HESI module 8

At 1600 the nurse checks a client's total parenteral nutrition (TPN) infusion bag and notes that the solution is running at a rate of 100 mL/hr. The bag was hung the previous day at 1800. The nurse plans to change the infusion bag and tubing this evening at what time? 1700 1800 2000 2100

1800

The health care provider's prescription reads, "Clindamycin phosphate 0.3 g in 50 mL NS, to be administered IV over 30 minutes." The medication label reads, "Clindamycin phosphate 150 mg/mL." How many milliliters of medication does the nurse prepare to ensure that the correct dose is administered?

2 .3g=300mg multiply 150x2= 300mg in 2 ml

The health care provider (HCP)prescribes the administration of total parenteral nutrition (TPN), to be started at a rate of 50 mL/hr by way of infusion pump through an established subclavian central line. After the first 2 hours of the TPN infusion, the client suddenly complains of difficulty breathing and chest pain. The nurse should take which immediate action? Obtain blood for culture Clamp the TPN infusion line Obtain an electrocardiogram (ECG) Obtain a sample for blood glucose testing

Clamp the TPN infusion line

A nurse has taught a client taking a methylxanthine bronchodilator, theophylline, about beverages that must be avoided. Which beverage choices by the client indicate to the nurse that the client needs further education? Select all that apply. Cocoa Coffee Lemonade Orange juice Chocolate milk

Cocoa Coffee Chocolate milk

A nurse discontinues an infusion of a unit of packed red blood cells (RBCs) because the client is experiencing a transfusion reaction. After discontinuing the transfusion, which action should the nurse take next? Remove the IV catheter Contact the health care provider Change the solution to 5% dextrose in water Obtain a culture of the tip of the catheter device removed from the client

Contact the health care provider

A nurse is assessing a client who is being hospitalized with a diagnosis of pneumonia. The client's husband tells the nurse that the client is taking donepezil hydrochloride. The nurse should ask the husband about the client's history of which disorder? Dementia Seizure disorder Diabetes mellitus Posttraumatic stress disorder

Dementia

A client who needs to receive a blood transfusion has experienced a pruritic rash during previous transfusions. The client asks the nurse whether it is safe to receive the transfusion. Which medication does the nurse anticipate will most likely be prescribed before the transfusion? Ibuprofen Acetaminophen Diphenhydramine Acetylsalicylic acid

Diphenhydramine

The serum theophylline level of a client who is taking the medication (Theo-24) is 16 mcg/mL. On the basis of this result, the nurse should take which action initially? Document the normal value on the chart Call the health care provider immediately Call the rapid response team to help with the emergency Call the pharmacy to alert the pharmacist regarding the client's theophylline level

Document the normal value on the chart

A nurse is assessing a peripheral intravenous (IV) site and notes blanching, coolness, and edema at the insertion site. What should the nurse do first? Remove the IV Apply a warm compress Check for blood return Measure the area of infiltration

Remove the IV

A nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous near the insertion point of the catheter. On the basis of this assessment, the nurse should take which action first? Remove the IV catheter Slow the rate of infusion Notify the health care provider Check for loose catheter connections

Remove the IV cath

A client taking hydrochlorothiazide reports to the clinic for follow-up blood tests. For which side/adverse effect of the medication does the nurse monitor the client's laboratory results? Hypokalemia Hypocalcemia Hypernatremia Hypermagnesemia

Hypokalemia

A nurse is preparing a plan of care for a client who will be receiving meperidine hydrochloride. Which side/adverse effects does the nurse make a note of needing to be alert to in the plan of care? Select all that apply. Hypotension Constipation Bradycardia Urine retention Respiratory depression

Hypotension Constipation Urine retention Respiratory depression

The health care provider prescribes an intramuscular dose of 200,000 units of penicillin G benzathine for an adult client. The label on the 10-mL ampule sent from the pharmacy reads, "Penicillin G benzathine, 300,000 units/mL." How many milliliters of medication does the nurse prepares to ensure administration of the correct dose? (Round to the nearest tenth.)

