Content Mastery exam

The nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. When describing a healthy stoma, which statement should the nurse be sure to include? -"The stoma should appear dark and have a bluish hue." -"At first, the stoma may bleed slightly when touched." -"The stoma should remain swollen distal to the abdomen." -"A burning sensation under the stoma faceplate is normal."

"At first, the stoma may bleed slightly when touched."

The nursing instructor asks the nursing student why shouldn't the nurse palpate both carotid arteries at the same time. Which response by the student is correct? -"The pulse can't be checked accurately if the arteries are palpated at the same time." -"Checking both carotid arteries at the same time may cause transient hypertension." -"Checking both carotid arteries at the same time may impair cerebral circulation." -"Checking both carotid arteries at the same time may cause severe tachycardia."

"Checking both carotid arteries at the same time may impair cerebral circulation."

The health care provider writes the following order for a client: "Digoxin .125 mg by mouth once daily." To prevent a dosage error, how should the nurse transcribe this order onto the medication administration record?

"Digoxin 0.125 mg by mouth once daily" Explanation: The nurse should always place a zero before a decimal point so that no one misreads the figure, which could result in a dosage error. The nurse should never insert a zero at the end of a dosage that includes a decimal point because this could be misread, possibly leading to a tenfold increase in the dosage.

A client presents to the emergency department with a closed head injury. What would the nurse ask the client to help assess cerebral function? -"Have you noticed a change in your memory?" -"Have you noticed a change in your muscle strength?" -"Have you had any coordination problems?" -"Have you had any problems with your eyes?"

"Have you noticed a change in your memory?"

A client is to be discharged on daily medication delivered by a transdermal disk. Which statement, given to the nurse by the client, indicates the need for further medication teaching?

"I'll place the disk on the same spot time." Explanation: A transdermal disk should be applied to a different site each time. The client should avoid placing it on uneven, damaged, or irritated skin, or on areas below the knee or elbow. The other options indicate an understanding of transdermal disk use.

A client with diabetes mellitus is receiving insulin. The nursing instructor asks the nursing student to correctly describe an insulin unit. How does the student appropriately respond?

"It is a measure of effect, not a standard measure of weight or quantity." Explanation: An insulin unit is a measure of effect, not a standard measure of weight or quantity. Different drugs measured in units may have no relationship to one another in quality or quantity. In the apothecary system, the minim is the smallest liquid unit of measurement and the grain is the smallest solid unit of measurement. In the avoirdupois system, solids include the ounce and pound. In the metric system, the liter is used for liquids and the gram is used for solids.

The nursing instructor asks the nursing student why should an infant be quiet and seated upright when the nurse checks his or her fontanels. Which is the best response? -"The mother will have less trouble holding a quiet, upright infant." -"Lying down can cause the fontanels to recede, making assessment more difficult." -"The infant can breathe more easily when sitting up." -"Lying down and crying can cause the fontanels to bulge."

"Lying down and crying can cause the fontanels to bulge."

The newly hired graduate nurse asks the nurse preceptor about heart sounds. Which information regarding heart sounds would the nurse preceptor include in his explanation? -"S1 and S2 sound equally loud over the entire cardiac area." -"S1 and S2 sound fainter at the apex." -"S1 and S2 sound fainter at the base." -"S1 is loudest at the apex, and S2 is loudest at the base."

"S1 is loudest at the apex, and S2 is loudest at the base."

A client is diagnosed with cancer and is told that surgery followed by chemotherapy will be necessary. The client states to the nurse, "I have read a lot about complementary therapies. Do you think I should try any?" The nurse should respond by making which appropriate statement? -"I would try anything that I could if I had cancer." -"No, because it will interact with the chemotherapy." -"Tell me what you know about complementary therapies." -"You need to ask your primary health care provider about it."

"Tell me what you know about complementary therapies."

The nurse is caring for a client who has suffered a severe stroke. During data collection, the nurse notices Cheyne-Stokes respirations. The client inquires about Cheyne-Stokes respirations. What information would the nurse include in her explanation? -"They are progressively deeper breaths followed by shallower breaths with apneic periods." -"They are rapid, deep breaths with abrupt pauses between each breath." -"Cheyne-Stokes are rapid, deep breaths and irregular breathing without pauses." -"Cheyne-Stokes shallow breaths with an increased respiratory rate."

"They are progressively deeper breaths followed by shallower breaths with apneic periods."

When auscultating a client's chest, the nursing student assesses a second heart sound (S2) and asks the nursing instructor why. How would the nursing instructor appropriately respond? -"This sound results from opening of the mitral and tricuspid valves." -"This sound results from closing of the mitral and tricuspid valves." -"This sound results from opening of the aortic and pulmonic valves." -"This sound results from closing of the aortic and pulmonic valves."

"This sound results from closing of the aortic and pulmonic valves."

The nurse is precepting a graduate nurse and preparing to give infant immunizations. The preceptor asks the graduate, "Infant injections should only be given in which muscle?" What is the best response by the graduate nurse?

"vastus lateralis"

A client is to be started on furosemide. Which interventions should be included in the teaching plan? Select all that apply.

-Advise the client to reduce dietary sodium intake. -Tell the client to alert the health care provider about any visible edema. -Instruct the client to take the medication as directed

A client is prescribed ampicillin 125 mg IM every 6 hours to a 10 kg child with a respiratory tract infection. The drug label reads, "The recommendeddose for a client weighing less than 40 kg is 25 to 50 mg/kg/day IM or IV in equally divided doses at 6- to 8-hour intervals." The drug concentration is 125 mg/5 mL. Which nursing interventions are appropriate at this time? Select all that apply.

-Determine if the client has allergies to penicillin. -Administer the medication because the dosage is within the recommended range. -Obtain a sputum culture, if ordered, before administering the medication.

A client with an IV reports pain at the insertion site. Observation of the site reveals a vein that is red, warm, and hard. Which actions should the nurse take? Select all that apply.

-Discontinue the infusion at the affected site. -Apply a warm compress to the IV site. -Document the assessment, nursing actions taken, and the client's response.

A client is prescribed enalapril maleate for the treatment of hypertension. Which instructions should the nurse reinforce regarding the administration of the medication? Select all that apply.

-Instruct the client to avoid salt substitutes. -Advice the client to report facial swelling or difficulty breathing immediately. -Advice the client not to change the position suddenly to minimize orthostatic hypotension.

The nurse is reviewing assessment data and admission orders of a client. The provider has ordered the I.V. administration of phenytoin. The nurse determines that further intervention is required when the admission assessment includes which findings? Select all that apply

-episodic nosebleeds history of Stokes-Adams syndrome -history of bone marrow depression

After reconstituting a multidose vial of medication, the nurse writes the date and time of reconstitution on the vial label. The nurse should write which additional information on the label? Select all that apply.

