hurst q 1
Which interventions should the nurse include when planning care for a client diagnosed with paranoid personality?
1. Develop a trusting relationship. 2. Be honest when communicating with the client. 5. Give clear explanations of procedures before hand.
The nurse is providing discharge education to a client after a concussion. What should the nurse emphasize to report to the primary healthcare provider?
1. Difficulty waking up 3. Blurry vision 5. Vomiting
Which observations by the nurse indicate that a mother is protecting her two day old female newborn from infection?
1. Cleans perineum from front to back after newborn soils diaper. 2. Makes certain the umbilical cord remains dry with each diaper change.
A woman, diagnosed with an ectopic pregnancy, asks the nurse the purpose of receiving methotrexate. What is the best reply for the nurse to make?
3. "This medication will stop the growth of the embryo to save your fallopian tube."
A child was diagnosed with attention-deficit/hyperactivity disorder (ADHD) in the clinic one week ago. Today the child's mother calls the clinic to tell the nurse, "My child has not been able to sleep since being put on methyphenidate." What is the best response for the nurse to make?
3. "To prevent insomnia, give your child the last daily dose at least 6 hours before bedtime."
The primary healthcare provider prescribes a combination of pyrazinamide and isoniazid to treat a client with tuberculosis. The client asks the nurse, "Why am I taking two drugs?" Which explanation should the nurse give the client?
3. Bacterial resistance is decreased.
The charge nurse has received report from the emergency department about a client diagnosed with Cushing's disease being admitted to the unit. Which client in a semi-private room would be appropriate for the charge nurse to have this client share?
3. Client who has a fractured hip.
Which client requires immediate intervention by the nurse?
3. Client with a fractured femur reporting sharp chest pain of 4/10.
The nurse is performing the admission assessment on a client who is having a breast augmentation. Which client information would be most important for the nurse to report to the surgeon before surgery?
3. Client's last menstrual period was 8 weeks ago.
What is priority for the nurse to determine about a client who is scheduled for a tubal ligation in the outpatient surgical center?
3. Client's plan for transportation and care at home.
A newborn in a neonatal unit is to receive penicillin G benzathine 50,000 units/kg intramuscularly (IM). The newborn weighs 6 lbs (2.7 kg). The dispensed dose is 25,000 units per 1 mL. What should the nurse do?
3. Consult with the pharmacy for a different medication concentration.
A hospice nurse is assessing a client reporting chronic pain (5/10 on the pain scale). In addition to the primary healthcare provider and the nurse, what member of the care team will assist in providing comfort therapies for this client?
3. Massage therapist
A client who has been on a psychiatric unit because of several attempted suicides states, "I am happy to be going home today." What is the nurse's best analysis of this statement?
3. May have decided on another suicide plan.
Which findings would indicate to the nurse that a client with Addison's disease has received too much glucocorticoid replacement?
3. Rapid weight gain 5. Increased cholesterol
A child is being admitted to the hospital with a diagnosis of acute glomerulonephritis. In performing the history and physical, what would be a priority assessment that the nurse should include when questioning the child and caregivers?
3. Recent sore throat
A charge nurse is planning care for several clients on the unit. Which activities can the nurse safely delegate to an unlicensed assistive personnel (UAP)?
3. Report a urinary output (UOP) less than 50 ml/hr on a post-op client. 4. Assist a client with obtaining a clean catch urine sample.
A nurse has received the following arterial blood gas results on a client with a post bowel resection: pH 7.48; PCO2 30; HCO3 24. Which acid/base imbalance is the client experiencing?
3. Respiratory alkalosis
The nurse is providing care to a client who has a large abdominal dressing. Which intervention is most likely to reduce the risk of skin irritation due to frequent dressing changes?
3. Secure the dressing with Montgomery straps.
The nurse is administering the prescribed Mantoux tuberculin skin test to a client. The nurse does not observe the tense blister-like formation at the injection site. Which action should the nurse take?
2. Administer another Mantoux tuberculin skin test at a different site.
Which pediatric client should the nurse see first?
