Physiological Aspects of Care

Filgrastim (Neupogen) 5 mcg/kg/day by injection is prescribed for a client who weighs 132 lb. The vial label reads filgrastim 300 mcg/mL. How many milliliters should the nurse administer? Record the answer using a whole number. ______ mL

1 mL

A client who experienced extensive burns is receiving IV fluids to replace fluid loss. The nurse should monitor for which initial sign of fluid overload? 1.Crackles in the lungs 2.Decreased heart rate 3.Decreased blood pressure 4.Cyanosis

1.Crackles in the lungs

A nurse addresses the needs of a client who is hyperventilating to prevent what complication? 1.Cardiac arrest 2.Carbonic acid deficit 3.Reduction in serum pH 4.Excess oxygen saturation

2.Carbonic acid deficit

What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess? 1.Rapid, thready pulse 2.Distended jugular veins 3.Elevated hematocrit level 4.Increased serum sodium level

2.Distended jugular veins

When caring for a client with varicella and disseminated herpes zoster, the nurse should implement which types of precautions? (Select all that apply.) 1.Airborne 2.Contact 3.Droplet 4.Hazardous Wastes 5.Standard

1.Airborne 2.Contact 5.Standard

A nurse is caring for an older adult who is taking acetaminophen (Tylenol) for the relief of chronic pain. Which substance is most important for the nurse to determine if the client is taking because it intensifies the most serious adverse effect of acetaminophen? 1.Alcohol 2.Caffeine 3.Saw palmetto 4.St. John's wort

1.Alcohol

A client with an abdominal wound infected with methicillin-resistant Staphylococcus aureus (MRSA) is scheduled for a computed tomography (CT) scan of the abdomen. To ensure client and visitor safety during transport, the nurse should implement which precaution? 1.No special precautions are required. 2.Cover the infected site with a dressing. 3.Drape the client with a covering labeled as biohazardous. 4.Place a surgical mask on the client

2.Cover the infected site with a dressing.

A client becomes anxious after being scheduled for a colostomy. What is the most effective way for the nurse to help the client? 1.Administer the prescribed as needed (prn) sedative. 2.Encourage the client to express feelings. 3.Explain the postprocedure course of treatment. 4.Reassure the client that there are others with this problem.

2.Encourage the client to express feelings.

A client reports vomiting and diarrhea for three days. What clinical finding most accurately will indicate that the client has a fluid deficit? 1.Presence of dry skin 2.Loss of body weight 3.Decrease in blood pressure 4.Altered general appearance

2.Loss of body weight

What factors are most important for the nurse to consider when delegating responsibilities? 1.Preferences of the clients and staff 2.Physical layout of the unit and client rooms 3.Staff member's level of education and expertise 4.Client's diagnosis and length of time in the hospital

3.Staff member's level of education and expertise

The nurse is preparing discharge instructions for a client who was prescribed enalapril maleate (Vasotec) for treatment of hypertension. Which is appropriate for the nurse to include in the client's teaching? 1.Do not change positions suddenly. 2.Light-headedness is a common adverse effect that need not be reported. 3.The medication may cause a sore throat for the first few days. 4.Schedule blood tests weekly for the first 2 months

1.Do not change positions suddenly.

An arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20 mEq/L. Which disturbance should the nurse identify based on these results? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis

1.Metabolic acidosis

Neomycin, 1 gram, is prescribed preoperatively for a client with cancer of the colon. The client asks why this is necessary. How should the nurse respond? 1."It is used to prevent you from getting a bladder infection before surgery." 2."It will decrease your kidney function and lessen urine production during surgery." 3."It will kill the bacteria in your bowel and decrease the risk for infection after surgery." 4."It is used to alter the body flora, which reduces spread of the tumor to adjacent organs."

3."It will kill the bacteria in your bowel and decrease the risk for infection after surgery."

A client is scheduled to receive phenytoin (Dilantin) 100 mg orally at 6 PM but is having difficulty swallowing capsules. What method should the nurse use to help the client take the medication? 1.Sprinkle the powder from the capsule into a cup of water. 2.Insert a rectal suppository containing 100 mg of phenytoin. 3.Contact the prescriber to determine if a change to a suspension form would be possible. 4.Obtain a change in the administration route to allow an intramuscular (IM) injection.

3.Contact the prescriber to determine if a change to a suspension form would be possible.