-nurse's initials or signature -strength of the medication

Which symptoms reported by a client indicate adverse effects of a drug? Select all that apply

-tight feeling in the throat and difficulty breathing -achy joints and a temperature of 101° F (38.3° C) -skin blisters accompanied by intense itching -double vision and difficulty hearing

A nurse is caring for a client with deep vein thrombosis who is scheduled to receive an injection of enoxaparin 75 mg subcutaneously daily. On hand is enoxaparin 100 mg per milliliter (ml). How many milliliter(s) should the nurse administer to the client? Record your answer using two decimal places.

0.75

The label of a drug package reads "hydralazine, 20 mg/ml." How many milliliters would the nurse give a client for a 25-mg dose?

1.25

The physician prescribes 250 mg of a drug. The drug vial reads 500 mg/ml. How much of the drug should the nurse give?

1/2 ml

A client with severe pain is prescribed hydromorphone 10 mg by mouth every 4 hours as needed for pain. The client rates pain as eight on a one-to-ten scale, so the nurse prepares to administer a dose. The oral liquid contained in the unit's opioid stock contains 5 mg/5 mL. How many milliliters of solution should the nurse give to the client? Record your answer using a whole number

10

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

120 ml/hour Explanation: First, the nurse determines how many milliliters (half of the total) to administer over the first 10 hours: 2,400 ml + 2 = 1,200 ml. Then, the nurse determines how many of these milliliters to deliver per hour: 1,200 ml + 10 hours = 120 ml/hour.

The nurse is caring for a client who underwent internal fixation of the right hip. Before administering the client's warfarin, the nurse checks the laboratory report for the client's International Normalized Ratio (INR) results. Which indicates the therapeutic range for this client?

2.0 to 3.0

The client is to receive an I.V. infusion of 3,000 ml of dextrose and normal saline solution over 24 hours. The nurse observes that the rate on the infusion pump is set at 150 ml/hour. If the solution runs continuously at this rate, the infusion will be completed in

20 hours

The health care provider prescribes acetaminophen 650 mg by mouth every 4 hours for a client with a temperature of 102°F (38.8°C) who has a feeding tube in place. The nurse has acetaminophen solution on hand containing 160 mg/5 mL. How many milliliters of solution should the nurse administer? Record your answer using one decimal place.

20.3

A client is to receive a glycerin suppository. When inserting the suppository, the nurse should advance it approximately how far into the client's rectum?

3" (7.5 cm) Explanation: The nurse should advance a rectal suppository far enough into the rectum to pass the internal anal sphincter. In an adult, this distance is approximately 3"

The physician orders dextrose 5% in water, 1,000 ml to be infused over 8 hours. The I.V. tubing delivers 15 drops/ml. The nurse should check that the I.V. is infusing at a rate of:

32 drops/minute. Explanation: Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes). Find the number of milliliters per minute as follows:125/60 minutes X/1 minute60X = 125 2.1 ml/minute. To find the number of drops per minute:2.1 ml/X gtt = 1 ml/15 gtt X = 32 gtt/minute, or 32 drops/minute

The nurse measures a client's temperature at 102° F. What is the equivalent Centigrade temperature? -39° C -47° C -38.9° C -40.1° C

38.9° C

A client is taking Humulin NPH insulin daily every morning. The nurse reinforces instructions to the client and should tell the client that which is the most likely time for a hypoglycemic reaction to occur?

6 to 14 hours after administration

The nurse, in collaboration with the health care practitioner, is performing vision evaluation on four clients. When reviewing the data collection, which client's criteria would suggest to the nurse that further visual evaluation is needed?

9-year-old with 20/20 vision in one eye and 20/40 vision in the other eye on two lines on the Snellen chart

When giving an intramuscular (IM) injection, which angle should the nurse insert the needle into the muscle?

90 degrees

The physician orders ampicillin, 500 mg by mouth every 6 hours. The nurse recognizes this as an example of which type of order?

A standard written order Explanation: A standard written order is an order that applies until the prescriber writes another order to alter or discontinue the first one. Many health care facilities have established policies dictating how long orders for certain classes of drugs, such as opioids or antibiotics, are to remain valid. A single order allows for a one-time dose only. An as-needed order allows for drug administration when the client needs it. A stat order includes such words as now, immediately, or stat.

For which rationale, when administering a Z-track injection, the nurse measures the correct medication dose and then draws a small amount of air into the syringe?

Adding air prevents the drug from flowing back into the needle track.

A client arrives in the emergency department reporting squeezing, substernal pain that radiates to the left shoulder and jaw. The client also reports nausea, diaphoresis, and shortness of breath. What nursing action is a priority?

Administer O2, attach a cardiac monitor, take vital signs, and administer aspirin and sublingual nitroglycerin.

A client with terminal cancer has a PRN order for morphine, 4 mg, IM q3-4hr. The last injection was given at 05:00. The client requests a pain shot again at 07:30. Which is the most appropriate nursing action?

Administer the morphine; evaluate the results of pain relief and notify the health care provider about breakthrough pain

An elderly client, age 75, is admitted to the health care setting. In what manner will the nurse modify this client's data collection? -Shortening it -Talking in a loud voice -Addressing the client by his first name -Allowing extra time for this task

Allowing extra time for this task

Which nursing action is appropriate when administering a glycerin suppository to a client?

Applying a lubricant to the suppository Explanation: A suppository should be lubricated before insertion to ease insertion and reduce discomfort. The nurse should assist the client in a left-side lying position (not right-side lying) to ease insertion. Because suppositories melt at body temperature, they usually require refrigeration until administration. Instructing the client to bear down would cause the anal sphincter to contract, making insertion difficult.

A client has not had a bowel movement for 2 days and is feeling uncomfortable. The physician writes an order that states, "laxative of choice." How should the nurse proceed with this order?

Ask the physician to prescribe a specific laxative.

A client with Parkinson disease who is scheduled for physiotherapy is experiencing nausea and weakness. What is the most appropriate action by the nurse? -Administer an antiemetic to reduce the nausea, and send the client to physiotherapy. -Assess the nausea and weakness, and call physiotherapy to cancel or reschedule the appointment. -Notify the dietitian to change the diet to clear fluids, and cancel physiotherapy until the client's strength resumes. -Place the client on NPO status, and notify the health care provider immediately.

Assess the nausea and weakness, and call physiotherapy to cancel or reschedule the appointment.

