NCLEX SKILLS

The nurse is reviewing the medication record and notes that a client is to receive heparin 6000 units subcutaneously. The medication label states heparin 10,000 units/mL. How much heparin will the nurse prepare to administer to the client? Fill in the blank. Record your answer using 1 decimal place.

0.6 mL Rationale:Use the formula to calculate the correct dose.Desired --------- × Volume = mL/dose Available 6000 units ------------- × 1 mL = 0.6 mL 10,000 units

The nurse is providing instructions to a client with kidney disease about a low-protein diet. The client demonstrates understanding of the dietary instructions by stating the need to limit which food in the diet? 1.Chicken 2.Whole milk 3.Swiss cheese 4.Peanut butter

1.Chicken Rationale:Chicken (3 ounces) contains 26 g of protein, and peanut butter (2 tablespoons) contains 9 g of protein. Whole milk (1 cup) contains 8 g of protein, and Swiss cheese (1 ounce) contains 7 g of protein.

The nurse is caring for a client who is receiving morphine sulfate by the intravenous route for acute pain. The nurse ensures that which medication is available in the event that the client's respiratory status and level of consciousness deteriorate? 1.Naloxone 2.Promethazine 3.Atropine sulfate 4.Protamine sulfate

1.Naloxone Rationale:Naloxone is an opioid antagonist that is used to treat opioid overdose. Atropine sulfate is an anticholinergic. Promethazine is an antiemetic medication, and protamine sulfate is the antidote for heparin.

The nurse is discussing pain management with a student who is caring for a 1-day postoperative abdominal surgery client who is a known opioid substance abuser. What comment by the student indicates a need for further education? 1.Opioid substance abusers are less tolerant to opioids and require decreased doses. 2.These clients should be allowed to choose their pain medications and dosing regimen. 3.Nonopioid therapies such as cutaneous stimulation are generally effective if used alone. 4.These clients are at an increased risk for abrupt physiological withdrawal when opioid agonists are abruptly withdrawn.

1.Opioid substance abusers are less tolerant to opioids and require decreased doses. Rationale:Opioid substance abusers have developed a tolerance to opioids and require higher, not decreased, doses for a therapeutic effect. The other statements are appropriate comments.

A client with a fractured femur who has had an open reduction-internal fixation is receiving ketorolac. Which assessment measurement will assist the nurse in determining the effectiveness of this medication? 1.Pain rating 2.Temperature 3.Serum calcium level 4.White blood cell count

1.Pain rating Rationale:Ketorolac is a nonopioid analgesic and nonsteroidal anti-inflammatory agent. It acts by inhibiting prostaglandin synthesis and produces analgesia that is peripherally mediated. The nurse evaluates the effectiveness of this medication by using the pain rating scale with the client. Options 2, 3, and 4 are unrelated to the use of this medication.

The nurse is providing dietary instructions to a client about food items that are high in niacin. Which food item should the nurse recommend as highest in niacin? 1.Poultry 2.Potatoes 3.Tomatoes 4.Strawberries

1.Poultry Rationale:Poultry, eggs, meats, and dairy products are high in niacin. Tomatoes, potatoes, and strawberries are high in ascorbic acid (vitamin C).

The nurse is performing colostomy irrigation on a client. During the irrigation, the client begins to complain of abdominal cramps. What is the appropriate nursing action? 1.Stop the irrigation temporarily. 2.Increase the height of the irrigation. 3.Notify the primary health care provider. 4.Medicate for pain and resume the irrigation.

1.Stop the irrigation temporarily. Rationale:If cramping occurs during colostomy irrigation, the irrigation flow is stopped temporarily and the client is allowed to rest. Cramping may occur from an infusion that is too rapid or is causing too much pressure. Increasing the height of the irrigation will cause further discomfort. The primary health care provider does not need to be notified. Medicating the client for pain is not the appropriate action in this situation.

The nurse is assisting in caring for a client after removal of an endotracheal tube. Which finding should be reported to the primary health care provider (PHCP) immediately? 1.Stridor 2.Lung congestion 3.Occasional pink-tinged sputum 4.Respiratory rate of 26 breaths/min

1.Stridor Rationale:The nurse reports the presence of stridor to the PHCP immediately. This is a high-pitched coarse sound that is heard with the stethoscope over the trachea. It indicates airway edema and places the client at risk for airway obstruction. Lung congestion and a respiratory rate of 26 breaths/min are abnormal, but additional data are needed to determine whether these pose a serious problem at this time. Occasional pink-tinged sputum may be expected at this time.

