Lippincott: Urinary elimination, stress, F and E, and IV therapy

An adult has been admitting to the emergency department diagnosed with food poisoning following an outdoor picnic. What should the nurse do? Select all that apply.

Assess vital signs Imitate support for the respiratory system Collect specimens for lab examination Monitor fluid and electrolyte status Provide anti-emetics, as prescribed

A client is experiencing mood swings after a stroke and often has episodes of tearfulness that are distressing to the family. Which is the best technique for the nurse to instruct family members to try when the client experiences a crying episode?

Attempt to divert the client's attention

In preparing for insertion of a peripheral I.V. catheter, the nurse must select an appropriate site. Which area should the nurse try first if an appropriate vein is found?

Back of hand

Prior to going to surgery, the client tells the nurse that it is not possible to hear without a hearing aid and asks to wear it to surgery and recovery. What is the nurse's best response?

Call the surgery unit to explain the client's concern, and ask if the client can wear the hearing aid to surgery.

A client with acute renal failure has a serum potassium level of 6.5 mEq/L. The nurse should monitor the client for which potential complication?

Cardiac arrest

The nurse is developing an education plan for clients with hypertension. The nurse should emphasize which long-term goal for the clients?

Commit to lifelong therapy

The physician has prescribed sodium chloride for a hospitalized 51-year-old client in metabolic alkalosis. Which nursing actions are required to manage this client? Select all that apply.

Compare ABG findings with previous results. Maintain intake and output records Document presenting signs and symptoms

A client with rheumatoid arthritis states, "I cannot do household chores without becoming tired. My knees hurt whenever I walk." Which goal for this client should take priority?

Conserve energy

The mother of a child with moderate diarrhea asks who to manage her child's illness. What should the nurse suggest?

Continue the child's regular diet

A client who is admitted to an alcohol treatment program says, "I'm going to have a small morning drink to face the day. Usually, I just keep drinking." The nurse understands the client is in which stage of alcoholism?

Crucial phase

A client is receiving spironolactone for treatment of bilateral lower extremity edema. The nurse should instruct the client to make which nutritional modification to prevent an electrolyte imbalance?

Decrease foods high in potassium

A client is admitted to the emergency department after being sexually assaulted. The nurse notes that the client is sitting calmly and quietly in the examination room and recognizes this behavior as a protective defense mechanism. What defense mechanism is the client exhibiting?

Denial

The nurse is assessing the client who has benign prostatic hypertrophy (BPH). The nurse should determine of the client had which symptom?

Difficulty starting the urinary stream

A graduate nurse is reviewing the procedure for removing a peripherally inserted central catheter (PICC) with the preceptor. Which planned action by the graduate nurse should the preceptor correct?

Discarding the catheter in a trash container

A client who comes to the crisis center in a very distressed state tells the nurse, "I just can't get over being fired last week. I've asked for help. I've talked to friends. I've tried everything to get through this, but nothing is working. Help me!" Which initial crisis intervention strategy should the nurse use?

Emotion management

A postpartum client has a temperature of 99.8 F (37.7 C) during the first 24 hours after birth. Which nursing intervention is appropriate?

Encourage more fluid intake

A client is undergoing a bone marrow aspiration and biopsy. The client is very worried about the procedure. What should the nurse do to prepare the client for the procedure?

Encourage the client to take slow, deep breaths to relax.

Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence?

Establish a regular voiding schedule

When administering IV replacement of 5% dextrose in water with potassium chloride, what should the nurse do first?

Evaluate laboratory results for electrolytes.

A nurse is reviewing a clients intake and output record. Fluid intake and urine output should relate in which way?

Fluid intake should be about equal to urine output

An elderly client admitted with new-onset confusion, headache, poor skin turgor, bounding pulse, and urinary incontinence has been drinking copious amounts of water. Upon reviewing the lab results, the nurse discovers a sodium level of 122 mEq/L (122 mmol/L). A report to the health care provider (HCP) should include what recommendations? Select all that apply.

