Comprehensive Practice
A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethazine hydrochloride (Phenergan) 50 mg IM to a preoperative client. List the order in which the nurse must carry out the following actions prior to the administration of preoperative medications. Raise the side rails on the bed Instruct the client to remain in bed Have the client empty bladder Place the call bell within reach
1. Have the client empty the bladder. The first step in the process is to have the client void prior to administering the pre-operative medication. If the client does not have a catheter, it is important to empty the bladder before receiving preoperative medications to prevent bladder injury (especially in pelvic surgeries). Else, a straight catheter or an indwelling catheter may be ordered to ensure the bladder is empty. 2. Instruct the client to remain in bed. Preoperative medications can cause drowsiness and lightheadedness which may put the client at risk for injury. 3. Raise the side rails on the bed. Raising the side rails on the bed helps prevent accidental falls and injury when the client decides to get out of the bed without assistance. 4. Place the call bell within reach. Call bells should always be within the reach of a client.
A female client with severe renal impairment is receiving enoxaparin (Lovenox) 30 mg SUBQ BID. Which laboratory value due to enoxaparin should the nurse report to the healthcare provider? A- creatinine clearance 25 mL/ minute B- calcium 9 mg/dl C- hemoglobin 12 grams/dl D- partial thromboplastin time (PTT) 30 seconds
A
The nurse plans to evaluate the effectiveness of a bronchodilator. Which assessment datum indicates that the desired effect of a bronchodilator has been achieved? A. Increased oxygen saturation B. Increased urinary output C. Decreased apical pulse rate D. Decreased blood pressure
A Bronchodilators increase the diameter of the bronchioles, resulting in improved oxygenation, reflected by an increase in oxygen saturation. Options B, C, and D do not indicate the desired effect of a bronchodilator.
After administration of a 0730 dose of Humalog 50/50 insulin to a client with diabetes mellitus, which nursing action has the highest priority? A. Ensure that the client receives breakfast within 30 minutes. B. Remind the client to have a midmorning snack at 1000. C. Discuss the importance of a midafternoon snack with the client. D. Explain that the client's capillary glucose will be checked at 1130.
A Insulin 50/50 contains 50% regular and 50% NPH insulin. Therefore, the onset of action is within 30 minutes and the nurse's priority action is to ensure that the client receives a breakfast tray to avoid a hypoglycemic reaction. Options B, C, and D are also important nursing actions but are of less immediacy than option A.
A client tells the nurse that he is suffering from insomnia. Which information is most important for the nurse to obtain? A. The client's usual sleeping pattern B. Whether the client smokes C. How much liquid the client consumes before bedtime D. The amount of caffeine that the client consumes during the day
A The first thing to determine is the client's usual sleeping pattern and how it has changed to become what the client describes as insomnia. Options B, C, and D provide additional information after option A is ascertained.
The nurse prepares to administer the prescribed aspirin to a client. Which client conditions cause the nurse to hold the medication? (Select all that apply.) A. The client has a history of being in multiple alcohol treatment programs. B. The client is receiving heparin for the presence of deep vein thrombosis. C. The client experiences severe pain related to a diagnosis of osteoarthritis. D. The client takes an oral hypoglycemic for treatment of type 2 diabetes mellitus. E. The client has a recent history of a respiratory infection and elevated temperature.
A, B, D 1. Aspirin is a possible cause of gastric discomfort and is an increased risk for the development of gastric ulcers. With a history of alcoholism and multiple treatment events, this client is already at risk for gastric ulcers. The nurse will hold the aspirin for this client. 2. Aspirin is contraindicated for clients receiving anticoagulant drugs, such as heparin or warfarin. Aspirin is known to have significant anticoagulant activity and will increase a client's bleeding time. The nurse should hold the aspirin for this client. 3. Aspirin is known to be effective for the pain and inflammation related to osteoarthritis. The nurse will not hold the aspirin prescribed for this client. 4. Aspirin may potentiate the action of oral hypoglycemic drugs given for type 2 diabetes mellitus. Therefore, the aspirin should be held to avoid causing hypoglycemia. 5. Aspirin is effective in treating the pain and discomfort associated with a respiratory infection, and produces mild to moderate relief of fever. The nurse will not hold the aspirin prescribed for this client.
