Senior Seminar

After the nurse teaches the parent of a child newly diagnosed with leukemia about the disease, which description if given by the parent best indicates understanding the nature of leukemia?

"Leukemia is a type of cancer characterized by an increase in immature white blood cells." Rationale: Leukemia is a neoplastic, or cancerous, disorder of blood-forming tissues that is characterized by a proliferation of immature white blood cells. Leukemia is not an infection, inflammation, or allergic disorder.

Normal BUN levels

10 to 20 mg/dL (3.6 to 7.1 mmol/L)

Normal neutrophil count

2200-7700

Normal neutrophil count

55-70%

The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit?

A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy

Which situation violates the a client's privacy?

A nurse gives a client's family members details of the client's condition from the medical records Rationale: A nurse may not give information about a client to anyone without that client's consent. Nursing students and medical students may review client charts for the purpose of instruction and learning. The client has the right to see their chart. By remaining with the client while the client reviews the chart, the nurse can explain notations that are confusing or unclear.

The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention, if noted in the plan, indicates the need for revision of the plan?

A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent accidental exposure of other clients to radiation.

Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)?

Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia

A client has nephropathy. The health care provider (HCP) prescribes a 24-hour urine collection for creatinine clearance. Which action is necessary to ensure proper collection of the specimen?

Collect the urine in a preservative-free container and keep it on ice. Rationale: All urine for creatinine clearance determination must be saved in a container with no preservatives and refrigerated or kept on ice. The first urine voided at the beginning of the collection is discarded, not the last.

A client is admitted to the acute psychiatric care unit after 2 weeks of increasingly erratic behavior. The client is unkempt, has lost approximately 9 lb (4 kg), has been sleeping poorly, and exhibits hyperactivity. The client loudly denies the need for hospitalization. What priority intervention will the nurse apply?

Decreasing environmental stimulation Rationale: This client is at increased risk for injuring self or others. Decreasing environmental stimulation, a measure the nurse may take independently, may reduce the client's hyperactivity

A client brought to the emergency department states that he has accidentally been taking 2 times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action?

Draw a sample for prothrombin time (PT) and international normalized ratio (INR).

A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds. On the basis of these laboratory values, the nurse anticipates which prescription?

Holding The normal PT is 11 to 12.5 seconds (conventional therapy and SI units). A therapeutic PT level is 1.5 to 2 times higher than the normal level.

Hyponatremia

Hyperactive bowel sounds indicate hyponatremia. . In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted.

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for?

Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid

Which health concern(s) should the nurse be aware of as risk factors when caring for clients of African American descent? Select all that apply.

Obesity, diabetes mellitus, hypertension, heart disease, asthma, and cancer are prevalent among this population. Hypothyroidism is not a particular risk factor

Which is the most important initial post procedure nursing assessment for a client who has had a cardiac catheterization?

Observe the puncture site for swelling and bleeding. Rationale: Assessment of circulatory status, including observation of the puncture site, is of primary importance after a cardiac catheterization

The nurse reviews a client's record and determines that the client is at risk for developing a potassium deficit if which situation is documented?

Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia.

A client has been diagnosed with metabolic alkalosis. The nurse should anticipate what finding from the client's arterial blood gases?

Serum bicarbonate of 28 mEq/L Rationale: Evaluation of arterial blood gases reveals a pH greater than 7.45 and a serum bicarbonate concentration greater than 26 mEq/L.

The nurse is administering packed red blood cells (PRBCs) to a client. What should the nurse do first?

Stay with the client during the first 15 minutes of infusion. Rationale: The most likely time for a blood transfusion reaction to occur is during the first 15 minutes or first 50 ml of the infusion. If a blood transfusion reaction does occur, it is imperative to keep an established I.V. line so that medication can be administered to prevent or treat cardiovascular collapse in case of anaphylaxis. PRBCs should be administered through a 19-gauge or larger needle; a peripherally inserted central catheter line is not recommended, in order to avoid a slow flow. RBCs will hemolyze in dextrose or lactated Ringer's solution and should be infused with only normal saline solution.

The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL (0.58 mmol/L). Which condition most likely caused this serum phosphorus level?

The normal serum phosphorus (phosphate) level is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L). The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide-based or magnesium-based antacids.