Foley catheter fluid restriction bed alarm vital signs every 4 hours instead of every shift repeat electrolytes, urine for sodium and specific gravity in the morning

Total parenteral nutrition (TPN) is prescribed for a client who has recently had a small and large bowel resection and who is currently not taking anything by mouth. What should the nurse do to safely administer the TPN?

Handle TPN using strict aseptic technique.

While making rounds, a nurse observes that a client's primary bag of intravenous (IV) solution is light yellow. The label on the IV bag says the solution is D5W. What should the nurse do first?

Hang a new bag of 5DW, and complete an incident report 3 60

A toddler admitted in respiratory distress keeps pulling at the oxygen mask, trying to remove it. Which interventions are indicated? Select all that apply.

Have the parent read to the child Encourage the parent to hold the child

A drug must enter the bloodstream before it can act within the body. Which parenteral administration route places a drug directly into the circulation, requiring no absorption?

I.V.

An 80-year-old woman who identifies herself as a devout Catholic has recently relocated to an assisted-living facility. The woman is pleased with most aspects of her new living situation, but laments the fact that she is no longer close to the church where she was in the habit of attending daily mass each morning. What nursing diagnosis may apply to this problem that the woman has identified?

Impaired Religiosity

A client with a history of renal calculi formation is being discharged after surgery to remove the calculus. What instructions should the nurse include in the client's discharge teaching plan?

Increase daily fluid intake to at least 2 to 3L

A nurse is caring for a client with a history of GI bleeding, sickle cell anemia, and a platelet count of 22,000 mm3. The client, who is dehydrated and receiving dextrose 5% in half-normal saline solution at 150 ml/hour, reports having severe bone pain and is scheduled to receive a dose of morphine sulfate. For which administration route should the nurse question an order?

Intramuscular (IM)

Which serum electrolytes findings should the nurse expect to find in an infant with persistent vomiting?

K+, 3.2; Cl-, 92; Na+, 120

A pediatric client is given morphine for postoperative pain following a fracture repair. As the nurse is assessing the client for pain 4 hours later, his parent leaves the room, and the child begins to cry. What assessment does the nurse make about the child's pain?

Less tolerant for pain because he is upset

When teaching about prevention of infection to a client with a long-term venous catheter, the nurse determines that the client has understood discharge instructions when the client makes which statement?

My husband will change the dressing three times per week, using sterile technique.

During the early postpartum period, a nurse is evaluating several clients' attachment to their neonates. Which client is the highest priority for the nurse?

One whose parent died recently

The nurse is caring for a 3-year-old child with acute kidney injury. Which laboratory finding should the nurse immediately report to the healthcare provider?

Potassium level of 6.5 mEq/L (6.5 mmol/L)

A nurse is teaching a client stress management. Which techniques would be considered adaptive coping skills? Select all that apply.

Practice relaxation technique balance sleep, rest, and exercise set realistic goals for each day

A client is scheduled for an ileostomy. Which would be most helpful in preparing the client psychologically for the surgery?

Provide a brief, thorough explanation of all preoperative and postoperative procedures.

A nurse fails to give the evening dose of an IV antibiotic that is to be administered every 12 hours. The evening dose was scheduled for 1800; it is now 2200. The nurse should next:

Report the incident to the health care provider

A nurse is reviewing arterial blood gas results on an assigned client. The pH is 7.32 with PCO2 of 49 mm Hg and a HCO3−of 28 mEq/L. The nurse reports to the physician which finding?

Respiratory acidosis

A client is receiving TPN administered through a central line. What should the nurse do to prevent complications associated with this infusion?

Secure all connections of the system

A client with nausea, vomiting, and abdominal cramps and distention is admitted to the healthcare facility. Which test result is most significant?

Serum potassium level of (3 mEq/L (3.0 mmol/L) )

A client with Addison's disease comes to the clinic for a follow-up visit. When assessing this client, the nurse should stay alert for signs and symptoms of...

Sodium and potassium abnormalities

The nurse teaches a primigravid client how to do kegel exercises. What does the nurse explain is the expected outcome of these exercises?

Strengthening the perineal muscle

The nurse is discussing concerns about sexual activity with a client with chronic renal failure. Which strategy would be most useful?

Suggest using alternative forms of sexual expression and intimacy.

