Lippincott Quiz Fundamentals of Nursing Exam 4
A client who had transurethral resection of the prostate has dribbling urine after his Foley catheter is removed on the second postoperative day. The nurse notes that the client had 200 mL of urine output in the last 8 hours with a 1,000-mL intake. What should the nurse do first? Obtain a urine specimen for culture. Assess for bladder distention. Apply a condom catheter. Teach the client Kegel exercises.
Assess for bladder distention.
An adult has been admitted to the emergency department diagnosed with food poisoning following an outdoor picnic. What should the nurse do? Select all that apply. Assess vital signs. Collect specimens for lab examination. Monitor fluid and electrolyte status. Initiate support for the respiratory system. Tell the family to discard contaminated food. Provide anti-emetics, as prescribed.
Assess vital signs. Collect specimens for lab examination. Monitor fluid and electrolyte status. Initiate support for the respiratory system. Provide anti-emetics, as prescribed.
A client is experiencing mood swings after a stroke and often has episodes of tearfulness that are distressing to the family. Which is the best technique for the nurse to instruct family members to try when the client experiences a crying episode? Tell the client that this behavior is unacceptable. Ignore the behavior. Attempt to divert the client's attention. Sit quietly with the client until the episode is over.
Attempt to divert the client's attention.
A 35-year-old has been killed as a result of a terrorist attack. What should the nurse advise the friends and relatives of the victim to do during the early stages of the recovery process? Select all that apply. Attend memorial or religious services. Speak out publicly about the impact of the loss. Attend community meetings with others who have lost loved ones. Use relaxation techniques and physical activities. Keep in contact with other family and friends.
Attend memorial or religious services. Attend community meetings with others who have lost loved ones. Use relaxation techniques and physical activities. Keep in contact with other family and friends.
In preparing for insertion of a peripheral I.V. catheter, the nurse must select an appropriate site. Which area should the nurse try first if an appropriate vein is found? Back of the hand. Outer aspect of the forearm. Inner aspect of the forearm. Inner aspect of the elbow.
Back of the hand.
Which actions by the nurse will most likely ensure that the correct client receives a medication? Select all that apply. Check the client's room number. Compare the date of birth on the client's medical record to the date of birth on the client's armband. Check the name on the armband with the name on the medication. Have the client state his or her name. Learn to recognize the client.
Check the name on the armband with the name on the medication Compare the date of birth on the client's medical record to the date of birth on the client's armband.
The nurse is developing an education plan for clients with hypertension. The nurse should emphasize which long-term goal for the clients? Commit to lifelong therapy. Monitor blood pressure regularly. Develop a plan to limit stress. Participate in a weight reduction program.
Commit to lifelong therapy.
A client with rheumatoid arthritis states, "I cannot do my household chores without becoming tired. My knees hurt whenever I walk." Which goal for this client should take priority? Employ a housekeeping service. Develop coping skills. Adapt self-care skills. Conserve energy.
Conserve energy.
The mother of a child with moderate diarrhea asks how to manage her child's illness. What should the nurse suggest? Offer foods that are low in fat. Continue the child's regular diet. Feed the child bananas, rice, applesauce, and toast. Begin clear liquids for 24 hours.
Continue the child's regular diet.
A physician orders hourly urine output measurement for a postoperative client with an indwelling catheter. The nurse records these amounts of output for 2 consecutive hours: 8 a.m. (0800): 50 ml; 9 a.m. (0900): 60 ml. Based on these amounts, which action should the nurse take? Notify the physician. Increase the I.V. fluid infusion rate. Continue to monitor and record hourly urine output. Irrigate the indwelling urinary catheter
Continue to monitor and record hourly urine output.
When making rounds on the pediatric neurology unit, the nurse manager notes that, when giving IV medications, many of the staff nurses are disconnecting the flush syringe first and then clamping the intermittent infusion device. The nurse manager is concerned that the nurses do not understand the benefits of positive pressure technique and turbulence flow flush in preventing clots. After the nurse manager discusses the problem with the staff educator, which intervention would be the most effective way to improve the nursing practice? Create a poster presentation on the topic with a required posttest. Send a group email discussing the importance of clamping the device first. Ask each nurse if they are aware that their practice is not current. Post an evidence-based article on the unit.
Create a poster presentation on the topic with a required posttest.
A client who is admitted to an alcohol treatment program says, "I'm going to have a small morning drink to face the day. Usually, I just keep drinking." The nurse understands the client is in which stage of alcoholism? Prealcoholic phase Early alcoholic phase Chronic phase Crucial phase
Crucial phase
A graduate nurse is reviewing the procedure for removing a peripherally inserted central catheter (PICC) with the preceptor. Which planned action by the graduate nurse should the preceptor correct? Measuring the length of the removed catheter and comparing it with the documented length of the inserted catheter Applying a dressing over the site and leaving it in place for 24 hours Discarding the catheter in a trash container Flushing the PICC with 0.9% sodium chloride before removing it
Discarding the catheter in a trash container
The physician has prescribed sodium chloride for a hospitalized 51-year-old client in metabolic alkalosis. Which nursing actions are required to manage this client? Select all that apply . Administer I.V. bicarbonate. Suction the client's airway. Document presenting signs and symptoms. Maintain intake and output records. Compare ABG findings with previous results.
