palpable bladder and reports lower abdominal discomfort with voiding 60 to 80 mL of urine every 4 hours. The vital signs are BP 110/88 mm Hg, HR 86 bpm, and RR of 20 breaths/min. What is the best nursing intervention?

Perform a bladder scan, and obtain an order for urinary catheterization. The client has overflow retention. A catheter relieves the discomfort by draining urine from the bladder. Permitting further distension could injure the bladder. Although an analgesic may relieve the discomfort, it will not resolve the primary cause. Nurses' self regulation practice can perform a bladder scan without an order. Other answers are incorrect because the client may have neurologic impairment and decreased sensation for voiding.

To provide oral hygiene for a client recovering from transsphenoidal hypophysectomy, what should the nurse instruct the client to do?

Rinse the mouth with saline solution. After transsphenoidal surgery, the client must be careful not to disturb the suture line while healing occurs. Frequent oral care should be provided with rinses of saline, and the teeth may be gently cleaned with oral swabs. Frequent or vigorous toothbrushing or flossing is contraindicated because it may disturb or cause tension on the suture line.

The nurse collects a urine specimen from a client for a culture and sensitivity analysis. What should the nurse do to preserve the specimen?

Send it to the laboratory immediately. A specimen for culture and sensitivity should be sent to the laboratory promptly so that a smear can be taken before organisms start to grow in the specimen.

A client with diabetes mellitus has a foot ulcer. The physician orders bed rest, a wet-to-damp dressing change every shift, and blood glucose monitoring before meals and at bedtime. Why are wet-to-damp dressings used for this client?

They debride the wound and promote healing by secondary intention. For this client, wet-to-damp dressings are most appropriate because they clean the foot ulcer by debriding exudate and necrotic tissue, thus promoting healing by secondary intention. Moist, transparent dressings contain exudate and provide a moist wound environment. Dry, sterile dressings protect the wound from mechanical trauma and promote healing. Hydrocolloid dressings prevent the entrance of microorganisms and minimize wound discomfort.

The nurse is assessing a 48-year-old client with a history of smoking during a routine clinic visit. The client, who exercises regularly, reports having pain in the calf during exercise that disappears at rest. Which finding requires further evaluation?

ankle brachial index of 0.65 An ankle-brachial index of 0.65 suggests moderate arterial vascular disease in a client who is experiencing intermittent claudication. A Doppler ultrasound is indicated for further evaluation. The bradycardic heart rate is acceptable in an athletic client with a normal blood pressure. The SpO2 is acceptable; the client has a smoking history.

When performing the Heimlich maneuver on a conscious adult victim, where should the nurse deliver the rescuer inward and upward thrusts?

below the xiphoid process and above the umbilicus The thrusts should be delivered below the xiphoid process, but above the umbilicus, to minimize the risk of internal injuries.

What is the best way for the nurse to position a chest tube for a client to prevent dislocation?

coiled flat on the bed and secured without putting tension on the tube Tubing that is coiled flat on the bed and secured without putting tension of the tube maintains a patent, free draining system. This prevents fluid accumulation and decreases the risk of infection, atelectasis, and tension pneumothorax. The other choices all have risks associated with becoming disconnected.

The nurse is administering a subcutaneous injection (see accompanying figure). After releasing the skin, prior to injecting the medication, the needle pulls out of the skin. The nurse should:

discard the needle, attach a new needle to the syringe, and administer the medication. If the needle becomes dislodged from the tissue prior to administering the medication, the nurse should discard the needle, attach a new needle, and reattempt to administer the medication using appropriate technique. The nurse should not reuse the needle but can reuse the syringe and medication. To administer a subcutaneous injection, the nurse should bunch the skin around the insertion site (not stretch the skin) to lift the subcutaneous tissue from the muscle.