The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client's pain should include which assessment? 1.The client's pain rating 2.Nonverbal cues from the client 3.The nurse's impression of the client's pain 4.Pain relief after appropriate nursing intervention

1.The client's pain rating Rationale:The client's self-report is a critical component of pain assessment. The nurse should ask the client to describe the pain and listen carefully to the words the client uses to describe the pain. Nonverbal cues from the client are important but are not the most appropriate pain assessment measure. The nurse's impression of the client's pain is not appropriate in determining the client's level of pain. Assessing pain relief is an important measure, but this option is not related to the subject of the question.

The nurse is instructing a client with hypertension on the importance of choosing foods low in sodium. The nurse should teach the client to limit intake of which food? 1.Apples 2.Bananas 3.Smoked sausage 4.Steamed vegetables

Smoked sausage Rationale:Smoked foods are high in sodium, which is noted in the correct option. The remaining options are fruits and vegetables, which are low in sodium.

The primary health care provider's prescription reads 150 mcg of a medication orally daily. The medication label reads 0.1 mg per tablet. The nurse should administer how many tablet(s) to the client? Fill in the blank.

1.5 tablets Rationale:It is necessary to convert 150 mcg to milligrams. In the metric system, to convert smaller to larger, divide by 1000 or move the decimal 3 places to the left: 150 mcg = 0.15 mg. Next, use the formula to calculate the correct dose. Formula: Desired --------- × Quantity = Tablets Available 0.15 mg -------- × 1 tablet = 1.5 tablet 0.1 mg

The nurse is assessing a client's postoperative pain using the PQRSTU method. Using this method, which questions would the nurse ask the client? Select all that apply. 1."Where is the pain located?" 2."Does pain medication help?" 3."What does the pain feel like?" 4."How does the pain affect you?" 5."Do you have the pain when you sleep?" 6."What makes your pain better or worse?"

1."Where is the pain located?" 3."What does the pain feel like?" 4."How does the pain affect you?" 6."What makes your pain better or worse?" Rationale:The PQRSTU method is 1 method of assessing pain. With this method, the nurse asks about the following: Provocative/palliative (option 6); Quality of the pain (option 3); Region or Radiation of the pain (option 1); Severity of the pain; Timing of the pain (continuous or intermittent); and How the pain affects yoU (option 4). Options 2 and 5 may be questions that would be asked; however, these are not a part of the PQRSTU method.

The nurse has reviewed with the preoperative client the procedure for the administration of an enema. Which statement by the client would indicate the need for further instruction? 1."The enema will be given while I am sitting on the toilet." 2."I should try and hold the fluid as long as possible after it is run in." 3."I know that there will be some cramping after the enema solution is run in." 4."I should tell the nurse if cramping occurs when the fluid is running in."

1."The enema will be given while I am sitting on the toilet." Rationale:The enema is never administered while on a toilet due to safety. The enema is administered while the client is in a left side-lying (Sims') position with the right knee flexed. This allows enema solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum. It is important for the client to retain the fluid for as long as possible to promote peristalsis and defecation. If the client complains of fullness or pain, the flow is stopped for 30 seconds and restarted at a slower rate. The higher the solution container is held above the rectum, the faster the flow and the greater the force in the rectum; this could increase cramping.

Diphenhydramine hydrochloride, 25 mg orally every 6 hours, is prescribed for a child with an allergic reaction. The child weighs 25 kg. The safe pediatric dosage is 5 mg/kg/day. The nurse should determine which concerning the dose prescribed? 1.The dose prescribed is safe. 2.The dose prescribed is too low. 3.The dose prescribed is too high. 4.There is not enough information to determine the safe dose.

1.The dose prescribed is safe. Rationale:The first step is to determine the total number of mg the client will receive based on the prescribed dose of 25 mg given 4 times daily (every 6 hours). Step 1: 25 mg × 4 = 100 mg The next step is to calculate the number of mg/kg based on the client's weight of 25 kg. Step 2: 5 mg × 25 kg = 125 mg The final step is to compare the prescribed dose to the safe dosage range.