.7 200,000/300,000

A client has a prescription for a unit of packed red blood cells (RBCs). Which IV solution should the nurse obtain to hang with the blood product at the client's bedside? 0.9% sodium chloride Lactated Ringer's solution (LR) 5% dextrose in 0.9% sodium chloride 5% dextrose in water in 0.45% sodium chloride

0.9% sodium chloride

The health care provider's prescription reads, "Phenytoin 0.1 g by mouth twice daily." The medication label indicates that the bottle contains 100-mg capsules. How many capsules does the nurse prepare for administration of one dose?

1

A nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. For how long does the nurse plan to stay with the client after the unit of blood is hung? 5 minutes 15 minutes 45 minutes 60 minutes

15

The health care provider's prescription for an adult client reads, "Potassium chloride 15 mEq by mouth." The label on the medication bottle reads, "20 mEq potassium chloride/15 mL." How many milliliters of KCl does the nurse prepare to ensure administration of the correct dose of medication? (Round to the nearest whole number.)

11 20/15=1.3 15/1.3

At 1300, the nurse is documenting the receipt of a unit of packed blood cells at the hospital blood bank. The nurse calculates that the transfusion must be started by which time? 1315 1330 1345 1400

1330

A client is receiving total parenteral nutrition (TPN) with fat emulsion (lipids) piggybacked to the TPN solution. For which signs of an adverse reaction to the fat emulsion should the nurse monitor the client? Select all that apply. Chills Pallor Headache Chest and back pain Nausea and vomiting Subnormal temperature

Chills Headache Chest and back pain Nausea and vomiting

The health care provider prescribes 1000 mL of 5% dextrose in water, to be infused over 24 hours. The drop factor is 60 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round to the nearest whole number).

42

A nurse is making initial rounds on a group of assigned clients. Which client should the nurse see first? A client receiving total parenteral nutrition (TPN) at a rate of 50 mL/hr for the last 24 hours A client receiving TPN at a rate of 50 mL/hr whose temp was 99° F (37.2°C) on the previous shift A client receiving TPN at a rate of 100 mL/hr who has complained of needing frequent trips to the bathroom to void A client whose TPN solution was decreased to a rate of 25 mL/hr who is now complaining of weakness, headache, and sweating

A client whose TPN solution was decreased to a rate of 25 mL/hr who is now complaining of weakness, headache, and sweating

A nurse is caring for a group of adult clients on an acute care nursing unit. Which clients does the nurse recognize as the most likely candidates for total parenteral nutrition (TPN)? Select all that apply. A client with pancreatitis A client with severe sepsis A client with renal calculi A client who has undergone repair of a hiatal hernia A client with a severe exacerbation of ulcerative colitis

A client with pancreatitis A client with severe sepsis A client with a severe exacerbation of ulcerative colitis

A nurse is reviewing the laboratory results of a client receiving intravenous chemotherapy. Which laboratory finding prompts the nurse to initiate neutropenic precautions? A clotting time of 10 minutes An ammonia level of 20 mcg N/dL (14.6 μmol N/L) A platelet count of 100 × 103/μL (100× 109/L). A white blood cell (WBC) count of 2.0 × 103/μL (2.0 × 109/L).

A white blood cell (WBC) count of 2.0 × 103/μL (2.0 × 109/L).

Fluoxetine hydrochloride is prescribed for a client, and the nurse provides instruction regarding the use of the medication. The nurse tells the client that it is best to take the medication at what time? At lunchtime In the morning With the evening meal Midafternoon, with an antacid

AM

A nurse is caring for a client with myasthenia gravis who is exhibiting signs of cholinergic crisis. Which medication does the nurse ensure is available to treat this crisis? Acetylcysteine Atropine sulfate Protamine sulfate Pyridostigmine bromide

Atropine sulfate

A nurse discontinues an infusion of a unit of blood after the client experiences a transfusion reaction. Once the incident has been documented appropriately, where does the nurse send the blood transfusion bag? Blood bank Risk management Microbiology laboratory Infection-control department