A client with chronic sinusitis comes to the outpatient department complaining of headache, malaise, and a nonproductive cough. When examining the client's paranasal sinuses, the nurse detects tenderness. To evaluate this finding further, the nurse should transilluminate the

frontal and maxillary sinuses. After detecting tenderness of the paranasal sinuses, the nurse should transilluminate both the frontal and maxillary sinuses; lack of illumination may indicate sinus congestion and pus accumulation. The sphenoidal and ethmoidal sinuses can't be transilluminated because of their location.

Nursing preparations for a client undergoing electroconvulsive therapy (ECT) resemble those used for:

general anesthesia. A nurse should prepare a client for ECT in a manner similar to that for general anesthesia. For example, the client should receive nothing by mouth for 8 hours before ECT to reduce the risk of vomiting and aspiration. Also, the nurse should have the client void before treatment to decrease the risk of involuntary voiding during the procedure; remove any full dentures, glasses, or jewelry to prevent breakage or loss; and make sure the client is wearing a hospital gown or loose-fitting clothing to allow unrestricted movement. These preparations aren't usually indicated for a client undergoing physical therapy, neurologic examination, or cardiac stress testing.

The nurse is evaluating a client who is using a flow incentive spirometer (see figure) following abdominal surgery 1 day ago. The client is performing the procedure correctly when the client does what? Select all that apply.

inhales for 3 seconds following fully expanding the lungs coughs after using the spirometer exhales passively before using the spirometer again sits upright The client should be in an upright position when using the spirometer. The client should exhale fully prior to using the spirometer and then inhale to expand the lungs and continue inhaling for 3 more seconds. The client should relax and exhale before inhaling for the next use of the spirometer. The client should cough and clear retained secretions following the use of the spirometer. The client should use the spirometer every 2 hours during the immediate postoperative period.

When preparing to obtain a neonatal screening test for phenylketonuria (PKU), the nurse understands that the neonate must have been fed what to ensure reliable results?

initial formula or breast milk at least 24 hours before the test PKU is an autosomal recessive disorder involving the absence of an enzyme needed to metabolize the essential amino acid phenylalanine to tyrosine. To ensure reliable results, the neonate must have ingested sufficient protein, such as breast milk or formula, for at least 24 hours. Testing the infant before that time, excessive vomiting, or poor intake can yield false-negative results. The infant does not need to fast 4 hours before the test. A loading dose of glucose water does not affect test values.

To reduce urethral irritation, where should the nurse tape the female client's Foley catheter?

inner thigh To reduce urethral irritation and allow drainage, the nurse should tape the Foley catheter to a female client's inner thigh. Taping the catheter also prevents excessive traction against the bladder neck. Taping the catheter to the groin or lower abdomen would not allow for proper drainage and would cause urethral discomfort. Taping the catheter to the lower thigh would pull on the catheter and cause urethral irritation.

During physical assessment, the nurse should further assess the client for signs of atrial fibrillation when the nurse palpates the radial pulse and notices which signs?

irregular rhythm with pulse rate greater than 100 bpm Characteristics of atrial fibrillation include pulse rate greater than 100 bpm, totally irregular rhythm, and no definite P waves on the ECG. During assessment, the nurse is likely to note the irregular rate and should report it to the health care provider (HCP) . A weak, thready pulse is characteristic of a client in shock. Two regular beats followed by an irregular beat may indicate a premature ventricular contraction.

To assess the client's dorsalis pedis pulse, the nurse should palpate the:

medial aspect of the dorsum of the foot. The dorsalis pedis pulse is found on the medial aspect of the dorsal surface of the foot in line with the big toe.The posterior tibial pulse is on the medial surface of the ankle just behind the medial malleolus.

A nurse is providing postprocedure care for a client who underwent percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. The nurse should instruct the client to:

notify the physician about cloudy or foul-smelling urine. The nurse should instruct the client to report the presence of foul-smelling or cloudy urine to the physician. Unless contraindicated, the client should be instructed to drink large quantities of fluid each day to flush the kidneys. Sandlike debris is normal because of residual stone products. Hematuria is common after lithotripsy.