The nurse is caring for a client with a dry suction chest drainage system. During assessment of the drainage system, what should the nurse expect to find? Select all that apply. 1.The dry suction control regulation set to the prescribed amount 2.The water filled suction control chamber filled to the prescribed amount 3.Increased intermittent bubbling in the water seal chamber when the system is to gravity 4.Continuous bubbling in the water seal chamber when the system is connected to suction 5.The drainage in the collection chamber marked each shift to monitor the amount of drainage

1.The dry suction control regulation set to the prescribed amount 5.The drainage in the collection chamber marked each shift to monitor the amount of drainage Rationale:There are 2 types of chest drainage systems: the wet drainage system and the dry drainage system. On routine assessment of the system, the nurse should look at the different chambers. For a dry drainage system, the nurse should check the dry suction control regulation and make sure it is set to the prescribed amount. The nurse should also look for the orange floater ball to appear in the window; this indicates that the suction is being applied correctly. Tidaling should be noted in the water seal chamber. The nurse should also check the water seal chamber; if the system is connected to suction (as opposed to gravity), tidaling may not be seen and the suction should be turned off to check for tidaling. If continuous bubbling is noted or the bubbling increases, an air leak may be present and the connections should be checked. In a dry drainage system, water is not added to the suction control chamber; this is done with a wet drainage system. The drainage collection chamber should be monitored and marked each shift to monitor the amount of drainage, if any.

The nurse is setting up a transcutaneous electrical nerve stimulation unit on a client with chronic pain. As the nurse turns up the level of stimulation, the client complains of discomfort. Based on this finding, the nurse should make which interpretation? 1.The maximal stimulation has been reached, and it should be decreased slightly. 2.This is a temporary effect, and the stimulation should continue to be increased. 3.The maximal stimulation has been far exceeded, and it should be decreased by half. 4.This is a complication of the device's use, and it should be discontinued immediately.

1.The maximal stimulation has been reached, and it should be decreased slightly. Rationale:Use of a transcutaneous electrical nerve stimulation (TENS) unit involves applying 2 electrodes from the machine to the skin and adjusting the level of stimulation to 1 lead at a time. Usually a physical therapist is responsible for administering TENS therapy, although nurses can be trained in the technique. The amount of stimulation is increased until the client feels discomfort, which indicates that the maximal stimulation necessary to block pain stimuli has been reached. The volume is then reduced by a small amount until no further muscle discomfort or contractions occur. The other options are incorrect.

The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history and determines it is necessary to contact the primary health care provider (PHCP) if the client is also taking which medications? Select all that apply. 1.Warfarin 2.Glimepiride 3.Amlodipine 4.Simvastatin 5.Atorvastatin

1.Warfarin 2.Glimepiride 3.Amlodipine Rationale:Nonsteroidal antiinflammatory drugs (NSAIDs) can amplify the effects of anticoagulants; therefore, these medications should not be taken together. Hypoglycemia may result for the client taking ibuprofen if the client is concurrently taking an oral antidiabetic agent such as glimepiride; these medications should not be combined. A high risk of toxicity exists if the client is taking ibuprofen concurrently with a calcium channel blocker such as amlodipine; therefore, this combination should be avoided. There is no known interaction between ibuprofen and simvastatin or atorvastatin.

The nurse is preparing to administer eye drops. Which interventions should the nurse take to administer the drops? Select all that apply. 1.Wash hands. 2.Put gloves on. 3.Place the drop in the conjunctival sac. 4.Pull the lower lid down against the cheekbone. 5.Instruct the client to squeeze the eyes shut after instilling the eye drop. 6.Instruct the client to tilt the head forward, open the eyes, and look down.

1.Wash hands. 2.Put gloves on. 3.Place the drop in the conjunctival sac. 4.Pull the lower lid down against the cheekbone. Rationale:To administer eye medications, the nurse should wash hands and put gloves on. The client is instructed to tilt the head backward, open the eyes, and look up. The nurse pulls the lower lid down against the cheekbone and holds the bottle like a pencil with the tip downward. Holding the bottle, the nurse gently rests the wrist of the hand on the client's cheek and squeezes the bottle gently to allow the drop to fall into the conjunctival sac. The client is instructed to close the eyes gently and not to squeeze the eyes shut to prevent the loss of medication.

