Physiological Aspects of Care

The nurse manager of the unit comes to work obviously intoxicated. The staff nurse's ethical obligation is to: 1.Call the security guard 2.Tell the nurse manager to go home 3.Have the supervisor validate the observation 4.Offer the nurse manager a large cup of coffee

3.Have the supervisor validate the observation

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 client with Addison's disease is receiving cortisone therapy. The nurse expects what clinical indicators if the client abruptly stops the medication? (Select all that apply.) 1.Diplopia 2.Dysphagia 3.Tachypnea 4.Bradycardia 5.Hypotension

3.Tachypnea 5.Hypotension

A child is to receive 60 mg of phenytoin (Dilantin). The medication is available as an oral suspension that contains 125 mg/5 mL. How many milliliters should the nurse administer? Record the answer using one decimal place. ______ mL

2.4 mL

A client presents with a severe stiff neck, shuffling gate, and other extrapyramidal symptoms. Benztropine 2.5 mg by mouth is prescribed. The medication is available in 1-mg scored tablets. How many tablets should the nurse administer? Record the answer using one decimal place. _________ tablets

2.5 tabs

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's chest tube has accidentally dislodged. What is the nursing action of highest priority? 1.Place the client in a left side-lying position. 2.Apply oxygen via non-rebreather mask. 3.Apply a petroleum gauze dressing over the site. 4.Prepare to reinsert a new chest tube

3.Apply a petroleum gauze dressing over the site

The nurse assesses an elderly client with a diagnosis of dehydration and recognizes which finding as an early sign of dehydration? 1.Sunken eyes 2.Dry, flaky skin 3.Change in mental status 4.Decreased bowel sounds

3.Change in mental status

What clinical finding indicates to the nurse that a client may have hypokalemia? 1.Edema 2.Muscle spasms 3.Kussmaul breathing 4.Abdominal distention

4.Abdominal distention

After abdominal surgery a client reports pain. What action should the nurse take first? 1.Reposition the client. 2.Obtain the client's vital signs. 3.Administer the prescribed analgesic. 4.Determine the characteristics of the pain

4.Determine the characteristics of the pain

A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the nurse question? 1.Oral psyllium (Metamucil) 2.Oral potassium supplement 3.Parenteral half normal saline 4.Parenteral albumin (Albuminar)

4.Parenteral albumin (Albuminar)

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

A nurse is teaching a community group about the basics of nutrition. A participant questions why fluoride is added to drinking water. The nurse should respond that it is a necessary element added to drinking water to promote: 1.Dental health. 2.Growth and development. 3.Improved hearing. 4.Night vision

1.Dental health.

A client has received instructions to take 650 mg aspirin (ASA) every 6 hours as needed for arthritic pain. What should the nurse include in the client's medication teaching? (Select all that apply.) 1.Take the aspirin with meals or a snack. 2.Make an appointment with a dentist if bleeding gums develop. 3.Do not chew enteric-coated tablets. 4.Switch to Tylenol (acetaminophen) if tinnitus occurs. 5.Report persistent abdominal pain

1.Take the aspirin with meals or a snack. 3.Do not chew enteric-coated tablets 5.Report persistent abdominal pain

A nurse provides teaching for a client who is scheduled for a cholecystectomy. In the initial postoperative period, the nurse explains that the most important part of the treatment plan is: 1.Early ambulation 2.Coughing and deep breathing 3.Wearing anti-embolic elastic stockings 4.Maintenance of a nasogastric tube

2.Coughing and deep breathing

A nurse is caring for a client who is receiving an intravenous (IV) infusion. What should the nurse do first if the IV infusion infiltrates? 1.Elevate the IV site. 2.Discontinue the infusion. 3.Attempt to flush the tubing. 4.Apply a warm, moist compress

2.Discontinue the infusion.

A visitor in the waiting room of the emergency department has a syncopal episode and collapses on the floor. The event is witnessed by a nurse, who provides initial care. The nurse assessed the client, maintained safety of the environment, and gave a report to the emergency department nurse, who will provide ongoing care. What should the nurse who witnessed the event do next? 1.Contact the family 2.Document the incident 3.Report the incident to the nurse manager 4.Escort the client to the radiology department

2.Document the incident

What are the clinical indicators that a nurse expects when an intravenous (IV) line has infiltrated? (Select all that apply.) 1.Heat 2.Pallor 3.Edema 4.Decreased flow rate 5.Increased blood pressure

2.Pallor 3.Edema 4.Decreased flow rate

A client receiving intravenous vancomycin (Vancocin) reports ringing in both ears. Which initial action should the nurse take? 1.Notify the primary healthcare provider. 2.Consult an audiologist. 3.Stop the infusion. 4.Document the finding and continue to monitor the client

3.Stop the infusion.