A new nurse is asked to start an I.V. on an antepartum client. The new nurse has performed the procedure only once and isn't familiar with the I.V. pumps used in this facility. The new nurse should:

review the unit's procedure manual. A nurse should always refer to a policy and procedure manual for instructions on correctly performing a procedure. Asking another new nurse for assistance or attempting to perform an unfamiliar procedure without the necessary information makes the new nurse liable for errors that occur. A nurse who tells a client that she isn't experienced decreases that client's confidence in the nurse's credibility.

In which parts of the body should the nurse administer an intramuscular injection to a 6-month-old infant?

the lateral middle third of the thigh between the greater trochanter and the knee The appropriate site to give an injection to an infant is the vastus lateralis. The dorsogluteal, ventrogluteal, and deltoid muscles are areas for older children and adults.

A multigravid client visits the clinic because she suspects that she is pregnant but is unable to tell the nurse when her last menstrual period began. The client has a history of preterm birth. The nurse instructs the client that the gestational age of the fetus can be estimated by which procedure?

ultrasonography An ultrasound can provide a fairly accurate estimate of the fetal gestational age through various measurements of fetal landmarks.Amniocentesis is appropriate for determining genetic deviations and fetal lung maturity (lecithin-to-sphingomyelin ratio).Percutaneous umbilical blood sampling is used to detect genetically transmitted (inherited) blood disorders, acidosis, or infection.Alpha-fetoprotein levels are performed between the 15th and 20th weeks of gestation to determine if neural tube defects are present.

The nurse is educating the parents of a 2-year-old child regarding immunizations. When the parents ask where the injections will be given the nurse answers that the most appropriate site for an intramuscular injection for a child this age is the:

vastus lateralis muscle. When administering an intramuscular injection to a 2-year-old child, the preferred site is the vastus lateralis. The dorsogluteal muscle is not a recommended injection site for any age, due to the risk of damaging nerves in the area. The deltoid muscle is underdeveloped in this age group, and therefore not recommended. The ventrogluteal muscle may be developed enough, but is not the first choice.

A nurse is caring for a client in her 34th week of pregnancy who wears an external monitor. Which statement by the client indicates an understanding of the nurse's teaching?

"I can lie in any comfortable position, but I should stay off my back." The client demonstrates understanding of the nurse's teaching when she states that she should stay off her back. A woman with an external monitor should lie in the position that is most comfortable to her, but the supine position should be discouraged. It isn't necessary for the client to lie perfectly still. The client should be encouraged to change her position as often as necessary; however, the monitor may need to be repositioned after a position change. The nurse still needs to frequently assess and provide emotional support to a woman in labor who's wearing an external monitor. Because an external monitor isn't invasive and is worn around the abdomen, it doesn't increase the risk of uterine infection.

The client is to receive theophylline 500 mg IV in 500 mL of normal saline solution to run over 4 hours. The tubing delivers 60 gtt/mL. The nurse should set the infusion pump to administer the solution at how many milliliters per hour? Record your answer using a whole number.

125 To administer IV fluids at 500 mL over 4 hours, the nurse must determine the number of milliliters to administer in 1 hour. To do so, divide 500 by 4 to arrive at 125 mL/h.

When performing external chest compressions on an adult during cardiopulmonary resuscitation, how deep should the rescuer depress the sternum?

2 in (5 cm) An adult's sternum must be depressed 2 inches (5 cm) with each compression to ensure adequate heart compression.

A client with a history of epilepsy is admitted to the medical-surgical unit. While assisting the client from the bathroom, the nurse observes the start of a tonic-clonic seizure. Which nursing interventions are appropriate for this client? Select all that apply.

