PrepU mod 9 & 10

The nurse is caring for a client who is postoperative day one after undergoing a total knee replacement. The nurse is conducting a client assessment when taking which action(s)? Select all that apply.

checking the strength of pedal pulses asking the client for a pain rating reviewing the client's intraoperative record observing the client's ability to move in the bed

A nurse is caring for a client with typhoid at a health care facility. The nurse checks the medication order in the client's chart for the drugs prescribed to the client. Which of the following is a required component of the medication order?

clients name

A nurse is evaluating the outcomes of a plan of care to teach an obese patient about the calorie content of foods. What type of outcome is this?

cognitive

A nurse is conducting an interview with a patient to collect a medication history. Which of the following questions would be used to ensure safe medication administration?

"Do you have any allergies to medications?"

A nurse is explaining the purpose of nursing diagnoses to a client. What would be the most appropriate statement for the nurse to make?

"Nursing diagnoses are used to guide the nurse in selecting appropriate nursing interventions."

A client with severe pain is prescribed hydromorphone 10 mg by mouth every 4 hours as needed for pain. The client rates the pain as eight on a one-to-ten scale, so the nurse prepares to administer a dose. The oral liquid contained in the unit's opioid stock contains 5 mg/5 ml. How many milliliters of solution should the nurse give to the client? Record your answer using a whole number.

10

The nurse is instructing the client on insulin administration. The client is performing a return demonstration for preparing the insulin. The client's morning dose of insulin is 10 units of regular and 22 units of NPH. The nurse checks the dose accuracy with the client. The nurse determines that the client has prepared the correct dose when the syringe reads how many units? Record your answer using a whole number.

32 units

Which of the following best exemplifies the role of the nurse as teacher?

A nurse discussing side effects of a medication with a client

A nurse gives a client 0.25 mg of digoxin instead of the prescribed dose of 0.125 mg. What should the nurse do next?

Assess the client and notify the client's physician.

A school-age client with type 1 diabetes is sick with the flu. What is the most important information for the nurse to convey regarding diabetes management during illness?

Blood glucose needs to be checked more frequently during illness.

An oral medication has been ordered for a patient who has a nasogastric tube in place. Which nursing activity would increase the safety of medication administration?

Check the tube placement before administration.

A nurse is evaluating an established plan of care. After identifying the evaluative criteria and standards (expected patient outcomes), what must the nurse do next?

Collect data about patient responses.

The client's expected outcome is "The client will maintain skin integrity by discharge." Which of the following measures is best in evaluating the outcome?

Condition of the skin over bony prominences.

You are caring for a patient who has a newly written order for "fluoxetine (Prozac) 20 mg by mouth daily for treatment of depression." You are unfamiliar with this medication. Which of the following actions is most appropriate?

Consult a professional medication reference before preparing to administer the medication.

You are reviewing a patient's newly written medication order and are unable to read the prescriber's handwriting. Which of the following actions by is most appropriate?

Contact the prescriber to clarify the order.

Which legislation classified drugs according to potential for abuse?

Controlled Substances Act

An adolescent with type 1 diabetes checks a blood glucose level at 9:00 p.m. (2100), 4 hours after dinner and regular insulin dose. The current blood glucose level is 60 mg/dl (3.3 mmol/L). The client reports shakiness. What should the nurse suggest?

Eat graham crackers with peanut butter and 8-oz (240 mL) of milk.

Which of the following clients is likely to have altered metabolism of medications?

Elderly

Federal legislation dictates a lengthy and rigorous process of testing for new drugs. What is the primary purpose of this testing process?

Ensure the safety of the public.

A nurse is administering evening medications and notices that a medication was omitted during the day shift. Which of the following statements demonstrates the principle of accountability?

Filling out an occurrence report and notifying the health care provider

Which agency is responsible for regulating the development and marketing of drugs?

Food and Drug Administration (FDA)

Which of the following medications is categorized as a loop diuretic?

Furosemide (Lasix)

The nurse is caring for a client who is administering insulin for diabetes mellitus for the first time. The nurse is instructing the client on mixing Humulin N insulin and Humulin R insulin in one syringe. Arrange the instructions in order. All options must be used.