The primary health care provider prescribes regular insulin, 6 units per hour by continuous intravenous (IV) infusion. The pharmacy prepares the medication and then delivers an IV bag labeled 50 units of regular insulin in 100 mL of normal saline. An infusion pump must be used to administer the medication. The nurse should set the infusion pump at how many milliliters per hour to deliver the correct dose? Fill in the blank.

12 mL/hr Rationale:Calculation of this problem can be done using a 2-step process. First, you need to determine the concentration of the solution; that is, the amount of regular insulin in 1 mL. The next step is to determine the infusion rate, or milliliters per hour. Step 1: Calculate the amount of medication (units) per milliliter (mL). Known amount of medication -------------------------- = Medication per mL Total volume of diluent 50 units ---- = 0.5 units/mL 100 mL Step 2: Calculate milliliters per hour. Dose per hour desired --------------------- = Milliliters per hour Concentration per mL 6 units ---- = 12 mL/hr 0.5 units

A primary health care provider's prescription reads acetaminophen liquid, 450 mg orally every 4 hours PRN (as needed) for pain. The medication label reads 160 mg/5 mL. The nurse prepares how many milliliters to administer 1 dose? Fill in the blank. Round your answer to the nearest whole number.

14 mL Rationale:Use the formula for calculating medication dosages. Desired --------- × Volume = mL/dose Available 450 mg ------ × 5 mL = 14.06 mL 160 mg = 14 mL (rounded)

The primary health care provider prescribes heparin sodium 800 units per hour, to be given by continuous intravenous (IV) infusion. The pharmacy prepares the medication and then delivers an IV bag labeled heparin 25,000 units in 500 mL of normal saline. An infusion pump must be used to administer the medication. The nurse should set the infusion pump at how many milliliters per hour to deliver the correct dose? Fill in the blank.

16 mL/hr Rationale:Calculation of this problem can be done using a 2-step process. First, you need to determine the concentration of the solution; that is, the amount of heparin in 1 mL. The next step is to determine the infusion rate, or milliliters per hour. Step 1: Calculate the amount of medication (units) per milliliter (mL). Known amount of medication -------------------------- = Medication per mL Total volume of diluent 25,000 units ------------ = 0.5 units/mL 500 mL Step 2: Calculate milliliters per hour. Dose per hour desired --------------------- = Milliliters per hour Concentration per mL 800 units --------- = 16 mL/hr 50 units

A client is to receive 1000 mL of 5% dextrose in water (D5W) at 100 mL per hour. The delivery rate (drop factor) is 10 drops (gtt) per mL. The nurse should set the flow rate at how many drops per minute? Fill in the blank. Round your answer to the nearest whole number.

17 gtt/min Rationale:Use the formula for calculating intravenous (IV) line flow rates. Total volume × Drop factor -------------------------- = gtt/min Time in minutes 1000 mL × 10 gtt --------------- = 16.67 gtt/min 600 minutes = 17 gtt/min (rounded)

Ampicillin sodium 250 mg in 50 mL of normal saline is to be administered over a period of 30 minutes. The drop factor is 10 drops (gtt) per mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

17 gtt/min Rationale:Use the formula to calculate the correct medication dose. The prescribed 50 mL is to be infused over 30 minutes. Follow the formula and multiply 50 mL by 10 (drop factor). Then divide the result by 30 minutes. The infusion is to run at 16.6, or 17, gtt/min. Total volume × Drop factor -------------------------- = gtt/min Time in minutes 50 mL × 10 gtt -------------- = 30 min 500 ------=16.6 gtt/min 30 17 gtt/min (rounded)

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 labeled heparin 25,000 units in 500 mL of normal saline. 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.

18 mL/hr Rationale:Calculation of this problem can be done using a 2-step process. First, you need to determine the amount of heparin sodium in 1 mL. The next step is to determine the infusion rate in milliliters per hour. Step 1: Determine the amount of regular insulin in 1 mL. Known amount of medication -------------------------- = Medication per mL Total volume of diluent 25,000 units ----------- = 18 units/mL 500 mL Step 2: Calculate mL per hour. Dose per hour desired --------------------- = Milliliters per hour Concentration per mL 900 units --------- = 18 mL/hr 50 units

A primary health care provider prescribes morphine sulfate 4 mg, intravenously (IV) stat, for a postoperative client in pain. The medication label states morphine sulfate 2 mg/mL. How many milliliters will the nurse prepare to administer to the client? Fill in the blank.