A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? (Select all that apply.) a- Monitor abdominal girth. b- Increase oral fluid intake to 1500 ml daily. c- Report serum albumin and globulin levels. d- Provide diet low in phosphorous. e- Note signs of swelling and edema.
A, C, E Rational: monitoring for increasing abdominal girth and generalized tissue edema and swelling are focused assessments that provide data about the progression of disease related complications. In advanced cirrhosis, liver function failure results in low serum albumin and serum protein levels, which caused third spacing that results in generalized fluid retention and ascites. Other options are not indicated in end stage liver disease.
What instruction(s) related to foot care is(are) appropriate for the client with type 1 diabetes mellitus? (Select all that apply.) A. Use lanolin to moisturize the tops and bottoms of the feet. B. Soak the feet in warm water for at least 1 hour daily. C. Wash feet daily and dry well, particularly between the toes. D. Use over-the-counter products to remove corns and calluses. E. Wear leather shoes that fit properly.
A, C, E Are therapeutic interventions for foot care in the diabetic client. Options B and D are contraindicated and could cause foot infection or injury.
The nurse manager in a pediatric clinic presents an in-service program to staff members about parental consent requirements. After the program, which clients will the nurse expect staff to recognize as needing parental consent? (Select all that apply.) A. A minor in college who requires emergency surgery. B. A minor who is married and the parent of a toddler child. C. Minors who are determined to be emancipated by a court. D. A school-age client who lives with a grandparent and requires an MRI. E. An adolescent who seeks screening for a sexually transmitted infection.
A, D 1. A minor who is in college and requires emergency surgery will need parental consent. An exception would be if the minor were emancipated, which is not indicated. 2. A minor who is married and is a parent of a toddler child is considered emancipated. This client would not need parental consent for medical treatment. 3. Minors who are emancipated by the court do not need parental consent for medical care. 4. A school-age client who is currently living with a grandparent will still require parental consent for medical treatment. An exception is if the grandparent has full custody of the client, which is not indicated.5. An adolescent client who is seeking screening for a sexually transmitted infection (STI) does not need parental consent. This is an exception to allow minors to seek medical treatment in a confidential manner. Without such an exception, the opportunity for assistance may be lost.
At a community health fair, the blood pressure of a 62-year-old client is 160/96 mmHg. The client states "My blood pressure is usually much lower." The nurse should tell the client to: a. Go get a blood pressure check within the next 15 minutes b. Check blood pressure again in two months c. See the healthcare provider immediately d. Visit the health care provider within one week for a BP check
A. Go get a blood pressure check within the next 15 minutes The blood pressure reading is moderately high with the need to have it rechecked after a few minutes to verify. The client states it is 'usually much lower.' Thus a concern exists for complications such as stroke.
A 25-year-old male client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication: a. Should be taken in the morning b. May decrease the client's energy level c. Must be stored in a dark container d. Will decrease the client's heart rate
A. Should be taken in the morning Levothyroxine (Synthroid) has a side effect of insomnia. Taking it in the morning could prevent interfering with the client's sleeping pattern.
The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is: a. Verify correct placement of the tube b. Check that the feeding solution matches the dietary order c. Aspirate abdominal contents to determine the amount of last feeding remaining in stomach d. Ensure that feeding solution is at room temperature
A. Verify correct placement of the tube Proper placement of the tube prevents aspiration and entrance of food content into the lungs. The definitive way to ascertain the position of the nasogastric tube is through visualization by an x-ray. Another method is to aspirate stomach contents and check its pH (usually pH 1 to 5). Aspirated stomach content can also be tested for bilirubin to confirm it is placed in the stomach.