3. Three year old with wheezes in right lower lobe.
A client at 36 weeks gestation is receiving magnesium sulfate for treatment of pre-eclampsia. Which finding by the nurse requires immediate action?
3. Urinary output (UOP) of 100cc/4hours
Blood and urine samples are sent to the laboratory for a client who has had a spinal cord injury. After reviewing these results, the nurse would expect which finding?
3. Urinary tract infection
The primary healthcare provider suspects the client has tuberculosis (TB) and prescribes a Mantoux test. What precautions should the nurse take when administering the Mantoux test?
3. Wear a particulate respirator 5. Initiate airborne precautions.
The nurse is instructing a client on achieving relaxation using deep breathing exercises. Which statement by the client indicates to the nurse that further teaching is necessary?
3. "I will inhale slowly and deeply through my mouth focusing on my chest expansion."
A client calls the clinic to ask the nurse if it would be okay to take the herbal medication kava-kava to help reduce anxiety. What is the nurse's best response?
3. "Kava-kava can cause liver damage, so we need to consult your healthcare provider."
During evening rounds, the nurse discovers that a violent client with a history of threats against a former girlfriend cannot be located. The client's window is open and personal belongings missing. Based on recent threats of violence against the girlfriend, what is the nurse's initial action?
3. Initiate the missing client protocol.
The nurse is caring for a newly diagnosed diabetic in diabetic hyperosmolar hyperglycemic nonketotic (HHNK) state. What does the nurse anticipate the immediate treatment plan for this client will include?
3. Intravenous administration of isotonic saline.
Which factor would most likely predispose a client to developing shock following a fracture of the femur?
3. Loss of blood into soft tissues surrounding the fracture
When assessing a client's testes, which finding would indicate to the nurse the need for further investigation?
3. Lump the size of a piece of rice.
The nurse is teaching a newly diagnosed diabetic about proper foot care. Which statements by the nurse are correct?
3. Wear appropriate fitting shoes at all times. 4. View the bottom of the feet daily. 5. Protect feet from hot and cold.
A nurse is teaching a client about the prescription aripiprazole discmelt. The nurse documents that teaching has been effective when the client makes which statement?
4. "I will allow the tablet to dissolve in my mouth."
A client admitted with a myocardial infarction has developed crackles in bilateral lung bases. Which prescription written by the primary healthcare provider should the nurse complete first?
4. Administer furosemide 20 mg intravenous push (IVP).
A client has returned to the burn unit after an escharotomy of the forearm. What is the priority nursing intervention?
4. Assess bilateral radial pulses
A nurse is caring for a client who has developed ventricular fibrillation. Where should the nurse place the conductive electrodes for maximum defibrillation effectiveness?
4. Below the right clavicle to the right of the sternum and just below the left nipple.
The nurse is caring for a client with hypothyroidism. Which dietary consideration is most important for the nurse to teach this client?
4. Increase fiber.
The nurse will be admitting a client from the operating room following a left total pneumonectomy for adenocarcinoma. Which type of chest drainage should the nurse anticipate that the client will have?
4. No chest drainage will be necessary.
What is most important for the nurse to have at the client's bedside when inserting a large orogastric tube for rapid gastric lavage?
4. Suction equipment
Which home routines help reduce the risk of skin damage in a client with impaired sensation?
4. Testing the water with the back of the wrist and forearm before getting in the shower. 5. Check condition of all equipment used in the home.
The nurse is working at the triage station. Which client should the nurse triage first?
2. A client with a cast on the right leg who states, "My right leg is killing me and nothing I do makes it stop hurting. "
A client is in the surgical suite to have a left total knee replacement. Prior to the surgeon initiating the first incision, what should the circulating nurse remind the surgical team to perform?
2. Time-out
The unit charge nurse is responsible for reporting all healthcare associated infections. Which client condition needs to be reported?
1. A client diagnosed with Clostridium Difficile while receiving intravenous (IV) antibiotics.
he nurse is caring for a client with hyperparathyroidism. The nurse will monitor the client for which complications?