Assist the client to the floor. Turn the client to the side. Place a pillow under the client's head. During a seizure, the nurse should assist the client to the floor to reduce the risk of falling and turn the client on the side to help clear the mouth of oral secretions. If available, it is appropriate to place a pillow under the client's head to protect against injury. It is inappropriate to introduce anything into the mouth during a seizure because of the risk of choking or compromising the airway; therefore, oral medications and suction devices should not be used.

The nurse observes a constant gentle bubbling in the water seal column of a water seal chest drainage system. What should the nurse do next?

Check the connectors between the chest and drainage tubes and where the drainage tube enters chest drainage system. There should never be constant bubbling in the water-seal system; normally, the bubbling is intermittent. Constant bubbling in the water-seal bottle indicates an air leak, which means that less negative pressure is being exerted on the pleural space. Decreasing the suction will not reduce the leak. It is not necessary to notify the HCP until the system has been checked and the problem identified.

A client is returned to his room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client's bedside?

Tracheostomy set After a subtotal thyroidectomy, swelling of the surgical site (the tracheal area) may obstruct the airway. Therefore, the nurse should keep a tracheostomy set at the client's bedside in case of a respiratory emergency. Although an indwelling urinary catheter and a cardiac monitor may be used for a client after a thyroidectomy, the tracheostomy set is more important. A humidifier isn't indicated for this client.

A neonate receives an IV infusion of dextrose 10% administered by an infusion pump. The nurse should verify the alarm settings on the infusion pump at which times? Select all that apply.

when the infusion is started at the beginning of each shift when the neonate returns from X-ray The alarm settings on infusion pumps should be verified at the time the infusion is started, at the beginning of each shift, and when the client is moved. The neonate can move in bed, but if the alarm is triggered, the nurse should verify the settings. Unless the neonate has moved or been taken out of the crib, it is not necessary to check alarm settings after the parents visit.

The nurse is to administer 1,200 mg of an antibiotic. The drug is prepared with 6 g of the drug in 2 mL of solution. The nurse should administer how many milliliters of the drug? Record your answer using one decimal place.

0.4 First, convert grams to milligram: 6 g = 6,000 mg.Next, set up a proportion:6,000 mg/2 mL = 1,200 mg/XX = (1,200/6,000) x 2 mLX = 0.4 mL.

An infusion of lidocaine hydrochloride is running at 30 mL/hour. The dilution is 1,000 mg/250 mL. What dosage is the client receiving per minute? Record your answer using a whole number.

2 First, calculate the concentration of mg/mL: 1,000 mg divided by 250 mL equals 4mg/mL.Next, multiply the number of milligrams per milliliter by the pump setting in milliliters per hour: 4 mg/mL x 30 mL/h = 120 mg/h.Next, divide the milligrams per hour by 60 to obtain milligrams per minute: 120 mg/h divided by 60 min/h equals 2 mg/min.

When administering a tube feeding to a client through a percutaneous feeding tube, how should the nurse position the client?

Head of bed elevated 30 to 45 degrees The client should be positioned with the head of the bed raised 30 to 45 degrees to help prevent aspiration and promote gastric emptying. Having the head of the bed raised to 90 degrees would also help prevent aspiration, but is uncomfortable and not feasible for many clients being tube fed, particularly those that are critically ill or who receive continuous feedings. Lying a client supine while tube feeding should be avoided, because it increases the risk for aspiration and can lead to many negative outcomes. Side lying on the left side with the top leg bent at the knee would be the proper positioning for an enema or rectal examination, not a tube feeding, because it would also increase the risk of aspiration and should be avoided.

While making rounds, the nurse finds a client with chronic obstructive pulmonary disease sitting in a wheelchair, slumped over a lunch tray. After determining the client is unresponsive and calling for help, what should the nurse do next?

Open the client's airway. The nurse has already called for help and established unresponsiveness so the first action is to open the client's airway; opening the airway may result in spontaneous breathing and will help the nurse determine whether or not further intervention is required. Pushing the "code blue" button may not be the appropriate action if the client is breathing and becomes responsive once the airway is open. A quick assessment upon opening the client's airway will help the nurse to determine if the rapid response team is needed. Calling for a defibrillator may not be the necessary or appropriate action once the client's airway has been opened.

