Saunders quiz #5
The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? Carol is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response? "I cannot discuss any client situation with you." "If you want to know about Carol, you need to ask Carol yourself." "Only because you're worried about a friend, I'll tell you that Carol is improving." "Being a friend, you know that Carol is having a difficult time and deserves privacy."
"I cannot discuss any client situation with you." Rationale: The nurse is required to maintain confidentiality regarding the client and the client's care. Confidentiality is basic to the therapeutic relationship and is a client's right. The most appropriate response to the neighbor is the statement of that responsibility in a direct, but polite manner. A blunt statement that does not acknowledge why the nurse cannot reveal client information may be taken as disrespectful and uncaring. The remaining options identify statements that do not maintain client confidentiality.
The nurse has completed teaching a new nursing graduate on how to avoid being judgmental. Which statement by the new nursing graduate would indicate to the nurse that there is a need for further teaching? "I don't think you need to do that." "Tell me about making that decision." "I would like to be sure I understood." "When did you first notice you felt that way?"
"I don't think you need to do that." Rationale: The correct option is very clearly a judgmental response, as it specifically casts judgment on an action. The remaining options seek to explore with the client as opposed to commenting on or giving advice.
The nurse is giving client instructions over the telephone about preparing for a mammography. The nurse would make which statement to the client? "Wear metal jewelry as desired." "Consume clear liquids only on the day of the test." "Use only lanolin-based skin lotions on the day of the test." "If possible, avoid using underarm deodorant on the day of the test."
"If possible, avoid using underarm deodorant on the day of the test." Rationale: The client would avoid the use of lotions or underarm deodorant on the day of mammography because this can affect breast and axilla positioning and obtaining clear mammography pictures. At the mammography suite, the client may also be asked to clean the underarms with the provided wipes. Mammography is a type of radiographic procedure. Therefore, the client is advised not to wear jewelry or metal objects on the day of the test. No special dietary preparation is needed.
The community health nurse who is conducting a teaching session about the risks of testicular cancer has reviewed a list of instructions regarding testicular self-examination (TSE) with the clients attending the session. Which statement by a client indicates a need for further instruction? TSE is performed once a month." "TSE would be performed on the same day each month." "It is best to do TSE first thing in the morning before a bath or shower." "The scrotum is held in one hand and the testicle is rolled between the thumb and forefinger of the other hand."
"It is best to do TSE first thing in the morning before a bath or shower." Rationale: TSE is performed once a month and needs to be done on the same day of each month, as an aid to help the client remember to perform the exam. The scrotum is held in one hand and the testicle is rolled between the thumb and forefinger of the other hand. It is best to perform the exam during or after (not before) a warm shower or bath, when the scrotum is most relaxed.
The child who weighs 17 lb is to receive 72 mg/kg/day of a prescribed medication intravenously every 4 hours. How many milligrams would the nurse administer to the child in a single dose? 92.64 139.1 448.8 673.2
92.64
When creating an assignment for a team consisting of a registered nurse (RN), a licensed practical nurse (LPN), and two assistive personnel (APs), which is the best client for the LPN? A client requiring frequent temperature checks A client requiring assistance with ambulation every 4 hours A client on a mechanical ventilator requiring frequent assessment and suctioning A client with a spinal cord injury requiring urinary catheterization every 6 hours
A client with a spinal cord injury requiring urinary catheterization every 6 hours Rationale: When creating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Frequent temperature checks and ambulation can most appropriately be provided by the APs, considering the clients identified in each option. The client on the mechanical ventilator requiring frequent assessment and suctioning would most appropriately be cared for by the RN. The LPN is skilled in urinary catheterization, so the client in option 4 would be assigned to this staff member.
The clinic nurse is providing instructions to a client who is scheduled for a barium enema. What instruction would the nurse provide to the client in preparation for this procedure? Liquids are restricted for 24 hours after the test. A clear liquid diet is required for 4 days before the test. Laxatives would not be taken for at least 1 week before the test. A low-fiber diet needs to be maintained for 1 to 3 days before the test.