1. Kidney stones 3. Osteoporosis
The nurse is caring for a client with myasthenia gravis. What is essential for the nurse to teach this client regarding treatment?
4. Setting the alarm clock for medication times.
What statements by a new nurse would indicate to the charge nurse an understanding of how to maintain skin integrity for a client on bedrest?
1. "Clients on bedrest should be placed on therapeutic mattresses." 3. "I will assess the skin using the Braden scale." 4. "A pillow will be placed between the knees when client is side lying." 5. "The incontinent client will be kept clean and dry."
A client is seen in the clinic for recurrent unexplained, vague stomach pain over the past 5 years. EGD, colonoscopy, gallbladder ultrasound, and lab results have revealed no physical reason for the symptoms. The client tells the nurse, "The doctor thinks the pain in my stomach is psychosomatic. But the pain is so bad some times that I can't function!" What is the nurse's most appropriate response?
1. "The pain you feel is real."
A new mother brings her infant to the clinic for a well-baby checkup. While at the clinic, the mother asks the nurse if there are any reasons why her infant should not have the measles, mumps, rubella (MMR) vaccine. The nurse's response is based on evidence that the MMR vaccine is contraindicated under which condition?
1. A known allergy to gelatin.
A client arrives at the emergency department after sustaining partial and full-thickness burns over the anterior neck, chest, and right arm. Which interventions will the nurse initiate?
1. Administer oxygen 2. Start two intravenous lines 3. Remove necklace 4. Elevate right arm
A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy to determine equipment needs upon discharge to home for hospice care. Which equipment should the case manager obtain for this client?
1. Alternating pressure mattress 2. Hospital bed 4. Suction equipment 5. Oxygen
A homebound client lives alone, has a history of poorly controlled diabetes, and has an open wound on the left heel. The home health nurse is concerned about the client's condition and the possible need for a referral. Which intervention should the nurse initiate for this client?
1. Ask the primary healthcare provider to prescribe a diabetes educator consult.
A nurse is planning to provide an education class on preconception health care to a group of young women wishing to become pregnant. What points should the nurse include in this class?
1. Attain a healthy weight. 2. Make sure immunizations are up to date. 3. Avoid drinking alcohol. 4. Learn family health history.
A nurse is attempting to develop trust with a psychiatric client exhibiting concrete thinking. Which nursing intervention would promote trust in this individual?
1. Attend an activity with the client who is reluctant to go alone. 3. Consider client preferences when possible in decisions concerning care. 4. Provide a blanket when the client is cold. 5. Provide food when the client is hungry.
While performing a vaginal examination on a client in labor, the nurse feels soft, squishy tissue instead of a head. What conclusion should the nurse make based on this assessment finding?
1. Breech presentation
Which tasks would be appropriate for the nurse to assign to an LPN/VN?
1. Changing a colostomy bag. 2. Administer antibiotic via intravenous piggyback (IVPB). 5. Check for urinary retention. 6. Remove wound sutures.
A quality assurance (QA) manager plans to evaluate performance improvement regarding the implementation of fall precautions for at risk clients. What steps should the QA manager include in this evaluation?
1. Chart review for fall precaution documentation. 2. Direct observation of unit staff. 4. Identify at risk clients on unit. 5. Make unannounced visits to the unit for evaluating staff performance.
What is the best instruction the nurse should provide when administering acetylsalicylic acid 81 mg to a client experiencing severe, crushing chest pain radiating up the left jaw?
1. Chew the acetylsalicylic acid prior to swallowing
The nurse is teaching parents of a school aged child about interventions to keep the child safe. Which interventions would be appropriate to include in the health promotion plan
1. Encourage bicycle helmet use when riding bikes. 2. Teach children to swim at an early age. 4. Keep firearms in the home locked and unloaded. 5. Teach "stop, drop, and roll" in case clothing catches on fire.
A client tells the nurse, "I am dying from cancer. I have told my primary healthcare provider that I do not want to be revived if my heart stops beating or I stop breathing." What action should the nurse take first to assure that the client's request is respected?