Gently roll both insulins between your hands. Wipe with alcohol and inject air (equal to units ordered) into the Humulin N insulin. Wipe with alcohol and inject air (equal to units ordered) into the Humulin R insulin. Withdraw the Humulin R. Withdraw Humulin N insulin. Double check the total number of units in syringe.

A client with allergy has been advised to have an allergy test. The nurse needs to administer an injection to the client for allergy testing. Which of the following injection routes is most suitable for allergy testing?

Intradermal

A nurse is performing an assessment on a client in which the nurse categorizes the data according to various categories of functions. Which assessment model is the nurse using?

Gordon's functional health patterns

A client admitted with Hodgkin disease has a handwritten prescription for vinblastine 3.7 mg intravenously (IV) weekly. The nurse interprets the prescription as vincristine 3.7 mg and administers the wrong medication. The client becomes neurovascularly compromised and has a fatal reaction to the medication. The client's family begins a litigious suit against the facility and the nurse's license is suspended by the board of nursing. In preparation for the lawsuit, the nurse meets with the nurse attorney to review the events. Which appropriate statement, if given by the nurse, indicates he has an understanding of the lawsuit?

I had a duty and it was my responsibility to get clarification before administering the medication, which I did not.

Which actions should the nurse perform during the planning step of the nursing process? Select all that apply.

Identifying expected client outcomes Selecting evidence-based nursing interventions Establishing priorities Communicating the plan of nursing care

In which way does a nurse play a key role in error prevention?

Identifying incorrect dosages or potential interactions of ordered medications

A nurse is caring for a client with severe lower back pain. The doctor orders administration of an analgesic as a stat dose. When should the nurse administer the medication?

Immediately

A client with newly diagnosed diabetes requests information about how to give an injection. The nurse will use which communication technique for this client?

Informing about the proper injection technique

A nurse is ordered to administer epinephrine to a child who was stung by a bee and is allergic to insect bites. Which means of drug administration would the nurse use to achieve rapid absorption and quicker results in this emergency situation?

Injection

A nursing student reports to the instructor that a medication due at 9 a.m. was omitted. Which of the following principles is the student demonstrating?

Integrity

You are caring for a patient who just returned from the postanesthesia care unit (PACU) and rates current pain as "9 out of 10." Which of the following prescribed medications will provide the fastest relief from pain?

Intravenous morphine sulfate

A nurse is preparing a prescribed dosage of an inhalant medication for a client with asthma. Which of the following explains why inhalation is a good route for medication administration?

It allows the lungs to quickly absorb the medication.

Which statements about the nursing process are accurate? Select all that apply.

It is an orderly way of solving client problems. It is important for providing individualized care to each client. It helps to emphasize the client's active role in making decisions.

What best describes the nurse's role in disaster preparedness?

Multiple roles including triage and the distribution of resources

When administering heparin subcutaneously, the nurse should

Never aspirate

A client newly diagnosed with congestive heart failure has a prescription for digoxin (Lanoxin). The nurse counts the heart rate before administration of the medication and obtains a heart rate of 51 beats per minute. Which action by the nurse demonstrates adherence to the standards of nursing care?

Nurse withheld the medication and notified the health care practitioner

Which of the following techniques is best for the nurse to use in evaluating the parents' ability to administer eardrops correctly?

Observe the parents instilling the drops in the child's ear.

The process by which a drug moves through the body and is eventually eliminated is

Pharmacokinetics

A school-age client with diabetes is placed on an intermediate-acting insulin and regular insulin before breakfast and before dinner. She will receive a snack of milk and cereal at bedtime. What does the nurse tell the client the snack is intended to do?

Prevent late night hypoglycemia.

Adherence to defined principles is recommended when delegating care tasks to assistive personnel. According to these principles, who is responsible and accountable for nursing practice?

RN

Which guidelines should the nurse consider when writing outcomes?

Resolution of the client problem should be a priority; therefore, at least one of the outcomes the nurse writes should show a direct resolution of the problem statement in the nursing diagnosis. Outcomes that are brief and specific are more readily evaluated. The nurse should derive each set of outcomes from a single nursing diagnosis, rather than a combination. The client and family must value the outcomes to work toward the goal. The outcomes must support the overall treatment plan; simply including a goal is not enough. Timelines for outcomes are necessary so that they can be measured and evaluated.