Document presenting signs and symptoms. Maintain intake and output records. Compare ABG findings with previous results.
A client is diagnosed with acute pyelonephritis. What should the nurse instruct the client to do? Empty the bladder every 2 to 3 hours. Take antibiotics for the rest of the client's life. Take bubble baths instead of showers. Decrease fluid intake to 1,000 mL per day.
Empty the bladder every 2 to 3 hours.
A postpartum client has a temperature of 99.8° F (37.7.° C) during the first 24 hours after birth. Which nursing intervention is appropriate? Check the client's breasts for red, swollen areas. Check for signs of puerperal infection. Encourage more fluid intake. Assess lochia for foul odor.
Encourage more fluid intake.
A client is undergoing a bone marrow aspiration and biopsy. The client is very worried about the procedure. What should the nurse do to prepare the client for the procedure? Allow the client time to express feelings. Allow the client's family to stay as long as possible. Encourage the client to take slow, deep breaths to relax. Stay with the client without speaking.
Encourage the client to take slow, deep breaths to relax.
A nurse is caring for a client recently diagnosed with cancer and experiencing moderate situational anxiety. Which interventions would the nurse include in the care plan? Select all that apply. Explain relevant aspects of chemotherapy. Provide positive thinking strategies for the client during periods of stress. Encourage the client to verbalize concerns regarding the diagnosis. Encourage the client to use deep-breathing exercises and other relaxation techniques during periods of increased stress. Teach the stages of grieving to the client. Maintain a calm, nonthreatening environment.
Encourage the client to verbalize concerns regarding the diagnosis. Encourage the client to use deep-breathing exercises and other relaxation techniques during periods of increased stress. Maintain a calm, nonthreatening environment.
Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence? Insert an indwelling urinary catheter. Establish a regular voiding schedule. Limit fluid intake to 1,000 mL/day. Administer prophylactic antibiotics, as prescribed.
Establish a regular voiding schedule.
When administering IV replacement of 5% dextrose in water with potassium chloride, what should the nurse do first? Check the rate for IV push administration. Add potassium chloride to the bag at the bedside. Prime tubing using sterile technique. Evaluate laboratory results for electrolytes.
Evaluate laboratory results for electrolytes.
A nurse is reviewing a client's fluid intake and output record. Fluid intake and urine output should relate in which way? Fluid intake should be half the urine output. Fluid intake should be double the urine output. Fluid intake should be about equal to the urine output. Fluid intake should be inversely proportional to the urine output.
Fluid intake should be about equal to the urine output.
An elderly client admitted with new-onset confusion, headache, poor skin turgor, bounding pulse, and urinary incontinence has been drinking copious amounts of water. Upon reviewing the lab results, the nurse discovers a sodium level of 122 mEq/L (122 mmol/L). A report to the health care provider (HCP) should include what recommendations? Select all that apply. Foley catheter vital signs every 4 hours instead of every shift encourage fluids repeat electrolytes, urine for sodium and specific gravity in the morning fluid restriction bed alarm 2-g sodium diet strict intake and output
Foley catheter vital signs every 4 hours instead of every shift repeat electrolytes, urine for sodium and specific gravity in the morning fluid restriction bed alarm strict intake and output
A physician orders an I.V. bolus injection of diltiazem hydrochloride for a client with uncontrolled atrial fibrillation. What should the nurse do before administering an I.V. bolus? Place a tourniquet on the arm in which the injection will be administered. Gently aspirate the I.V. catheter to check for a blood return. Warm the I.V. medication to room temperature. Insert a second I.V. line into the opposite arm.
Gently aspirate the I.V. catheter to check for a blood return
Total parenteral nutrition (TPN) is prescribed for a client who has recently had a small and large bowel resection and who is currently not taking anything by mouth. What should the nurse do to safely administer the TPN? Designate a peripheral IV site for TPN administration. Handle TPN using strict aseptic technique. Administer TPN through a nasogastric or gastrostomy tube. Auscultate for bowel sounds prior to administering TPN.
Handle TPN using strict aseptic technique.
While making rounds, a nurse observes that a client's primary bag of intravenous (IV) solution is light yellow. The label on the IV bag says the solution is D5W. What should the nurse do first? Notify the health care provider (HCP). Hang a new bag of D5W, and complete an incident report. Ask another nurse to look at the solution. Continue to monitor the bag of IV solution.
Hang a new bag of D5W, and complete an incident report.