A 16-year-old adolescent with meningococcal meningitis is receiving a continuous IV infusion of penicillin G, which is prescribed as 20 million units in a total volume of 2 liters of normal saline every 24 hr. The pharmacy delivers 10 million units/liters of normal saline. How many ml/hr should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.)
Answer 83
The nurse plans to collect a 24- hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client? A- Clearance around the meatus, discard first portion of voiding, and collect the rest in a sterile bottle B- Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours. C- For the next 24 hours, notify the nurse when the bladder is full, and the nurse will collect catheterized specimens. D- Urinate immediately into a urinal, and the lab will collect specimen every 6 hours, for the next 24 hours.
B
A client is treated in the emergency department for an anaphylactic reaction and receives two doses of epinephrine. The client's medical health history indicates that the client takes human regular insulin for a diagnosis of diabetes mellitus. Which action is most appropriate if the client begins to exhibit restlessness, irritability, diaphoresis, and tremors? A. Administer a prescribed dose of lorazepam for anxiety. B. Obtain a blood glucose level to determine hypoglycemia. C. Initiate safety measures to prevent injury related to restlessness. D. Use therapeutic communication techniques to decrease irritability.
B. 1. A client experiencing anaphylaxis may exhibit restlessness and tremors in response to two doses of epinephrine. Administration of the anti-anxiety drug, lorazepam, may help the client to relax. However, not all the manifestations support this action. 2. The nurse should recognize the client's collective symptoms as an indication of hypoglycemia. Therefore, it is most appropriate to obtain a blood glucose level and respond accordingly. The nurse must remember that epinephrine is a drug that will antagonize hypoglycemic effects. Other drugs to consider are corticosteroids and thyroid hormones. 3. Safety measures are always important. However, not all of the client's manifestations are addressed by this action. 4. The use of therapeutic communication techniques may be effective in reducing the client's irritability. However, not all the manifestations support this action.
The nurse provides care for a client admitted with a diagnosis of sepsis. Which assessment data does the nurse recognize as the early development of systemic inflammatory response syndrome (SIRS) when providing client care? A. Blood glucose level rises from 180 mg/dL (9.99 mmol/L) to 220 mg/dL (12.2 mmol/L) in one hour. B. Temperature is 101°F (38.3°C), pulse is 98 beats/minute, and respirations are 26 breaths/minute. C. Bleeding from IV sites and body orifices indicating disseminated intravascular coagulation (DIC). D. Hourly urinary output continues to decrease, and last urinary output assessment indicates 5 mL/hour.
B. 1. Another indication of severe sepsis with amplified SIRS is increasing levels of hyperglycemia. The lab values listed indicate a notable increase in blood glucose levels. 2. The criteria for sepsis with SIRS can include a temperature of more than 101°F (38.3°C) or less than 96.8°F (36°C). Other indicators of SIRS is a pulse greater than 90 beats/minute, and a respiratory rate greater than 20 breaths/minute. 3. When bleeding occurs from IV sites and body orifices, it is indicative of the client developing DIC, which supports severe sepsis with amplified SIRS. 4. Septic shock is identified when organ failure occurs. An hourly urine output of 5 mL/hour is indicative of kidney failure.
A nurse with 10 years‟ experience working in the emergency room is reassigned to the perinatal unit to work an 8-hour shift. Which client is best to assign to this nurse? a- A client who is leaking clear fluid b- A mother who just delivered a 9 pounds boy c- A mother with an infected episiotomy. d- A client at 28- weeks‟ gestation in pre-term labor.
C An infected episiotomy is essentially an infected surgical incision, and an experienced emergency room nurse is likely be able to care for such a client. A, B and D required specialized maternity nursing care.
When caring for a postpartum client, which intervention is best for the nurse to implement to promote increased peripheral vascular activity? A. Encourage the client to turn from side to side every 2 hours. B. Elevate the foot of the client's bed at least 6 inches. C. Encourage the client to ambulate every 3 hours. D. Teach the client how to perform leg exercises while in bed.