While collecting data from a client diagnosed with impulse-control disorder (and who displays violent, aggressive, and assaultive behavior), the nurse can expect to find which of the following? Select all that apply.

The client functions well in other areas of life The client has a history of parental substance abuse or a chaotic, abusive family life The degree of aggression is disproportionate to the stressor.

When a client with an indwelling urinary catheter wants to walk to the hospital lobby to visit with family members, the nurse teaches the client how to do this without compromising the catheter. Which client action indicates an accurate understanding of this information?

The client keeps the drainage bag below the bladder at all times. SUBMIT ANSWER

The nurse notes that a client with acute pancreatitis occasionally experiences muscle twitching and jerking. How should the nurse interpret the significance of these symptoms?

The client may be developing hypocalcemia

A nurse recognizes improvement in a client with the nursing diagnosis of Ineffective role performance related to the need to perform rituals. Which behaviors indicate improvement? Select all that apply.

The client verbalizes the relationship between stress and ritualistic behaviors. The client refrains from performing rituals during stress The client verbalizes that he uses "thought stopping" when obsessive thoughts occur.

A client has a serum calcium level of 7.2 mg/dl (1.8mmol/L). During the physical examination, the nurse expects to assess.

Trousseau's sign

Which signs and symptoms might a nurse observe in a client having an adverse reaction to a loop diuretic? Select all that apply.

Weakness Irregular pulse Decrease muscle tone Potassium level of 3.1 mEq/L Ventricular arrhythmias

Which client is at the highest risk from developing a urinary tract infection?

a man with an indwelling urinary catheter

A client with post-traumatic stress disorder needs to find new housing and wants to wait for a month before setting another appointment to see the nurse. How should the nurse interpret this action?

a necessary break in treatment

Small air bubbles adhering to the interior surface of the syringe might have which effect on parenteral administration?

altered drug dose

Which client has most likely exhibit dehydration?

an 8-month-old infant with persistent diarrhea for 24 hours

A chronically ill school-age child is most vulnerable to which stressor?

anxiety over school absences

Which finding would alert the nurse to suspect that a child with severe gastroenteritis who has been receiving intravenous therapy for the past several hours may be developing circulatory overload?

auscultation of moist crackles

When admitting a neonate whose mother received magnesium sulfate, the nurse should assess the baby for which complication? Select all that apply.

decreased muscle tone decreased respirations

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should assess the client for which alteration in fluid and electrolyte balance?

decreased serum sodium level

In a client with a urine specific gravity of 1.040, a subnormal serum osmolality, and a serum sodium level of 128 mEq/L, the nurse should question an order for which I.V. fluid?

dextrose 5% in water (D5W)

After a third arrest for abusing a neighbor's cat, a client is admitted to the psychiatric unit for treatment of antisocial personality disorder. This client has a history of conduct disorder. Which action is most appropriate for the nurse assigned to this client?

examining personal feelings toward the client

A client is ready to be discharged following an inguinal hernia repair. Which criteria must the client meet before the nurse can discharge the client? Select all that apply. The client:

has voided. can walk to the bathroom unassisted. is able to tolerate oral fluids.

Which finding is a risk factor for hypovolemic shock?

hemorrhage

The nurse should assess a client who is in the emergent phase of burn management for:

hyperkalemia

A client has had an exacerbation of ulcerative colitis with cramping and diarrhea persisting longer than 1 week. The nurse should assess the client for which complication?

hypokalemia

A client who has been vomiting for 2 days has a nasogastric tube inserted. The nurse notes that over the past 10 hours, the tube has drained 2 L of fluid. The nurse should further assess the client for which electrolyte imbalance?

hypokalemia

In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation?

increased restlessness

Using Abraham Maslow's hierarchy of human needs, the nurse assigns highest priority to which client need?

inserting a Foley catheter

After teaching the parents about the urethral catheter placed after surgical repair of their son's hypospadias, the nurse determines that the teaching was successful when the mother states that the catheter in her child's penis accomplishes which goal?

keeps the new urethra from closing

The nurse is coaching a client with heart failure about reducing fluid retention. Which strategy will be most effective in reducing a client's fluid retention?

low-sodium diet

The nurse monitors IV replacement therapy for a client with a nasogastric (NG) tube attached to low suction in order to:

maintain fluid and electrolyte balance.