A toddler admitted in respiratory distress keeps pulling at the oxygen mask, trying to remove it. Which interventions are indicated? Select all that apply. Encourage the parent to hold the child. Administer a sedative. Have the parent read to the child. Ask the parent to leave the child's bedside. Tell the child the mask will help him breathe better. Restrain the child.
Have the parent read to the child. Encourage the parent to hold the child.
An 80-year-old woman who identifies herself as a devout Catholic has recently relocated to an assisted-living facility. The woman is pleased with most aspects of her new living situation, but laments the fact that she is no longer close to the church where she was in the habit of attending daily mass each morning. What nursing diagnosis may apply to this problem that the woman has identified? Spiritual Distress Spiritual Pain Hopelessness Impaired Religiosity
Impaired Religiosity
A client with a history of renal calculi formation is being discharged after surgery to remove the calculus. What instructions should the nurse include in the client's discharge teaching plan? Eliminate dairy products from the diet. Strain all urine for one week. Increase daily fluid intake to at least 2 to 3 L. Follow measures to alkalinize the urine.
Increase daily fluid intake to at least 2 to 3 L.
A nurse is caring for a client with a history of GI bleeding, sickle cell anemia, and a platelet count of 22,000 mm3. The client, who is dehydrated and receiving dextrose 5% in half-normal saline solution at 150 ml/hour, reports having severe bone pain and is scheduled to receive a dose of morphine sulfate. For which administration route should the nurse question an order? Intramuscular (IM) Subcutaneous (s.q.) Intravenous (IV) Oral
Intramuscular (IM)
A nurse is administering IV fluids to a dehydrated client. When administering an IV solution of 3% sodium chloride, what should the nurse do? Select all that apply. Insert an indwelling urinary catheter. Encourage the client to drink more fluids. Measure the intake and output. Evaluate the client for neurologic changes. Inspect the jugular veins for distention.
Measure the intake and output. Evaluate the client for neurologic changes. Inspect the jugular veins for distention.
The nurse is discussing concerns about sexual activity with a client with chronic renal failure. Which strategy would be most useful? Tell the client to plan rest periods after sexual activity. Help the client to accept that sexual activity will be decreased. Suggest using alternative forms of sexual expression and intimacy. Refer the client to a counselor.
Suggest using alternative forms of sexual expression and intimacy.
The nurse notes that a client with acute pancreatitis occasionally experiences muscle twitching and jerking. How should the nurse interpret the significance of these symptoms? The client has a nutritional imbalance. The client may be developing hypocalcemia. The client needs a muscle relaxant to promote rest. The client is experiencing a reaction to meperidine.
The client may be developing hypocalcemia.
A client is receiving a bowel preparation the evening before a scheduled colonoscopy. Which factor should the nurse consider when providing care for this client? Eating large meals should be encouraged to prevent weight loss. Side rails should be raised at all times. The client may require fluid and electrolyte replacement. Antidiarrheal medication should be given if the client has more than two loose stools.
The client may require fluid and electrolyte replacement.
A nurse recognizes improvement in a client with the nursing diagnosis of Ineffective role performance related to the need to perform rituals. Which behaviors indicate improvement? Select all that apply. The client performs ritualistic behaviors in private. The client avoids stressful situations. The client refrains from performing rituals during stress. The client verbalizes that he uses "thought stopping" when obsessive thoughts occur. The client verbalizes the relationship between stress and ritualistic behaviors. The client rationalizes ritualistic behavior.
The client refrains from performing rituals during stress. The client verbalizes that he uses "thought stopping" when obsessive thoughts occur. The client verbalizes the relationship between stress and ritualistic behaviors.
A client is to be discharged from same-day surgery 7 hours after his inguinal hernia repair. Which nursing observation indicates this client is ready to be discharged? The client voids 500 mL of urine. The client is pain free. The client walks in the hallway unassisted. The client tolerates eating a hamburger.
The client voids 500 mL of urine.
A shy 12-year-old girl who must change school systems just before she begins junior high school begins cutting her arms to relieve the stress that she feels about leaving long-standing friends, having to develop new friendships, and meeting high academic standards in her new school. After she has been cutting for a few weeks, her parent discovers the injuries and takes her to a psychiatrist mental health provider who prescribes a therapeutic group at the local mental health center and medication to help decrease her anxiety. Which findings indicate that the girl had made appropriate progress toward recovery? Select all that apply. The girl says she has developed a friendship with a girl in her class and one in her therapy group. The girl's grades are good, and her hours of study are not excessive. The girl indicates that she had joined three clubs at school and agreed to be an officer in one of them. The girl begins saying she must study hard so she can get into a good university. The girl wears short-sleeved and/or sleeveless tops when the weather is warm.
The girl says she has developed a friendship with a girl in her class and one in her therapy group. The girl's grades are good, and her hours of study are not excessive.