The nurse is evaluating the effectiveness of fluid resuscitation during the emergency period of burn management. Which finding indicates that adequate fluid replacement has been achieved?

The urine output is greater than 35 mL/h. Rationale: A urine output of 30 to 50 mL/h indicates adequate fluid replacement in the client with burns

UAP can

UAPs' limited scope includes (but may not be limited to) assisting with ADLs such as bathing, feeding, toileting, obtaining vital signs, input and output (I/O), performing point of care (POC) tests, such as a blood sugar check or 12-lead electrocardiogram, and recording height and weight. UAPs cannot reinforce teaching, create a plan of care or assume nursing care for a client - even if the client is stable.

A nurse is caring for a client receiving chemotherapy. Which nursing action is most appropriate for handling chemotherapeutic agents?

Wear protective clothing. Rationale: A nurse must wear two layers of chemotherapy-approved disposable gloves and protective clothing to prevent skin contact with chemotherapeutic agents

When assessing a client during a routine checkup, the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. Aphthous stomatitis is best described as

a canker sore of the oral soft tissues. Rationale: Aphthous stomatitis refers to a canker sore of the oral soft tissues, including the lips, tongue, and inside of the cheeks. Aphthous stomatitis isn't an acute stomach infection, acid indigestion, or early sign of peptic ulcer disease.

A client develops chronic pancreatitis. What would be the appropriate home diet for a client with chronic pancreatitis?

a low-fat, bland diet distributed over five to six small meals daily Rationale: A low-fat, bland diet prevents stimulation of the pancreas while providing adequate nutrition.

What observation should the nurse instruct the client with an ileostomy to report immediately?

absence of drainage from the ileostomy for 6 or more hours Rationale: Any sudden decrease in drainage or onset of severe abdominal pain should be reported to the health care provider (HCP) immediately because it could mean that an obstruction has developed. The ileostomy drains liquid stool at frequent intervals throughout the day. Undigested food may be present at times. A temperature of 99.8° F (37.7° C) is not necessarily abnormal or a cause for concern.

A client has impaired skin integrity related to compromised circulation. What should the nurse include in the teaching plan regarding nutritional considerations?

adequate intake of vitamins A and C, protein, and zinc Rationale: For clients with a risk for impaired skin integrity related to compromised circulation, good nutrition in the form of adequate intake of vitamins A and C, protein, and zinc is recommended. Only clients who are overweight or obese need a diet that helps with weight reduction. Research does not support that supplementation with vitamins and antioxidants prevents vascular disease. There is no need to eliminate carbohydrates and fats from someone's diet.

The nurse is caring for a client postoperatively after having a low anterior resection of the colon 6 hours prior. The client rates incisional pain 6/10. The prescribed orders include morphine 1 to 2 mg IV every hour as needed for pain. The client is alert with vital signs within normal limits. How will the nurse best manage the client's pain?

administer morphine 1 mg IV and reassess pain level in 20 minutes Rationale: Morphine is an opioid analgesic. Prevention of respiratory depression and increased sedation begins with the administration of the lowest effective dose. To best manage the client's pain with dose range orders, the nurse would begin with the lowest prescribed dose and titrate as needed to achieve effective analgesia while minimizing side effects. After administering the lowest prescribed dose, the nurse would assess the client's pain level and response to the therapy in 20 minutes (morphine peaks in 20 minutes). Based on the client's response, the nurse would then administer additional morphine as necessary.

A 30-year-old multiparous client has been prescribed oral contraceptives as a method of birth control. The nurse instructs the client that decreased effectiveness may occur if the client is prescribed which drug?

ampicillin Rationale: Oral contraceptives may interact with other medications, and the effectiveness may be decreased if the client is prescribed ampicillin, tetracycline, or anticonvulsants, such as phenytoin.

Kussmaul's respirations

are abnormally deep and increased in rate. These occur as a result of the compensatory action by the lungs

A client with fever, weight loss, and watery diarrhea is being admitted to the facility. While assessing the client, a nurse inspects the client's abdomen and notices that it is slightly concave. Additional assessment should proceed in which order?

auscultation, percussion, and palpation Rationale: The correct order of assessment for examining the abdomen is inspection, auscultation, percussion, and palpation. The reason for this approach is that the nurse would perform the less-intrusive techniques before the more-intrusive techniques. Percussion and palpation can alter natural findings during auscultation.