A health care provider prescribes an antibiotic intravenous piggyback (IVPB) twice a day for a client with an infection. The health care provider prescribes peak and trough levels 48 and 72 hours after initiation of the therapy. The client asks the nurse why there is a need for so many blood tests. The nurse's best response is, "These tests will: 1.determine adequate dosage levels of the drug." 2.detect if you are having an allergic reaction to the drug." 3.permit blood culture specimens to be obtained when the drug is at its lowest level." 4.allow comparison of your fever to when the blood level of the antibiotic is at its highest."

1.determine adequate dosage levels of the drug."

After gastric surgery a client has a nasogastric tube in place. What should the nurse do when caring for this client? 1.Monitor for signs of electrolyte imbalance. 2.Change the tube at least once every 48 hours. 3.Connect the nasogastric tube to high continuous suction. 4.Assess placement by injecting 10 mL of water into the tube

1.Monitor for signs of electrolyte imbalance.

A nurse manager works on a unit where the nursing staff members are uncomfortable taking care of clients from cultures that are different from their own. How should the nurse manager address this situation? 1.Assign articles about various cultures so that they can become more knowledgeable. 2.Relocate the nurses to units where they will not have to care for clients from a variety of cultures. 3.Rotate the nurses' assignments so they have an equal opportunity to care for clients from other cultures. 4.Plan a workshop that offers opportunities to learn about the cultures they might encounter while at work

4.Plan a workshop that offers opportunities to learn about the cultures they might encounter while at work

A client with rheumatoid arthritis does not want the prescribed cortisone and informs the nurse. Later, the nurse attempts to administer cortisone. When the client asks what the medication is, the nurse gives an evasive answer. The client takes the medication and later discovers that it was cortisone. The client states an intent to sue. What factors in this situation must be considered in a legal action? (Select all that apply.) 1.Clients have a right to refuse treatment. 2.Nurses are required to answer clients truthfully. 3.The health care provider should have been notified. 4.The client had insufficient knowledge to make such a decision. 5.Legally prescribed medications are administered despite a client's objections

1.Clients have a right to refuse treatment. 2.Nurses are required to answer clients truthfully. 3.The health care provider should have been notified.

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 nursing supervisor sends unlicensed assistive personnel (UAP) to help relieve the burden of care on a short-staffed medical-surgical unit. Which tasks can be delegated to UAP? (Select all that apply.) 1.Taking routine vital signs. 2.Applying a sterile dressing. 3.Answering clients' call lights. 4.Administering saline infusions. 5.Changing linens on an occupied bed. 6.Assessing client responses to ambulation.

1.Taking routine vital signs. 3.Answering clients' call lights 5.Changing linens on an occupied bed

A prescription is written for famotidine (Pepcid) 20 mg intravenous piggyback (IVPB) every 12 hours. The vial is labeled 10 mg/1 mL. How many milliliters should the nurse administer? Record the answer using a whole number. _______ mL

2 Explaination: Have 10 mg 1 mL 10x = 20 x = 20 ÷ 10 x = 2 mL

Based on the client's reported pain level, the nurse administers 8 mg of the prescribed morphine. The medication is available in a 10 mg syringe. Wasting of the remaining 2 mg of morphine should be done by the nurse and a witness. It is most appropriate for the nurse to ask which member of the health care team to be the witness? 1.Nursing supervisor 2.Licensed practical nurse (LPN) 3.Client's health care provider 4.Designated nursing assistant

2.Licensed practical nurse (LPN)

An adolescent is taken to the emergency department of the local hospital after stepping on a nail. The puncture wound is cleansed and a sterile dressing applied. The nurse asks about having had a tetanus immunization. The adolescent responds that all immunizations are up to date. Penicillin is administered, and the client is sent home with instructions to return if there is any change in the wound area. A few days later, the client is admitted to the hospital with a diagnosis of tetanus. Legally, what is the nurse's responsibility in this situation? 1.The nurse's judgment was adequate, and the client was treated accordingly. 2.The possibility of tetanus was not foreseen because the client was immunized. 3.Nurses should routinely administer immunization against tetanus after such an injury. 4.Data collection by the nurse was incomplete, and as a result the treatment was insufficient

4.Data collection by the nurse was incomplete, and as a result the treatment was insufficient

The intake and output of a client over an eight-hour period is: 0800: Intravenous (IV) infusing; 900 mL left in bag; 0830: 150 mL voided; From 0900-1500 time period: 200 mL gastric tube formula + 50 mL water; Repeated x 2.; 1300: 220 mL voided; 1515: 235 mL voided; 1600: IV has 550 mL left in bag. What is the difference between the client's intake and output? Record the answer using a whole number. _________ mL

495 Explaination: Intake includes 350 mL of IV fluid, 600 mL of nasogastric intubation (NGT) feeding, and 150 mL of water via NGT, for a total intake of 1100 mL; output includes voidings of 150, 220, and 235 mL, for a total output of 605 mL. Subtract 605 mL from 1100 mL for a difference of 495 mL.