A shy middle school student set up a social network site. A popular student sent a message that included a suggestive picture of himself and suggested the student send a similar picture. When the student sent back a picture of himself dressed only in his boxers, the popular student sent it to all his friends and encouraged them to pass it along. Soon the whole school had seen the picture identified as "Joe's Crotch." The student was so humiliated that he tried to hang himself but was found by his parent before he succeeded. Which outcomes would be most realistic and appropriate with regard to this situation? Select all that apply. The popular student who sent the message to his friends is disciplined by the school authorities. Through therapy, Joe learns social skills to improve his confidence level and help him relate to peers more easily. The social network privileges of all those who forwarded the message are revoked for a year. All students in the school are educated about the risks of cyberbullying and how to respond to it. Joe can use the Internet after being educated about cyberbullying and completing a safety plan.
The popular student who sent the message to his friends is disciplined by the school authorities. Through therapy, Joe learns social skills to improve his confidence level and help him relate to peers more easily. All students in the school are educated about the risks of cyberbullying and how to respond to it. Joe can use the Internet after being educated about cyberbullying and completing a safety plan.
Which client is at highest risk for developing a urinary tract infection? a woman who has given vaginal birth to two children a woman with well-controlled diabetes mellitus a man with an indwelling urinary catheter a man with a past medical history of renal calculi
a man with an indwelling urinary catheter
A client with posttraumatic stress disorder needs to find new housing and wants to wait for a month before setting another appointment to see the nurse. How should the nurse interpret this action? a method of avoidance a necessary break in treatment the end of treatment a detriment to progress
a necessary break in treatment
Which question should the nurse ask first when obtaining a history from the parent of a school-age child with a fever, malaise, and swelling around the eyes? a. "Does the child urinate as much as usual?" b. "Is the urine pale in color?" c. "Is the child playing with friends as usual?" d. "Has the child had a sore throat recently?"
a. "Does the child urinate as much as usual?"
Using Abraham Maslow's hierarchy of human needs, the nurse assigns highest priority to which client need? a. inserting a Foley catheter b. raising the side rails on the client's bed c. arranging a visit from a support group member d. placing the client in a double room with another client the same age
a. inserting a Foley catheter
When assessing an 18-year-old primipara who gave birth under epidural anesthesia 24 hours ago, the nurse determines that the fundus is firm but to the right of midline. Based on this finding, the nurse should further assess for which complication? a. urinary retention b. perineal hematoma c. uterine inversion d. paralytic ileus
a. urinary retention
Small air bubbles adhering to the interior surface of the syringe might have which effect on parenteral administration? altered drug dose altered drug absorption altered onset of action altered duration
altered drug dose
Which client is most likely to exhibit dehydration? a 21-year-old man with profuse diaphoresis after a game of football a 75-year-old woman who has been placed on NPO status 8 hours before surgery a 60-year-old man with pneumonia and a temperature of 101°F (38.3°C) an 8-month-old infant with persistent diarrhea for 24 hours
an 8-month-old infant with persistent diarrhea for 24 hours
A chronically ill school-age child is most vulnerable to which stressor? anticipatory grief fear of hospital procedures anxiety over school absences mutilation anxiety
anxiety over school absences
Which finding would alert the nurse to suspect that a child with severe gastroenteritis who has been receiving intravenous therapy for the past several hours may be developing circulatory overload? a drop in blood pressure marked increase in urine output change to slow, deep respirations auscultation of moist crackles
auscultation of moist crackles
The nurse is instructing an unlicensed assistive personnel (UAP) to collect a urine specimen from an indwelling catheter. Which statement indicates that the UAP understands the instructions? a. "I'll disconnect the drainage tube from the catheter and let urine run from the catheter into the specimen container." b. "I'll get a sterile syringe and remove urine from the catheter through the collection port to place in the specimen container." c. "I should collect urine from the catheter drainage bag at the end of the shift and place it in the specimen container." d. "I'll empty the catheter drainage bag, have the client drink some water, and an hour later collect the urine that drains into the bag."
b. "I'll get a sterile syringe and remove urine from the catheter through the collection port to place in the specimen container."
A client with fever and urinary urgency must provide a urine specimen for culture and sensitivity. The nurse should instruct the client to collect the specimen from the a. full volume of urine from the bladder. b. middle stream of urine from the bladder. c. first stream of urine from the bladder. d. final stream of urine from the bladder.
b. middle stream of urine from the bladder.
A nurse is inserting a urinary catheter into a client who is extremely anxious about the procedure. The nurse can facilitate the insertion by asking the client to: initiate a stream of urine. hold the labia or shaft of the penis. turn to the side. breathe deeply.
breathe deeply.