A child with partial- and full-thickness burns is admitted to the pediatric unit. What should be the priority at this time?

maintaining fluid and electrolyte balance

Immediately after surgery to create an ileostomy, which goal has the highest priority?

maintaining fluid and electrolyte balance

A nurse is administering IV fluids to a dehydrated client. When administering an IV solution of 3% sodium chloride, what should the nurse do? Select all that apply.

measure the intake and output inspect the jugular veins for distention evaluate the client for neurologic

A 9-month-old infant is admitted with diarrhea and dehydration. The nurse plans to assess the child's vital signs frequently. Which other action provides important assessment information?

measuring the infant's weight

What finding indicates that a child is receiving too much IV fluid too rapidly?

moist crackles in the lung fields

A client is admitted to the psychiatric clinic for treatment of anorexia nervosa. At the beginning of the client's hospitalization, the most important nursing action is to:

monitor the client's vital signs, serum electrolyte levels, and acid-base balance.

What instruction should the nurse's discharge teaching plan for the client with heart failure include?

obtaining daily weights at the same time each day

A 3-month-old has moderate dehydration. The nurse should assess the client for which sign of moderate dehydration?

oliguria

The nurse assesses an older adult for signs of dehydration. Which findings would be consistent with a diagnosis of dehydration?

orthostatic hypotension

A nurse may delegate adding medications to I.V. fluid containers to a

pharmacist.

Which factor should a nurse anticipate having the most influence on the outcome of a client facing a crisis situation?

previous coping skills

A client with colon cancer experiences an increase in feelings of anxiety and depression and has suicidal ideation. The nurse realizes that these feelings occur during which stage of the disease?

recurrence of the disease

The major goal of therapy in crisis intervention is to:

resolve the immediate problem.

The nurse observes a client with an onset of heart failure having rapid, shallow breathing at a rate of 32 breaths/minute. What blood gas analysis does the nurse anticipate finding initially?

respiratory alkalosis

The nurse is conducting a counseling session with a client experiencing posttraumatic stress disorder (PSTD) using a 2-way video telehealth system from the hospital to the client's home, which is 2 hours away from the nearest mental health facility. What are expected outcomes of using telehealth as a venue to provide health care to this client? Select all that apply. The client will:

save travel time from the house to the health care facility. receive health care for this mental health problem. avoid reliving a traumatic event which might be precipitated by visiting a health care facility.

A client with multiple myeloma presents to the emergency department complaining of excessive thirst and constipation. The client's family members report that the client has been confused for the last day. Which laboratory value is most likely responsible for this client's symptoms?

serum calcium level 13.8 mg/dl (0.766 mmol/L)

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.

When reviewing the plan of care for a client with Alzheimer's disease, which intervention would the nurse question?

stress management

When positioned properly, the tip of a central venous catheter should lie in the

superior vena cava.

Which finding is the best indication that fluid replacement for the client in hypovolemic shock is adequate?

urine output greater than 30 ml/hour

A client with heart failure must be monitored closely after starting diuretic therapy. The best indicator for the nurse to monitor is

weight

A client is scheduled to have an elective mandibular osteotomy to correct a mandibular fracture sustained in an accident 6 months earlier. Which statement by the client indicates to the nurse that the client is having difficulty coping?

"I'll be glad to have my jaw fixed because my wife thinks I don't look like myself."

As a representative of the treatment team, a nurse is reviewing results of diagnostic studies with the family of an adolescent with anorexia nervosa. What explanation should the nurse give the family about the client's abnormal blood urea nitrogen (BUN) value?

"The BUN is elevated because your daughter is dehydrated."

Which client statement indicates that the client has copes effectively with a relationship problem?

"We are really listening to each other about our different view on issues."

The nurse is instructing an unlicensed assistive personnel (UAP) to collect a urine specimen from an indwelling catheter. Which statement indicates that the UAP understands the instructions.

"i'll get a sterile syringe and remove urine from the catheter though the collection port to place in the specimen container."