1. Ensure a do-not-resuscitate prescription has been provided.
The primary healthcare provider is preparing to drain a large abdominal abscess. The client has dementia and moves about on the bed frequently. Which personal protective equipment (PPE) should the nurse wear while holding the client for the procedure?
1. Face shield 3. Gown 4. Mask 5. Regular exam gloves
A nurse is instructing a client who had a cesarean birth 2 days ago about adverse signs that should be reported to the primary health care provider. Which signs should the nurse include?
1. Fever greater than 100.4° F (38° C) for 2 or more days. 3. Calves with localized pain, redness, and swelling. 4. Burning with urination. 5. Feeling of apathy toward newborn.
The nurse is caring for a client suffering from major depression. The client spends all day in bed. Which nursing action is appropriate?
1. Frequently initiate contact with client.
The nurse is teaching the client about benzodiazepines. Which comments by the client indicate adequate understanding of the drug effects/side effects?
1. I should not drive my car until I see how the medication affects me. 2. I can expect my reaction time to be slowed in the beginning 4. I must be careful to take the medication for a limited time. 5. There is a risk for dependence on this medication
What should the nurse teach a pregnant client who comes to the clinic reporting hemorrhoids and constipation?
1. Increased rectal pressure from the gravid uterus may result in hemorrhoids. 2. Hormones decrease maternal GI motility, resulting in constipation. 3. The client needs more fiber in the diet. 5. The client needs to increase fluid intake.
The nurse is caring for a client in an outpatient clinic. The client is being treated with warfarin for prevention of a stroke due to atrial fibrillation. The international normalized ratio (INR) was noted to be 4.6. What should the nurse do?
1. Inform the primary healthcare provider immediately. 3. Inform the client to watch for signs of bleeding.
The nurse observes a client at a follow-up appointment using correct cane walking technique but losing balance each time the quad cane is lifted off of the floor. The client reports a history of recent falls. What is the best action for the nurse to take?
1. Inform the primary healthcare provider of the observations made regarding quad cane use, and imbalance assessment.
The nurse is caring for an adolescent client diagnosed with depression. The client is prescribed fluoxetine. What is the best response by the nurse when the client says, "What will this medicine do to me?"
1. It will increase the level of serotonin in the brain.
A nurse is preparing to conduct a presentation on barriers to therapeutic communication with clients from a culture other than the nurse's culture. Which points should the nurse include in the presentation?
1. Lack of knowledge about a client's culture is a major barrier to therapeutic communication. 4. Do not touch the client until you know what the cultural belief is about touching. 5. Adapt care to client's cultural needs and preferences.
What should the nurse include in the post-op care of a client following the removal of the posterior pituitary gland?
1. Monitor intake and output. 3. Weigh daily. 4. Monitor urine specific gravity. 5. Assess the level of consciousness (LOC). 6. Instruct client to avoid blowing the nose forcefully.
A nurse is planning to teach a group of men about their sildenafil prescription. What information should the nurse include?
1. Notify primary healthcare provider if prescribed an alpha-adrenergic blocker. 3. Sildenafil should be taken only once per day if needed. 5. The most common side effects are flushing, headache, and dyspepsia.
A nurse has just inserted an indwelling urinary catheter in a client scheduled for surgery. What should the nurse document?
1. Perineal skin assessment 2. Client teaching 3. Color of urine 4. Date and time of insertion 5. Type catheter inserted
Which assignment would be most appropriate for the charge nurse to assign to the LPN/VN in the Labor, Delivery, Recovery and Postpartum Unit (LDRP)?
1. Primipara needing assistance with breastfeeding. 3. Primipara who is two days post op cesarean section.
Which interventions should the nurse initiate to lessen acid reflux in a client diagnosed with gastroesophagel reflux disease (GERD)?
1. Provide small, frequent meals. 2. Avoid carbonated beverages. 3. Administer omeprazole as prescribed. 4. Assist with smoking cessation.
An elderly client arrives in the emergency department (ED) after a fall. What assessment findings would lead the nurse to suspect that the client has a fractured right hip?