A low-fiber diet needs to be maintained for 1 to 3 days before the test. Rationale: Preparation for a barium enema includes maintaining a low-fiber diet for 1 to 3 days before the test. Clear liquids or water may be allowed 12 to 24 hours before the test. Laxatives and enemas may be prescribed before the test to cleanse the bowel. The client is encouraged to drink liquids after the procedure to facilitate the passage of barium.
The nurse is instructing a client to perform a 2-point gait for crutch walking. The nurse would tell the client to perform which action? Advance the right foot and then the left foot, followed by both crutches. Advance both crutches forward, followed by the left foot and then the right foot. Move the left foot and then the left crutch forward, followed by the right crutch and then the right foot. Advance the right crutch and the left foot forward, followed by advancing the right foot and the left crutch forward.
Advance the right crutch and the left foot forward, followed by advancing the right foot and the left crutch forward. Rationale: The 2-point gait is used when weight bearing is allowed on both feet. Only 2 points are in contact with the floor. The 2-point gait closely resembles normal walking. Options 1 and 2 describe 3 points of contact. Option 3 describes 4 points of contact.
The nurse is supervising a nursing student who is delivering care to a client with a burn injury to the chest. Nitrofurazone is prescribed to be applied to the site of injury. The nurse would intervene if the student planned to implement which action to apply the medication? Wash the burn site. Apply the medication with a sterile gloved hand. Apply saline-soaked dressings over the medication. Apply 1/16-inch (1.5-mm) film directly to the burn sites.
Apply saline-soaked dressings over the medication. Rationale: Nitrofurazone is applied topically to the burn and has a broad spectrum of antibiotic activity. It is used in second- and third-degree burns when bacterial resistance to other agents is a potential problem. The burn site is washed before medication application. A film of 1/16 inch (1.5 mm) is applied directly to the burn using a sterile gloved hand. Saline-soaked dressings are not used with this medication because they will inactivate the medication's effect. In addition, wet dressings present the risk for infection, and infection is a primary concern with a client who is burned.
A computed tomography scan of the chest with contrast is scheduled to be performed in a client suspected of having a pulmonary embolism. In planning the preprocedure care for this client, which nursing action is necessary? Encourage intake of fluids. Shave the anticipated entry site. Ask the client about allergies and previous reactions. Contact the operating room regarding the need for the procedure.
Ask the client about allergies and previous reactions. Rationale: A computed tomography scan is not performed in the operating room; therefore, it is not necessary that the nurse contact this department. There is no surgical entry site; therefore, shaving is unnecessary. The procedure is explained to the client, who also is asked about allergies to shellfish or contrast media. Oral ingestion except for sips of water is avoided for 4 to 6 hours before the test.
The nurse has a prescription to collect a 24-hour urine specimen from a client. The nurse is demonstrating correct procedure when which technique is performed? Ask the client to void, save the specimen, and note the start time. Place the specimen in various containers as necessary for the test. Ask the client to save a sample voided at the end of the collection time. Remove urine from the collection container for other prescribed specimens.
Ask the client to save a sample voided at the end of the collection time. Rationale: Because the 24-hour urine test is a timed quantitative determination, the test must be started with an empty bladder; therefore, the first urine is discarded. Fifteen minutes before the end of the collection time, the client would be asked to void, and this specimen is added to the collection. The urine sample needs to be placed in the appropriate container and may be refrigerated or placed on ice to prevent changes in the urine. Because this is a quantitative determination of constituents in the urine, no urine would be removed from the container.
The nurse is creating a plan of care for a client receiving enteral feedings. Which client problem is the highest priority? Diarrhea Nutrition Aspiration Deficient fluid volume
Aspiration Rationale: Any condition in which gastrointestinal motility is slowed or esophageal reflux is possible places the client at risk for aspiration. Diarrhea and nutrition may be appropriate problems, but they are not of highest priority. Deficient fluid volume is not likely to occur in this client.