A nurse is transcribing a practitioner's orders for a group of clients. Which order should the nurse clarify with the practitioner? 1.Discharge in am 2.Blood glucose monitoring ac and bedtime 3.Erythropoietin (Procrit) 6000 units subcutaneously TIW 4.Dalteparin (Fragmin) 5000 international units Sub-Q BID

3.Erythropoietin (Procrit) 6000 units subcutaneously TIW

A primary nurse receives prescriptions for a newly admitted client and has difficulty reading the health care provider's writing. Who should the nurse ask for clarification of this prescription? 1.Nurse practitioner 2.House health care provider that is on-call 3.Health care provider who wrote the prescription 4.Nurse manager familiar with the health care provider's writing

3.Health care provider who wrote the prescription

An assessment of the client on total parenteral nutrition (TPN) reveals a bounding pulse, distended jugular veins, dyspnea, and cough. What is the priority nursing intervention? 1.Ask the registered nurse start the client's infusion at a peripheral site 2.Slow the rate of the client's infusion of the TPN 3.Interrupt the client's infusion and notify the charge nurse or health care provider 4.Obtain the vital signs and continue monitoring the client's status

3.Interrupt the client's infusion and notify the charge nurse or health care provider

A client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has Vancomycin Resistant Enterococcus (VRE). After notifying the physician, which action should the nurse take to decrease the risk of transmission to others? 1.Insert a urinary catheter. 2.Initiate Droplet Precautions. 3.Move the client to a private room. 4.Use a high efficiency particulate air (HEPA) respirator during care.

3.Move the client to a private room.

A nurse assesses for hypocalcemia in a postoperative client. One of the initial signs that might be present is: 1.Headache 2.Pallor 3.Paresthesias 4.Blurred vision

3.Paresthesias.

The health care provider prescribes a low-fat, 2-gram sodium diet for a client with hypertension. The nurse should explain that the purpose of restricting sodium is to: 1.Chemically stimulate the loop of Henle 2.Diminish the thirst response of the client 3.Prevent reabsorption of water in the distal tubules 4.Cause fluid to move toward the interstitial compartment

3.Prevent reabsorption of water in the distal tubules

What is a nurse's responsibility when administering prescribed opioid analgesics? (Select all that apply.) 1.Count the client's respirations. 2.Document the intensity of the client's pain. 3.Withhold the medication if the client reports pruritus. 4.Verify the number of doses in the locked cabinet before administering the prescribed dose. 5.Discard the medication in the client's toilet before leaving the room if the medication is refused.

1.Count the client's respirations. 2.Document the intensity of the client's pain. 4.Verify the number of doses in the locked cabinet before administering the prescribed dose.

A client is admitted to the hospital with a tentative diagnosis of infectious pulmonary tuberculosis. What infection control measures should the nurse take? 1.Don an N95 respirator mask before entering the room. 2.Put on a permeable gown each time before entering the room. 3.Implement contact precautions and post appropriate signage. 4.After finishing with patient care, remove the gown first and then remove the gloves.

1.Don an N95 respirator mask before entering the room.

A health care provider prescribes digoxin (Lanoxin) for a client. The nurse teaches the client to be alert for which common early indication of digoxin toxicity? 1.Nausea 2.Urticaria 3.Photophobia 4.Yellow vision

1.Nausea

The count of hydrocodone (Vicodin) is incorrect. After several minutes of searching the medication cart and Physiological Aspects of Care records, no explanation is found. Who should the primary nurse notify about the discrepancy? 1.Nursing unit manager 2.Hospital administrator 3.Quality control manager 4.Health care provider prescribing the medication

1.Nursing unit manager

A nurse is preparing to administer an oil-retention enema and understands that it works primarily by: 1.Stimulating the urge to defecate. 2.Lubricating the sigmoid colon and rectum. 3.Dissolving the feces. 4.Softening the feces

2.Lubricating the sigmoid colon and rectum.

A client is to receive 125 mL of intravenous (IV) fluid every hour. The drop factor of the IV tubing is 10 gtt/mL. How many drops per minute should the nurse administer? Record your answer using a whole number. ______ gtts/min.

21

A client is scheduled for a transurethral resection of the prostate (TURP). Which statement made by the client most indicates the need for further preoperative teaching? 1."My urine will be red after surgery." 2."I will have a catheter after surgery." 3."My incision will probably be painful." 4."I will need to drink a lot after surgery.

3."My incision will probably be painful."

A client had extensive, prolonged surgery. Which electrolyte level should the nurse monitor most closely? 1.Sodium 2.Calcium 3.Chloride 4.Potassium

4.Potassium