The primary reason for lubricating the urinary catheter generously before inserting the catheter into a male client is to prevent which problem? a. the number of organisms gaining entrance to the bladder.. b. spasms at the orifice of the bladder.. c. friction along the urethra when the catheter is being inserted.. d. the formation of encrustations that may occur at the end of the catheter..
c. friction along the urethra when the catheter is being inserted..
After teaching the parents about the urethral catheter placed after surgical repair of their son's hypospadias, the nurse determines that the teaching was successful when the mother states that the catheter in her child's penis accomplishes which goal? a. measures his urine correctly b. decreases pain at the surgical site c. keeps the new urethra from closing d. prevents bladder spasms
c. keeps the new urethra from closing
A client with acute renal failure has a serum potassium level of 6.5 mEq/L (6.5 mmol/L). The nurse should monitor the client for which potential complication? circulatory collapse pulmonary edema hemorrhage cardiac arrest
cardiac arrest
The health care provider's (HCP's) prescription for an intravenous infusion is 3% normal saline to infuse at 125 mL/h. The client's most recent sodium level is 132 mEq/L (132 mmol/L). The nurse should: hang 0.9% Normal Saline at 125 mL/h. start the IV solution as prescribed. hang the IV solution prescribed at 62 mL/h. consult the prescriber about the prescription.
consult the prescriber about the prescription.
A nurse interviews the family of a client hospitalized with severe depression and suicidal ideation. What family assessment information is essential when formulating an effective discharge plan? Select all that apply. current family stressors communication patterns employment skills personal responsibilities role expectations physical pain
current family stressors communication patterns role expectations
The nurse interviews the family of a client who is hospitalized with severe depression and suicidal ideation. Which family assessment information is essential to formulating an effective plan of care? Select all that apply. employment skills current family stressors client's experience with physical pain role expectations personal responsibilities communication patterns
current family stressors role expectations communication patterns
A registered nurse and a nursing assistant are caring for a group of clients. Which client's care may safely be delegated to the nursing assistant? a. A client with uncontrolled diabetes mellitus who underwent radical suprapubic prostatectomy 1 day ago and has an indwelling urinary catheter draining yellow urine with clots b. A client who underwent surgery 12 hours ago whose suprapubic catheter is draining burgundy-colored urine c. A client who requires neurological assessment every 4 hours after sustaining a spinal cord injury in a motor vehicle accident that left him with paraplegia d. A client diagnosed with renal calculi who must ambulate four times daily and drink plenty of fluids.
d. A client diagnosed with renal calculi who must ambulate four times daily and drink plenty of fluids.
A confused client with carbon monoxide poisoning experiences dizziness when ambulating to the bathroom. What should the nurse do? a. Ask the unlicensed assistive personnel (UAP) to place restraints on the client's upper extremities. b. Put all four side rails up on the bed. c. Request that the client's roommate put the call light on when the client is attempting to get out of bed. d. Check on the client at regular intervals to ascertain the need to use the bathroom.
d. Check on the client at regular intervals to ascertain the need to use the bathroom.
When a client with an indwelling urinary catheter wants to walk to the hospital lobby to visit with family members, the nurse teaches the client how to do this without compromising the catheter. Which client action indicates an accurate understanding of this information? a. The client loops the drainage tubing below its point of entry into the drainage bag. b. The client clamps the catheter drainage tubing while visiting with the family. c. The client sets the drainage bag on the floor while sitting down. d. The client keeps the drainage bag below the bladder at all times.
d. The client keeps the drainage bag below the bladder at all times.
When admitting a neonate whose mother received magnesium sulfate, the nurse should assess the baby for which complication? Select all that apply. increased Moro reflex decreased respirations increased respirations decreased muscle tone increased temperature
decreased respirations decreased muscle tone
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should assess the client for which alteration in fluid and electrolyte balance? decreased serum sodium level decreased blood pressure increased urine output increased osmolality of the plasma
decreased serum sodium level
A client is admitted to the emergency department after being sexually assaulted. The nurse notes that the client is sitting calmly and quietly in the examination room and recognizes this behavior as a protective defense mechanism. What defense mechanism is the client exhibiting? denial displacement regression intellectualization
denial
In a client with a urine specific gravity of 1.040, a subnormal serum osmolality, and a serum sodium level of 128 mEq/L, the nurse should question an order for which I.V. fluid? dextrose 5% in water (D5W) normal saline solution. lactated Ringer's solution. dextrose 5% in half-normal saline solution.