The nurse is identifying a unit of packed red blood cells with a coworker before administration. The client's blood type is AB negative. Which blood type can safely be administered to this client?

B negative Explanation: A client with AB negative blood can receive A negative, B negative, and AB negative blood. It's unsafe to administer Rh-positive blood to an Rh-negative client.

The nurse educator is presenting an in-service on pediatric assessments. Why should the educator instruct nursing staff to inspect first and then auscultate when collecting data on a pediatric clients? -Because the nurse's touch may calm the child -Because the child may cry as data collection proceeds, making auscultation difficult -Because the nurse's touch may frighten the child -Because the nurse's hand or stethoscope may feel cold, making the child recoil

Because the child may cry as data collection proceeds, making auscultation difficult

Rho(D) immune globulin is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition?

Being affected by Rh incompatibility

The physician orders an intramuscular (I.M.) injection for a client. The nurse knows which factor may affect the drug absorption rate from an I.M. injection site?

Blood flow to the injection site Explanation: Blood flow to the I.M. injection site affects the drug absorption rate. Muscle tone and strength have no effect on drug absorption. The amount of body fat at the injection site may help determine the size of the needle and the technique used to localize the site; however, it doesn't affect drug absorption (unless the nurse inadvertently injects the medication into the subcutaneous tissue instead of the muscle).

The nurse should suspect an adverse effect in a client who is taking aspirin for arthritis if the client reports which symptom? -Buzzing in the ears -Mild gastric irritation -Mild bleeding of the gums -Decrease in arthritic pain

Buzzing in the ears

A client has just undergone a bronchoscopy. Which priority nursing intervention will the nurse perform at this time?

Check airway patency

A client reports difficulty swallowing when the nurse tries to administer a medication in capsule form. What action should the nurse take to resolve this problem?

Check for availability of a liquid preparation. Explanation: The nurse should find out whether the medication is available in liquid form. Dissolving or breaking the capsule may interfere with drug action or absorption. The nurse shouldn't withhold any medication without first notifying the physician.

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

Check the tubing for kinks and reposition the client's wrist and elbow. Explanation: The nurse should first check for common causes of a decreased I.V. flow rate, such as kinks in the tubing and poor positioning of the affected arm. The nurse should discontinue the I.V. infusion only if other measures fail to solve the problem. Irrigating I.V. tubing may dislodge clots, if present. Elevating the I.V. fluid bag may help if no kinks are found and if repositioning doesn't resolve the problem.

Which finding should the nurse expect to observe in a client with cholelithiasis who is experiencing obstructive jaundice? -Straw-colored urine -Reduced hematocrit -Clay-colored stools -Elevated urobilinogen in the urine

Clay-colored stools

A nurse must evaluate a client's splinted extremity for neurovascular damage. What is the priority action by the nurse? -Evaluate all extremities, ensuring that the extremity with the splint feels cooler. -Manually move the client's fingers and toes to test movement. -Compare color and capillary refill of both extremities. -Be aware that edema and pulse checks are not part of a neurovascular evaluation

Compare color and capillary refill of both extremities

The nurse is preparing to administer an I.V. medication to an unconscious client. What is the bestaction by the nurse?

Compare the client's name and ID on the chart to the client's wristband.

Elderly clients may be concerned about taking too many medications and can be unsure of the reasons for some of the medications. What is the best action by the nurse?

Consult with a pharmacist to discuss the medications, effects, side effects, and interactions; initiate physician referrals as needed.

A nurse is caring for a client who has several medications ordered to treat the diagnosed condition. The client is refusing the medications, stating that the benefits do not outweigh the side effects. What is the nurse's best response to this situation?

Consult with the prescribing physician

When preparing to give a client a prescribed drug, the nurse realizes that the drug is one the nurse has never administered before. No drug references on the nursing unit contain information about the drug in question. What is the nurse's best action?

Contact a pharmacist to obtain information about the drug. Explanation: Pharmacists are the best resources for drug information when print sources aren't available, and they can provide this information quickly and reliably. Pharmacists have more up-to-date and accurate drug information than do physicians and other nurses. The nurse should refuse to give a drug only if no information about the drug is available.

A client has a prescription to take guaifenesin every 4 hours, as needed. The nurse determines that the client understands the most effective use of this medication if the client makes which statement?

Correct response: "I will take the tablet with a full glass of water."

The nurse is teaching a client how to rotate insulin injection sites. The client asks what is the purpose of rotating injection sites. How does the nurse appropriately respond? Select all that apply.

Correct response: "It is to promote adequate drug absorption." "It is to prevent the formation of hard nodules."

The nurse is preparing a client for an intravenous pyelogram (IVP). Which questions are most appropriate to ask before the procedure? Select all that apply

Correct response: -"Are you allergic to iodine or seafood?" -"Do you take any oral hypoglycemic agents?" -"Have you eaten any food before the test?"

A client has just been prescribed oxycodone-acetaminophen following an ankle injury. When the client says, "I am glad I cannot get hooked on this drug," what is the appropriate response from the nurse? Select all that apply

Correct response: -"This drug does have addictive properties." -"It will be very important for you to take this drug only as prescribed.

The nurse is using the Z-track method of intramuscular (IM) injection to administer iron dextran to a client with iron-deficiency anemia. What nursing intervention should be performed when administering this medication? Select all that apply.

Correct response: -Confirm the client's identity before administering the iron dextran. -Change the needle after drawing up the iron dextran. -Before inserting the needle, displace the skin laterally by pulling it away from the injection site. -Inject the iron dextran after aspirating for a blood return.

A client with an intravenous (IV) line reports pain at the insertion site. The nurse obtains information that reveals a red, warm, and hard vein. Which actions should the nurse take? Select all that apply

Correct response: -Discontinue the infusion. -Have the RN restart the infusion in the opposite arm. -Apply warm soaks to the IV site. -Document assessment of the IV site, the nurse's actions, and the client's response.

A client with pancreatitis has been receiving parenteral nutrition (PN) for the past week. Which nursing interventions help determine if the client is receiving adequate nutrition? Select all that apply.

Correct response: -Monitor the client's weight every day. -Monitor serum protein, electrolytes, and blood glucose periodically. -Monitor the client's energy levels.

The nurse transcribes the physician's order onto the client's medication record: September 15, 2012 Administer 10 gtt of timolol maleate ophthalmic solution AU daily. John Bloom, MD Which components of the medication order should the nurse question? Select all that apply:

Correct response: -number of drops -route

The nurse inadvertently gives a client a double dose of a prescribed medication. After discovering the error, whom should the nurse immediately notify? Select all that apply.