1. Severe pain in the right hip and groin. 2. Inability to bear weight on the right leg. 4. External rotation of right lower leg. 5. Bruising and swelling around the right hip.
The public health nurse is planning to participate in local forums regarding the placement of a factory that is known to produce pollution through discharge of chemical by-products into the air. What actions demonstrate ethical nursing practice in the public health arena?
1. Speaking up for the underrepresented, such as the poor and uneducated persons 3. Requesting that forums be held throughout the community at various times of the day or evening. 4. Asking for information regarding the health status of people in other factory locations. 5. Requesting information from individuals in areas where the factories are currently located.
The home care nurse visits a client who has moderate cognitive impairment and whose family provides care for the client. Which suggestions would be helpful for this family to reduce the risk of injury?
1. Suggest that the family lock up medications and poisons and keep the keys. 2. Encourage the family to place locks high on the door frame to make it difficult for the client to leave. 4. Suggest that the family remove knobs from stove when not in use. 5. Keep fire extinguishers present and in working order.
The nurse is planning health promotion strategies for a single parent of young children who is trying to increase personal physical activity level but expresses a lack of time. Which interventions would help the client get more regular physical activity into the day?
1. Suggest walking up and down steps at home several times each morning and evening. 2. Suggest parking further away from the grocery store and work. 3. Walk with the children in the evening instead of watching TV with them.
A nurse from the neonatal unit is transferred to the adult medical-surgical unit. Which client should the charge nurse assign to the neonatal nurse?
1. Undergoing surgery for placement of a central venous catheter.
The nurse in the outpatient clinic performs an assessment on a client who takes propranolol for management of palpitations associated with mitral valve prolapse. Which statement by the client should be reported immediately to the primary healthcare provider?
2. "I feel a little short of breath when walking."
The nurse is obtaining a health assessment from the preoperative client scheduled for hip replacement surgery. Which statement by the client would be most important for the nurse to report to the primary healthcare provider?
2. "I had rheumatic fever when I was 10 years old."
The nurse is teaching a client regarding buspirone. The nurse recognizes that teaching has been effective when the client makes which statements?
2. "I should not drink alcohol while taking this medication." 3. "I will rise slowly from lying to sitting or standing." 4. "I will notify my primary healthcare provider of any unusal facial movements.
The charge nurse is evaluating knowledge of tracheostomy suctioning of a new nurse prior to that procedure being performed. Which statement by the new nurse would indicate to the charge nurse that additional education is needed?
2. "I will instill normal saline bullets to liquefy secretions."
A nurse is calling the primary healthcare provider about a client who is experiencing dyspnea and chest pain two days post total knee replacement. Which statements by the nurse are appropriate according to the communication tool SBAR (Situation, Background, Assessment and Recommendation)?
2. "Jane Doe is having increasing dyspnea and is reporting chest pain." 3. "Jane Doe had a total knee replacement two days ago. Pulse is 120, BP 128/54, Resp 32. She is restless." 4. "From my assessment, I think she may be having a cardiac event or a pulmonary embolism." 5. "I recommend that you see the client immediately and that we start oxygen stat. Do you agree?"
A nurse has responded to the scene of a natural disaster to triage clients. Which client should the nurse triage with a black disaster tag?
2. 2nd and 3rd degree burns over 75 % of the body.
A 13 year old, found unresponsive in the park, is brought into the emergency department. The nurse sees a medical alert bracelet stating "Diabetic", and notes a fruity smell to the breath. There are no family members available to obtain consent for treatment and an attempt to call them has been unsuccessful. What action should the nurse take?
2. Begin treatment by inserting two large bore IVs of Normal Saline.
Post thyroidectomy, the nurse assesses the client for complications by performing which assessment?
2. Check for a positive Chvostek's 3. Assess swallowing reflex 4. Monitor neck dressings for change in fit and comfort
The occupational health nurse is leading a group discussion about addiction. What should the nurse include as the primary barrier to the client with alcohol addiction seeking treatment?
2. Denial
A client has been admitted to the medical unit and placed on airborne precautions for suspected pulmonary tuberculosis (TB). The nurse will assess for which signs and symptoms?