dextrose 5% in water (D5W)
The nurse is assessing a client who has benign prostatic hypertrophy (BPH). The nurse should determine if the client has which symptom? hematuria impotence flank pain difficulty starting the urinary stream
difficulty starting the urinary stream
A nurse discovers that an I.V. site in a client's hand has infiltrated, causing localized pain and swelling. Which intervention would relieve the client's discomfort most effectively? elevating the hand and wrapping it in a warm towel administering an as-needed analgesic wrapping the arm in an elastic bandage from wrist to elbow placing an ice pack on the hand
elevating the hand and wrapping it in a warm towel
A client who comes to the crisis center in a very distressed state tells the nurse, "I just can't get over being fired last week. I've asked for help. I've talked to friends. I've tried everything to get through this, but nothing is working. Help me!" Which initial crisis intervention strategy should the nurse use? unemployment assistance referral for counseling emotion management support system assessment
emotion management
An infant diagnosed with Hirschsprung's disease is scheduled to receive a temporary colostomy. When the nurse is initially discussing the diagnosis and treatment with the parents, which action by the nurse would be most appropriate? encouraging them to ask questions giving them printed material on the procedure assessing the adequacy of their coping skills reassuring them that their child will be fine
encouraging them to ask questions
A client admitted to the psychiatric unit for treatment of a panic attack comes to the nurses' station in obvious distress. After finding the client short of breath, dizzy, trembling, and nauseated, a nurse should first: administer an antianxiety medication, as ordered, and instruct the client to lie down in his room. ask the client why he is upset. escort the client to a quiet area and suggest that he use a relaxation exercise he's been taught. assure the client that his symptoms will disappear after he lies down and relaxes.
escort the client to a quiet area and suggest that he use a relaxation exercise he's been taught.
After a third arrest for abusing a neighbor's cat, a client is admitted to the psychiatric unit for treatment of antisocial personality disorder. This client has a history of conduct disorder. Which action is most appropriate for the nurse assigned to this client? encouraging the client to use problem-solving techniques insisting that the client obey all unit rules and attend all unit activities examining personal feelings toward the client administering antianxiety medication as ordered
examining personal feelings toward the client
Since the diagnosis of stomach cancer, the client has been having trouble sleeping and is frequently preoccupied with thoughts about how life will change. The client says, "I wish my life could stay the same." The nurse determines that the client is experiencing which problem? going through a grieving process having difficulty coping experiencing a sleep disorder showing signs of anxiety
going through a grieving process
The nurse should assess a client who is in the emergent phase of burn management for: metabolic alkalosis. hemodilution. hypernatremia. hyperkalemia.
hyperkalemia.
Which type of solution, when administered I.V., would cause fluid to shift from body tissues to the bloodstream? isotonic sodium chloride hypertonic hypotonic
hypertonic
A client has had an exacerbation of ulcerative colitis with cramping and diarrhea persisting longer than 1 week. The nurse should assess the client for which complication? deep vein thrombosis heart failure hypocalcemia hypokalemia
hypokalemia
A client who has been vomiting for 2 days has a nasogastric tube inserted. The nurse notes that over the past 10 hours, the tube has drained 2 L of fluid. The nurse should further assess the client for which electrolyte imbalance? hypocalcemia hypokalemia hypermagnesemia hypernatremia
hypokalemia
A nurse is assessing a client for lifestyle factors that might affect normal coping. Which factor should the nurse most likely consider? inadequate diet adopting a child divorce job promotion
inadequate diet
A nurse is caring for an elderly adult client admitted to the hospital from a nursing home because of a change in behavior. The client has a diagnosis of Alzheimer's disease and has started to experience episodes of incontinence. The hospital staff is having difficulty with toileting because the client wanders around the unit all day. To assist with elimination, a nurse should: ask the physician to order restraints to prevent wandering. have the client wear two briefs at a time to ensure absorption of incontinent urine. ask the physician to order sedation to allow the client to rest. incorporate the client's toileting schedule into the pattern of his wandering.
incorporate the client's toileting schedule into the pattern of his wandering.
In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation? increased blood pressure decreased level of consciousness (LOC) increased restlessness decreased heart rate
increased restlessness
A week ago, a tornado destroyed the client's home and seriously injured her husband. The client has been walking around the hospital in a daze without any outward display of emotions. The client is being admitted to the stress unit with the diagnosis of acute stress disorder. The client tells the nurse in a matter-of-fact manner that her husband is paraplegic, "but that is better than total paralysis." Which protective mechanism is the client exhibiting? rationalization intellectualization suppression denial
intellectualization
A client is ready to be discharged following an inguinal hernia repair. Which criteria must the client meet before the nurse can discharge the client? Select all that apply. The client: is able to tolerate oral fluids. can walk to the bathroom unassisted. has pain no greater than 5 on a scale of 1 to 10. has transportation home via a taxicab. has voided.
is able to tolerate oral fluids. can walk to the bathroom unassisted. has voided.
A pediatric client is given morphine for postoperative pain following a fracture repair. As the nurse is assessing the client for pain 4 hours later, his parent leaves the room, and the child begins to cry. What assessment does the nurse make about the child's pain? less tolerant of pain because he is upset in pain because he is crying not in pain, because he was medicated 4 hours ago not in pain because the crying began after the parent leaves
less tolerant of pain because he is upset
The nurse is coaching a client with heart failure about reducing fluid retention. Which strategy will be most effective in reducing a client's fluid retention? low-sodium diet restricting fluid intake elevating the feet walking for 20 minutes three times a week
low-sodium diet
The nurse monitors IV replacement therapy for a client with a nasogastric (NG) tube attached to low suction in order to: facilitate osmotic diuresis. maintain fluid and electrolyte balance. promote urination. equalize intake and output.
maintain fluid and electrolyte balance.