A physician writes an order for ampicillin 1 gram every 6 hours for Mr. Jameson Owens. What is missing in this order?

Route

A nurse in a long-term care facility consistently administers clients' medications 60 to 90 minutes after the scheduled administration time. The nurse also leaves scheduled treatment procedures for nurses to complete on the next shift. Which of the following would be an appropriate strategy for this nurse to pursue?

Seek input and direction on time management and priority setting

A hospitalized patient asks the nurse for "some aspirin for my headache." There is no order for aspirin for this patient. What will the nurse do?

State that an order from the doctor is legally required and check with the doctor.

Which components must be included in an outcome? Select all that apply.

The action the client will perform The particular circumstances in which the outcome is to be achieved A target time by which the client is expected to be able to achieve the outcome The client or some part of the client

What behaviors reflect planning? Select all that apply.

The nurse decides to assist the client with ambulation in the hallway twice per shift. The nurse seeks input from the client and family regarding acceptable, nonpharmacologic pain management strategies. The nurse considers the developmental level of the client when selecting education materials

Which actions occur during the initial planning of client care? Select all that apply.

The nurse who performs the admission nursing history and physical assessment makes the initial plan. After the initial plan is developed, the nurse prioritizes nursing diagnoses. The nurse identifies client goals and the related nursing care in the initial plan.

A nurse is caring for a client at a health care facility who is undergoing nicotine withdrawal therapy and has been prescribed a nicotine patch. Which of the following is true with regard to the application of a transdermal patch?

The patch is applied to a skin area with adequate circulation.

What is the term used for the concentration of drug in the blood serum that produces the desired effect without causing toxicity?

Therapeutic range

The nurse is interviewing a client who is newly admitted to the unit. Which technique(s) used by the nurse will facilitate communication during the interview? Select all that apply.

Use broad opening statements. Share observations. Use silence.

The nurse is performing a physical assessment on a newly admitted client. During the assessment, the nurse notices the client grimacing and holding the abdomen. When the nurse asks the client whether the client is in pain, the client answers, "No." What is the best thing for the nurse to do next?

Validate the data

The nurse is teaching the patient to instill eye drops. Which of the following statements is correct?

Wash your hands before and after instilling eye drops and do not touch the tip of the bottle.

The nurse is preparing to administer digoxin to a client with heart failure. The nurse obtains an apical pulse rate for 1 minute and determines a rate of 52 beats/minute. What is the first action by the nurse?

Withhold the medication and notify the physician of the heart rate.

After administering a medication to a client, the client reports an upset stomach. The nurse interprets this as a negative effect of the drug and identifies it as a(n):

adverse affect

A client has just received a dose of theophylline I.V. for asthma. What assessment finding should the nurse expect?

decreased pulmonary wheezing

When using the nursing process, the nurse notes that there is a great deal of overlapping of the steps, with each step flowing into the next. What is the term for this characteristic of the nursing process?

dynamic

Mrs. Still is an 89-year-old woman who has been admitted to the hospital with a diagnosis of failure to thrive. She has become constipated in recent days, in spite of maintaining a high fluid intake and taking oral stool softeners. She admits to her nurse that the problem is rooted in the fact that she feels mortified to attempt a bowel movement on a commode at her bedside where staff and other patients can hear her. The nurse should respond by modifying which of the following resources?

environment

A nurse is caring for a client with scabies. The client has been prescribed a drug that has a topical route of administration. Which of the following should the nurse tell the client regarding the administration of the drug?

it has to be applied on the skin

A client has been prescribed a drug that will be administered by buccal application. What should the nurse tell the client regarding buccal application of the drug?

it is placed against the mucous membrane of the inner cheek.

The nurse is caring for a client who has been prescribed an enteric-coated drug. Which of the following should the nurse inform the client regarding the administration of this drug?

it should not be chewed or crushed

Which of the following routes of medication administration is most commonly prescribed?

oral

Which of the following group of terms best describes the nursing process?

patient-centered, systematic, outcomes-oriented

A child's physician orders a drug for home use. Before the child is discharged, the nurse should:

provide the family with the drug's name, dosage, route, and frequency of administration.