2. Fatigue 3. Hemoptysis 4. Diaphoresis during sleep 5. Anorexia
A client with Crohn's disease develops a fever and symptoms of an infection. The nurse recognizes this complication may occur as a result of which finding?
2. Fistula formation with an abscess
A client who has developed hypovolemic shock is receiving albumin. What assessment finding by the nurse indicates that the albumin has been effective?
2. Increase in uninary output
An elderly Asian woman has been in the hospital for three weeks, and it seems that her condition is such that nursing home placement is in the client's best interest. The family is against placing their relative in the nursing home. How should the nurse respond to this?
2. Listen to the family's concerns and report those to the primary healthcare provider.
An elderly client is admitted to the floor with vomiting and diarrhea for three days. She is receiving IV fluids at 200 mL/hr via pump. What is the priority nursing action?
2. Lung assessments every 2-4 hours.
A nurse is planning a health education seminar for a group of females who are age 45-54. What should the nurse recommend be done annually?
2. Mammography 3. Influenza vaccine
A client has been prescribed chlorpromazine for the treatment of schizophrenia. The nurse makes afternoon rounds and finds the client's temperature to be 104.7º F/40.4º C. The client has extreme muscle rigidity, and the vital signs have been fluctuating for the last four hours. What should the nurse do first?
2. Notify the primary healthcare provider immediately.
Which nursing tasks can the RN delegate to an unlicensed assistive personnel (UAP)?
2. Obtain blood pressure of client diagnosed with nephrotic syndrome. 4. Document the intake and output of a client in acute renal failure. 6. Perform perineal care of a client who has urinary incontinence.
A client received a leg cast that was applied following fracturing the left femur. What assessment finding would be a priority for the nurse to report to the primary healthcare provider?
2. Pain not relieved by elevation, cold packs, and pain medication.
Which finding should a nurse expect when assessing a healthy 65 year old client?
2. Presbyopia
A client with a history of increasing dyspnea over the past week comes to the emergency department. After arterial blood gases (ABGs) are drawn, which information would be important for the nurse to document?
2. The client was on 2 L of oxygen by nasal canula.
A client with chronic alcoholism has been admitted to the intensive care unit after overdosing on alcohol. Which medication should the nurse prepare to administer?
2. Thiamine 100 mg IV twice a day
A client recently diagnosed with diabetes is sent home with a prescription for subcutaneous insulin. What statement made by the client indicates that teaching has been effective regarding safe needle disposal?
3. "I may use any hard plastic container with a screw-on cap."
The nurse is teaching a class to primiparas on breastfeeding. How many extra kilocalories per day would the nurse instruct the class participants to consume post-delivery to compensate for the increased energy requirements of lactation?
3. 500
Which intervention can the nurse safely delegate to an unlicensed assistive personnel (UAP)?
3. Apply a condom catheter to an incontinent client.
The nurse is caring for a client with renal failure. The client has a 24 hour intake of 2500 mL and a 24 hour urinary output of 200 mL. What is the priority nursing assessment?
3. Auscultate breath sounds.
A teenage client is placed on life-support as a result of a motor vehicle accident (MVA). Following an electroencephalogram (EEG), the client has been declared brain dead. Which action by the nurse would take priority?
3. Contact the regional organ procurement team.
A home care nurse is preparing to perform venipuncture to draw blood. As the nurse gathers supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of losing control. What should be the nurse's first action?
3. Decrease stimuli in the room.
A client with dementia has been admitted to the medical floor. The family informs the nurse that the client tends to wander at night. When planning client safety goals, which action by the nurse would take priority?
3. Designate an unlicensed assistive personnel (UAP) to sit with the client through the night.
The nurse is caring for a client with pneumococcal pneumonia. Which nursing observations would indicate a therapeutic response to the treatment regime for the infection?
3. Expectorating moderate amounts of thin, white sputum 5. Crackles clearing with cough
A client arrives in the emergency department with fever, nuchal rigidity, and seizures. What action should the nurse take first?
