146NAXLEX46-90A male preoperative
A client who weighs 176 pounds receives a prescription for norepinephrine 2 mcg/min intravenously (IV). The IV bag is labeled, "Norepinephrine 4 mg in dextrose 5% in water (D;W) 1,000 mL." How many mL/hour should the nurse program the infusion pump? (Enter numerical value only.).
30
A client who has atrial fibrillation is prescribed warfarin therapy. Which of the following statements by the client indicates an understanding of the medication? A. "I should avoid foods that are high in vitamin K.". B. "I should take this medication with food.". C. "I should report any unusual bleeding or bruising to my provider.". D. "I should avoid taking aspirin while taking this medication.".
A. "I should avoid foods that are high in vitamin K.".
A nurse is teaching a client who has a urinary tract infection (UTI) about trimethoprim/sulfamethoxazole. The client asks why he needs to take two antibiotics together. What should the nurse say? A. "The combination of trimethoprim and sulfamethoxazole has a synergistic effect that inhibits bacterial growth more effectively than either drug alone.". B. "The combination of trimethoprim and sulfamethoxazole has an additive effect that reduces the dosage and frequency of administration of each drug.". C. "The combination of trimethoprim and sulfamethoxazole has an antagonistic effect that prevents the development of resistance to either drug.". D. "The combination of trimethoprim and sulfamethoxazole has a selective effect that targets only the bacteria causing the UTI and spares the normal flora.".
A. "The combination of trimethoprim and sulfamethoxazole has a synergistic effect that inhibits bacterial growth more effectively than either drug alone.".
A client with chronic kidney disease receives a prescription for darbepoetin alfa 40 mcg subcutaneous every 7 days. The darbepoetin alfa vial is labeled, "60 mcg/mL." How many mL should the nurse administer? round to the nearest tenth. A. 0.7 mL. B. 1.0 mL. C. 1.3 mL. D. 1.7 mL.
A. 0.7 mL.
The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational materials include which characteristics? (Select all that apply.). A. Contains a list with definitions of unfamiliar terms. B. Written at a twelfth-grade reading level. C. Uses common words with few syllables. D. Uses pictures to help illustrate complex ideas. E. Printed using a 12-point type font.
A. Contains a list with definitions of unfamiliar terms. D. Uses pictures to help illustrate complex ideas.
A nurse is caring for a client who has variant angina and is prescribed verapamil. Which of the following are expected outcomes of this medication? (Select all that apply.) A. Decreased heart rate B. Increased contractility C. Dilated coronary arteries D. Reduced blood pressure E. Relieved chest pain.
A. Decreased heart rate C. Dilated coronary arteries D. Reduced blood pressure E. Relieved chest pain.
A nurse is reviewing laboratory results for a client who has been taking amoxicillin-clavulanate (Augmentin) for a bacterial respiratory tract infection. Which of the following findings should alert the nurse to a possible adverse effect of this medication? (Select all that apply.). A. Elevated serum creatinine level. B. Elevated serum alanine aminotransferase level. C. Elevated serum potassium level. D. Elevated white blood cell count.
A. Elevated serum creatinine level. B. Elevated serum alanine aminotransferase level. D. Elevated white blood cell count.
When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? (Select all that apply.). A. Fresh or frozen vegetables without sauce. B. Fruits without sauce. C. Pickled olives. D. Canned soup. E. Cottage cheese.
A. Fresh or frozen vegetables without sauce. B. Fruits without sauce
The nurse on the medical-surgical unit is receiving a transfer report from the post-anesthesia care unit (PACU) nurse for a client who had an exploratory laparotomy. The PACU nurse provides the following information: "1000 mL normal saline is infusing at 125 mL/hr into the left wrist with 600 mL remaining. Ondansetron 4 mg intravenously every 8 hours is prescribed for nausea. The last dose was administered at 0700. The client is currently describing pain at a level 2 on a 0 to 10 pain scale. The client has a prescription for hydromorphone 1 mg intravenously every 2 hours as needed for pain. The last dose was administered at 1000." Which additional information should the PACU nurse report? A. History of vomiting at home for 3 days prior to surgery. B. Soft abdomen, absent bowel sounds, no bleeding on dressing. C. Declining to take ice chips for complaints of dry mouth. D. Peripheral pulses present with full ran
A. History of vomiting at home for 3 days prior to surgery.
The nurse is preparing an older male adult for discharge who does not read and has bilateral hearing loss. The client's daughter who lives close to her father tells the nurse that she will stop by daily to check on her father. Which intervention(s) should the nurse implement? (Select all that apply.). A. Include the family in the discharge teaching. B. Encourage the client to attend reading classes. C. Face the client when speaking. D. Speak loudly when teaching. E. Provide the daughter with written instructions.