Correct response: -the nursing supervisor -the prescriber

A client who is at risk for blood clots after orthopedic surgery is scheduled to receive subcutaneous heparin. A multidose vial of heparin contains 10000 units in 1 mL. How many milliliters should the nurse administer for an ordered dose of 5,000 units?

Correct response: 0.5 mL Explanation: The nurse should administer 0.5 mL of heparin.(1 mL/10000 units) x 5000 units/dose = 0.5 mL/dose.

A client receives a short-acting insulin and an intermediate-acting insulin before breakfast at 0800. Using the chart shown, when should the nurse expect the onset of the intermediate-acting insulin to take effect?

Correct response: 1000 Explanation: The timing of insulin's effects varies according to the type. Referring to the chart, the nurse would note that the onset of action for the intermediate-acting insulin (Humulin NPH) is 1 to 2 hours. Because the administration time was 0800, the effects should begin 1 to 2 hours after administration, at approximately 1000

What is the maximum amount of medication (in milliliters) that a nurse can administer into the deltoid muscle? Record your answer using a whole number

Correct response: 2 Explanation: The deltoid muscle is usually the site for injecting a small amount of medication. If more than 2 mL is given in the deltoid muscle, there is a risk of brachial artery and nerve damage.

A client sustained burns to the entire back and left arm. Using the Rule of Nines, calculate the percentage of burns on this client's body.

Correct response: 27% Explanation: According to the Rule of Nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface; the head, neck, and arms each make up 9% of the total body surface; and the perineum makes up 1%. In this case, the client received burns to the back (18%) and one arm (9%), totaling 27% of the body

The physician orders milk of magnesia, 2 teaspoons by mouth as needed, for a constipated client. What is the equivalent of 1 teaspoon in the metric system?

Correct response: 5 ml

A client is scheduled for an excretory urography at 10 a.m. (1000). An order states to insert a saline lock I.V. device at 9:30 a.m. (0930). The client requests a local anesthetic for the I.V. procedure and the physician orders lidocaine-prilocaine cream (EMLA cream). The nurse should apply the cream at:

Correct response: 7:30 a.m. (0730) Explanation: It takes up to 2 hours for lidocaine-prilocaine cream (EMLA cream) reach its maximum effectiveness. Therefore, if the cannulation is scheduled for 9:30 a.m. (0930), EMLA cream should be applied at 7:30 a.m. (0730). Applying EMLA at 6:30 a.m. (0600) is too early. The other time options are too late for the local anesthetic to be effective.

A client is scheduled to receive levothyroxine at 0900. When the nurse is finally able to administer the medication at 0930, the client is eating breakfast. The nurse knows that levothyroxine should be administered on an empty stomach. Which action by the nurse is best?

Correct response: Administer the medication 30 minutes after the client is finished eating. Explanation: The nurse should delay the administration for 30 minutes after the client finishes eating because food interferes with the drug's absorption

Which method is best when approaching a 2-year-old child to listen to breath sounds?

Correct response: Ask the child if the child would like the nurse to listen to the front or the back of the chest first.

A nurse is monitoring a client receiving intravenous (IV) fluid via pump. The alarm of the pump starts to beep for occlusion. What should the nurse do first?

Correct response: Check the roller clamp.

The nurse is administering medications to a client with advanced Alzheimer's dementia who is confused to person, place, and time. Prior to administering the medication, what action should the nurse perform to verify the client's identity?

Correct response: Compare the name and ID number on the client's wristband to the medication administration record.

The nurse is caring for a client receiving morphine through a PCA pump who reports severe itching on his or her arms and legs bilaterally. What is the nurse's best action?

Correct response: Contact the health care provider.

A client with a fluid volume deficit is receiving an I.V. infusion of dextrose 5% in water and lactated Ringer's solution at 125 ml/hour. Which data collection finding indicates the need for additional I.V. fluids?

Correct response: Dark amber urine Explanation: Normally, urine appears light yellow; dark amber urine is concentrated and suggests decreased fluid intake

A nurse is teaching a client regarding his or her medication schedule. What is the best nursing intervention to improve this client's compliance with the prescribed medication schedule?

Correct response: Devise the simplest medication schedule possible. Explanation: To improve client compliance, nurses should simplify the medication schedule as much as possible. Compliance drops sharply when more than three medications are prescribed

A nurse is evaluating a client for the risk of falls. What information should the nurse collect?

Correct response: Gait and balance information

The nurse is reinforcing dietary instructions to the client prescribed cyclosporine. Which priority food item should the nurse instruct the client to avoid?

Correct response: Grapefruit juice Explanation: A compound present in grapefruit juice inhibits metabolism of cyclosporine. As a result, the consumption of grapefruit juice can raise cyclosporine levels by 50% to 100%, thereby greatly increasing the risk of toxicity

Which nursing intervention takes highest priority when caring for a client who's receiving a blood transfusion?

Correct response: Instructing the client to report any itching, swelling, or dyspnea

The nurse is checking a client's intravenous (I.V.) infusion rate at the beginning of the shift. The nursing Kardex states that the infusion should run at 125 ml/hour. Which information must the nurse know about the drip factor to verify the I.V. drip rate?

Correct response: Number of drops in one milliliter Explanation: The drip factor is the number of drops in one milliliter, not the number of milliliters in one drop. The drip rate refers to the number of drops infused per minute. The flow rate is the number of milliliters, not the number of drops, infused per hour.

A client is prescribed digoxin 0.125 mg by mouth stat. The pharmacy dispenses digoxin 0.25 mg. The nurse promptly administers the medication and then realizes the incorrect dose has been administered. How should the nurse proceed?

Correct response: Obtain vital signs, and immediately notify the primary health care provider and charge nurse of the error

A client reports abdominal pain. During her focused assessment, which action would the nurse implement to aid in her investigation of this complaint?

Correct response: Palpating the painful area last

A nurse administers the client's prescribed antibiotic. The client tells the nurse, "I usually take a white tablet, not a yellow tablet." What is the priority action by the nurse?

Correct response: Perform a recheck of the medication name and strength.

The nurse is examining a client with suspected peritonitis. What nursing intervention does the nurse use to elicit rebound tenderness?

Correct response: Press the affected area firmly with one hand, release pressure quickly, and note any tenderness on release

A client has been prescribed a brand-name medication for a newly diagnosed condition. The client tells the nurse, "I do not know what to do. I cannot afford that medication. I may just have to keep suffering with these symptoms." What should the nurse do to best assist this client?

Correct response: Recommend the client ask the health care provider if the client can take the generic brand of the medication instead of the brand-name medication.

A client is to begin a 6-month course of therapy with isoniazid. The nurse should plan to provide which information to the client?