After teaching the mother of a young girl about measures to help prevent urinary tract infection, which statement by the mother indicates successful teaching?

"we'll make sure she takes a water bottle with her to after school events."

A parent brings her 3-month-old child into the emergency department. The child is listless with dry mucous membranes, tenting of the skin on the forehead, a depressed fontanel, and a history of vomiting and diarrhea for the last 36 hours. In what order from first to last should the nurse implement the primary care provider's prescriptions? All options must be used.

1. Obtain vital signs and weight 2. Apply a urine collection bag 3. Insert an IV and infuse fluids as prescribed 4. Draw blood for laboratory tests

The physician 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 1 unit of packed red blood cells over 2 hours. There are 250 mL in the infusion bag. The IV administration infusion set delivers 10 gtt/mL. At what flow rate (in drops per minute) should the nurse run the infusion? Record your answer using a whole number.

21

A client who is experiencing an exacerbation of ulcerative colitis is receiving IV fluids that are to be infused at 125 mL/h. The IV tubing delivers 15 gtt/mL. How quickly should the nurse infuse the fluids in drops per minute to infuse the fluids at the prescribed rate? Record your answer using a whole number.

31

A client with a deep vein thrombosis has heparin sodium infusing at 1,500 units/hour. The concentration of heparin is 25,000 units/500 mL. If the infusion remains at the same rate for a full 12 hour shift, how many milliliters of fluid will infuse? Record your answer using a whole number.

360

A true crisis state, involving a period of severe disorganization, is difficult to endure emotionally and physically. The nurse recognizes that a client will only be able to tolerate being in crisis for how long?

4 to 6 weeks

A client is receiving a bowel preparation the evening before a scheduled colonoscopy. Which factor should the nurse consider when providing care for this client?

A client may require fluid and electrolyte replacement

A nurse is caring for a 22-year-old female client with type 1 diabetes mellitus and toxic shock syndrome (TSS). Which action should the nurse perform first?

Administer 5% dextrose in half-normal saline solution at 150 mL/h IV.

A shy middle school student set up a social network site. A popular student sent a message that included a suggestive picture of himself and suggested the student send a similar picture. When the student sent back a picture of himself dressed only in his boxers, the popular student sent it to all his friends and encouraged them to pass it along. Soon the whole school had seen the picture identified as "Joe's Crotch." The student was so humiliated that he tried to hang himself but was found by his parent before he succeeded. Which outcomes would be most realistic and appropriate with regard to this situation? Select all that apply.

All students in the school are educated about the risks of cyberbullying and how to respond to it. The popular student who sent the message to his friends is disciplined by the school authorities. Through therapy, Joe learns social skills to improve his confidence level and help him relate to peers more easily. Joe can use the Internet after being educated about cyberbullying and completing a safety plan.

A nurse is inserting a urinary catheter into a client who is extremely anxious about the procedure. The nurse can facilitate the insertion by asking the client to:

breathe deeply.

A nurse discovers that an I.V. site in a client's hand has infiltrated, causing localized pain and swelling. Which intervention would relieve the client's discomfort most effectively?

elevating the hand and wrapping it in a warm towel

Which question should the nurse ask first when obtaining a history from the parent of a school-age child with a fever, malaise, and swelling around the eyes?

"Does the child urinate as much as usual?"

On admission to the inpatient psychiatric unit, a client's facial expression indicates severe panic. The client repeatedly states, "I know the police are going to shoot me. They found out that I'm the child of the devil." What should the nurse say to initiate a therapeutic relationship with this client?

"Hello, my name is ___. I'm a nurse, and I'll care for you when I'm on duty. Should I call you ___, or do you prefer something else?"

A nurse is caring for a client who is an employee in the hospital. The client has recently received a diagnosis of genital herpes and is being treated for a urinary tract infection (UTI). A co-worker asked the nurse how the employee is doing. What is the nurse's best response?

"I'll be sure to tell the client you said hello"

The mother tells the nurse that the diagnosis of colic upsets her because she knows her infant will continue to have colicky pain. Which response by the nurse would be most appropriate?