2 mL Rationale:Use the formula for calculating the appropriate medication dosage. In this question, it is not necessary to perform a conversion. Desired ----------- x Volume = mL/dose Available 4 mg ------ × 1 mL = 2 mL 2 mg

Sulfisoxazole, 1 g orally twice daily, is prescribed for an adolescent with a urinary tract infection. The medication label reads "500-mg tablets." The nurse has determined that the dosage prescribed is safe. The nurse administers how many tablets per dose to the adolescent? 1.1, 2 tablet 2.1 tablet 3.2 tablets 4.3 tablets

2 tablets Rationale:Change 1 g to milligrams, knowing that 1000 mg = 1 g. Also, when converting from grams to milligrams (larger to smaller), move the decimal point 3 places to the right: 1 g = 1000 mg. Next, use the formula to calculate the correct dose. Formula: Desired ----------- × Tablet = Tablet/dose Available 1000 mg ------- = 2 tablets 500 mg

The primary health care provider prescribes digoxin 0.25 mg orally daily for a client with heart failure. The medication label states 0.125 mg per tablet. The nurse should administer how many tablet(s) to the client? Fill in the blank.

2 tablets Rationale:Use the formula for calculating medication doses. Desired --------- × Tablets = Tablets/dose Available 0.25 mg ------- × 1 tablet = 2 tablets 0.125 mg

A client who was receiving enteral feedings in the hospital has been started on a regular diet and is almost ready for discharge. The client will be self-administering supplemental tube feedings between meals for a short time after discharge. The client expresses concern about performing this procedure at home. What is the nurse's best response? 1."Maybe a friend will do the feeding for you." 2."Tell me more about your concerns about going home." 3."Do you want to stay in the hospital a few more days?" 4."Have you discussed your feelings with your family and doctor?"

2."Tell me more about your concerns about going home." Rationale:A client often has fears about leaving the secure environment of a health care facility. This client has a specific fear about not being able to handle tube feedings at home. An open communication statement such as "Tell me more about . . ." often leads to valuable information about the client and his or her concerns. Options 1 and 4 are nontherapeutic responses because they place the client's issues on hold. Option 3 is beyond the scope of practice for the nurse to implement and may not be necessary.

A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage should the nurse expect? 1.Serous 2.Bloody 3.Serosanguineous 4.Bloody, with frequent small clots

2.Bloody Rationale:In the first few hours after surgery, the drainage from the chest tube is bloody. After several hours, it becomes serosanguineous. The client should not experience frequent clotting. Proper chest tube function should allow for drainage of blood before it has the chance to clot in the chest or the tubing.

A breast-feeding mother of an infant with lactose intolerance asks the nurse about dietary measures. What foods should the nurse tell the mother are acceptable to consume while breast-feeding? Select all that apply. 1.1% milk 2.Egg yolk 3.Dried beans 4.Hard cheeses 5.Green leafy vegetables

2.Egg yolk 3.Dried beans 5.Green leafy vegetables Rationale:Breast-feeding mothers with lactose-intolerant infants need to be encouraged to limit dairy products. Milk and cheese are dairy products. Alternative calcium sources that can be consumed by the mother include egg yolk, dried beans, green leafy vegetables, cauliflower, and molasses.

Which should the nurse do when caring for a client with a chest tube attached to a chest drainage system? 1.Empty the drainage collection chamber every shift. 2.Ensure the water level in the water seal chamber is at the 2cm level. 3.Maintain the drainage collection device at the level of the client's chest. 4.Clamp the chest tube before moving the client from the bed to the chair.

2.Ensure the water level in the water seal chamber is at the 2cm level. Rationale:The water seal chamber acts as a 1-way valve. It allows air and fluid to leave the pleural space but prevents reentry of atmospheric air. The minimum amount needed is 2 cm of water. A closed chest drainage system must remain airtight at all times. The device is kept below the level of the chest. If the device is kept at the level of the chest, there can be backflow of drainage into the pleural cavity. A chest tube should not be clamped unless specifically prescribed.

The nurse is monitoring the nutritional status of a client receiving enteral nutrition. Which intervention should the nurse implement to determine the effectiveness of the tube feedings? 1.Use a calorie count. 2.Obtain a daily weight. 3.Evaluate intake and output. 4.Monitor serum protein level.

