nclex pn nursing process implementation

The nurse is preparing for the administration of ribavirin (Virazole) to a child with respiratory syncytial virus. Which supplies will the nurse obtain for the administration of this medication?

A pair of goggles

A caloric test is prescribed for a client suspected of having a disease of the labyrinth. The nurse obtains which essential item in preparation for this test?

An otoscope

The nurse is caring for a client following total hip replacement who has a wound suction drain in place. At the end of the 8-hour shift, the nurse empties 45 mL of drainage from the wound-suction device. Based on this amount of drainage, which action is appropriate?

Document the findings.

The nurse is caring for a client with pheochromocytoma. The client asks for a snack and something warm to drink. Which is the appropriate choice for this client to meet nutritional needs?

Graham crackers and warm milk

A client who has just suffered a large flail chest is experiencing severe pain and dyspnea. Which would be the appropriate nursing action?

Notify the registered nurse.

A client is about to undergo a lumbar puncture (LP). The nurse tells the client that which position will be used during the procedure?

Side-lying with the legs pulled up and the head bent down onto the chest

Megestrol acetate (Megace), an antineoplastic medication, is prescribed for the client with metastatic endometrial carcinoma. The nurse reviews the client's history and contacts the registered nurse if which diagnosis is documented in the client's history?

Thrombophlebitis

A 7-year-old child is admitted to the pediatric unit with acute exacerbation of asthma due to infection. The health care provider has written the following prescriptions. In which priority order should the nurse implement the prescriptions? Arrange the actions in the order that they should be performed. All options must be used.

high fowlers postiom o2 at 2 l Erythromycin ethylsuccinate (EryPed) 200 mg orally every 6 hours Chest x-ray Clear liquids PO as tolerated

Bethanechol chloride (Urecholine) is prescribed for a client. When should the nurse tell the client to take the medication?

Two hours after meals

The nurse is caring for a client who is on airborne precautions. The nurse notes that the client is scheduled for a magnetic resonance imaging (MRI) test. Which nursing action would be most appropriate in preparing the client for the test?

Place a surgical mask on the client for transport and for contact with other individuals.

The nurse is caring for a client who is developing pulmonary edema. The client exhibits respiratory distress, but the blood pressure is unchanged from the client's baseline. As an immediate action before help arrives, the nurse should perform which action?

Place the client in high-Fowler's position.

The client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking vital signs, which immediate action should the nurse take?

Raise the head of the bed and remove the noxious stimulus.

Ampicillin sodium 250 mg in 50 mL of normal saline (NS) is being administered over a period of 30 minutes. The drop (gtt) factor is 10 drops (gtt) per mL. The nurse is asked to check the flow rate of the infusion. The nurse determines that the infusion is running at the prescribed rate if the infusion is delivering how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

17

A health care provider has told the mother of a newborn diagnosed with strabismus that surgery will be necessary to realign the weakened eye muscles. The mother asks the nurse when the surgery might be performed. Which time frame for the surgery should the nurse explain to the mother?

Before the child is 3 years old

A client wishes to donate blood for a family member and asks the nurse about the procedure for identifying compatibility. The nurse tells the client that which test will be done to test compatibility?

Indirect Coombs'

The nurse is caring for a client with a diagnosis of hyperparathyroidism. Laboratory studies are performed, and the serum calcium level is 12.0 mg/dL. Based on this laboratory value, the nurse should take which action?

Inform the registered nurse of the laboratory value.

A female client arrives at the health care clinic and tells the nurse that she was just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that she removed the tick and flushed it down the toilet. Which nursing action is appropriate?

Instruct the client to return in 4 to 6 weeks to be tested, because testing before this time is not reliable.

Dantrolene (Dantrium) is prescribed for a client with a spinal cord injury for discomfort resulting from spasticity. The nurse tells the client about the importance of follow-up and the need for which blood study?

Liver function studies

A client diagnosed with schizophrenia is experiencing an acute dystonia reaction. Which interventions should the licensed practical nurse (LPN) initiate? Select all that apply.

Monitor airway. Notify the registered nurse (RN) Remain with the client to provide support. Administer a prescribed IM antiparkinsonian medication.

A licensed practical nurse (LPN) assisting a registered nurse in the cardiac care unit (CCU) prepares to admit a client with a diagnosis of myocardial infarction (MI). The LPN should be certain to have which item(s) readily available on the unit when the client arrives by stretcher?

Oxygen cannula and flowmeter

The nurse is collecting data on a client who sustained circumferential burns of both legs. The nurse should check which first?

Peripheral pulses