Blood bank

A client with HIV infection has been started on therapy with zidovudine. The nurse tells the client to report to the laboratory in 3 months for testing to detect adverse effects of the therapy. Which laboratory test is most important to monitor for this client? Creatinine Serum potassium Blood urea nitrogen (BUN) Complete blood count (CBC)

CBC

Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit values. The nurse takes the client's temperature orally before hanging the blood transfusion and notes that it is 100.0° F (37.7 C). What should the nurse do next? Call the health care provider Begin the transfusion as prescribed Administer an antihistamine and begin the transfusion Administer 2 tablets of acetaminophen and begin the transfusion

Call the health care provider

The first bag of total parenteral nutrition (TPN) solution has arrived on the clinical unit for a client beginning this nutritional therapy. The solution is to be infused by way of a central line. Which essential piece of equipment should the nurse obtain before hanging the solution? Pulse oximeter Blood glucose meter Electronic infusion device Noninvasive blood pressure monitor

Electronic infusion device

Betaxolol eye drops have been prescribed for the treatment of a client's glaucoma. The nurse tells the client to return to the clinic for follow-up for which purpose? To have weight checked To give a sample for urinalysis To have the blood glucose level checked For measurement of blood pressure and apical pulse

For measurement of blood pressure and apical pulse

A client is taking a folic acid supplement. Which laboratory parameter does the nurse use to evaluate the effectiveness of this therapy? Select all that apply. Magnesium Hemoglobin Blood glucose Hematocrit Alkaline phosphatase

H&H

A nurse answers a call bell and finds that the total parenteral nutrition (TPN) solution bag of an assigned client is empty. The new prescription was written for a new bag at the beginning of the shift, but it has not yet arrived from the pharmacy. Which action should the nurse take first? Call the health care provider Call the pharmacy for further instructions Hang a solution of 10% dextrose in water Hang a solution of 5% dextrose in 0.9% sodium chloride

Hang a solution of 10% dextrose in water

A nurse is caring for a client who has been taking acetazolamide for glaucoma. Which, if documented in the assessment data, indicates to the nurse that the client may be experiencing an adverse effect of the medication? Tinnitus Jaundice No change in peripheral vision Pupillary constriction in response to light

Jaundice

Baclofen is prescribed for a client with a spinal cord injury who is experiencing muscle spasms. While providing instructions to the client, which side effect does the nurse tell the client is possible? Photosensitivity Nasal congestion Increased appetite Increased salivation

Nasal congestion

A nurse is monitoring a client who is receiving total parenteral nutrition (TPN). Which signs and symptoms causes the nurse to suspect that the client is experiencing hyperglycemia as a complication? Pallor, weak pulse, and anuria Nausea, vomiting, and oliguria Nausea, thirst, and increased urine output Sweating, chills, and decreased urine output

Nausea, thirst, and increased urine output

Erythromycin is prescribed for a client with a respiratory tract infection. The nurse provides instructions to the client regarding the administration of the oral medication and tells the client that it is best to take the medication in which way? With juice With a meal On an empty stomach At bedtime, with a snack

On an empty stomach

Phenelzine sulfate is being administered to a client with depression. The client suddenly complains of a severe frontally radiating occipital headache, neck stiffness and soreness, and vomiting. On further assessment, the client exhibits signs of hypertensive crisis. Which medication should the nurse prepare to administer, anticipating that it will be prescribed as the antidote to treat phenelzine-induced hypertensive crisis? Phentolamine Acetylcysteine Protamine sulfate Calcium gluconate

Phentolamine

A nurse notes that the site of a client's peripheral IV catheter is reddened, warm, painful, and slightly edematous in the area of the insertion site. After taking appropriate steps to care for the client, the nurse documents in the medical record that the client has experienced which problem? Phlebitis of the vein Infiltration of the IV line Hypersensitivity to the IV solution An allergic reaction to the IV catheter material