C Ambulation is the best way to increase peripheral vascular activity. Options A, B, and D will increase peripheral vascular activity but are not as effective as ambulation.
The nurse is teaching the parents of a 10-year-old child with rheumatoid arthritis measures to help reduce the pain associated with the disease. Which instruction should the nurse provide to these parents? A. Administer a nonsteroidal anti-inflammatory drug (NSAID) to the child prior to getting the child out of bed in the morning. B. Apply ice packs to edematous or tender joints to reduce pain and swelling. C. Warm the child with an electric blanket prior to getting the child out of bed. D. Immobilize swollen joints during acute exacerbations until function returns.
C Early morning stiffness and pain are common symptoms of rheumatoid arthritis. Warming the child in the morning helps reduce these symptoms. Although moist heat is best, an electric blanket could also be used to help relieve early morning discomfort. Option A on an empty stomach is likely to cause gastric discomfort. Warm (not cold) packs or baths are used to minimize joint inflammation and stiffness. Option D is contraindicated, because joints should be exercised, not immobilized.
The only RN on a surgical unit is performing an admission assessment on a client scheduled for surgery in 2 hours. The UAP reports to the RN that an unresponsive male client with a continuous feeding tube has just vomited. Which action should the RN delegate to the UAP? A. Obtain the remainder of the preoperative admission information. B. Check the vomiting client for signs of tube feeding aspiration. C. Position the client who has vomited on his side and obtain vital signs. D. Teach the preoperative client coughing and deep breathing exercises.
C The UAP can be assigned to perform tasks that do not require the judgment of the nurse, such as positioning the client and obtaining vital signs. Options A and B involve assessment, which should be performed by a nurse. Option D involves initial client teaching, which should be performed by the nurse.
A nurse-manager of a long-term care facility learns that the nursing administrator plans to remove the television from the residents' day room because night shift staff members are sitting around watching television. How should the nurse-manager respond to this situation? A. Advocate for the rights of the staff to watch television once their assignments are complete. B. Confront the administrator about making a decision that will negatively affect the residents. C. Offer to develop an alternate solution so that the residents can continue to watch television. D. Remind the administrator that watching television helps the night shift staff remain awake.
C The role of the nurse-manager in the mediation process is to assess the problem, analyze the information, and reframe it in a manner that might provide compromise. The staff do not have the right to watch television while being paid to work. Option B challenges the administrator and is likely to alienate the administrator, causing anger and shutting off further communication. Option D is not a sound rationale for the use of the television.
While assessing a one-month-old infant, which of the findings warrants further investigation by the nurse? Select all that apply. A. Abdominal respirations B. Irregular breathing rate C. Inspiratory grunt D. Increased heart rate with crying E. Nasal flaring F. Cyanosis G. Asymmetric chest movement
C, E, F, G C. Grunting occurs when an infant attempts to maintain an adequate functional residual capacity in the face of poorly compliant lungs by partial glottic closure. As the infant prolongs the expiratory phase against this partially closed glottis, there is a prolonged and increased residual volume that maintains the airway opening and also an audible expiratory sound. E: Nasal flaring occurs when the nostrils widen while breathing and is a sign of troubled breathing or respiratory distress. F: Cyanosis refers to the bluish discoloration of the skin and indicates a decrease in oxygen attached to the red blood cells in the bloodstream. G: Asymmetric chest movement occurs when the abnormal side of the lungs expands less and lags behind the normal side. This indicates respiratory distress. -------------------------------------------------------------- A: Abdominal respiration is normal among infants and young children. Since their intercostal muscles are not yet fully developed, they use their abdominal muscles much more to pull the diaphragm down for breathing. B: Newborns can have irregular breathing patterns ranging from 30 to 60 breaths per minute with short periods of apnea (15 seconds). D: An increase in heart rate is normal for an infant during activity (including crying). Fluctuations in heart rate follow the changes in the newborn's behavioral state - crying, movement, or wakefulness corresponds to an increase in heart rate.