2.Obtain a daily weight. Rationale:The most accurate measurement of the effectiveness of nutritional management of the client is through the use of daily weighing. These weight checks should be done every day at the same time (preferably early morning), in the same clothes, and using the same scale. Options 1, 3, and 4 assist in measuring nutrition and hydration status. However, the effectiveness of the diet is measured by maintenance of body weight.

A client with a tracheostomy tube who is on a ventilator is at risk for impaired gas exchange. The nurse should assess for which finding as the best indicator of adequate ongoing respiratory status? 1.Oxygen saturation of 89% 2.Respiratory rate of 16 breaths/minute 3.Moderate amounts of tracheobronchial secretions 4.Small to moderate amounts of frank blood suctioned from the tube

2.Respiratory rate of 16 breaths/minute Rationale:Impaired gas exchange could occur after tracheostomy because of excessive secretions, bleeding into the trachea, restricted lung expansion because of immobility, or concurrent respiratory conditions. An oxygen saturation of 89% is less than optimal. A respiratory rate of 16 breaths/minute is in the normal range.

The nurse works in a long-term care facility, caring for older clients. The nurse should make which interpretation when an older client complains of pain? 1.Pain is a natural and expected outcome of aging. 2.Something is wrong, and an assessment should be made. 3.Nonpharmacological relief measures are not effective in older clients. 4.It is best to treat the symptom of pain immediately rather than focus on identifying the cause.

2.Something is wrong, and an assessment should be made. Rationale:A complaint of pain by an older client should be addressed promptly because the pain indicates a physiological problem. Options 1, 3, and 4 are incorrect. Pain is not a natural and expected outcome of aging. Nonpharmacological relief measures such as massages and warm soaks may be effective. The cause of the pain is always assessed before the pain is treated.

The primary health care provider's prescription for an antibiotic reads "500 mg in 250 mL of 5% dextrose in water and administer over 2 hours." The drop factor is 10 drops (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.

21 gtt/min Rationale:Use the formula for intravenous (IV) flow rate. Total volume × Drop factor -------------------------- = gtt/min Time in minutes 250 mL × 10 gtt 2500 --------------- = ------ = 20.83 gtt/min 120 min 120 = 21 gtt/min (rounded)

A primary health care provider prescribes 3000 mL of D5W to infuse over a 24-hour period. The drop factor is 10 drops (gtt)/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

21 gtt/min Rationale:Use the intravenous (IV) flow rate formula. Total volume × Drop factor -------------------------- = gtt/min Time in minutes 3000 mL × 10 gtt 30,000 ---------------- = ---------- = 20.8 gtt/min 1440 min 1440 = 21 gtt/min (rounded)

A primary health care provider prescribes 1000 mL of normal saline to be infused over a period of 10 hours. The drop factor is 15 drops (gtt) per mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank.

25 gtt/min Rationale:The prescribed 1000 mL is to be infused over 10 hours. Follow the formula and multiply 1000 mL by 15 (drop factor). Then divide the result by 600 minutes (10 hours × 60 minutes). The infusion is to run at 25 gtt/min. Total volume × Drop factor -------------------------- = gtt/min Time in minutes 1000 mL × 15 gtt ---------------- = 600 min 15,000 ------ = 25 gtt/min 600

A primary health care provider's prescription reads phenytoin 0.3 g orally daily. The medication label states 100-mg capsules. The nurse prepares how many capsule(s) to administer 1 dose? Fill in the blank.

3 capsules Rationale:Use the formula to calculate the correct dose. It is necessary to convert 0.3 g to milligrams. To convert grams to milligrams, multiply by 1000 or move the decimal 3 places to the right; therefore, 0.3 g = 300 mg. After conversion from grams to milligrams, use the formula to calculate the correct dose. Desired --------- × Capsules = Capsules/dose Available 300 mg ------ × 1 capsule = 3 capsules 100 mg

A staff nurse is precepting a new graduate nurse and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management? 1."I will be sure to ask my client what his pain level is on a scale of 0 to 10." 2."I know that I should follow up after giving medication to make sure it is effective." 3."I will be sure to cue in to any indicators that the client may be exaggerating their pain." 4."I know that pain in the older client might manifest as sleep disturbances or depression."