The nurse is reviewing the surgeon's prescription sheet for a preoperative client, which states that the client must be NPO (nothing by mouth) after midnight. Which medication would the nurse clarify to be given and not withheld? Atenolol Atorvastatin Cyclobenzaprine Conjugated estrogen
Atenolol Rationale: Atenolol is a beta blocker. Beta blockers would not be stopped abruptly, and the health care provider needs to be contacted about the administration of this medication before surgery. If a beta blocker is stopped abruptly, the myocardial need for oxygen is increased. Atorvastatin is a cholesterol-lowering medication used to treat high cholesterol. Cyclobenzaprine is a skeletal muscle relaxant. Conjugated estrogen is an estrogen used for hormone replacement therapy in postmenopausal clients. The other three medications may be withheld before surgery without undue effects on the client.
The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action? Call the police. Cut up the photograph and throw it away. Call the nursing supervisor and report the incident. Call the laboratory and ask for the name of the individual who sent the photograph.
Call the nursing supervisor and report the incident. Rationale: Ensuring a safe workplace is a responsibility of an employing institution. Sexual harassment in the workplace is prohibited by state and federal laws. Sexually suggestive jokes, touching, pressuring a coworker for a date, and open displays of sexually oriented photographs or posters or the transmission of such images are examples of conduct that could be considered sexual harassment by another worker. If the nurse believes that they are she is being subjected to unwelcome sexual conduct, these concerns would be reported to the nursing supervisor immediately. Option 1 is unnecessary at this time. Options 2 and 4 are inappropriate initial actions.
The nurse is triaging pediatric clients as they arrive to the emergency department after a school bus accident. In what order would the nurse triage the victims from highest priority to lowest? All options must be used. Confused child with bright red blood pulsating from a leg wound Child with a simple fracture of the arm complaining of arm pain Child with a closed head wound and multiple compound fractures of the arms and legs Sobbing child with several minor lacerations on the face, arms, and legs
Child with a closed head wound and multiple compound fractures of the arms and leg .Sobbing child with several minor lacerations on the face, arms, and legs .Confused child with bright red blood pulsating from a leg wound .Child with a simple fracture of the arm complaining of arm pain Rationale: Triage systems identify which victims are the priority and need to be treated first. Rankings are based on immediacy of needs, including victims with immediate threat to life requiring immediate treatment (emergent), victims whose injuries are not life threatening provided that they are treated within 30 minutes to 2 hours (urgent), and victims with sustained local injuries who do not have immediate complications and can wait at least 2 hours for medical treatment (nonurgent). The confused child with bright red blood pulsating from a leg wound indicates arterial puncture. The child is also confused, which indicates the presence of hypoxia and shock (emergent). The child with a closed head wound and multiple compound fractures of the arms and legs has sustained multiple traumas, so this victim is also classified as emergent and would require immediate treatment; however, the confused child with bright red blood pulsating from a leg wound is the higher priority because of the arterial puncture. The child with a simple fracture of the arm complaining of arm pain has sustained injuries that are not life threatening provided that the injuries can be treated in 30 minutes to 2 hours (urgent). The sobbing child with several minor lacerations on the face, arms, and legs has sustained minor injuries that can wait at least 2 hours for treatment (nonurgent).
The nurse is reviewing the plan of care with a non-American client who does not speak English. The client frequently nods the head during the review. Based upon this behavior, what would be the nurse's next action? Contact a qualified medical interpreter. Give corresponding written information to the client. Check to see whether the client has an English-speaking family member. Ignore the behavior and start to review the plan of care with the client.
Contact a qualified medical interpreter. Rationale: The nurse must contact a qualified medical interpreter to correctly provide the information to the client. The nurse needs to be alert to nonverbal communication and have a professional interpreter discover the language that the client understands. In some cultures, head nodding does not necessarily mean that the client is in agreement with what is being presented, agrees with the plan, or is anxious.