3. Place on droplet precautions.
The nurse is preparing to provide oral care to an unconscious client. What is the most important step for the nurse to provide?
3. Positioning the client in side-lying position.
A client was prescribed thioridazine hcl five days ago and presents to the emergency department with a shuffling gait, tremors of the fingers, drooling, and muscle rigidity. Which adverse reaction to this medication does the nurse suspect?
3. Pseudoparkinsonism
The nurse is planning daily activities for a client who has a diagnosis of schizophrenia. The client tends to spend most of the time in bed and is very uncomfortable when other clients are in the day area of the unit. What activity would be most therapeutic for this client?
3. Spending time in brief one on one interactions with the nurse.
What should a nurse teach a client who has been diagnosed with hepatitis A?
3. Symptoms of hepatitis A include malaise, dark colored urine, and jaundice.
A client develops pernicious anemia after a Billroth II procedure and is to receive vitamin B12 intramuscularly. What should the nurse include in discharge instructions?
3. The B12 injections will be continued for the client's life.
Which client must the nurse assign to a private room?
4. Postpartum client 32 hours after delivery with a temperature of 101º F (38.05 ° C)
Which actions by the nurse, working in the recovery room, should be performed to prevent injury from a needle stick?
4. Replace the puncture resistant biohazard container when three-quarters full. 5. Use "needleless" devices whenever possible.
In what position should the nurse place a client post liver biopsy?
4. Right Lateral Decubitus
A client has an order for two units of packed red blood cells (PRBCs) to be administered. The current IV prescribed is D5LR with 20 mEq KCL at 125 mL/hr infusing through a 22 gauge needle to the left hand. What action should the nurse take?
4. Start another IV with an 18 gauge needle to the right arm.
The charge nurse observes a staff nurse caring for a new mother with oral herpes simplex type I. Which action by the nurse indicates that further instruction on transmission of this disease is needed?
4. States that the newborn may contract herpes from the birth canal.
The nurse is caring for a client while fluorouracil is being infused. The client reports burning at the intravenous (IV) site. What should the nurse do first?
4. Stop the infusion.
A parent tells the clinic nurse, "My child has just been diagnosed with attention-deficit/hyperactivity disorder (ADHD). What will be done to help my child?" How should the nurse best respond to the parent?
4. The standard of care for children with ADHD includes central nervous system stimulants along with behavior and family therapy.
What is most important for the nurse to do prior to initiating peritoneal dialysis?
4. Warm the dialysate fluid.
The nurse is caring for a client in the emergency department. The primary healthcare provider prescribed 1000 mL of D5 ½ NS. The IV is infusing at 25 gtts/min. (Drop factor is 60 gtts/mL). What is the infusion time in hours? Round your answer to the nearest whole number.
40
Based on the Parkland formula, the primary healthcare provider has determined that a burn victim needs 9,250 mL of LR intravenously over the first 24 hours. How many milliliters of LR should the nurse administer over the first eight hours? Round answer to the nearest whole number.
4625
A client has been admitted with a diagnosis of septic shock and has been successfully intubated. The nurse performs and documents a rapid assessment. Which information from the assessment requires the most immediate action by the nurse?
Blood pressure reading.
A primary healthcare provider has prescribed the insertion of a nasogastric (NG) tube. In what order should the nurse perform this procedure?
Elevate head of bed to fowler's position. Measure distal NG tube from nose tip to earlobe to xiphoid process. Lubricate 2-3 inches of distal NG tube. Insert NG tube into unobstructed naris. Advance NG tube upward and backward until resistance is met. Rotate catheter and advance into nasopharynx. Have client swallow ice as NG tube advances into stomach. Secure NG tube.
A client diagnosed with pancreatitis becomes increasingly restless, confused and has pulled out the NG tube and IV catheter. HR-128/min, BP 96/62. Oxygen saturation = 90%. Skin is cool and clammy to touch. Prioritize the actions that the nurse should take.
Initiate oxygen. Insert another IV line. Obtain blood sugar level. Insert NG tube. Repeat vital sign checks