Phlebitis of the vein

Methylergonovine intramuscularly is prescribed for a postpartum client. Before administering the medication, the nurse explains to the client that the medication will promote which effect? Reduce lochial drainage Prevent postpartum bleeding Maintain a normal blood pressure Decrease the strength of uterine contractions

Prevent postpartum bleeding

A nurse is to administer a dose of digoxin to a client with atrial fibrillation and notes that the client has a potassium level of 4.6 mEq/L (4.6 mmol/L). The nurse determines which about the administration of the dose? Should be withheld that day Should be administered as prescribed Should be preceded with a dose of potassium Should be withheld and the health care provider notified

Should be administered as prescribed

A nurse hangs a 500-mL bag of intravenous (IV) fluid for an assigned client. One hour later the client complains of chest tightness, is dyspneic and apprehensive, and has an irregular pulse. The IV bag has 100 mL remaining. Which action should the nurse take first? Remove the IV Sit the client up in bed Shut off the IV infusion Slow the rate of infusion

Shut off the infusion

A nurse has a written prescription to remove an intravenous (IV) line. Which item should the nurse obtain from the unit supply area for use in applying pressure to the site after removing the IV catheter? Alcohol swab Adhesive bandage Sterile 2 × 2 gauze Povidone-iodine (Betadine) swab

Sterile 2 × 2 gauze

A home care nurse has been assigned a client who has been discharged home with a prescription for total parenteral nutrition (TPN). Which parameters does the nurse plan to check at each visit as a means of identifying complications of the TPN therapy? Select all that apply. Weight Glucose test Temperature Peripheral pulses Hemoglobin and hematocrit

Weight, glucose, temp

A client with rheumatoid arthritis is taking high doses of acetylsalicylic acid. While assessing the client for aspirin toxicity, which question should the nurse ask the client? "Are you constipated?" "Are you having any diarrhea?" "Do you have any double vision?" "Do you have any ringing in the ears?"

"Do you have any ringing in the ears?"

A client with a thoracic spinal cord injury is receiving dantrolene sodium. Which statement by the client indicates to the nurse that the client is experiencing an adverse effect of the medication? "I'm feeling really drowsy." "My legs are very relaxed." "I can't seem to get enough to eat." "I urinate about the same amount as I always did."

"I'm feeling really drowsy."

Warfarin sodium has been prescribed, and the nurse teaches the client about the medication. Which statement by the client indicates that further teaching is necessary? "I won't play football anymore." "I won't take any over-the-counter medications except aspirin." "I'll use an electric shaver until the doctor stops the Coumadin prescription." "I'll buy one of those medication alert tags that tells people I'm taking an anticoagulant."

"I won't take any over-the-counter medications except aspirin."

A client with heart failure being discharged home will be taking furosemide. Which statement by the client indicates to the nurse that the teaching has been effective? "I'll weigh myself every day." "I'll take my pulse every day." "I'll measure my urine output." "I'll check my ankles every day for swelling."

"I'll weigh myself every day."

A nurse is providing dietary instructions to a client taking spironolactone. The nurse realizes the teaching has been effective if the client selects which food items from the menu? Select all that apply. Rice Cereal Carrots Bananas Citrus fruits

Rice, cereal, carrots

A client who has been taking lisinopril complains to the nurse of a persistent dry cough. What should the nurse tell the client? This is a side effect of therapy He probably has an upper respiratory infection He needs to have his blood counts checked A chest x-ray is required because the cough is a sign of heart failure

This is a side effect of therapy

A nurse instructs a client with hypothyroidism about the dosage, method of administration, and side effects of levothyroxine sodium. Which statement by the client indicates an understanding of the nurse's instructions? "I should take the medication in the evening." "I can expect diarrhea, insomnia, and excessive sweating." "If I feel nervous or have tremors, I should only take half the dose." "I need to report any episodes of palpitations, chest pain, or dyspnea."

"I need to report any episodes of palpitations, chest pain, or dyspnea."