Correct response: Report yellow eyes or skin immediately. Explanation:Isoniazid is hepatotoxic, and therefore the client is taught to report signs/symptoms of hepatitis immediately (which include yellow skin and sclera)

A nurse is working on the oncology unit when a chemotherapy drug spills on the floor. What should the nurse do next?

Correct response: Restrict access to area of the spill.

A nurse is teaching a client about a newly prescribed drug. What physiological changes does the nurse recognize that could cause a geriatric client to have difficulty learning about prescribed medications?

Correct response: Sensory deficits

After reconstituting a multidose vial of medication, the nurse writes the date and time of reconstitution on the vial label. What else should the nurse write on the label?

Correct response: Strength of the medication

A child with rheumatic fever must have his heart rate measured while awake and while sleeping. Why are two readings necessary?

Correct response: To compensate for the effects of activity on the heart rate

The nurse has an order to administer an iron dextran 50 mg intramuscular (I.M.) injection. When carrying out this order, which method should the nurse utilize?

Correct response: Use the Z-track technique. Explanation: Iron dextran is an iron preparation given using the Z-track technique to prevent leakage into the subcutaneous tissue and staining of the skin. When giving an I.M. injection using the Z-track technique, the nurse pulls the skin laterally away from the injection site to seal the drug in the muscle, inserts the needle at a 90-degree angle, waits 10 seconds after injecting the medication to ensure drug dispersion, and then simultaneously withdraws the needle and releases the skin to seal the needle track

The nurse is preparing to administer an injection from an ampoule. To avoid injury, how should the nurse open the ampoule?

Correct response: Using a pad, break ampoule away from the body. Explanation: Using a pad and breaking the ampoule away from the nurse protects the nurse from cutting from the sharp edge of the broken ampoule. Gloves are thin and can easily be cut by a broken glass

Silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the need for monitoring by the nurse?

Correct response: White blood cell count of 3000

The nurse has just received the shift report. Which client should the nurse assess first?

Correct response: a 60-year-old client admitted with chronic obstructive pulmonary disease (COPD) whose oxygen saturation level is 84%

The nurse is caring for a 2-year-old child following surgery. The nurse is preparing to administer a dose of hydrocodone syrup to the child for postoperative pain. What should the nurse select to administer this drug?

Correct response: an oral syringe Explanation: Oral medications should only be administered using oral syringes.

The nurse is caring for a client who is taking an anticoagulant. The nurse should teach the client to:

Correct response: avoid foods high in vitamin K

A client is receiving furosemide, 40 mg by mouth twice per day. In the plan of care, the nurse should emphasize teaching the client about the importance of consuming:

Correct response: bananas and oranges.

What finding would the nurse expect to see in a client admitted for possible Cushing's syndrome?

Correct response: buildup of adipose tissue in the face and trunk Explanation: In a client with Cushing's syndrome, changes in fat distribution cause adipose tissue to accumulate in the trunk, face (moon face), and dorsocervical areas (buffalo hump).

For a hospitalized client, the health care provider (HCP) orders morphine, 4 mg IM, every 4 hours as needed for pain. However, the client refuses to take injections. Which nursing action is most appropriate?

Correct response: calling the HCP to request an oral pain medication Explanation: The most appropriate action is to call the HCP to request an oral pain medication. By doing so, the nurse is adhering to the client's wishes.

A client who suffered a head injury is receiving 30 mL of aluminum hydroxide through a nasogastric tube every 4 hours because of an increased risk for a stress ulcer. Which potential adverse effect should the nurse monitor for with this client?

Correct response: constipation

The nurse administers an I.M. injection. Afterward, the nurse should:

Correct response: discard the uncapped needle in a puncture-proof container. Explanation: Discarding uncapped needles in a puncture-proof, leakproof container is the appropriate procedure. To reduce the risk of accidental needle sticks, the nurse should never recap a needle.

Which information must be included in a medication order?

Correct response: health care provider's signature Explanation: The health care provider's signature must be included in a medication order. Other components of a medication order include the client's full name, drug name, dosage form, dose amount, administration route, time schedule, and the date and time of the order.

The nurse is assessing the pain level of a postoperative client. The client reports "mild" incisional pain rated at a 4 on the numeric pain scale of 0/10. Which medication should the nurse administer to the client?

Correct response: oxycodone Explanation: Oxycodone is appropriate for mild surgical pain.

The physician orders heparin, 7,500 units, to be administered subcutaneously every 6 hours. The vial reads 10,000 units per milliliter. The nurse should anticipate giving how much heparin for each dose?

Correct response: ¾ ml

The nurse is providing care to a client with asthma. The healthcare provider orders albuterol sulfate INH 2 puffs q 6 hours for maintenance dosing. What should the nurse do Select all that apply.

Correct response: -Clarify the order with the healthcare provider. -Hold the medication.

A nurse is collecting data on a client admitted with a diagnosis of small bowel obstruction. When evaluating the client's pulse rate, what should the nurse remember? -Always count for 30 seconds and multiply by 2. -Count the apical pulse only. -Count the apical or radial pulse for 60 seconds. -Count for 15 seconds and multiply by 4.

Count the apical or radial pulse for 60 seconds.

A client has a nasogastric (NG) tube. The physician prescribes an oral medication that is not available in liquid form. Which action should the nurse utilize to administer the tablet form to this client?

Crush the tablets and prepare a liquid form, and then insert it into the NG tube using a syringe. Explanation: To administer oral medications in tablet form through an NG tube, the nurse must reproduce the disintegration and dissolution processes by crushing the tablets and preparing a liquid form, if appropriate for that medication. After confirming NG tube placement, the nurse then inserts the liquid into the NG tube using a syringe. Washing cut tablets or crushed powder down the tube may cause the medication to stick to the sides of the tube, possibly providing inaccurate dosing and causing the tube to clog.

A client's blood glucose level is 45 mg/dL. Which signs and symptoms should the nurse be alert for in this client? -Decreased level of consciousness (LOC), anxiety, confusion, headache, and cool, moist skin -Kussmaul respirations, dry skin, hypotension, and bradycardia -Polyuria, polydipsia, hypotension, and hypernatremia -Polyuria, polydipsia, polyphagia, and weight loss

Decreased level of consciousness (LOC), anxiety, confusion, headache, and cool, moist skin

Before administering the evening dose of a prescribed medication, the nurse on the evening shift finds an unlabeled, filled syringe in the client's medication drawer. What priority action should the nurse implement?