3."I will be sure to cue in to any indicators that the client may be exaggerating their pain." Rationale:Pain is a highly individual experience, and the new graduate nurse should not assume that the client is exaggerating his pain. Rather, the nurse should frequently assess the pain and intervene accordingly through the use of both nonpharmacological and pharmacological interventions. The nurse should assess pain using a number-based scale or a picture-based scale for clients who cannot verbally describe their pain to rate the degree of pain. The nurse should follow up with the client after giving medication to ensure that the medication is effective in managing the pain. Pain experienced by the older client may be manifested differently than pain experienced by clients in other age groups, and they may have sleep disturbances, changes in gait and mobility, decreased socialization, and depression; the nurse should be aware of this attribute in this population.

The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate? 1.Notify the surgeon. 2.Clamp the surgical drain. 3.Change the dressing as prescribed. 4.Remove and replace the perineal packing.

3.Change the dressing as prescribed. Rationale:Immediately after surgery, profuse serosanguineous drainage from the perineal wound is expected. Therefore, the nurse should change the dressing as prescribed. A surgical drain should not be clamped because this action will cause the accumulation of drainage within the tissue. The nurse does not need to notify the surgeon at this time. Drains and packing are removed gradually over a period of 5 to 7 days as prescribed. The nurse should not remove the perineal packing.

The nurse has a written prescription to discontinue an intravenous (IV) line. The nurse obtains which item from the unit supply area for use in applying pressure to the site after removing the IV catheter? 1.Band-Aid 2.Alcohol swab 3.Sterile 2 × 2 gauze 4.Povidone-iodine swab

3.Sterile 2 × 2 gauze Rationale:A dry sterile dressing, such as sterile 2 × 2 gauze, is used to apply pressure to the discontinued IV site. This material is absorbent, sterile, and nonirritating. A povidone-iodine swab or alcohol swab would irritate the opened puncture site and would not stop the blood flow. A Band-Aid may be used to cover the site after hemostasis has occurred.

Penicillin G procaine, 1,000,000 units IM (intramuscularly), is prescribed for an adolescent with an infection. The medication label reads "1,200,000 units per 2 mL." The nurse has determined that the dose prescribed is safe. The nurse administers how many milliliters per dose to the adolescent? Round answer to the nearest tenth position. 1.0.8 mL 2.1.2 mL 3.1.4 mL 4.1.7 mL

4.1.7 mL Rationale:Use the medication calculation formula. Desired -------- × Volume = mL/dose Available 1,000,000 mg ------------ × 2 mL = 1.66 mL 1,200,000 mg = 1.7 mL (rounded)

Collagenase is prescribed for a client with a severe burn to the hand. The nurse is providing instructions to the client and spouse regarding wound treatment. Which should the nurse include in the instructions? 1.Apply once a day and leave it open to the air. 2.Apply twice a day and leave it open to the air. 3.Apply twice a day and cover it with a sterile dressing. 4.Apply once a day and cover it with a sterile dressing.

4.Apply once a day and cover it with a sterile dressing. Rationale:Collagenase is used in the treatment of dermal lesions and severe burns. Its action is to debride the affected area. It is applied once daily and covered with a sterile dressing. Options 1, 2, and 3 are incorrect application procedures.

The low-exhaled volume alarm sounds on a mechanical ventilator of a client with an endotracheal tube. The nurse determines that the cause for alarm activation may be which complication? 1.Excessive secretions 2.Kinks in the ventilator tubing 3.The presence of a mucous plug 4.Displacement of the endotracheal tube

4.Displacement of the endotracheal tube Rationale:The low-exhaled volume alarm will sound if the client does not receive the preset tidal volume. Possible causes of inadequate tidal volume include disconnection of the ventilator tubing from the artificial airway, a leak in the endotracheal or tracheostomy cuff, displacement of the endotracheal tube or tracheostomy tube, and disconnection at any location of the ventilator parts. Options 1, 2, and 3 would cause the high-pressure alarm to sound.

The nurse is teaching a client with tuberculosis about nutrition and foods that should be increased in the diet. The nurse should suggest that the client increase which food items? 1.Potatoes and fish 2.Eggs and spinach 3.Grains and broccoli 4.Meats and citrus fruits

4.Meats and citrus fruits Rationale:The nurse teaches the client with tuberculosis to increase intake of protein, iron, and vitamin C. Foods rich in vitamin C include citrus fruits, berries, melons, pineapple, broccoli, cabbage, green peppers, tomatoes, potatoes, chard, kale, asparagus, and turnip greens. Food sources that are rich in iron include liver and other meats. Less than 10% of iron is absorbed from eggs, and less than 5% is absorbed from grains and vegetables.