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. If a PICC line is dislodged and does not come all the way out, the health care provider needs to be notified after the line is secured. The health care provider may order a chest x-ray to determine where the tip is located. Changing the dressing and documenting the incident do not address the concern. The nurse should not push the catheter back into place.

A client is to receive 100 mg of cefazolin following an open reduction and internal fixation for repair of a fractured femur. The pharmacy has sent 100 mg of cefazolin in 50 ml of dextrose. The medication is to be administered over 30 minutes. Calculate the drip rate (gtt/min) using a set with a drop factor of 20 gtt/ml. Record your answer using a whole number.

33 Formula for I.V. calculations:Drip rate = (Volume/Rate) x set drop factorA medication volume of 50 ml is to be administered in 30 min using a 20 gtt/ml set.X = (50 ml / 30 min) x (20 gtt/min)X = 33.33, which rounds to 33 gtt/min.

The nurse is caring for a client who reports right lower quadrant pain. Which assessment is mostimportant for this client?

palpation The nurse caring for the client with right lower quadrant abdominal pain would perform a complete abdominal assessment including inspection, auscultation, percussion, and palpation, but palpation is the most important. The nurse must assess for tenderness with palpation, which is associated with inflammation of the peritoneal cavity and may be caused by appendicitis. The report of tenderness with palpation is often the defining factor when planning care for the client with right lower quadrant pain.

The client's order is for 5 units of regular insulin and 10 units of NPH (neutral protamine Hagedorn) insulin given as a basal dose. The client also is to receive an amount prescribed from the medium-dose sliding scale (shown image) based on morning blood glucose levels. The current bedside blood glucose measurement is 264 mg/dL (14.7 mmol/L). How many total units of insulin would the nurse administer to the client? Record your answer using a whole number.

21 The basal dose for this client is 5 units of regular insulin and 10 units of NPH insulin. The medium-dose sliding scale indicates that, based on the glucose reading of 264 mg/dL (264 mmol/L), the client should receive an additional 6 units of regular insulin, totaling 21 units (5 units + 10 units + 6 units = 21 units).

A client has nephropathy. The health care provider (HCP) prescribes a 24-hour urine collection for creatinine clearance. Which action is necessary to ensure proper collection of the specimen?

Collect the urine in a preservative-free container and keep it on ice. All urine for creatinine clearance determination must be saved in a container with no preservatives and refrigerated or kept on ice. The first urine voided at the beginning of the collection is discarded, not the last. A self-report of weight may not be accurate. It is not necessary to have an indwelling urinary catheter inserted for urine collection.

A 27-year-old primigravid client with insulin-dependent diabetes at 34 weeks' gestation undergoes a nonstress test, the results of which are documented as reactive. What should the nurse tell the client that the test results indicate?

There is evidence of fetal well-being. The nonstress test is considered reactive when two or more fetal heart rate accelerations of at least 15 bpm occur (from a baseline fetal heart rate of 120 to 160 bpm), along with fetal movement, during a 10- to 20-minute period. A reactive nonstress test indicates fetal heart rate accelerations and well-being. There is no indication for further evaluation (such as a contraction stress test). However, contraction stress tests are commonly scheduled for pregnant clients with insulin-dependent diabetes in the latter part of pregnancy and are repeated periodically until birth. Chorionic villus sampling is usually performed early in the pregnancy to detect fetal abnormalities.

A client is scheduled for amniocentesis. When preparing the client for the procedure, the nurse should:

ask the client to void. To prepare for amniocentesis, the nurse should ask the client to empty the bladder to reduce the risk of bladder perforation. Before transabdominal ultrasound, the nurse may instruct the client to drink 1 L of fluid to fill the bladder (unless ultrasound is done before amniocentesis to locate the placenta). I.V. anesthesia isn't given for amniocentesis. The client should be supine during the procedure; afterward, place the client on the left side to avoid supine hypotension, promote venous return, and ensure adequate cardiac output.