Disulfiram is prescribed for a client. Which questions does the nurse make a priority of asking the client before administering this medication? Select all that apply. "When did you have your last full meal?" "Do you have a history of diabetes insipidus?" "When was your last drink of alcohol?" "Do you have a history of thyroid problems?" "Do you have a history of cancer in your family?"

"When was your last drink of alcohol?" "Do you have a history of thyroid problems?"

A nurse provides instructions to a client who will be taking furosemide. Which statement by the client indicates to the nurse that the client needs additional instruction? "I need to sit or stand up slowly." "I need to maintain my fluid intake." "This medication will make me urinate." "I should expect to have ringing in my ears."

"I should expect to have ringing in my ears."

A client with schizophrenia who has been taking an antipsychotic medication calls the clinic nurse and says, "I need to cancel my appointment with the psychiatrist again, because I still have this awful sore throat. It's so bad that my mouth has a sore." How does the nurse respond to the client? "I wouldn't be upset. It happens when you aren't drinking enough water." "I think you need to come in for blood work today, because this may be an adverse effect of your medicine." "Do you remember when you started this medication? Your psychiatrist told you how important it is to keep your appointments with him." "You probably have a simple flu, but it might help if you gargle with some antiseptic mouthwash every 2 hours or so and drink plenty of water."

"I think you need to come in for blood work today, because this may be an adverse effect of your medicine."

A young female client with schizophrenia says to the nurse, "Since I started on olanzapine last year, I'm doing well in school and all, but I've gained so much weight, and it's really bothering me. What can I do about this?" Which response by the nurse would be therapeutic? "Well, I think you're overreacting. Today people think they should be skinny-minnies, even though it's not healthy." "Weight gain can be a side effect of the medication, so you need to watch your diet and exercise. How much weight have you gained?" "That medication isn't any more likely to cause weight gain than the others you're taking. Perhaps we could go over your diet and exercise habits." "I want you to stop taking this medication immediately, and I'm calling the doctor, because this is a very serious side effect and you may need dialysis."

"Weight gain can be a side effect of the medication, so you need to watch your diet and exercise. How much weight have you gained?"

The health care provider prescribes 1000 mL of normal saline 0.45% for infusion over 8 hours. The drop factor is 10 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round to the nearest whole number).

21

The health care provider prescribes 2000 mL of 5% dextrose and normal saline 0.45% for infusion over 24 hours. The drop factor is 15 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round to the nearest whole number).

21 2,000/24 15/60 multiply the 2 answers

The health care provider prescribes 1000 mL of 5% dextrose in water to be infused over 8 hours. The drop factor is 15 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round to the nearest whole number).

31

The emergency department staff prepares for the arrival of a child who has ingested a bottle of acetaminophen. Which medication does the nurse ensure is available? Pancreatin Phytonadione Acetylcysteine Protamine sulfate

Acetylcysteine

A client with schizophrenia has been taking an antipsychotic medication for 2 months. For which adverse effect should the nurse monitor the client closely? Akathisia Pelvic thrusts Athetoid limbs Protruding tongue

Akathisia

A client has been given a prescription to begin using nitroglycerin transdermal patches for the management of angina pectoris. What should the nurse tell the client about the medication? Place the patch in the area of a skin fold to promote adherence Apply the patch at the same time each day and leave it in place for 12 to 16 hours as directed If the patch becomes dislodged, do not reapply and wait until the next day to apply a new patch. Alternate daily dose times between the morning and the evening to prevent the development of tolerance to the medication

Apply the patch at the same time each day and leave it in place for 12 to 16 hours as directed

A client with heart failure is being given furosemide and digoxin. The client calls the nurse and complains of anorexia and nausea. Which action should the nurse take first? Administer an antiemetic Administer the daily dose of digoxin Discontinue the morning dose of furosemide Check the result of laboratory testing for potassium on the sample drawn 3 hours ago

Check the result of laboratory testing for potassium on the sample drawn 3 hours ago

Risperidone is prescribed for a client with a diagnosis of schizophrenia. Which laboratory study does the nurse expect to see among the health care provider's prescriptions? Platelet count Creatinine level Sedimentation rate Red blood cell count