A child with partial- and full-thickness burns is admitted to the pediatric unit. What should be the priority at this time? evaluating vital signs frequently managing the child's pain maintaining fluid and electrolyte balance preventing wound infections
maintaining fluid and electrolyte balance
Immediately after surgery to create an ileostomy, which goal has the highest priority? providing relief from constipation maintaining fluid and electrolyte balance assisting the client with self-care activities minimizing odor formation
maintaining fluid and electrolyte balance
A 9-month-old infant is admitted with diarrhea and dehydration. The nurse plans to assess the child's vital signs frequently. Which other action provides important assessment information? measuring the infant's weight inspecting the infant's posterior fontanel obtaining a stool specimen for analysis obtaining a urine specimen for analysis
measuring the infant's weight
The nurse observes a client with an onset of heart failure having rapid, shallow breathing at a rate of 32 breaths/minute. What blood gas analysis does the nurse anticipate finding initially? metabolic alkalosis respiratory acidosis respiratory alkalosis metabolic acidosis
metabolic alkalosis
What finding indicates that a child is receiving too much IV fluid too rapidly? evidence of protein in the urine marked increase in abdominal girth dark amber-colored urine moist crackles in the lung fields
moist crackles in the lung fields
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: severely restrict the client's physical activities. instruct the client to keep an accurate record of food and fluid intake. weigh the client daily, after the evening meal. monitor the client's vital signs, serum electrolyte levels, and acid-base balance.
monitor the client's vital signs, serum electrolyte levels, and acid-base balance.
A nurse is caring for an 8-year-old girl with multiple chronic urinary tract infections. The child's parents appear protective, never leaving their daughter's side. While the nurse helps the child's mother provide morning care, the child states, "My uncle doesn't clean me that way." Her mother becomes visibly upset and gives the girl a stern warning not to discuss the matter. She states, "Don't tell anyone about that again." The nurse has a legal responsibility to: note on the child's chart that the mother is overprotective. offer to clean the child the way her uncle does. notify the nursing supervisor and the authorities of the possibility of abuse. leave the room so the mother and daughter can have privacy.
notify the nursing supervisor and the authorities of the possibility of abuse.
Which aspects of client care would be most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? catheterizing a 75-year-old male client who has an enlarged prostate obtaining a urine specimen for a culture and sensitivity analysis from a client who has an indwelling urinary catheter inserted changing the IV fluid bag for a client whose IV fluid level is running low administering an antacid to a client with heartburn after verifying the client's report of pain
obtaining a urine specimen for a culture and sensitivity analysis from a client who has an indwelling urinary catheter inserted
What instruction should the nurse's discharge teaching plan for the client with heart failure include? remaining sedentary for most of the day walking 2 miles (3.2 km) every day obtaining daily weights at the same time each day maintaining a high-fiber diet
obtaining daily weights at the same time each day
A 3-month-old has moderate dehydration. The nurse should assess the client for which sign of moderate dehydration? bulging eyes oliguria sunken posterior fontanel pale skin color
oliguria
During the early postpartum period, a nurse is evaluating several clients' attachment to their neonates. Which client is the highest priority for the nurse? one who lost a job recently one who is an only child one with little knowledge of parent-neonate attachment one whose parent died recently
one whose parent died recently
The nurse assesses an older adult for signs of dehydration. Which findings would be consistent with a diagnosis of dehydration? bounding pulse moist crackles shortness of breath orthostatic hypotension
orthostatic hypotension
A nurse may delegate adding medications to I.V. fluid containers to a nursing assistant. pharmacist. student nurse. pharmacy technician.
pharmacist.