The nurse instructs the unlicensed assistive personnel on how to collect a 24-hour urine specimen. Which of the following instructions is correct for a collection that is scheduled to start at 7 a.m. (0700) Monday and end at 7 a.m. (0700) Tuesday?

Collect and save the urine voided at 7 a.m. (0700) on Tuesday. When finishing a 24-hour urine collection, the final voided urine is saved and added to the collection container. The first urine specimen, voided at 7 a.m. (0700) Monday, is discarded. The urine is not sent for a urine culture. It is not necessary to separate each day's collection of urine.

While the nurse is delivering abdominal thrusts to a 6-year old who is choking on a foreign body, the child begins to cry. What should the nurse do next?

Observe the child closely. Crying indicates that the airway obstruction has been relieved. No additional thrusts are needed. However, the child needs to be observed closely for complications, including respiratory distress. Tapping or shaking the shoulders is used initially to determine unresponsiveness in someone who appears unconscious. Delivering chest or back slaps could jeopardize the child's now-patent airway. Because the obstruction has been relieved, there is no need to sweep the child's mouth. Additionally, blind finger sweeps are contraindicated because the object may be pushed further back, possibly causing a complete airway obstruction.

A triple-lumen indwelling urinary catheter is inserted for continuous bladder irrigation following a transurethral resection of the prostate. In addition to balloon inflation, the functions of the three lumens include:

continuous inflow and outflow of irrigation solution. When preparing for continuous bladder irrigation, a triple-lumen indwelling urinary catheter is inserted. The three lumens provide for balloon inflation and continuous inflow and outflow of irrigation solution.

A 14-year-old is using glargine and lispro to manage type 1 diabetes. The prescription for sliding scale lispro reads as follows:Lispro subcutaneous give units according to sliding scale:Blood glucose: 70-150 mg/dL (3.9 to 8.3 mmol/L) = 0 units151-200 mg/dL (8.4 to 11.1 mmol/L) = 1 unit201-250 mg/dL (11.2 to 13.9 mmol/L) = 2 units251-300 mg/dL (13.9 to 16.7 mmol/L) = 3 units301-350 mg/dL (17 to 19.4 mmol/L) = 4 unitsCall for Blood glucose > 350 mg/dL (19.4 mmol/L)In addition give 1 unit for every 15 g of carbohydrate.The morning blood glucose is 202 mg/dL (11.2 mmol/L), and the client is going to eat two carbohydrate exchanges. The nurse has the client administer how many units of lispro? Record your answer using a whole number.

4 Each carbohydrate food exchange has 15 g of carbohydrate. Two units are needed to cover the current blood glucose and 2 units are needed to cover the anticipated carbohydrate intake

The nurse is using home telehealth monitoring to manage care for an 80-year-old who is home bound. The client spends most of the day in bed. Two months ago, the nurse detected sacral redness from friction and shearing force of being in bed. Last month, the client had increased sacral redness, and the area was classified as a stage I pressure ulcer. On this visit, the nurse is assessing the sacral area using a video camera. The nurse compares the site from a visit made 1 month ago (see figure part A) to the assessment made at this visit (see figure part B). Upon comparing the change of the pressure ulcer from this visit to the previous visit, what should the nurse do next?

Contact the health care practitioner (HCP) to request a hydrocolloid dressing. The pressure ulcer has changed from stage I to stage II and requires the use of a protective dressing. Repositioning and use of foam mattresses are appropriate interventions for stage I pressure ulcers. While the daughter can take pictures and send them to the nurse, it is the nurse's responsibility to make decisions about needed care. Telehealth monitoring equipment is providing sufficient visualization of the skin changes; the nurse does not need to make a home visit at this time.