Common food sources of potassium include

avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, ve

The normal aPTT varies

between 30 and 40 seconds (30 and 40 seconds), depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 (45 to 60) and 2.5 (75 to 100) times normal. This means that the client's value should not be less than 45 seconds or greater than 100 seconds.

A client is admitted with a diagnosis of ulcerative colitis. The nurse should assess the client for:

bloody, diarrheal stools. Rationale: Diarrhea is the primary symptom of ulcerative colitis. It is profuse and severe; the client may pass as many as 15 to 20 watery stools per day. Stools may contain blood, mucus, and pus. The frequent diarrhea is often accompanied by anorexia and nausea.

Which finding would the nurse most expect to find in a neonate born at 28 weeks' gestation who is diagnosed with intraventricular hemorrhage (IVH)?

bulging fontanels Rationale: A common finding of IVH is a bulging fontanel. The most common site of hemorrhage is the periventricular subependymal germinal matrix, where there is a rich blood supply and where the capillary walls are thin and fragile. Rapid volume expansion, hypercarbia, and hypoglycemia contribute to the development of IVH. Other common manifestations include neurologic signs such as hypotonia, lethargy, temperature instability, nystagmus, apnea, bradycardia, decreased hematocrit, and increasing hypoxia. Seizures also may occur.

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths per minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats per minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding?

clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3- to increase.

A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require?

contact Rationale: A client with rabies requires contact isolation because the disease is highly transmissible through close or direct contact. Rabies isn't transmitted through the air, eliminating the need for strict isolation, which aims to prevent transmission of highly contagious or virulent infections spread by both air and contact. Respiratory isolation, which prevents transmission only through the air, isn't sufficient for a client with rabies. Enteric isolation is inappropriate because rabies isn't transmitted through direct or indirect contact with feces.

A client develops decreased renal function and requires a change in antibiotic dosage. On which factor should the physician base the dosage change?

creatinine clearance Rationale: The physician should base changes to antibiotic dosages on creatinine clearance test results, which gauge the kidney's glomerular filtration rate; this factor is important because most drugs are excreted at least partially by the kidneys. The GI absorption rate, therapeutic index, and liver function studies don't help determine dosage change in a client with decreased renal function.

Which physical sensation will the client who has had an abdominal hysterectomy most likely experience if she hyperventilates while performing deep-breathing exercises?

dizziness Rationale: Hyperventilation occurs when the client breathes so rapidly and deeply that she exhales excessive amounts of carbon dioxide. A characteristic symptom of hyperventilation is dizziness. To avoid hyperventilation, the nurse should assist the client in the practice of slow, deep breathing in a regular breathing pattern. Dyspnea, blurred vision, and mental confusion are not associated with hyperventilation.

Electrocardiographic changes associated with hyperkalemia include

flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves.

A client is having a level 2 ultrasound. A nurse knows that physicians order this procedure

for diagnostic purposes when fetal development is in question. Rationale: Level 2 ultrasound is more sophisticated and can visualize fetal structures more clearly than a level 1 ultrasound. It's used for diagnostic purposes when fetal development is in question. Typically, level 1 ultrasound is used to assess gestational age. Diagnostic ultrasounds aren't ordered to satisfy the client's curiosity or to provide images of the fetus for family and friends.

The normal reference range for the glycosylated hemoglobin A1c is

less than 6.0%. This test measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. Erythrocytes live for about 120 days, giving feedback about blood glucose for the past 120 days. Elevations in the blood glucose level will cause elevations in the amount of glycosylation. Thus, the test is useful in identifying clients who have periods of hyperglycemia that are undetected in other ways. The estimated average glucose for a glycosylated hemoglobin A1c of 8% is 205 mg/dL (11.42 mmol/L).

Clinical manifestations of respiratory alkalosis include

lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities

A client is admitted to the psychiatric clinic for treatment of anorexia nervosa. At the beginning of the client's hospitalization, the most important nursing action is to:

monitor the client's vital signs, serum electrolyte levels, and acid-base balance. Rationale: An anorexic client who requires hospitalization is in poor physical condition as a result of starvation and may die as a result of arrhythmias, hypothermia, malnutrition, infection, or cardiac abnormalities secondary to electrolyte imbalances. Therefore, monitoring the client's vital signs, serum electrolyte level, and acid-base balance is crucial.

