Fundamentals

The parents of an infant who just died from sudden infant death syndrome (SIDS) are angry at God and refuse to see any members of the clergy. How would the nurse respond?

"Is there anyone else I can call to support you at this time?"

A client reports abdominal pain. Which action allows the nurse to investigate this complaint?

assessing the painful area last

The nurse needs to administer verapamil 0.3 mg/kg I.V. once a day to a pediatric client who weighs 20 lb (9.07 kg). The dose on hand is 5 mg/2 ml. How many milliliters will the nurse administer to the pediatric client? Round to the nearest tenth.

1.1

Which is the highest priority action by the nurse before starting this skill?

Assess stomach residual

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

Clean the incision and drain site separately.

The nurse has received a change-of-shift report. The nurse should assess which client first?

a 72-year-old admitted 2 days ago with a blood alcohol level of 0.08 who has exhibited agitation, fearfulness, and sleeplessness over the last 36 hours

The nurse is conducting walking rounds and observes the client (see figure). What should the nurse do?

Assess the client to determine why she wants to sit up.

When administering an I.V. medication through a central line, the nurse notes that a client's central line gauze dressing was last changed 24 hours previously. What is the appropriate action by the nurse?

Proceed to administer the I.V. medication.

At 0900, the nurse started an infusion of 1 L of 5% dextrose and normal saline (D5NS) infusing at a keep-vein-open rate. At 0945, the client reports a pounding headache, is dyspneic, is experiencing chills, and has a heart rate of 116 bpm. The nurse notes that the IV bag has 400 mL remaining. The nurse should take which action first?

Slow the IV infusion.

The nurse provides care to a verbally unresponsive client diagnosed with terminal cancer. The client's family refuses palliation on religious grounds. The nurse experiences great anxiety and distress when caring for the client due to the level of suffering perceived. What action should the nurse take?

Speak to the charge nurse about the nurse's moral conflict.

When teaching a client older than age 50 who is receiving long-term prednisone therapy, the nurse should make which suggestion?

Take the prednisone with food.

An overweight adolescent has been diagnosed with type 2 diabetes. What should the nurse do to increase the client's self-efficacy to manage the disease?

Utilize a peer with type 2 diabetes to role model lifestyle changes.

The nurse is making a discharge plan for a client recovering from a total laryngectomy. What is an expected outcome? The client will:

communicate feelings about body image changes.

An older adult who was admitted with new-onset confusion, headache, and bounding pulse has been drinking copious amounts of water and voiding frequently. The nurse reviews the lab results (see chart). Which abnormal lab value is consistent with the client's symptoms?

serum sodium