The nurse notes that the primary health care provider has documented a suspected diagnosis of herpes zoster in the client's chart. The nurse would prepare the client for which diagnostic test to confirm this diagnosis? Patch test Skin biopsy Culture of the lesion Wood's lamp examination
Culture of the lesion Rationale: With the classic presentation of herpes zoster, the clinical examination is diagnostic. A viral culture of the lesion provides the definitive diagnosis. Herpes zoster is caused by a reactivation of the varicella-zoster virus, the cause of chicken pox. A patch test is a skin test that involves the administration of an allergen to the skin's surface to identify specific allergies. A biopsy identifies tissue type. In a Wood's lamp examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin.
The nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the document to correct the error. The nurse would take which actions to correct the error? Select all that apply. Document a late entry in the client's record. Draw one line through the error, initialing and dating it. Try to erase the error for space to write in the correct data. Use whiteout to delete the error to write in the correct data. Write a concise statement to explain why the correction was needed.6Document the correct information and end with the nurse's signature and title.
Draw one line through the error, initialing and dating it. Document the correct information and end with the nurse's signature and title. Rationale: If the nurse makes an error in narrative documentation, the nurse would follow agency policies to correct the error. This includes drawing one line through the error, initialing and dating the line, and then documenting the correct information. A late entry is used to document additional information not remembered at the initial time of documentation, not to make a correction of an error. Documenting the correct information with the nurse's signature and title is correct. Erasing data and the use of whiteout are prohibited. There is no need to write a statement to explain why the correction was necessary.
An adolescent is admitted to the hospital after an accidental self-inflicted gunshot wound to the foot. The nurse would plan to take which action as a first step for the prevention of future injury? Explore the client's knowledge of gun safety. Assess the client for a history of risk-taking behaviors. Refer the client to a firearm safety class sponsored by the hospital. Have the client watch a video on the tragedies of improper firearm use.
Explore the client's knowledge of gun safety. Rationale: A leading cause of accidental death in the adolescent population is improper use of firearms. Before implementing firearm safety goals, the nurse needs to obtain baseline data through a firearm safety history, which is described in the correct option. Option 2 may be indicated because of the relationships among accidents, impulsivity, and risk-taking behaviors, but assessing past risk-taking behaviors would not be the first step directed at prevention. Option 3 may be effective, but referral to a firearm safety course would not come before assessing the client's knowledge of gun safety. Option 4 may or may not be effective, at some point, for this client.
The nurse is creating a plan of care for a client scheduled for surgery. The nurse would include which activity in the nursing care plan for the client on the day of surgery? Avoid oral hygiene and rinsing with mouthwash. Verify that the client has not eaten for the last 24 hours. Have the client void immediately before going into surgery. Report immediately any slight increase in blood pressure or pulse.
Have the client void immediately before going into surgery. Rationale: The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 6 to 8 hours (or longer depending on the procedure and as prescribed) before surgery instead of 24 hours. A slight increase in blood pressure and pulse is common during the preoperative period and is usually the result of anxiety.
An adult client suspected of having leukemia is scheduled for bone marrow aspiration. The nurse prepares the client knowing that which possible site could be used for obtaining the bone marrow? Ribs Femur Scapula Iliac crest
Iliac crest Rationale: The most common sites for bone marrow aspiration in the adult are the iliac crest and the sternum. These areas are rich in bone marrow and are easily accessible for testing. The ribs, femur, and scapula are incorrect options.
The student nurse is caring for an infant with a tracheostomy and is preparing to suction the infant. The nursing instructor would intervene if the nursing student stated taking which action to perform this procedure? Limit insertion and suctioning time to 15 seconds to prevent hypoxia. Insert the catheter the length of the tracheostomy tube with the suction off. Apply intermittent suction and withdraw the catheter with a twisting motion. Reoxygenate between insertion passes with the suction catheter and allow sufficient recovery time with each pass.
Limit insertion and suctioning time to 15 seconds to prevent hypoxia. Rationale: When suctioning a tracheostomy in an infant, it is necessary to limit insertion and suctioning time to 5 seconds to prevent hypoxia. Correct suctioning procedures for an infant include inserting the catheter the length of the tracheostomy tube with the suction off, applying intermittent suction and withdrawing the catheter with a twisting motion, and reoxygenating between each insertion pass with the suction catheter.