What instruction should the nurse's discharge teaching plan for the client with heart failure include?

obtaining daily weights at the same time each day Rationale: Heart failure is a complex and chronic condition. Education should focus on health promotion and preventive care in the home environment. Signs and symptoms can be monitored by the client. Instructing the client to obtain daily weights at the same time each day is very important. The client should be told to call the health care provider (HCP) if there has been a weight gain of 2 lb (0.91 kg) or more. This may indicate fluid overload, and treatment can be prescribed early and on an outpatient basis, rather than waiting until the symptoms become life threatening.

Contact Precautions

reduce the risk of transmission by direct or indirect contact. Indirect transmission involves contact with a contaminated object. Gloves Gown Mask and eye protection, if splashing or splattering of any contaminated substance is likely Indications: Gastrointestinal infections, e.g., foodborne illness such as norovirus or Clostridium difficile (C. diff.) Diarrhea of unknown origin Skin infections or infestations, e.g., impetigo, scabies Presence of, or colonization with, multidrug-resistant bacteria, e.g. methicillin-resistant Staphylococcus aureus (MRSA) Place the client in a private room or cohort with clients who have the same infection. The client should stay in room except for medically-necessary procedures or therapies. Dedicated equipment/care items (e.g., blood pressure cuff, thermometer) that can be discarded or disinfected after discharge. For Herpes Zoster (shingles) infection: if disseminated (lesions present outside the primary or adjacent dermatomes), implement both contact and airborne precautions until lesions are dry and crusted.

The aPTT monitors

the effects of heparin therapy

When clients use crutches

their hands should rest on the handgrips of the crutches. The client's weight should not be resting on their axillae, as this could lead to damage of the axillary nerve.Clients should check the integrity of their crutches, including the rubber tips. The crutches should be in good working order and not broken or worn down.Clients should have a spare pair of crutches, including rubber tips.A three-point crutch gait is used for people who only have one weight-bearing leg.

The nurse is preparing a teaching plan about increased exercise for a female client who is receiving long-term corticosteroid therapy. What type of exercise is most appropriate for this client?

walking Rationale: The best exercise for females who are on long-term corticosteroid therapy is a low-impact, weightbearing exercise such as walking or weight lifting. Floor exercises do not provide for the weightbearing. Stretching is appropriate but does not offer sufficient weightbearing. Running provides for weightbearing but is hard on the joints and may cause bleeding.

The normal hemoglobin level for an adult female client is

12 to 16 g/dL

After the birth of her first neonate, a mother asks the nurse about the reddened areas at the nape of the neonate's neck. How should the nurse respond?

"They're normal and will disappear as the baby's skin thickens." Rationale: Capillary hemangioma (also called a "stork bite") may appear on the neonate's upper eyelids, the bridge of the nose, or the nape of the neck. They result from vascular congestion and will disappear as the skin thickens. They are not associated with congenital abnormalities, traumatic delivery, or blocked apocrine glands.

A client in a long-term care facility signed a form requesting not to be resuscitated. The client develops pneumonia, and the client's health rapidly deteriorates. The client is no longer competent, but the family wants everything possible done for the client. When the family asks the nurse what will be done, what is the best response by the nurse?

"We will continue to use antibiotics to treat the pneumonia." Rationale: The client has signed a document indicating a wish not to be resuscitated. Treating the client's pneumonia with antibiotics would not be considered a resuscitation measure. The other options do not respect the client's choice.

Normal platelet count

150,000-400,000

A client with diabetes mellitus develops sinusitis and otitis media accompanied by a temperature of 100.8° F (38.2° C). What should the nurse anticipate in this client's plan of care?

An increased need for insulin and blood glucose monitoring Rationale: Insulin requirements increase in response to growth, pregnancy, increased food intake, stress, surgery, infection, illness, increased insulin antibodies, and some medications. Insulin requirements are decreased by hypothyroidism, decreased food intake, exercise, and some medications.