Which is the correct order, from first to last, for proper placement of a urinary catheter? All options must be used.

Prepare a sterile field. Lubricate the catheter adequately with a water-soluble lubricant. Insert the catheter far enough into the bladder to prevent trauma to the urethral tissue. Ensure free flow of urine. After gathering appropriate supplies, the nurse should prepare a sterile field. After lubricating the catheter adequately with a water-soluble lubricant to minimize trauma to the urethra, the nurse should insert the catheter far enough into the bladder so the retention balloon does not traumatize urethral tissues. Ensuring a free flow of urine prevents infection; improper drainage occurs when tubing is kinked or twisted.

A client hasn't voided since before surgery, which took place 8 hours ago. When assessing the client, a nurse will

palpate the bladder above the symphysis pubis. Eight hours is a long time not to have voided. The kidneys typically produce 35 to 55 ml of urine in 1 hour. After 8 hours of not voiding, the bladder would be full of urine and palpable above the symphysis pubis.

After returning home, a client who has had cataract surgery will need to continue to instill eye drops in the affected eye. The client is instructed to apply slight pressure against the nose at the inner canthus of the eye after instilling the eye drops. What is the expected outcome of applying pressure? Pressure:

prevents the medication from entering the tear duct. Applying pressure against the nose at the inner canthus of the closed eye after administering eye drops prevents the medication from entering the lacrimal (tear) duct. If the medication enters the tear duct, it can enter the nose and pharynx, where it may be absorbed and cause toxic symptoms. Eye drops should be placed in the eye's lower conjunctival sac. Applying pressure will not prevent the drug from running down the face as long as the drops are instilled in the eye. Pressure does not affect the cornea or facilitate distribution of the medication over the eye surface.

Which is the correct technique when the nurse is instilling eye drops for an adult who is alert? Select all that apply.

Hold the dropper over the eye, and instill the drops into the lower lid. Have the client tilt the head back and look up. Blot excess drops from the client's face. Correct technique for instilling eyedrops includes having the client tilt the head back and look up to protect the cornea; holding the dropper over the eye and pulling the lower eyelid down to release the drops in the conjunctival sac.The client should not apply pressure on the eyes and can gently apply pressure over the inner canthus to prevent systemic absorption of the drug, but is not told to apply pressure to the eyes. The drops should not be instilled on the cornea.After instilling the medication the nurse can blot any excess medication from the clients face.

A nurse is performing a wound irrigation during a client's postoperative dressing change. Which action would be most important in preventing wound infection with the procedure?

pouring wound cleaner from the clean end of wound to the dirty end All of these actions are parts of a general procedure with changing a dressing that needs wound irrigation. The nurse should change gloves before applying a new dressing, but with the wound irrigation, it is most important to ensure the irrigating fluid drains from the clean part of the wound to the dirty part. In this way, the wound doesn't get contaminated and the waterproof pad is in place to protect other surfaces, including the linens on the bed. The client should be in a position for ease of access but this doesn't prevent infection of the wound but makes it easier for the nurse to perform the irrigation.

A client is admitted to the labor and delivery unit at 30 weeks' gestation. She has a history of cesarean birth, and reports severe abdominal pain that started less than one hour ago. When the nurse palpates tetanic contractions, the client again reports severe pain. After the client vomits, she states that the pain is better and then loses consciousness. The fetal heart rate is 100. What is the nurse's priority intervention?

Prepare the client for immediate surgery Uterine rupture is a medical emergency that may occur before or during labor. Signs and symptoms typically include abdominal pain that may ease after uterine rupture, vomiting, vaginal bleeding, hypovolemic shock, and fetal distress. The client should be prepared for immediate surgery to save her life and that of the fetus. While assessing and relieving pain are important, they are not priorities in this life-threatening situation. Placing the client in a left lateral position will not affect her condition. Antibiotics may be administered but aren't the highest priority in this situation.