A. Include the family in the discharge teaching. C. Face the client when speaking. E. Provide the daughter with written instructions.
A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? (Select all that apply.). A. Monitor ETT markings between 22 and 26 cm at teeth line. B. Check for capillary refill of 3 seconds or less. C. Obtain a portable chest x-ray to verify ETT location. D. Assess for symmetrical chest movement. E. Auscultate for presence of bilateral breath sounds.
A. Monitor ETT markings between 22 and 26 cm at teeth line. C. Obtain a portable chest x-ray to verify ETT location. D. Assess for symmetrical chest movement. E. Auscultate for presence of bilateral breath sounds.
The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu item(s) should the nurse request for this client? (Select all that apply). A. Orange juice. B. Apple juice. C. Hot chocolate. D. Chicken broth. E. Black coffee.
A. Orange juice. B. Apple juice. D. Chicken broth.
A client who has been prescribed propranolol for the treatment of arrhythmias reports experiencing shortness of breath and difficulty breathing while lying down at night. Which of the following should the nurse instruct the client to do? A. Sleep with an extra pillow under their head B. Sleep on their left side C. Sleep on their right side D. Sleep on their back. E. Relieved chest pain.
A. Sleep with an extra pillow under their head
A nurse is reviewing the laboratory results of a client who is receiving intravenous unfractionated heparin. The nurse notes that the client's activated partial thromboplastin time (aPTT) is 120 seconds. What are the appropriate nursing actions in this situation? Select all that apply. *. A. Stop the heparin infusion immediately. B. Administer protamine sulfate as ordered. C. Notify the health care provider of the result. D. Draw a prothrombin time (PT) and international normalized ratio (INR) level. E. Monitor the client for signs and symptoms of bleeding.
A. Stop the heparin infusion immediately. B. Administer protamine sulfate as ordered. C. Notify the health care provider of the result. E. Monitor the client for signs and symptoms of bleeding.
A client is admitted with an exacerbation of heart failure secondary to chronic obstructive pulmonary disease (COPD). Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply.). A. The client's oxygen saturation level is 85%. B. The client is eating less than half of meals C. The client's heart rate is 110 beats per minute. D. The client is reading a book. E. The client's blood pressure is 160/90 mmHg.
A. The client's oxygen saturation level is 85%. C. The client's heart rate is 110 beats per minute. E. The client's blood pressure is 160/90 mmHg.
After a client receives a dose of albuterol, the nurse evaluates the medication's effects by auscultating the client's lung fields. Which action should the nurse take next based on the assessment? A. Use a peak flow meter to assess the respiratory status. B. Administer a stat dose of corticosteroids. C. Document the normal finding in the client's health record. D. Repeat a dose of the client's rescue drug.
A. Use a peak flow meter to assess the respiratory status.
A nurse is teaching a client who has a fungal infection about fluconazole. Which of the following statements by the client indicates an understanding of the teaching? A. "I should take this medication with food to prevent stomach upset.". B. "I should avoid drinking alcohol while taking this medication.". C. "I should use a barrier method of contraception while taking this medication.". D. "I should stop taking this medication if I develop a rash.".
B. "I should avoid drinking alcohol while taking this medication.".
A client is diagnosed with influenza A and is prescribed oseltamivir. Which of the following statements by the client indicates a need for further education? A. "This medication will shorten the duration of my symptoms.". B. "This medication will prevent me from spreading the virus to others.". C. "This medication will work best if I start taking it within 48 hours of symptom onset.". D. "This medication may cause nausea and vomiting as side effects.".
B. "This medication will prevent me from spreading the virus to others.".
A client with delusions tells the nurse, "You aren't doing your job. Go get those people over there and shoot them before they get me." Which statement is the nurse's best response? A. "There is no one who will hurt you.". B. "You seem quite frightened right now.". C. "You are in a safe place.No one can get to you here.". D. "What would you like to see me do to protect you?".