The nurse provides care for a number of clients in an acute care setting. Which client issues will prompt the nurse to follow up with the client's health care provider? (Select all that apply.) A. A client who is 6 hours postoperative with an oral temperature of 100.7°F (38.2°C). B. A client admitted from the ED following seizure activity, who is lethargic and sleepy. C. A client who has a moderate amount of creamy red drainage on a surgical dressing. D. A client with a cardiac disorder and a serum potassium level of 4.7 mEq/L (4.7 mmol/L). E. A client with dehydration who has an hourly urinary output of 25 mL of dark amber urine.
C. 1. A client who is 6 hours postoperative will have an elevated temperature from the body's response to surgical trauma. The temperature increase is expected and not elevated enough to require the nurse to follow up. 2. After a client has a seizure, it is expected for the client to be lethargic and sleepy. The nurse will make sure that the client is on seizure precautions and safety needs are met. The nurse will not follow up with the health care provider. 3. Creamy red drainage from a surgical site is indicative of an infection. The nurse will follow up with the the client's health care provider to report the finding and receive any new prescriptions. 4. A client with a cardiac disorder has a normal serum potassium level of 4.7 mEq/L (4.7 mmol/L). There is no reason for the nurse to follow up on this client's laboratory report. 5. A client who is dehydrated will be placed on strict I&O. The nurse notes an hourly output of 25 mL of dark amber urine and will recognize that follow up with the health care provider is necessary. The amount of urine is below the normal range (30 mL/hour). Therefore, the nurse needs to follow up with the health care provider. The dark color of the urine is expected with dehydration.
A client is treated for cardiac dysrhythmias. The health care provider prescribes the calcium channel blocker verapamil, 80 mg orally every 6 hours. Which assessment finding does the nurse identify as a serious adverse effect of the medication? A. Dizziness. B. Flushed skin. C. Mood changes. D. Peripheral edema.
C. 1. Dizziness is a common adverse effect for clients prescribed verapamil. The nurse needs to initiate safety measures to prevent injury from the increased risk for falls. 2. Flushed skin is a common adverse effect for clients prescribed verapamil. The nurse should monitor the client's vital signs to rule out the presence of fever. 3. Mood changes are an indication that the client is experiencing a serious adverse effect related to verapamil. The nurse should report the assessment finding to the health care provider. Other serious adverse effects include hepatotoxicity, heart failure, myocardial infarction, and confusion. 4. Peripheral edema is a common adverse effect for clients prescribed verapamil. The nurse should monitor the degree of edema and teach the client to keep extremities elevated above the level of the heart when possible. The client should also be made aware of the manifestations of heart failure related to peripheral edema.
The nurse provides care for a client diagnosed with tuberculosis (TB). Which information does the nurse consider when determining if the client's treatment is effective? A. The client has been on a regimen of isoniazid (INH) for 7 days. B. The client's chest x-ray is clear and without the presence of lesions. C. The client's sputum culture is negative after 3 months of medication. D. The client no longer has a cough that produces blood streaked mucus.
C. Rationale: 1. A client must be on a regimen of isoniazid (INH) for a period of 2 to 3 weeks before the risk of TB transmission is reduced. A regimen of 7 days is too short to determine if treatment is effective. 2. A client diagnosed with TB will not have a clear chest x-ray free from lesions. A chest x-ray is used after a positive skin test to detect active TB or old, healed lesions, which are permanent. 3. A sure and valid method of determining treatment effectiveness of treatment for a client with TB is with a sputum culture. Cultures are usually negative after 3 months of prescribed treatment. 4. The absence of a cough and/or of blood streaked mucus is not a valid method of determining if a client's treatment for TB is effective.