"It can be difficult to listen to your baby cry so long, so try to make sure that you get some free time"

A client who weighs 187 lb (85 kg) has an order to receive enoxaparin 1 mg/kg. This drug is available in a concentration of 30 mg/0.3 mL. What dose would the nurse administer in milliliters? Record your answer using two decimal places.

0.85

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

14

A client who had transurethral resection of the prostate has dribbling urine after his foley catheter is removed on the second postoperative day. The nurse notes that the client had 200mL of urine output in the last 8 hours with a 1,000-mL intake. What should the nurse do first?

Assess for bladder distention

If a client's central venous catheter accidentally becomes disconnected, what should a nurse do first?

Clamp the catheter

A client is diagnosed with acute pyelonephritis. What should the nurse instruct the client to do?

Empty the bladder every 2 to 3 hours.

The primary reason for lubricating the urinary catheter generously before inserting the catheter into a male client is to prevent which problem?

Friction along the urethra when the catheter is being inserted

A physician orders an I.V. bolus injection of diltiazem hydrochloride for a client with uncontrolled atrial fibrillation. What should the nurse do before administering an I.V. bolus?

Gently aspirate the I.V catheter to check for a blood return

A nurse is caring for an elderly adult client admitted to the hospital from a nursing home because of a change in behavior. The client has a diagnosis of Alzheimer's disease and has started to experience episodes of incontinence. The hospital staff is having difficulty with toileting because the client wanders around the unit all day. To assist with elimination, a nurse should:

Incorporate the client's toileting schedule into the pattern of his wandering

The nurse is preparing a preoperative teaching plan for a client who is undergoing a bilateral breast reduction. Which aspect of the plan is the priority?

Physiologic integrity

A nurse is caring for a spiritually distressed client. Which are the factors affecting spiritual distress? Select all that apply.

Self-alienation Chronic illness Sociocultural deprivation

The nurse finds an unopened bag of IV 50% dextrose in a sink on the nursing unit. What should the nurse do with the IV bag?

Send it to the pharmacy.

A shy 12-year-old girl who must change school systems just before she begins junior high school begins cutting her arms to relieve the stress that she feels about leaving long-standing friends, having to develop new friendships, and meeting high academic standards in her new school. After she has been cutting for a few weeks, her parent discovers the injuries and takes her to a psychiatrist mental health provider who prescribes a therapeutic group at the local mental health center and medication to help decrease her anxiety. Which findings indicate that the girl had made appropriate progress toward recovery? Select all that apply.

The girl wears short-sleeved and/or sleeveless tops when the weather is warm. The girl's grades are good, and her hours of study are not excessive. The girl says she has developed a friendship with a girl in her class and one in her therapy group.

When assessing an 18-year-old primipara who gave birth under epidural anesthesia 24 hours ago, the nurse determines that the fundus is firm but to the right of midline. Based on this finding, the nurse should further assess for which complication?

Urinary retention

A client developed cardiogenic shock after a severe myocardial infarction and has now developed acute renal failure. The client's family asks the nurse why the client has developed acute renal failure. What should the nurse tell the family? "Because of the cardiogenic shock, there is:

a decrease in the blood flow through the kidneys."

A nurse interviews the family of a client hospitalized with severe depression and suicidal ideation. What family assessment information is essential when formulating an effective discharge plan? Select all that apply.

current family stressors role expectation communication patterns

A client admitted to the psychiatric unit for treatment of a panic attack comes to the nurses' station in obvious distress. After finding the client short of breath, dizzy, trembling, and nauseated, a nurse should first:

escort the client to a quiet area and suggest that he use a relaxation exercise he's been taught

Since the diagnosis of stomach cancer, the client has been having trouble sleeping and is frequently preoccupied with thoughts about how life will change. The client says, "I wish my life could stay the same." The nurse determines that the client is experiencing which problem?

going through a grieving process

Which type of solution, when administered I.V., would cause fluid to shift from body tissues to the bloodstream?

hypertonic

Which aspects of client care would be most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?

obtaining a urine specimen for a culture and sensitivity analysis from a client who has an indwelling urinary catheter inserted