The client is suspected of having a skeletal muscle disorder. Which isoenzyme value reported with the creatine kinase (CK) level would the nurse assess for elevation? MM MB BB MS
MM Rationale: CK is a cellular enzyme that can be fractionated into three isoenzymes. The MM band reflects CK from skeletal muscle. This band would be elevated in skeletal muscle disease. The MB band reflects CK from myocardial muscle. The BB band reflects CK from the brain. There is no MS band.
The nurse is planning care for a client who has just returned to the nursing unit after an oral cholecystogram. The nurse would expect to delete which prescription on the client's care plan? Monitor hydration status. Assess for nausea and vomiting. Monitor for abdominal discomfort. Maintain a clear liquid diet for 72 hours.
Maintain a clear liquid diet for 72 hours. Rationale: The client would be able to resume the usual diet once the nurse is sure that the client's gastrointestinal (GI) function is normal. It is not necessary to keep the client on clear liquids for 72 hours after the procedure. The nurse would also assess hydration status as part of routine care for the client undergoing a GI diagnostic test. The nurse would monitor the client for complaints of GI discomfort and nausea and vomiting.
The community health nurse is instructing a group of young clients about breast self-examination. The nurse would instruct the clients to perform the examination at which time? At the onset of menstruation Every month during ovulation Weekly at the same time of day One week after menstruation begins
One week after menstruation begins Rationale: The breast self-examination needs to be performed regularly, 7 days after the onset of the menstrual period. Performing the examination weekly is not recommended. At the onset of menstruation and during ovulation, hormonal changes occur that may alter breast tissue.
The nurse is preparing medications when a pill pops out of the medication container and falls onto the countertop. What action would the nurse take? Promptly pick up the pill and put it into the medicine cup. Promptly pick up the pill, blow off the dust, and then put it into the medicine cup. Promptly pick up the pill, dispose of it properly, and obtain a new one from the pharmacy. Promptly pick up the pill, use an alcohol swab to clean it off, and put it into the medicine cup.
Promptly pick up the pill, dispose of it properly, and obtain a new one from the pharmacy. Rationale: Medication that is dropped on any surface is considered contaminated and would not be administered; therefore, the remaining options are incorrect.
The nurse is preparing to perform an otoscopic examination on an adult client. Which action would the nurse take to perform this examination? Pull the pinna up and back before inserting the speculum. Pull the earlobe down and back before inserting the speculum. Tilt the client's head forward and down before inserting the speculum. Use the smallest speculum available to decrease the discomfort of the exam.
Pull the pinna up and back before inserting the speculum. Rationale: The nurse tilts the client's head slightly away and holds the otoscope upside down as if it were a large pen. The pinna is pulled up and back, and the nurse visualizes the external canal while slowly inserting the speculum. The remaining options are incorrect procedures.
The nurse is caring for a client with impaired mobility that occurred as the result of a stroke. The client has right-sided arm and leg weakness. Which assistive device would the nurse suggest that the client use to provide the best stability for ambulating? Walker Crutches Quad cane Single straight-legged cane
Quad cane Rationale: Crutches and a walker can be difficult to maneuver for a client with weakness on one side. A cane is better suited for the client with weakness of the arm and leg on one side, and a quad cane would provide the most stability because of the structure of the cane and because a quad cane has four legs.
The nurse would plan to take which action next after assessing a homeless pediatric client who is a victim of abuse? Ask the parents who abused the child. Report signs of abuse and document it. Find out where the child sleeps at night. Ask the child if they are scared of the parents or anyone else.
Report signs of abuse and document it. Rationale: Health care considerations for abused or neglected individuals are to treat them with compassion, respect, and dignity. Nurses are mandated reporters for domestic violence and abuse incidence, so a report needs to be done. Documentation of all injuries is also necessary for legal reasons. Asking the parents who abused the child and asking the child if they are scared of the parents or anyone else may cause fear and conflict. Finding out where the child sleeps at night may be helpful at some point of care but is not a next specific action.