The nurse assesses vital signs for multiple clients. Which assessment and client condition will cause the nurse the most concern? A. The postoperative client medicated 3 hours prior for pain with a blood pressure of 194/88 mm Hg. B. The older adult client diagnosed with bacterial pneumonia with a temperature of 100.8°F (38.2°C). C. The adult client receiving patient controlled administration of morphine who has a respiratory rate of 9 breaths/minute. D. The adult client admitted through the ED following a car accident with a pulse rate of 92 beats/minute.
C. 1. The nurse will be concerned about the postoperative client who was medicated 3 hours ago for pain. The client's blood pressure is elevated, which is likely to be indicative of needing additional pain medication. However, of the clients presented, this is not the client that will cause the nurse the most concern. 2. The nurse would expect an older adult client diagnosed with bacterial pneumonia to have an elevated temperature. A temperature of 100.8°F (38.2°C) will not cause the nurse concern. However, the temperature and other vital signs should be assessed on a regular basis. 3. Morphine is a narcotic drug used for pain control. One adverse effect of morphine is respiratory suppression. A respiratory rate of 9 breaths/minute is low and the nurse should be most concerned about this client. The client may need to have the dosage of morphine decreased or have the time between doses increased. 4. There is no reason for the nurse to be most concerned about the client who has a pulse rate of 92 beats/minute following a car accident. However, the nurse will continue to monitor the client for changes that are indicative of hemorrhage or shock.
Which pathophysiologic response supports the contraindication for opioids, such as morphine, in clients with increased intracranial pressure (ICP)? A. Sedation produced by opioids is a result of a prolonged half-life when the ICP is elevated. B. Higher doses of opioids are required when cerebral blood flow is reduced by an elevated ICP. C. Dysphoria from opioids contributes to altered levels of consciousness with an elevated ICP. D. Opioids suppress respirations, which increases PCO2 and contributes to an elevated ICP.
D The greatest risk associated with opioids such as morphine is respiratory depression that causes an increase in PCO2, which increases ICP and masks the early signs of intracranial bleeding in head injury. Options A, B, and C do not support the risks associated with opioid use in a client with increased ICP.
A client with inflammatory arthritis who takes prednisone is scheduled for an elective surgery. Which client teaching is most important for the nurse to provide? A. The purpose of coughing and deep breathing after anesthesia. B. The resources that are available to assist with care after discharge. C. The signs and symptoms that indicate the development of infection. D. The explanation of a precise schedule for stopping steroid medication.
D. 1. The nurse will promote client compliance by explaining the purpose for coughing and deep breathing after anesthesia. The information is important in order to prevent respiratory complication. However, it is not the most important teaching for this client. 2. Preoperative teaching about available client care resources following surgery is important, and is based on each client's specific needs. However, it is not the most important teaching for this client. 3. The nurse will teach the client how to recognize the signs and symptoms that indicate the development of infection in order to promote healing and prevent complications. However, this is not the most important teaching for this client. 4. The most important teaching for this client is to explain the precise schedule to follow for stopping the prescribed prednisone. Dose adjustment is required before surgery. However, the drug needs to be gradually decreased to prevent withdrawal symptoms and to promote adrenal recovery.
Which findings would suggest to the nurse that diagnosis of glomerulonephritis is correct? A. History of pneumonia. B. Hypotension C. Polyuria D. Hematuria
Patients with glomerulonephritis experience dark colored urine due to hematuria. They experience hypertension, not hypotension so option B is incorrect. They experience oliguria, thus option is C incorrect and they have a history of strep throat not pneumonia.
An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. What effect is the nurse likely to note because of this increases in glaucoma surgeries? A- Decrease morbidity in the elderly population B- Decrease prevalence of glaucoma in the population. C- Increase mortality in the elderly population D- Increased incidence of glaucoma in the population.
Rationale: Prevalence describe the number of existing causes of glaucoma. Since glaucoma occurs mostly in the elderly population and the elderly are obtaining the curative surgery, a decrease prevalence of glaucoma in the population at large can be expected.