Creatinine level

A nurse is teaching a client how to mix regular and NPH insulin in the same syringe. The nurse should provide the client with which information about the insulin? Keep insulin refrigerated at all times Draw the regular insulin into the syringe first Shake the NPH insulin bottle before mixing the two types Remove all of the air from the bottle before mixing the two types

Draw the regular insulin into the syringe first

A nurse is caring for a client with a diagnosis of chronic kidney disease who is receiving dialysis. Epoetin alfa, to be administered subcutaneously, has been prescribed, and the nurse is drawing the medication from a single-use vial. What should the nurse do to prepare the medication? Shake the vial before drawing up the medication Draw up the medication and discard the unused portion Obtain the medication from the medication freezer and allow it to thaw Mix the medication with 0.1 mL of heparin before administration to prevent clotting

Draw up the medication and discard the unused portion

A home health nurse provides instructions to a client who is taking allopurinol for the treatment of gout. The nurse realizes the instructions have been effective if the client verbalizes the importance of which teaching point? Place an ice pack on the lips if they swell Drink at least 8 glasses of fluid every day Take the medication on an empty stomach 2 hours before meals Use an over-the-counter (OTC) antihistamine lotion if a rash develops

Drink at least 8 glasses of fluid every day

Metoprolol has been prescribed for a client with hypertension. For which common side effects of the medication does the nurse monitor the client? Select all that apply. Fatigue Dry eyes Weakness Erectile dysfunction Nightmares

Fatigue Weakness Erectile dysfunction

Carbamazepine is prescribed for a client with trigeminal neuralgia. Which side/adverse effects does the nurse instruct the client to report to the health care provider? Select all that apply. Fever Nausea Headache Sore throat Mouth sores

Fever Sore throat Mouth sores

A nurse is preparing a client for the insertion of a central intravenous line into the subclavian vein by the health care provider. The nurse gathers the equipment, places it at the bedside, and prepares to assist the health care provider with the procedure. As further preparation for the procedure, the nurse places the client in which position? Flat on the left side In the prone position In the supine position In a slight Trendelenburg position

In a slight Trendelenburg position

A nurse is caring for a client with histoplasmosis who is receiving intravenous amphotericin B . Which is the most critical observation for the nurse to make while the medication is being administered? Monitor the client's urine output Monitor the client for hypothermia Check the client's neurological status Check the client's blood glucose level

Monitor the client's urine output

A nurse has taught a client who is taking lithium carbonate about the medication. The nurse determines that the client needs additional teaching if the client makes which comment to the nurse? The medication should be taken with meals The lithium blood levels must be monitored very closely It is important to decrease fluid intake while taking the medication to avoid nausea The health care provider must be called if excessive diarrhea, vomiting, or diaphoresis occurs

It is important to decrease fluid intake while taking the medication to avoid nausea

A nurse suspects that a client receiving total parenteral nutrition (TPN) through a central line has an air embolism. The nurse immediately places the client in which position? Left side with the head lower than the feet Left side with the head higher than the feet Right side with the head lower than the feet Right side with the head higher than the feet

Left side with the head lower than the feet

A client with tuberculosis is being started on isoniazid and the nurse stresses the importance of returning to the clinic for follow-up blood testing. The nurse realizes the client understands the instructions if the client verbalizes the need to return to the clinic for which blood test? Liver enzymes Serum creatinine Blood urea nitrogen Red blood cell count

Liver enzymes

A client is receiving intravenous bleomycin sulfate. During administration of the chemotherapy, nursing assessment is the priority? Heart rate Lung sounds Peripheral pulses Level of consciousness

Lung sounds

A nurse is providing instruction to a client who is taking codeine sulfate for severe back pain. Which instruction should the nurse provide to the client? Decrease fluid intake Maintain a high-fiber diet Avoid all exercise to help prevent lightheadedness Avoid the use of stool softeners to help prevent diarrhea