The nurse is reviewing laboratory results for a client with chronic kidney disease before a hemodialysis treatment. The serum electrolyte levels are sodium 142 mEq/L (142 mmol/L), chloride 103 mEq/L (103 mmol/L), potassium 5.2 mEq/L (5.2 mmol/L), and bicarbonate 23 mEq/L (23 mmol/L). What action would the nurse plan to take? Take no action. Order a stat hemodialysis treatment. Recheck the labs because these values are all abnormal. Page the primary health care provider (PHCP) with the results.
Take no action. Rationale: No action is needed because all of the blood levels are normal for a hemodialysis client before a treatment. The normal adult ranges of serum electrolyte levels are sodium 135 to 145 mEq/L (135 to 145 mmol/L), chloride 98 to 106 mEq/L (98 to 106 mmol/L), bicarbonate (venous) 21 to 28 mEq/L (21 to 28 mmol/L), and potassium 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Although the potassium level is elevated, the normal range for potassium for a client with chronic kidney disease receiving hemodialysis is 4 to 6.5 mEq/L (4 to 6.5 mmol/L).
The charge nurse is planning the assignment for the day. Which factors would the nurse remain mindful of when delegating tasks? Select all that apply. he acuity level of the clients Specific requests from the staff The clustering of the rooms on the unit The number of anticipated client discharges Client needs and workers' needs and abilities
The acuity level of the clients Client needs and workers' needs and abilities Rationale: There are guidelines that the nurse would use when delegating tasks. These include the following: ensure client safety; be aware of individual variations in work abilities; determine which tasks can be delegated and to whom; match the task to the delegatee on the basis of the nurse practice act and appropriate position descriptions; provide directions that are clear, concise, accurate, and complete; validate the delegatee's understanding of the directions; communicate a feeling of confidence to the delegatee and provide feedback promptly after the task is performed; and maintain continuity of care as much as possible when assigning client care. Staff requests, convenience (as in clustering of client rooms), and anticipated changes in unit census are not specific guidelines to use when delegating tasks, but may be considered when making assignments.
The nurse is delegating the morning hygienic care to the assistive personnel (AP). In reviewing the assigned tasks, the nurse would instruct the AP to use an electric razor for which client? The client with severe pain related to osteoporosis The client with hypokalemia related to diuretic therapy The client with thrombocytopenia related to chemotherapy The client with an elevated white blood cell count related to infection
The client with thrombocytopenia related to chemotherapy Rationale: The client with thrombocytopenia has a low platelet count. Using a straight razor increases the risk of abrasion and bleeding caused by ineffective clotting capability. The client with hypokalemia has a low potassium level. Shaving the client has no relationship to the client's potassium level. The client with severe pain is not affected by the different choices in shaving tools. Likewise, the client with an elevated white blood cell count will not be affected by the different choices in shaving tools.
The charge nurse is assessing the nurse's knowledge about the use of an interpreter. Which statement made by the nurse requires a need for further teaching? Using friends to interpret is a conflict of interest Family members would not be used due to confidentiality The use of an interpreter decreases the risk of relaying inaccurate information The use of an interpreter does not need to occur until the client requests one
The use of an interpreter does not need to occur until the client requests one Rationale: The use of an interpreter would occur regularly and frequently while interacting with the client. Family members and friends would not be asked by a health care professional to be an interpreter. Confidentiality, conflict of interest, and the risk of relaying inaccurate information are all barriers to not using a designated health care agency interpreter.
The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment? Urine pH of 6 Urine that is pale yellow Urine output of 40 mL/hr Urine specific gravity of 1.032
Urine specific gravity of 1.032 Rationale: The client who is not adequately hydrated will have an elevated urine specific gravity. Normal values for urine specific gravity range from approximately 1.005 to 1.030. Pale yellow urine is a normal finding, as is a urine output of 40 mL/hr (minimum is 30 mL/hr). A urine pH of 6 is adequate (4.6 to 8.0 normal), and this value is not used in monitoring hydration status.