Discard the syringe to avoid a medication error. Explanation: As a safety precaution, the nurse should discard an unlabeled syringe that contains medication. The other options are considered unsafe because they promote error. While it may be appropriate to speak to the day nurse about the presence and contents of the syringe (and to reinforce that unlabeled, filled syringes present a safety risk), the syringe should first be disposed of to ensure that it does not become the source of a medication error.

The licensed practical nurse (LPN) enters a client's room and finds the client lying on the bathroom floor. The LPN calls the registered nurse, who checks the client thoroughly and then assists the client back into bed. The LPN completes an incident report, and the nursing supervisor and primary health care provider (PHCP) are notified of the incident. Which is the next nursing action regarding the incident? -Place the incident report in the client's chart. -Make a copy of the incident report for the PHCP. -Document a complete entry in the client's record concerning the incident. -Document in the client's record that an incident report has been completed.

Document a complete entry in the client's record concerning the incident

When the nurse arrives at the bedside to bathe an older adult client, the client states, "I don't want a bath." Which action by the nurse is most appropriate?

Explaining why a bath is important to overall health

The nurse is preparing to administer digoxin, 0.125 mg orally, to a client with heart failure. Which vital sign is most important for the nurse to check before administering the medication?

Heart rate

A nurse is explaining how to measure blood pressure in a client who has lymphedema in both arms and requires blood pressure measurement using a thigh cuff. In reference to the client's baseline arm blood pressure, what information would the nurse expect to find when utilizing the thigh? -Higher systolic blood pressure reading -Higher diastolic blood pressure reading -Lower systolic blood pressure reading -Lower diastolic blood pressure reading

Higher systolic blood pressure reading

The nurse is caring for a 62-year-old client with type 2 diabetes. The client takes an oral antidiabetic to control blood glucose levels. The physician prescribed ramipril to help treat this client's elevated blood pressure. The nurse should be alert for which drug interaction?

Hypoglycemia

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

Hypokalemia Explanation: A loop diuretic removes water and, along with it, sodium and potassium. This may result in hypokalemia, hypovolemia, and hyponatremia.

A client comes to the clinic for diagnostic allergy testing. The nurse understands that intradermal injections are used for such testing based on which principle?

Intradermal drugs diffuse more slowly.

A nursing student is preparing to administer a parenteral medication. The nursing instructor asks the student which administration route places a drug directly into the circulation, requiring no absorption. Which method does the student relay to the instructor?

Intravenous (I.V.)

A nurse provides care for a client who developed hives after having an allergic reaction to strawberries. Which finding indicates to the nurse that the client has experienced improvement of symptoms? -Itching is relieved. -The rash improves. -The pain of the rash subsides. -Erythema decreases.

Itching is relieved.

A nurse is performing a focused cardiac assessment. In which position would the nurse ask the client to assume, so he or she can auscultate for heart sounds more easily?

Leaning forward

In which position does the nurse place the client when administering an intramuscular (I.M.) injection into a client's left vastus lateralis muscle?

Lying supine

A 76-year-old client with no debilitating conditions belongs to which geriatric population? -Young-old -Middle-old -Old-old -Frail elderly

Middle-old

What is the priority action that a nurse should take after omitting an ordered medication?

Notify the prescriber

The health care provider prescribes 60 mEq of potassium chloride liquid as a one-time dose. The pharmacy supplies a liquid containing 20 mEq/15 ml. How many milliliters of solution should the nurse administer?

O 45 ml v Explanation: The nurse should administer 45 ml of solution. The nurse can calculate the dose by setting up the following equation: 60 mEq/20 mEq = X ml/15 ml Then cross-multiply the fractions: Xx 20 mEq = 15 ml x 60 mEq Then solve for X: X= 45 ml

The nurse is monitoring the effectiveness of a client's drug therapy. The health care practitioner orders a trough level. When will the nurse obtain the blood sample to measure the trough drug level?

O Immediately before administering the next dose Explanation: Measuring the blood drug concentration helps determine whether the dosing has achieved the therapeutic goal. For measurement of the trough, or lowest, blood level of a drug, the nurse draws a blood sample immediately before administering the next dose. Depending on the drug's duration of action and half-life, peak blood drug levels typically are drawn after administering the next dose.

A client is scheduled for surgery at 8 a.m. While completing the preoperative checklist, the nurse sees that the surgical consent form hasn't been signed. It's time to administer the preoperative analgesic. Which nursing action takes the highest priority in this situation?

O Notifying the surgeon that the consent form hasn't been signed v Explanation: Notifying the surgeon takes priority because informed consent must be obtained before the client receives drugs that can alter cognition. Giving the preoperative analgesic at the scheduled time would alter the client's ability to give informed consent. Obtaining consent for surgery isn't within the scope of nursing practice, although the nurse may confirm or witness consent. Canceling surgery also isn't within the scope of nursing practice.

When preparing to administer a drug dose to a client, the nurse examines the drug label. The nurse understands which information that the Food, Drug, and Cosmetic Act (Canada's Food and Drug Act and Regulations) requires drug labels to display?

O Presence, quantities, and proportions of certain ingredients Explanation: A drug label must state the active ingredients and their quantities and proportions as well as directions for use, a description of the package contents, and certain other information. The law does not require any other information on the label.

The nurse educator is preparing an in-service on administration of sustained-release tablets. Which true statement about sustained-release tablets would the educator include in the preparation?

O They should never be split, crushed, or chewed. v Explanation: Sustained-release tablets should never be split, crushed, or chewed because doing so may alter the drug's absorption rate, causing adverse reactions or subtherapeutic effects.

The nurse is teaching a client how to rotate insulin injection sites. What is the purpose of rotating injection sites?

O To prevent the formation of hard nodules v Explanation: Rotating injection sites promotes adequate drug absorption and prevents the formation of hard nodules caused by repeated injections into the same site. Nodules may impede drug absorption with future injections. Rotating sites doesn't prevent bruising, medication leakage, or erratic drug distribution.

A client presents to the emergency room with abdominal pain and blood in the stool. The client is sweating and appears to be in moderate distress. Which nursing action would be a priority at this time? -Obtain vital signs. -Document history of the symptoms. -Assess bowel sounds and abdominal tenderness. -Insert an NG tube and connect to suction.

Obtain vital signs

A nurse administers the client's prescribed antibiotic. The client tells the nurse, "I usually take a white tablet, not a yellow tablet." What is the priority action by the nurse?

Perform a recheck of the medication name and strength.

A client continually reports of pain after the administration of an oral analgesic. The physician writes an order for the nurse to administer a placebo to the client the next time the client reports of pain. The doctor states, "Tell the client it is a stronger analgesic." What would be the appropriate action by the nurse?

