STUDY!

The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which most essential items into the client's room?

Electrocardiographic monitoring electrodes and intubation tray

The nurse is administering a dose of pirbuterol to a client. The nurse should monitor for which side or adverse effect of this medication?

Increased pulse

The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding?

Place the client in Trendelenburg's position. When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with her hips higher than her head to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to summon help, and other staff members should call the health care provider and notify the delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it because that could traumatize it and further reduce blood flow. Oxygen at 8 to 10 L/min by face mask is administered to the mother to increase fetal oxygenation.

The nurse is preparing to administer furosemide to a client with a diagnosis of heart failure. Which is the most important laboratory test result for the nurse to check before administering this medication?

Potassium level

The nurse is developing a plan of care for a 5-week-old infant being admitted with hypertrophic pyloric stenosis who is scheduled for pyloromyotomy. In the preoperative period, the nurse should place the infant in which best position?

Prone with the head of the bed elevated

A client has begun medication therapy with pancrelipase. Which finding indicates that the medication has been effective?

Reduction of steatorrhea

The nurse is preparing to perform an abdominal examination on a client. The nurse should place the client in which position for this examination?

Supine with the head raised slightly and the knees slightly flexed

A client with type 1 diabetes mellitus is to begin an exercise program, and the nurse is providing instructions regarding the program. Which instruction should the nurse include in the teaching plan?

Take a blood glucose test before exercising.

Glyburide daily is prescribed for a client. What instruction should the nurse include in the client's teaching plan?

Take the medication in the morning before breakfast.

The nurse reading the operative record of a client who had cardiac surgery notes that the client's cardiac output immediately after surgery was 3.2 L/min. Evaluation of the cardiac output results leads the nurse to make which conclusion?

The cardiac output is below the normal range. The normal cardiac output for the adult can range from 4 to 7 L/min. Therefore a cardiac output of 3.2 L/min is below normal range.

A client with trigeminal neuralgia is being treated with carbamazepine, 400 mg orally daily. Which value indicates that the client is experiencing an adverse effect to the medication?

White blood cell count, 3000 mm3 (3.0 × 109/L)

A client with diabetes mellitus has been instructed in the dietary exchange system. The client asks the nurse if bacon is allowed in the diet. Which nursing response is most appropriate?

"One strip of bacon may be eaten if you eliminate 1 teaspoon of butter."

A client with type 1 diabetes mellitus who takes NPH daily in the morning calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an adequate understanding of the peak action of NPH insulin and exercise?

"The best time for me to exercise is after breakfast"

A client in the later stages of chronic kidney disease (CKD) has hyperkalemia. With CKD, what other factors besides tissue breakdown can cause high potassium levels? Select all that apply

-Blood transfusions -Bleeding or hemorrhage -Ingestion of potassium in medications -Failure to restrict dietary potassium

The primary health care provider prescribes meperidine 60 mg and atropine sulfate 0.4 mg intramuscularly. The medications are compatible and will be mixed into 1 syringe. The label on the prefilled meperidine syringe states 100 mg/mL. The label on the prefilled atropine sulfate syringe states 0.4 mg/mL. How many milliliters of meperidine and how many milliliters of atropine sulfate will be prepared for administration?

0.6

The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH) and has serum sodium of 118 mEq/L (118 mmol/L). Which prescriptions should the nurse anticipate receiving? Select all that apply.

1.Initiate an infusion of 3% NaCl. 3.Restrict fluids to 800 mL over 24 hours. 5.Administer a vasopressin antagonist as prescribed.

Potassium chloride intravenously is prescribed for a client with hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply.

1.Obtain an intravenous (IV) infusion pump. 3.Prepare the medication for bolus administration. 4.Monitor the IV site for signs of infiltration or phlebitis. 5.Ensure that the medication is diluted in the appropriate volume of fluid. 6.Ensure that the bag is labeled so that it reads the volume of potassium in the solution.

A unit of platelets was just received from the blood bank for transfusion to an assigned client. The nurse should select tubing with which feature for the transfusion?

An in-line filter

A client is scheduled for discharge and will be taking phenobarbital for an extended period. The nurse would place highest priority on teaching the client which point that directly relates to client safety

Avoid drinking alcohol while taking this medication.

The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. When analyzing the results of the urinalysis, which should the nurse most likely expect to note?

Bacteriuria

The nurse has given a client taking ethambutol information about the medication. The nurse determines that the client understands the instructions if the client states that they will immediately report which finding?

Difficulty in discriminating the color red from green