A week ago, a tornado destroyed the client's home and seriously injured her husband. The client has been walking around the hospital in a daze without any outward display of emotions. She tells the nurse that she feels like she is going crazy. Which intervention should the nurse use first?

reassure the client that her feelings are typical reaction to serious trauma

The parent of a soldier who was killed 2 days ago is admitted after a serious suicide attempt. The client is medically stable, and a safety plan is in place. During a talk with the nurse, the client says, "Terrorism and war are holding me and the whole world hostage. It's so unfair. I would rather be dead than live alone in constant fear." Which nursing interventions are important in the next few days? Select all that apply.

strategizing about ways to increase a personal sense of security teaching stress management and relaxation techniques discussing effective ways to express justifiable anger identifying community groups for relatives of military personnel

The neonate has a prescribed IV rate of 8 mL/h. Fluid totals are recorded every 2 hours on the even hours. There is a new prescription written at 1030 to decrease the IV rate to 6 mL/h. What is the fluid total to be infused and recorded at 1200? Record your answer using a whole number.

13

The parents of a child who requires skeletal traction are unable to visit their child for more than 1 hour a day because there are five other children at home and both parents work outside of the home. The nurse recognizes expressions of guilt in both parents. To help alleviate this guilt, the nurse should make which statement?

"It is important that you visit even for 1 hour."

A client is in the acute phase of rheumatoid arthritis. In which order of priority from first to last should the nurse establish the goals? All options must be used.

1. Relieve pain 2. Preserve joint function 3. Prevent joint deformity 4.Maintain usual ways of accomplishing tasks

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

2

A physician orders hourly urine output measurement for a postoperative client with an indwelling catheter. The nurse records these amount of output for 2 consecutive hours: 8 a.m. (0800): 50mL; 9 a.m. (0900): 60 mL. Based on these amounts, which action should the nurse take?

Continue to monitor the record hourly urine output

When making rounds on the pediatric neurology unit, the nurse manager notes that, when giving IV medications, many of the staff nurses are disconnecting the flush syringe first and then clamping the intermittent infusion device. The nurse manager is concerned that the nurses do not understand the benefits of positive pressure technique and turbulence flow flush in preventing clots. After the nurse manager discusses the problem with the staff educator, which intervention would be the most effective way to improve the nursing practice?

Create a poster presentation on the topic with a required posttest.

A client is to be discharged from same-day surgery 7 hours after his inguinal hernia repair. Which nursing observation indicates that client is ready to be discharged.

The client voids 500 mL of urine.

An infant diagnosed with Hirschsprung's disease is scheduled to receive a temporary colostomy. When the nurse is initially discussing the diagnosis and treatment with the parents, which action by the nurse would be most appropriate?

encouraging then to ask questions

A week ago, a tornado destroyed the client's home and seriously injured her husband. The client has been walking around the hospital in a daze without any outward display of emotions. The client is being admitted to the stress unit with the diagnosis of acute stress disorder. The client tells the nurse in a matter-of-fact manner that her husband is paraplegic, "but that is better than total paralysis." Which protective mechanism is the client exhibiting?

intellectualization

A client is receiving magnesium sulfate at 3 g/h intravenously. The bag of 1,000 mL normal saline contains 20 g of magnesium sulfate. At what rate (in mL/hour) should the nurse set the IV pump to deliver 3 g/h? Record your answer using a whole number.

150

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

37.5

A registered nurse and a nursing assistant are caring for a group of clients. Which client's care may safely be delegated to the nursing assistant?

A client diagnosed with renal calculi who must ambulate four times daily and drink plenty of fluids

A 35-year-old has been killed as a result of a terrorist attack. What should the nurse advise the friends and relatives of the victim to do during the early stages of the recovery process? Select all that apply.

Use relaxation techniques and physical activities. Attend memorial or religious services. Keep in contact with other family and friends Attend community meetings with others who have lost loved ones.

When caring for a client with a central venous line, which nursing actions should be implemented in the plan of care for chemotherapy administration? Select all that apply.