Refuse to administer the placebo to the client.

When checking a client's medication profile, the nurse notes that the client is receiving a drug that is contraindicated in clients with glaucoma. The nurse knows that this client has a history of glaucoma and has been receiving the medication for the past 3 days. What should the nurse do first?

Report the information to the physician to ensure client safety. Explanation: The nurse should report the information to the physician because the client's safety may be endangered. The fact that the client has received the drug for several days doesn't guarantee that giving another dose is safe. Filing an incident report and finding out whether there are extenuating reasons for giving the drug wouldn't address client safety.

A client undergoes a total abdominal hysterectomy. When checking the client 10 hours later, the nurse identifies which finding as an early sign of shock? -Restlessness -Pale, warm, dry skin -Heart rate of 110 beats/minute -Urine output of 30 ml/hour

Restlessness

The nurse is reconstituting a powdered medication a vial. After adding the solution to the powder, which action should the nurse perform next?

Roll the vial gently between palms

A client has been admitted to the hospital with signs of dehydration. Which action would be least beneficial in increasing the client's fluid intake? -Explaining the need for increased fluid -Placing the client's choices of beverages at the bedside -Serving fluids in large amounts -Serving fluids at appropriate temperatures

Serving fluids in large amounts

The nurse has an order to administer intramuscular (I.M.) injection using the Z-track technique. When carrying out this order, what nursing intervention should the nurse implement?

Simultaneously withdraw the needle and release the skin. Explanation: When giving an I.M. injection using the Z-track technique, the nurse pulls the skin laterally away from the injection site, inserts the needle at a 90-degree angle, waits 10 seconds after injecting the medication, and then simultaneously withdraws the needle and releases the skin.

A client is to receive several oral medications. Which nursing instruction or action is appropriate in this situation?

Stating the name and action or use of each medication before administering it Explanation: When administering several oral medications, the nurse should state the name of each medication and its action or use before administering it. The client may take the medications all at once or one at a time with any amount or type of fluid. Leaving medications at the bedside may lead to errors such as the client not taking them. The nurse should always observe the client taking medication to ensure that it has been taken.

After reconstituting a multidose vial of medication, the nurse writes the date and time of reconstitution on the vial label, What else should the nurse write on the label?

Strength of the medication

The nurse is administering two drugs concomitantly to a client. Which interaction, recognized by the nurse, occurs when two drugs with the same qualitative effects produce a response when given together that is greater than the response either drug produces when given alone?

Synergism Explanation: Synergism, or a synergistic effect, occurs when two drugs with the same qualitative effects produce a response when given together greater than either drug produces when given alone. Tolerance is a decreased response or decreased sensitivity of the receptor to a drug. Antagonism occurs when the combined response to two drugs given together is less than the response either drug produces when given alone. Hyporeactivity is a less-than-usual response to a normal drug dose.

A client with a recent history of a stroke has been discharged from the rehabilitation facility with a walker. On a return visit to the health care provider, the nurse observes the gait. Which observation indicates the need to reinforce client education about walker use? -The client moves his weak leg forward with the walker. -The client moves his hands to the chair armrests before lowering himself into the chair. -The client's arms are fully extended when using the walker. -The client backs up to the chair until his legs touch the chair, and then sits down.

The client's arms are fully extended when using the walker.

The nurse is helping a client ambulate for the first time after 3 days of bed rest. Which observation will the nurse document that indicates the client tolerated the activity without distress? -The client took small steps at a rate of 40 to 50 per minute. -The client reported feeling dizzy and weak and perspired profusely. -The client's head was down, with gaze cast down and toes were pointed outward. -The client's pulse and respiratory rates increased moderately during ambulation

The client's pulse and respiratory rates increased moderately during ambulation

A first-term nursing student is preparing to use a stethoscope to auscultate a client's chest. The nursing instructor asks the student to explain the working of the stethoscope. Which statement, provided by the student, about a stethoscope with a bell and diaphragm is true? -"The bell detects high-pitched sounds best." -"The diaphragm detects high-pitched sounds best." -"The bell detects thrills best." -"The diaphragm detects low-pitched sounds best."

The diaphragm detects high-pitched sounds best

A medication order reads "Meperidine 1 ml intramuscular (I.M.) stat." Which action will the nurse responsible for administering the drug base the next step on?

The order should be clarified with the physician. Explanation: The nurse must clarify this order with the physician because meperidine is available in several dosage strengths, and 1 ml may contain varying amounts of the drug. Stat orders need not specify an exact administration time. Meperidine commonly is given I.M. Because the order specifies the drug volume but not the dosage, the nurse shouldn't consider this order correct and valid.

The nurse inadvertently gives a client a double dose of a prescribed medication. After discovering the error, whom should the nurse notify?

The prescriber Explanation: After discovering a medication error, the nurse should immediately notify only those persons who can do something to rectify the error, such as the prescriber, the nursing supervisor, or the pharmacist.

An unconscious client is admitted to the emergency department. The nurse suspects which source is the cause of airway obstruction in this client, as it is the most common source of airway obstruction in the unconscious victim? -A foreign object -Saliva or mucus -The tongue -Edema

The tongue

Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication?

Tinnitus

A client with hypothyroidism is prescribed levothyroxine 0.05 mg by mouth daily before breakfast. As the nurse gives the client the medication, the client states, "What dose am I getting? I've been taking 0.15 mg every day for years." Which action by the nurse is most appropriate?

Verify the dose against the health care provider's prescription in the client's medical record

A client with acute muscle spasms has been taking baclofen. The client calls the clinic nurse because of continuous feelings of weakness and fatigue and asks the nurse about discontinuing the medication. The nurse should make which appropriate response to the client?

Weakness and fatigue commonly occur and will diminish with continued medication use.

During a bedside shift report, the nurse finds that the client is receiving the wrong I.V. solution. Which action by the nurse is indicated?

Write up an incident report describing the error

The nurse is preparing a client who has been newly diagnosed with asthma for discharge. As part of his discharge orders, the client is prescribed albuterol via nebulizer every 8 hours for 3 days, followed by one dose daily thereafter. Which instruction should the nurse include when teaching the client about nebulizer use?

You should take your pulse before and after treatment; if your pulse rate increases by more than 30 beats/minute you should notify your physician.