Maintain a high-fiber diet

A nurse is preparing a plan of care for a client with a diagnosis of cancer who is receiving morphine sulfate for pain. Which action does the nurse identify as a priority in the plan of care for this client? Monitoring urine output Encouraging increased fluids Monitoring the client's temperature Monitoring the client's respiratory rate

Monitoring RR

A nurse is developing a plan of care for a client, hospitalized with heart failure, who has a history of Parkinson disease and is taking benztropine mesylate daily. Which intervention does the nurse identify as a priority in the plan? Monitoring intake and output Monitoring the client's pupillary response Placing the client in a right side-lying position Checking the client's hemoglobin level daily

Monitoring intake and output

A nurse is reading the medical record of a client receiving haloperidol. The nurse notes that the health care provider has documented that the client is experiencing signs of akathisia. On the basis of the health care provider's note, which clinical manifestation would the nurse expect to find during assessment of the client? Motor restlessness Puffing of the cheeks Puckering of the mouth Protrusion of the tongue

Motor restlessness

A client has just undergone insertion of a central venous catheter by the health care provider at the bedside. Which result would the nurse be sure to check before initiating infusion of the IV solution that the health care provider has prescribed? Serum osmolality Serum electrolytes Portable chest x-ray Intake and output record

Portable chest x-ray

A client with a peripheral intravenous (IV) line in place has a new prescription for infusion of total parenteral nutrition (TPN), a solution containing 25% glucose. Which action should be taken by the nurse? Hanging the IV solution as prescribed Questioning the health care provider about the prescription Diluting the solution with sterile water to half-strength Hanging the IV solution but setting the infusion at just half the prescribed rate

Questioning the health care provider about the prescription

A nurse has just hung a transfusion of packed red blood cells and stayed with the client for the appropriate amount of time. Before leaving the room, the nurse tells the client that it is most important to immediately report which specific signs if it occurs? Select all that apply. Rash Chills Fatigue Backache Tiredness

Rash Chills Backache

A nurse is providing instructions to a client regarding quinapril hydrochloride. The nurse should teach the client to implement which measure? To take the medication with meals To rise slowly from a lying to a sitting position To discontinue the medication if nausea occurs That a therapeutic effect will be felt immediately

To rise slowly from a lying to a sitting position

Zidovudine is prescribed for an adult client with HIV infection. The nurse should provide which instruction to the client about the medication? That the medication must be taken with milk That aspirin can be taken to treat headache To discontinue the medication if nausea occurs To space the doses evenly around the clock

To space the doses evenly around the clock

A client has a prescription for short-term therapy with enoxaparin . The nurse explains to the client that this medication is being prescribed for which purpose? Prevent pain Relieve back spasms Increase the client's energy level Reduce the risk of deep vein thrombosis

Reduce the risk of deep vein thrombosis

The client rings the call bell and complains of pain at the site of an IV infusion. The nurse assesses the site and determines that phlebitis has developed. Which actions should the nurse take? Select all that apply. Removing the IV catheter at that site Applying warm, moist compresses to the IV site Notifying the health care provider about the finding Encouraging the client to scrub the site while in the shower Starting a new IV line in a proximal portion of the same vein

Removing the IV catheter at that site Applying warm, moist compresses to the IV site Notifying the health care provider about the finding

A client receiving total parenteral nutrition (TPN) requires fat emulsion (lipids), which will be piggybacked to the TPN solution. On obtaining a bottle of fat emulsion, the nurse notes that fat globules are floating at the top of the solution. Which action should the nurse take? Shake the bottle vigorously Request a new bottle from the pharmacy Rotate the bottle gently back and forth to mix the globules Run the bottle under warm water until the globules disappear

Request a new bottle from the pharmacy

A nurse is monitoring a client who is receiving a continuous intravenous infusion of morphine sulfate. Which finding should cause the nurse to contact the health care provider? Temperature of 97.6° F (36.4°C) Urine output of 30 mL/hr Blood pressure of 100/60 mm Hg Respiratory rate of 10 breaths/min