The nurse is preparing to insert an intravenous (IV) angiocatheter into a client's inner forearm. Before cannulating the vein, what motion will the nurse implement to cleanse the site? Scrubbing from the wrist toward the elbow Scrubbing from the elbow toward the wrist Using a circular motion from the center outward Using a circular motion inward toward the center
Using a circular motion from the center outward Rationale: The nurse cleans the skin by using a circular motion from inward to outward. This is the standard, accepted aseptic technique to carry microorganisms away from the insertion site. The same technique is used to cleanse any area requiring surgical asepsis. Options 1, 2, and 4 are incorrect procedures and do not represent aseptic technique.
The home health nurse visits a client with suspected scabies. Which precaution would the nurse institute during the assessment of the client? Wear gloves only. Wear a mask and gloves. Wear a gown and gloves. Avoid touching the client's home furnishings.
Wear a gown and gloves. Rationale: The Centers for Disease Control and Prevention recommends wearing gowns and gloves for close contact with a client infested with scabies. Masks are not necessary. Transmission via clothing and other inanimate objects is uncommon. Scabies usually is transmitted from client to client by direct skin contact. All contacts that the client has had need to be treated at the same time.
The nurse provides instructions to a client who is scheduled for an electroencephalogram. Which statement by the client indicates a need for further instruction? "The test will take between 45 minutes and 2 hours." "My hair needs to be washed the evening before the test." Cola, tea, and coffee are restricted on the day of the test."4 All medications need to be withheld on the day of the test."
"All medications need to be withheld on the day of the test." Rationale: The client is informed that the test will take 45 minutes to 2 hours and that medications usually are not withheld before the test unless specifically prescribed. Preprocedural instructions include informing the client that the procedure is painless. Cola, tea, and coffee are stimulants and need to be restricted on the morning of the test. The hair needs to be washed the evening before the test, and gels, hair sprays, and lotion would be avoided.
A primary health care provider (PHCP) writes a prescription to begin to wean the client from the mechanical ventilator by use of intermittent mandatory ventilation/synchronized intermittent mandatory ventilation (IMV/SIMV). The registered nurse determines that the new graduate nurse understands this modality of weaning if which statement is made? "The respiratory rate is decreased gradually until the client can assume the work of breathing without ventilatory assistance." "A T-piece will be attached to the ventilator and provide supplemental oxygen at a concentration that is 10% higher than the ventilator setting." "It will provide pressure support to decrease the workload of breathing and increase the client's ability to initiate spontaneous breathing efforts."4 It involves removing the ventilator from the client and closely monitoring the client's ability to breathe spontaneously for a predetermined amount of time
"The respiratory rate is decreased gradually until the client can assume the work of breathing without ventilatory assistance." Rationale, Strategy, Tip Rationale: IMV/SIMV is one of the methods used for weaning. With this method, the respiratory rate is gradually decreased until the client assumes all of the work of breathing on their own. This method works exceptionally well in the weaning of clients from short-term mechanical ventilation, such as that used in clients who have undergone surgery. The respiratory rate frequently is decreased in increments on an hourly basis until the client is weaned and is ready for extubation. Therefore, the remaining options are incorrect.
The nurse is explaining to a client what electroencephalography (EEG) involves. What response by the client indicates that further teaching is needed? This test is minimally invasive." "There is no risk of electric shock." "It can help diagnose and treat my seizures." "Electrodes are placed on specific areas of my scalp."
"This test is minimally invasive." Rationale: An EEG is noninvasive, not minimally invasive. All of the other options are correct.
The primary health care provider prescribes ketorolac 15 mg intravenous push. The medication vial states "30 mg/mL." How many milliliters will the nurse administer? Fill in the blank.
0.5mL
A client has a prescription to have blood drawn to measure peak and trough vancomycin levels to determine the effectiveness of therapy with this medication. The nurse arranges with the laboratory to have the peak level specimen drawn at which time? 1 hour before administration of the scheduled dose 1.5 hours after completion of the scheduled infusion Immediately after administration of the scheduled dose 30 minutes before administration of the scheduled dose
1.5 hours after completion of the scheduled infusion Rationale: Peak serum medication levels would be monitored to ensure that the dosage is appropriate and would be drawn 1.5 to 2.5 hours after the intravenous infusion is completed. Peak levels of 30 to 40 mcg/mL generally are acceptable. Options 1, 3, and 4 are incorrect.