B. "You seem quite frightened right now."
Which is the best approach for the nurse to use when interviewing a client about intimate partner violence? A. Ask questions in a vague, non-specific format. B. Begin with questions that are less sensitive in nature. C. Get the most difficult questions over with first. D. Share personal values to put the client at ease.
B. Begin with questions that are less sensitive in nature.
The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having unprotected sex. Which response should the nurse provide? A. Emphasize that using safe sex practices removes the risk of STIs. B. Explain that reinfections occur from sex with untreated partners. C. Clarify that all STIs are transmitted through sexual intercourse. D. Provide counseling that most contraceptives protect against infection.
B. Explain that reinfections occur from sex with untreated partners.
An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies. Which is the best response by the nurse? A. Gather information regarding how long it will take for the children to arrive. B. Explain that the client will start to lose consciousness and the body systems will slow down. C. Offer to discuss the client's health status with each of the adult children. D. Reassure the spouse that the healthcare provider will notify when to call the children.
B. Explain that the client will start to lose consciousness and the body systems will slow down.
While caring for a client with a full-thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values? A. Serum blood glucose (BG) level. B. Neutrophil count. C. Serum albumin. D. Hematocrit.
B. Neutrophil count.
A male client who is admitted with bipolar disorder, manic psychosis, is placed in seclusion after unsuccessful attempts to de-escalate him during a sudden mood swing from laughter to jumping and screaming threats while waving a plastic dinner knife. The client is given haloperidol. 5 mg intramuscularly STAT prior to seclusion. Which intervention is most important for the nurse to implement immediately after seclusion? A. Release the client as soon as composure is regained. B. Observe for extrapyramidal symptoms, such as dystonia. C. Secure the room with padded walls and minimal furnishings. D. Provide one-on-one observation at all times.
B. Observe for extrapyramidal symptoms, such as dystonia.
An adolescent who is brought to the emergency department (ED) with a fever and persistent lower right quadrant abdominal pain is anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid-base imbalance? A. Metabolic alkalosis. B. Respiratory alkalosis. C. Metabolic acidosis. D. Respiratory acidosis.
B. Respiratory alkalosis.
The nurse is planning care for a client who has a fourth-degree midline laceration that occurred during vaginal delivery of an 8-pound 10-ounce (3674 grams) infant. Which intervention has the highest priority for this client? A. Administer prescribed PRN sleep medications. B. Encourage use of prescribed analgesic perineal sprays. C. Administer prescribed stool softener. D. Encourage breastfeeding to promote uterine involution.
C. Administer prescribed stool softener.
A nurse is caring for a client who has hypertension and is prescribed metoprolol, a beta blocker. The nurse should monitor the client for which of the following adverse effects? A. Tachycardia B. Hyperglycemia C. Bronchospasm D. Hyperkalemia.
C. Bronchospasm
A client at 42-weeks gestation arrives at the labor and delivery unit for a scheduled induction but refuses the prescribed oxytocin infusion because she wants to have a "natural" delivery. Which action is most important for the nurse to implement? A. Discuss the character of labor from endogenous vs. exogenous oxytocin. B. Ask the healthcare provider to discuss the issue with the client. C. Discuss alternative ways to support the client's birth plan. D. Explain the indications for induction related to post-term pregnancy.
C. Discuss alternative ways to support the client's birth plan.
When caring for an older male client with urinary frequency, which measure is most important for the nurse to implement to help the client prepare to go to bed for the night? A. Reassure the client that someone will check on him hourly. B. Place fresh water and a glass within reach on the bedside table. C. Ensure that the call bell is easily accessible to the client. D. Offer the client an evening snack before providing oral care.
C. Ensure that the call bell is easily accessible to the client.
A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely? A. Ketonuria. B. Peripheral edema. C. Hypokalemia. D. Elevated blood pressure.
C. Hypokalemia.
The nurse is preparing a community outreach program on primary disease prevention. Which topic should the nurse plan to include in this event? A. Domestic violence assistance. B. Blood pressure screening. C. Immunizations that are available. D. Outreach for support group information.
C. Immunizations that are available.
When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take? A. Refer client to the social worker for support therapy. B. Encourage client to implement relaxation techniques. C. Leave the client's room and return later in the day. D. Explain that insulin is a life-saving drug for the client. E. Explain that insulin is a life-saving drug for the client.
C. Leave the client's room and return later in the day.
While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values? A. Serum sodium level. B. Hematocrit. C. Neutrophil count. D. Platelet count.