Airborne precautions

Airborne precautions reduce the risk of transmission of infectious microorganisms that remain suspended in the air for long periods of time and are carried on air currents. Varicella (chicken pox) Tuberculosis Measles (rubella) A NIOSH-approved, fit-tested respirator (N95) must be worn by all health care personnel caring for the client Gloves should be worn when in contact with respiratory secretions The client must be placed in a private room with special ventilation (negative pressure) and the door must be kept closed. The client should stay in the room except for essential reasons. The client should wear a regular or surgical mask when out of the room. NIOSH-approved, fit-tested respirators (N95) must be worn by all health care personnel when entering the client's room. With chicken pox or measles, a respirator is only required if the person entering has not had the disease or has not been immunized. Dedicated equipment/care items (e.g., blood pressure cuff, thermometer) that can be discarded or disinfected after discharge. The client should be taught to cover their nose and mouth with tissues when coughing or sneezing and to discard tissues into a bag.

What is the highest nursing priority in the plan of care for a client with peripheral vascular problems?

Promote arterial and venous circulation. Rationale: Maslow's hierarchy defines priorities with physiological needs as the highest priority. In the case of a client with peripheral vascular disease, the highest priority would be tissue perfusion. Once this is established, the nurse can address the problems of pain and skin integrity. It is also important to educate the client and provide a self-care program. However, the client's physiological needs must be met first.

A client has been taking aluminum hydroxide 30 mL six times per day at home to treat a peptic ulcer. The client has been unable to have a bowel movement for 3 days. What should the nurse determine is the most likely cause of the client's constipation?

The client is experiencing an adverse effect of the aluminum hydroxide. Rationale: It is most likely that the client is experiencing an adverse effect of the antacid. Antacids with aluminum salt products, such as aluminum hydroxide, form insoluble salts in the body. These precipitate and accumulate in the intestines, causing constipation. Increasing dietary fiber intake or daily exercise may be a beneficial lifestyle change for the client but is not likely to relieve the constipation caused by the aluminum hydroxide. Constipation, in isolation from other symptoms, is not a sign of a bowel obstruction.

An adolescent with pneumonia shares fears of having contracted human immunodeficiency virus (HIV). The adolescent wants to be tested but does not want parental involvement. What should the nurse say?

"The healthcare provider will run the test confidentially." Rationale: Federal laws state that adolescents may be tested for sexually transmitted diseases without their parents' permission. The rules of confidentiality apply to this adolescent. The adolescent doesn't have to speak with anyone before the test.

Anthrax is caused by

Bacillus anthracis and can be contracted through the digestive system or abrasions in the skin, or inhaled through the lungs. It cannot be spread from person to person, and it is not contracted via bites from ticks or deer flies.

Benztropine (Cogentin)

Benztropine is an anticholinergic medication used in the treatment of Parkinson's disease that blocks excess cholinergic stimulation in the brain and reduces muscular tremors and rigidity. Tachycardia is a potential adverse drug event, but a heart rate increase of 15 bpm is within acceptable limits. Due to their blocking actions of the parasympathetic nervous system, anticholinergics are contraindicated with glaucoma, where they can cause an increase in intraocular pressure (IOP), which can lead to vision loss and blindness.

A client newly admitted to a psychiatric inpatient setting demands a soda from a staff member who tells him to wait until lunch arrives in 20 minutes. The client becomes angry, pushes over a sofa, throws an end table, and dumps a potted plant. Which goal should a nurse consider to be of primary importance?

Demonstrating control over aggressive behavior Rationale: The client must demonstrate control over his aggressive behavior so that he won't hurt himself or others or destroy property in the hospital setting

Droplet Precautions

Droplet precautions reduce the risk of transmission of infectious droplets that are released when the infected person sneezes or coughs. Infectious droplets can spread as far as six feet. A regular or surgical mask should be worn if within six feet of the client. Gloves and gown should be worn when in direct contact while delivering care. Influenza Meningococcal meningitis Mumps Rubella (German measles) Diphtheria Pertussis (Whooping cough) Infections caused by drug-resistant Streptococcus pneumoniae

The nurse is caring for a client with Crohn's disease who has a calcium level of 8 mg/dL (2 mmol/L). Which patterns would the nurse watch for on the electrocardiogram? Select all that apply.

Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged QT interval and prolonged ST segment. A shortened ST segme

A client arrives in the emergency department with an ischemic stroke. What should the nurse do before the client receives tissue plasminogen activator (t-PA)?

Identify the time of onset of the stroke. Rationale: Studies show that clients who receive recombinant t-PA treatment within 3 hours after the onset of a stroke have better outcomes. The time from the onset of a stroke to t-PA treatment is critical. A complete health assessment and history is not possible when a client is receiving emergency care. Upcoming surgical procedures may need to be delayed because of the administration of t-PA, which is a priority in the immediate treatment of the current stroke. While the nurse should identify which medications the client is taking, it is more important to know the time of the onset of the stroke to determine the course of action for administering t-PA.

The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which food items on the list? Select all that apply.

Margarine, cream cheese, and luncheon meats are high-fat foods.

The nurse caring for a refugee considers which health care need a priority for this client?

Mental health problems are the primary issue for this population as a result of tortuous events.

The nurse receives their client care assignment for the upcoming shift. The nurse has been assigned a client with a nephrostomy tube. The nurse has never cared for a client with a nephrostomy tube before. Which is the most appropriate action by the nurse?

One of the first principles of safe assignments is to match skill level with the task. Nurses should not be assigned tasks for which they are not competent. It would be most appropriate for the nurse to request the assignment be changed. Learning about the tube from the charge nurse or literature would be beneficial for the nurse, but would not make the nurse competent and safe to care for this client at this time. The nurse should have proper training and competency before caring for a client with special equipment.

The nurse in the emergency department is admitting a client for pneumonia and sepsis. The health care provider (HCP) has given the nurse orders. Prioritize the order of implementation from highest (1) to lowest (5) priority. Apply oxygen at 2 L/min via nasal cannula. Start an IV infusion of 0.9% NaCl at 100 mL/hr. Give ceftriaxone 1 gram every 12 hours IVPB. Teach the patient how to use incentive spirometry. Obtain a set of blood cultures.

Oxygen administration is the first priority; the client is likely hypoxic given they have pneumonia. The next priority would be to draw blood for the cultures. Blood cultures must be drawn prior to starting the antibiotics. Then IV fluids should be started, followed by the IVPB antibiotic. Client teaching about incentive spirometry can occur last, and continue to be reinforced throughout the hospital stay.

A client is admitted to the psychiatric unit exhibiting extreme agitation, disorientation, and incoherence of speech with frantic and aimless physical activity and grandiose delusions. Which would the highest priority goal in planning nursing interventions?

The client will show no self-harm or harm to staff. Rationale: The client is at increased risk for injury because of their hyperactivity, agitation, and disorientation. The goal for no self-harm or harm to staff best fits the priority for this situation. Although the client's anxiety and orientation is a concern and is important for the client's care, the client's safety always takes highest priority. The nurse should plan first and foremost to prevent injury and harm for which the client is at risk given their current condition.

The nurse has observed that a client who identifies as a Mormon has drunk the coffee that was on the breakfast tray. How should the nurse best interpret this observation?

The client's personal religious practices may differ from those of the larger religious group. Rationale: When identifying characteristics or behaviors of particular religions it is important to know that there is often wide variation between individuals and groups. Not every person who says that he or she is a Mormon will always forgo coffee, for example, even though it is not acceptable. At the same time, it would presumptuous to conclude that the client no longer adheres to this particular religion.

Glypozide

There are a number of medications that should be avoided, if possible, for the homeless person due to the safety risks. Glipizide is an oral hypoglycemic medication and is classified as a sulfonylurea. A major side effect of this medication is hypoglycemia, which presents a safety risk to the homeless person.

Duloxetin

is a selective serotonin and norepinephrine reuptake inhibitor (SNRI) that can be used to treat depression but also can be used to treat pain associated with diabetic neuropath

A client has expressed her desire to give birth with minimal intervention. She is now moving into the active phase of labor. What intervention by the nurse would be the priority of care?

offering support by reviewing the short-pant form of breathing Rationale: By helping the client use the pant form of breathing, the nurse can help the client manage her contractions. This is appropriate because the client has expressed a desire to deliver with minimal intervention. The client may elect to have opiod analgesia or epidural anesthesia at some point, but this is not the priority at this time. The nurse will observe for ruptured membranes, but this is not the priority.