Respiratory rate of 10 breaths/min

A client who is taking bupropion in an attempt to stop smoking tells a nurse that he has been doubling the daily dose to make it easier to resist smoking. The nurse warns the client that doubling the daily dosage is dangerous. Of which adverse effect of the medication does the nurse warn the client? Insomnia Seizures Weight gain Orthostatic hypotension

Seizures

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. Which assessment finding indicates to the nurse that the client is experiencing magnesium toxicity? Proteinuria of +3 Sudden drop in fetal heart rate Presence of deep tendon reflexes Serum magnesium level of 2.5 mEq/L (1.25 mmol/L)

Sudden drop in fetal heart rate

The nurse is preparing to change the solution bag and intravenous tubing of a client receiving total parenteral nutrition (TPN) through a left subclavian central venous line. Which essential action does the nurse ask the client to perform just before switching the tubing? Turn the head to the left Turn the head to the right Exhale slowly and evenly Take a deep breath and hold it

Take a deep breath and hold it

A client who has undergone adrenalectomy is prescribed prednisone. Which finding indicates that the client is experiencing an adverse effect of the medication? Dry mouth Tarry stools Hypotension Hypoglycemia

Tarry stool's

A client is receiving heparin sodium by way of continuous IV infusion. For which adverse effects of the therapy does the nurse assess the client? Select all that apply. Tinnitus Tarry stools Slowed pulse Bleeding from the gums Increased blood pressure

Tarry stools Bleeding from the gums

A client taking metronidazole for the treatment of trichomoniasis vaginalis calls the clinic nurse to express concern because her urine has turned dark in color. The nurse should provide which information to the client? To increase her fluid intake To discontinue the medication That darkening of the urine is a harmless side effect To report to the clinic to see the health care provider

That darkening of the urine is a harmless side effect

A client has been taking metoprolol. Which finding indicates to the nurse that the medication is effective? The client's ankles are swollen. The client's weight has increased. The client's blood pressure has decreased. The client has wheezes in the lower lobes of the lungs.

The client's blood pressure has decreased.

A client with newly diagnosed angina pectoris has taken 2 sublingual nitroglycerin tablets for chest pain. The chest pain is relieved, but the client complains of a headache. What should the nurse tell the client? This is an indication that the medication should not be used again Headache indicates medication tolerance, and the dosage must be increased This may be an allergic reaction to the nitroglycerin, and the health care provider must be notified This is an expected side effect of the nitroglycerin, and the client can relieve it by taking acetaminophen

This is an expected side effect of the nitroglycerin, and the client can relieve it by taking acetaminophen

A nurse is changing the central line dressing of a client receiving total parenteral nutrition (TPN). The nurse notes moisture under the dressing covering the catheter insertion site. What should the nurse assess next? Temperature Time of the last dressing change Expiration date on the infusion bag Tightness of the tubing connections

Tightness of the tubing connections

Cyclophosphamide has been prescribed for a client with a diagnosis of breast cancer, and the nurse is providing instructions to the client. The nurse realizes the instructions have been effective if the client makes the statement she will change which aspect of care? To avoid salt while taking this medication That it is best to take the medication with food To increase fluid intake to 2000 mL to 3000 mL/day To drink at least 2 glasses of orange juice every day

To increase fluid intake to 2000 mL to 3000 mL/day

A nurse is preparing a plan of care for a pregnant client who will be given oxytocin to induce labor. Which occurrence does the nurse include in the plan of care as a reason for immediate discontinuation of the oxytocin infusion? Uterine atony Severe drowsiness Uterine hyperstimulation Early decelerations of the fetal heart rate

Uterine hyperstimulation

A nurse has obtained a unit of blood from the blood bank and properly checked the blood bag with another nurse. Which parameter should the nurse assess just before hanging the transfusion? Skin color Vital signs Latest platelet count Urine output over the last 24 hours

VS

Intravenous tobramycin sulfate is prescribed for a client with a respiratory tract infection. For which of the following symptoms, indicative of an adverse effect, does the nurse monitor the client? Nausea Vertigo Vomiting Hypotension

Vertigo