A child with iron-deficiency anemia has been prescribed iron supplements. The child's parent brings the child to the clinic 3 months later, and the child's hematocrit remains about the same. What information should the nurse first elicit from the parent?

a description of the child's stools

The nurse is teaching a client how to administer subcutaneous (subQ) insulin injections. Which injection site would be appropriate for the client to use?

administer subcutaneous client to Anterior aspect of the thigh

The experienced nurse is confirming the pediatric dose calculated by the graduate practical nurse. The child weighs 84 lb (38.2 kg). The dosage prescribed is atomoxetine 20 mg PO daily. The recommended daily oral dosage is 0.5 mg/kg PO daily in the morning. Following the drug calculations by the graduate nurse, the graduate nurse states that the dosage is close, but not exact, and the health care provider needs to be notified. Which action by the experienced nurse is best?

agreeing and placing the call to the pharmacist

A client with terminal cancer is receiving large doses of opioids for pain control. The client becomes agitated and continues trying to get out of bed but can't stand without the assistance of two people. To reduce the client's risk of falling, which type of restraint should the nurse request for this client?

chemical restraints

A home health nurse is evaluating a client's fall risk. Which observations would concern the nurse?

decreased strength in lower extremities

A client is prescribed misoprostol for treatment of a gastric ulcer. The nurse should be alert for which common adverse reaction related to dosage? -diarrhea -nausea -vomiting -bloating

diarrhea

The nursing instructor is demonstrating a head-to-toe assessment. Which plane would the instructor use to divide the body longitudinally into anterior and posterior regions?

frontal plane

The nurse is caring for a homeless client with pneumonia. Laboratory testing reveals the following results: blood urea nitrogen (BUN) 180 mg/dL, creatinine 30 mg/dL, potassium 6.2 mEg/L, and hemoglobin 6.2%. Based on the health care provider's order below, which drug order should the nurse question?

gentamicin Explanation: Based on the high BUN, creatinine, and potassium levels, the client is in renal failure. Gentamicin is nephrotoxic and can exacerbate the renal failure.

A nurse, driving on a highway, is the first on the scene after a multivehicle collision. Which assessment data for the accident victims would require immediate care? -head injuries -lacerations -bleeding and bruising -controlled bleeding

head injuries

A client has an I.V. line in place for 3 days and begins to report discomfort at the insertion site. Based on the client's progress notes shown, what condition has most likely occurred?

infiltration

A client has an IV line in place for 3 days and begins to report discomfort at the insertion site. Based on the client's progress notes shown, which condition has most likely occurred?

infiltration Explanation: The assessment findings of pallor, swelling, skin that is cool to the touch at the IV insertion site, and a normal WBC count all indicate infiltration. The infusion should be discontinued and restarted in a different site. Phlebitis would be evidenced by redness at the cannula tip and along the vein. Infection would be evidenced by an elevated WBC count.

A facility has a system for transcribing medication orders to a Kardex as well as a computerized medication administration record (MAR). A physician writes the following order for a client: "Prednisone 5 mg by mouth daily for 3 days." The order is correctly transcribed on the Kardex. However, the nurse who transcribes the order onto the MAR neglects to place the limitation of 3 days on the prescription. On the 4th day after the order was instituted, a nurse administers prednisone 5 mg by mouth. During an audit of the chart, the error is identified. The person most responsible for the error is the:

nurse who administered the erroneous dose.

A client underwent a bowel resection and has been using an incentive spirometer postoperatively. Which finding indicates to the nurse that the client's use of incentive spirometry is effective? -oxygen saturation level 96% on room air -respiratory rate 20 breaths per minute and shallow -partial pressure of carbon dioxide (PaCO2) 48 mm Hg -partial pressure of oxygen (PaO2) 78 mm Hg

oxygen saturation level 96% on room air

A client is diagnosed with otitis externa. Which finding should the nurse anticipate during data collection? -pain that occurs when the pinna of the ear is pulled -erythema of the ear canal accompanied by a high fever -symptoms of an upper respiratory infection -history of using cotton-tipped applicators to clean the ear

pain that occurs when the pinna of the ear is pulled

A primipara client at 32 weeks' gestation comes to the hospital reporting vaginal bleeding. She has soaked one peri-pad and has no pain or cramps. Based on this data, the nurse would most likely suspect which condition? -placenta previa -abruptio placentae -vasa previa -incompetent cervix

placenta previa Explanation: Painless vaginal bleeding is the classic sign of placenta previa. Abruptio placentae is painful. Vasa previa occurs with ruptured membranes. An incompetent cervix causes pressure sensations.

A nurse measures a client's apical pulse rate as 82 beats/min while another nurse simultaneously measures the client's radial pulse as 76 beats/min. What term will the nurse use to document this finding? -pulse pressure -pulse deficit -pulse rhythm -pulsus regularis

pulse deficit

A client in a nursing home is receiving continuous nasogastric (NG) feedings. At the start of the shift, a nurse finds the client turned on the side with the bed flat. The feeding is running with a volumetric pump at 75 mL/hour, as prescribed. The formula container is filled with 150 mL of fluid. Based on this information, which action should the nurse take?

raise the head of the bed (HOB) at least 30 degrees Explanation: Clients receiving NG tube feedings should have the HOB elevated at least 30 degrees at all times to prevent aspiration.

A client scheduled for a colonoscopy has received nothing by mouth since midnight. The procedure is scheduled for 8 a.m. At 6:30 a.m. the nurse collects a fingerstick glucose sample that registers 40 mg/dl on the glucose monitor. The client is alert, has clear speech, and states, "I don't feel like my sugar is too low." Initially, the nurse should:

repeat the fingerstick glucose test.

While performing rounds, a nurse finds that a client is receiving the wrong I.V. solution. The nurse's initial response should be to

slow the I.V. flow rate and hang the appropriate solution. Explanation: When a client is getting the wrong I.V. solution, the nurse should maintain the access and start the proper solution. The nurse doesn't have to remove the catheter. Doing so would subject the client to unnecessary needle sticks. Waiting until the next bottle is due is inappropriate and places the client at risk for problems and the nurse in legal jeopardy. After starting the correct solution, the nurse should complete an incident report describing the specific error.

The nurse knows which drug administration routes provides the most rapid response in a client?

sublingual Explanation: drug dissolved in the mouth enters the client's bloodstream more quickly, thereby avoiding the barriers of food and the destructive effects of stomach acid. With oral, L.M., or subQ administration, the response to the drug is slower.

A nurse gathers data on a client who has developed a paralytic ileus. Which type of bowel sounds should the nurse anticipate hearing? -36 or more short sounds per minute -three to four peristaltic sounds per minute -at least 15 blowing sounds per minute -eight high-pitched tinkling sounds per minute

three to four peristaltic sounds per minute

The nurse administers a medication by the intramuscular route to a client. Which action would put the nurse most at risk for a needlestick injury?

using one-handed needle recapping immediately after administration

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

withhold the suppository and notify the client's physician.