The nurse working in the hospital hears a client call out that there is a fire in the hospital room. What actions would the nurse take? Arrange the actions in the order that they would be performed. All options must be used.
1.Extinguish the fire. 2.Activate the fire alarm. 3.Rescue the client from injury. 4.Pull the pin on the fire extinguisher. 5.Close the doors to the other clients' rooms.
A primary health care provider prescribes heparin sodium 900 units per hour by continuous intravenous (IV) infusion. The pharmacy prepares the medication and delivers an IV bag that is labeled heparin sodium 20,000 units per 250 mL of 5% dextrose in water. An infusion pump must be used to administer the medication. How many milliliters per hour are required to deliver the prescribed dose? Fill in the blank. Record your answer to the nearest whole number.
11mL/hr
Cefuroxime sodium, 1 g in 50 mL normal saline (NS), is to be administered over 30 minutes. The drop factor is 15 drops (gtt)/1 mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank.
25drops per minute
A primary health care provider's prescription reads "cyanocobalamin (vitamin B12) 1000 mcg by the intramuscular route." The medication label reads "cyanocobalamin (vitamin B12) 0.5 mg/mL." The nurse prepares the medication and administers how many milliliters to the client? Fill in the blank.
2mL
The primary health care provider's prescription reads levothyroxine, 150 mcg orally daily. The medication label reads levothyroxine, 0.1 mg per tablet. The nurse would plan to administer how many tablet(s) to the client? Fill in the blank.
2tablets
Normal saline 50 mL is to be given by intravenous (IV) infusion over a 15-minute period. The drop factor for the tubing is 10 gtt/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Round your answer to the nearest whole number.
33gtt/min
The nurse is reviewing the results of the electrolyte panel for a client seen in the health care clinic. The nurse determines that the client's potassium level is normal if which value is noted? 2.0 mEq/L (2.0 mmol/L) 4.0 mEq/L (4.0 mmol/L) 5.3 mEq/L (5.3 mmol/L) 6.0 mEq/L (6.0 mmol/L)
4.0 mEq/L (4.0 mmol/L) Rationale: The normal serum potassium level in the adult is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium level of 2.0 mEq/L (2.0 mmol/L) identifies a low level, while 5.3 and 6.0 mEq/L (5.3 and 6.0 mmol/L) identify elevated levels.
The nursing instructor is discussing the topic of pain with a student nurse who is assessing the status of pain in a cognitively impaired older adult. What comment by the student implies that further education is needed? Older adults tend to report pain less often than do younger adults. Clients in this age group are less sensitive to pain and have a greater pain tolerance. Mental images of pain are a less effective means to assess pain in this group than visual representations. Pain in the cognitively impaired older adult may require more frequent assessments than in clients who are not impaired.
Clients in this age group are less sensitive to pain and have a greater pain tolerance. Rationale: Cognitive impairment in the older adult acts as a barrier to pain assessment, and pain may be more accurately reported at the moment when it occurs than when prompted by the nurse. Clients in this age group are not less sensitive to pain and do not necessarily have a greater pain tolerance. The other options are correct statements.
The nurse is providing instructions to an assistive personnel (AP) who is assigned to care for a client who had a brain attack (stroke) and is experiencing hemiparesis of the right arm and leg. Where would the nurse instruct the AP to place personal articles for morning care? Within the client's reach on the left side Within the client's reach on the right side Just out of the client's reach on the left side Just out of the client's reach on the right side
Within the client's reach on the left side Rationale: Hemiparesis is weakness of the face, arm, and leg on one side. The nurse would instruct the assistive personnel to place objects on the unaffected side and within reach of the client. Options 2, 3, and 4 are incorrect and would not be helpful or safe for the client.