The nurse plans care for an older client admitted with a fractured hip. Which analgesic prescribed by the primary health care provider at standard doses and frequencies would the nurse question? 1.Ibuprofen by oral route 2.Morphine sulfate by intravenous route 3.Tramadol hydrochloride by oral route 4.Meperidine hydrochloride by intramuscular route

4.Meperidine hydrochloride by intramuscular route Rationale:Ibuprofen, morphine sulfate, tramadol, and meperidine are all analgesics. Ibuprofen is a nonsteroidal anti-inflammatory medication and is acceptable for use in the older client. Tramadol hydrochloride is a centrally acting nonopioid analgesic used for moderate to moderately severe pain and is a suitable option in this situation. Morphine sulfate and meperidine hydrochloride are both opioid analgesics, and both are effective in treating acute pain. Because meperidine hydrochloride produces a neurotoxic metabolite, it should be used only short term and is not recommended for use in older clients.

A client's baseline vital signs are as follows: temperature 98.8º F (37.1º C) oral, pulse 74 beats/min, respirations 18 breaths/min, and blood pressure 124/76 mm Hg. The client's temperature suddenly spikes to 103º F (39.4º C). Which corresponding respiratory rate should the nurse anticipate in this client as part of the body's response to the change in status? 1.Respiratory rate of 12 breaths/min 2.Respiratory rate of 16 breaths/min 3.Respiratory rate of 18 breaths/min 4.Respiratory rate of 22 breaths/min

4.Respiratory rate of 22 breaths/min Rationale:Elevations in body temperature cause a corresponding increase in respiratory rate. This occurs because the metabolic needs of the body increase with fever, requiring more oxygen. Therefore, the remaining options are incorrect.

A client has a chest tube attached to a water seal drainage system. As part of routine nursing care, the nurse should ensure that which intervention is implemented? 1.The water seal chamber has continuous bubbling, and assessment for crepitus is done once a shift. 2.The amount of drainage into the chest tube is noted and recorded every 24 hours in the client's record. 3.The suction control chamber has sterile water added every shift, and the system is kept below waist level. 4.The connection between the chest tube and the drainage system is taped, and an occlusive dressing is maintained at the insertion site.

4.The connection between the chest tube and the drainage system is taped, and an occlusive dressing is maintained at the insertion site Rationale:The nurse ensures that all system connections are securely taped to prevent accidental disconnection and that an occlusive dressing is maintained at the chest tube insertion site. Continuous bubbling in the water seal chamber indicates an air leak in the system and requires immediate investigation and correction. Drainage is noted and recorded every hour during the first 24 hours after insertion and every 8 hours thereafter. The system is kept below the level of the waist. Assessment for crepitus is done once every 8 hours. Sterile water is added to the suction control chamber only as needed to replace evaporation losses.

The nurse has provided dietary instructions to a client regarding food items that are high in vitamin B complex. The client demonstrates understanding of the dietary instructions by stating the importance of including which food item in the diet? 1.Milk 2.Butter 3.Grains 4.Tomatoes

Grains Rationale:Grains contain the highest amount of vitamin B complex. Butter contains vitamin A. Tomatoes are high in vitamin C, whereas milk is high in vitamin D.

The nurse is teaching a mother to instill drops in her infant's ear. The nurse explains that to give the ear drops correctly, the mother needs to take which action? 1.Pull up and back on the earlobe and direct the solution toward the eardrum. 2.Pull down and back on the auricle and direct the solution toward the eardrum. 3.Pull up and back on the auricle and direct the solution toward the wall of the canal. 4.Pull down and back on the earlobe and direct the solution toward the wall of the canal.

Pull down and back on the earlobe and direct the solution toward the wall of the canal. Rationale:The infant should be turned onto the side, with the affected ear uppermost. With the wrist of the nondominant hand resting on the infant's head, the mother pulls down and back on the earlobe and aims the solution at the wall of the canal, rather than directly onto the eardrum. In the adult, the auricle is pulled up and back to straighten the auditory canal.