Verify patency of the line by the presence of a blood return at regular intervals. Inspect the insertion site for swelling, erythema, or drainage if unable to aspirate blood, reposition the client and encourage the client to cough Contact the health care provider about verifying placement if the status is questionable

A pregnant client in her third trimester asks why she meeds to urinate frequently again, as she did during the first trimester. What should the nurse tell her?

This symptom is normal and results from the fetus exerting pressure on the bladder

An adolescent client is admitted to a psychiatric day treatment program due to severe lower back pain since her mother's death 3 years ago. Medical examinations have not discovered a physical cause for her pain. She cares for her four younger siblings after school and on weekends because of her father's long work hours. Which predischarge statement indicates that treatment for her condition has been successful?

"My back pain is worse on weekends with more responsibility and homework."

The nurse is to administer chloramphenicol 50 mg IV in 100 mL of dextrose 5% in water over 30 minutes. The infusion set administers 10 gtt/mL. At what flow rate (in drops per minute) should the nurse set the infusion? Round to the nearest whole number.

33

A health care provider prescribes intravenous heparin 25,000 units in 250 ml of normal saline solution to infuse at 600 units/hour for a client who suffered an acute myocardial infarction (MI). After 6 hours of heparin therapy, the client's partial thromboplastin time is subtherapeutic. The health care provider orders the infusion to be increased to 800 units/hour. The nurse would set the infusion pump to deliver how many milliliters per hour? Record your answer using a whole number.

8

The health care team has noticed an increase in IV infiltrations on the pediatric floor. As part of a "Plan, Do, Study, Act" quality improvement plan, the team should perform the actions in which order? All options must be used.

Decide to monitor IV gauges perform chart audits Analyze the data Write a new IV insertion policy

A nurse is caring for a client recently diagnosed with cancer and experiencing moderate situational anxiety. Which interventions would the nurse include in the care plan? Select all that apply.

Encourage the client to verbalize concerns regarding the diagnosis. Maintain a calm, nonthreatening environment. Encourage the client to use deep-breathing exercises and other relaxation techniques during periods of increased stress.

The health care provider's (HCP's) prescription for an intravenous infusion is 3% normal saline to infuse at 125 mL/h. The client's most recent sodium level is 132 mEq/L (132 mmol/L). The nurse should:

consult the prescriber about the prescription

The nurse interviews the family of a client who is hospitalized with severe depression and suicidal ideation. Which family assessment information is essential to formulating an effective plan of care? Select all that apply.

current family stressors role expectations communication patterns

A client with a fever and urinary urgency must provide a urine specimen for culture and sensitivity. The nurse should instruct the client to collect the specimen from the...

middle stream of urine from the bladder

To determine the I.V. drip rate, a nurse must know the drip factor, which is

the number of drops in one milliliter

The nurse is caring for an 8-year-old girl with multiple chronic urinary tract infections. The child's parents appear protective, never leaving their daughter's side. While the nurse helps the child's mother provide morning care, the child states, "My uncle doesn't clean me that way." Her mother becomes visibly upset and gives the girl a stern warning not to discuss the matter. She states, "Don't tell anyone about that again. "The nurse has a legal responsibly to:

Notify the nursing supervisor and the authorities of the possibility of abuse

A client expresses to the nurse that they cannot get the mental support needed to prepare to undergo treatment for leukemia. Which nursing diagnosis is most appropriate for the client?

Spiritual distress

A nurse is helping a physician insert a subclavian central line. After the physician has gained access to the subclavian vein, the physician connects a 10-ml syringe to the catheter and withdraws a sample of blood. The physician then disconnects the syringe from the port. Suddenly, the client becomes confused, disoriented, and pale. The nurse suspects an air embolus. The nurse should

turn the client on the left side and place the bed in Trendelenburg's position.

A confused client with carbon monoxide poisoning experiences dizziness when ambulating to the bathroom. What should the nurse do?

Check on the client at regular intervals to ascertain the need to use the bathroom

Which actions by the nurse will most likely ensure that the correct client receives a medication? Select all that apply.

Check the name on the armband with the name on the medication Compare the date of birth on the client's medical record to the date of birth on the client's armband

A nurse is assessing a client for lifestyle factors that might affect normal coping. Which factor should the nurse most likely consider?

Inadequate diet