C. Neutrophil count.
The nurse observes an 18-month-old toddler keeping a bottle of milk in the mouth throughout the history-taking and assessment process during a well-child visit. The mother confirms that the child has a bottle available most of the day and remarks that it makes a great pacifier. Which response should the nurse provide? A. A bottle is generally much better than using a pacifier. B. The bottle will assist in preventing thumb sucking. C. Prolonged bottle use can increase the risk for cavities. D. Using milk rather than juice helps to avoid tooth decay.
C. Prolonged bottle use can increase the risk for cavities.
A nurse is administering protamine sulfate to a client who has received an overdose of heparin. What are some important nursing considerations for this medication? *. A. Protamine sulfate should be given slowly intravenously within 30 minutes of heparin administration. B. Protamine sulfate should be given rapidly intramuscularly within 60 minutes of heparin administration. C. Protamine sulfate should be given slowly intravenously within 60 minutes of heparin administration. D. Protamine sulfate should be given rapidly intramuscularly within 30 minutes of heparin administration.
C. Protamine sulfate should be given slowly intravenously within 60 minutes of heparin administration.
A nurse is administering tetracycline to a client who has acne vulgaris. The client tells the nurse that he usually takes calcium supplements with his meals. How should the nurse respond? A. "You can continue to take calcium supplements as long as you take them with food.". B. "You should avoid taking calcium supplements while you are on tetracycline therapy.". C. "You can take calcium supplements with tetracycline as long as you drink plenty of water.". D. "You should take calcium supplements at least 2 hours before or after tetracycline.".
D. "You should take calcium supplements at least 2 hours before or after tetracycline.".
A child who weighs 55 pounds receives a prescription for cefotaxime 150 mg/kg/day intravenously in divided doses every 6 hours. How many mg should the nurse administer each day? A. 3000 mg. B. 3300 mg. C. 3600 mg. D. 3750 mg.
D. 3750 mg.
The nurse is assessing an adolescent female diagnosed with anorexia nervosa who is admitted to the unit with severe malnutrition and electrolyte imbalance. Which pathological process results from the adolescent's consistent maladaptive behavior? A. Sinus tachycardia. B. Menstrual cramps. C. Hypertension. D. Amenorrhea. E. Amenorrhea.
D. Amenorrhea
Which computer documentation indicates that activities to prevent postoperative venous stasis were performed correctly? A. Leg exercises not performed because of placement of antiembolism hose. B. Antiembolism stockings removed hourly during leg exercises. C. Client demonstrates ability to move all extremities well. D. Antiembolism stockings on, leg exercises performed hourly.
D. Antiembolism stockings on, leg exercises performed hourly.
A woman at 12 weeks' gestation comes to the clinic for her first prenatal visit. After completing a health history, the nurse should discuss which topic about pregnancy at this initial visit? A. Concerns about parenting. B. Cultural practices related to childbearing. C. Complications associated with childbirth. D. Knowledge about labor and delivery.
D. Knowledge about labor and delivery.
A 5-year-old child with a history of a waddling gait and frequent falls is brought into the hospital for diagnostic testing. When explaining the diagnostic testing to the parents, the nurse should provide information based on which understanding of the underlying disease pathology? A. Systemic autoimmune vasculopathy. B. Autonomic neuropathy. C. Impaired neuron function. D. Muscle fiber degeneration.
D. Muscle fiber degeneration.
A client arrives at the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold? A. Aspirin. B. Heparin. C. Morphine. D. Nitroglycerin.
D. Nitroglycerin.
After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next? A. Continue with the blood pressure assessment. B. Reposition the stethoscope over the brachial artery. C. Reinflate the cuff to a higher number. D. Note the presence of an auscultatory gap.
D. Note the presence of an auscultatory gap.
A nurse is caring for a client who has meningitis caused by Streptococcus pneumoniae. The provider orders penicillin G IV for this client. Before administering the medication, which of the following actions should the nurse take? A. Check the client's temperature B. Assess the client's level of consciousness. C. Ask the client about any history of allergies. D. Obtain a blood sample for culture and sensitivity.
D. Obtain a blood sample for culture and sensitivity.
The nurse is providing education to a client who receives a prescription for zolpidem. Which information about the medication should the nurse include? A. Crush to increase absorption. B. Store at room temperature. C. Administer with a meal. D. Take before bedtime. E. Take before bedtime.
D. Take before bedtime.