Which signs and symptoms might a nurse observe in a client having an adverse reaction to a loop diuretic? Select all that apply. potassium level of 3.1 mEq/L hyperactive bowel sounds decreased muscle tone irregular pulse ventricular arrhythmias weakness
potassium level of 3.1 mEq/L decreased muscle tone irregular pulse ventricular arrhythmias weakness
The nurse is caring for a 3-year-old child with acute kidney injury. Which laboratory finding should the nurse immediately report to the healthcare provider? sodium 130 mEq/L (130 mmol/L) potassium level of 6.5 mEq/L (6.5 mmol/L) blood urea nitrogen (BUN) 40 mg/dL (urea 14.3 mmol/L) creatinine 2.5 mg/dL (221 umol/L)
potassium level of 6.5 mEq/L (6.5 mmol/L)
Which factor should a nurse anticipate having the most influence on the outcome of a client facing a crisis situation? self-actualization previous coping skills self-esteem age
previous coping skills
The nurse is preparing a preoperative teaching plan for a client who is undergoing a bilateral breast reduction. Which aspect of the plan is the priority? psychosocial integrity health promotion and maintenance reduction of risk potential physiologic adaptation
psychosocial integrity
A client with colon cancer experiences an increase in feelings of anxiety and depression and has suicidal ideation. The nurse realizes that these feelings occur during which stage of the disease? initiation of definitive treatment end of the first course of treatment recurrence of the disease end stage of the disease
recurrence of the disease
A nurse fails to give the evening dose of an IV antibiotic that is to be administered every 12 hours. The evening dose was scheduled for 1800; it is now 2200. The nurse should next: administer the 1800 dosage now. assess the client for increasing signs of infection. report the incident to the health care provider. call the pharmacist for instructions.
report the incident to the health care provider.
The major goal of therapy in crisis intervention is to: resolve the immediate problem. decrease anxiety. withdraw from the stress. provide documentation of events.
resolve the immediate problem.
The nurse is conducting a counseling session with a client experiencing posttraumatic stress disorder (PSTD) using a 2-way video telehealth system from the hospital to the client's home, which is 2 hours away from the nearest mental health facility. What are expected outcomes of using telehealth as a venue to provide health care to this client? Select all that apply. The client will: save travel time from the house to the health care facility. obtain group support from others with a similar health problem. experience a shorter recovery time than being treated by being on-site at a health care facility. avoid reliving a traumatic event which might be precipitated by visiting a health care facility. receive health care for this mental health problem.
save travel time from the house to the health care facility. avoid reliving a traumatic event which might be precipitated by visiting a health care facility. receive health care for this mental health problem.
A client with multiple myeloma presents to the emergency department complaining of excessive thirst and constipation. The client's family members report that the client has been confused for the last day. Which laboratory value is most likely responsible for this client's symptoms? platelet count 300,000/mm3 (0.3 L) serum sodium level of 133 mEq/L (133 mmol/L) serum calcium level 13.8 mg/dl (0.766 mmol/L) hemoglobin of 9.8 g/dl (98 g/L)
serum calcium level 13.8 mg/dl (0.766 mmol/L)
A client with nausea, vomiting, and abdominal cramps and distention is admitted to the healthcare facility. Which test result is most significant? urine specific gravity of 1.025 serum potassium level of [3 mEq/L (3.0 mmol/L)] blood urea nitrogen (BUN) level of [29 mg/dl (10.4 mmol/L)] serum sodium level of [132 mEq/L 132 mmol/L)]
serum potassium level of [3 mEq/L (3.0 mmol/L)]
A nurse is teaching a client stress management. Which techniques would be considered adaptive coping skills? Select all that apply. set realistic goals for each day maintain control of my life practice relaxation techniques balance sleep, rest, and exercise try to eliminate total anxiety
set realistic goals for each day practice relaxation techniques balance sleep, rest, and exercise
While performing rounds, a nurse finds that a client is receiving the wrong I.V. solution. The nurse's initial response should be to slow the I.V. flow rate and hang the appropriate solution. remove the I.V. catheter and call the physician. write up an incident report describing the mistake. wait until the next bottle is due and then change to the proper solution.
slow the I.V. flow rate and hang the appropriate solution.
A nurse is caring for a spiritually distressed client. Which are the factors affecting spiritual distress? Select all that apply. sociocultural deprivation self-alienation seeing a religious leader ability to introspect chronic illness
sociocultural deprivation self-alienation chronic illness
A client with Addison's disease comes to the clinic for a follow-up visit. When assessing this client, the nurse should stay alert for signs and symptoms of calcium and phosphorus abnormalities . chloride and magnesium abnormalities. sodium and chloride abnormalities. sodium and potassium abnormalities.
sodium and potassium abnormalities.
The nurse teaches a primigravid client how to do Kegel exercises. What does the nurse explain is the expected outcome of these exercises? reducing the risk of hemorrhoids strengthening the perineal muscles strengthening the abdominal muscles alleviating lower back discomfort
strengthening the perineal muscles
When reviewing the plan of care for a client with Alzheimer's disease, which intervention would the nurse question? stress management pet therapy reminiscence group walking
stress management
When positioned properly, the tip of a central venous catheter should lie in the jugular vein. basilic vein. superior vena cava. subclavian vein.
superior vena cava.
The parent of a soldier who was killed 2 days ago is admitted after a serious suicide attempt. The client is medically stable, and a safety plan is in place. During a talk with the nurse, the client says, "Terrorism and war are holding me and the whole world hostage. It's so unfair. I would rather be dead than live alone in constant fear." Which nursing interventions are important in the next few days? Select all that apply. teaching stress management and relaxation techniques identifying community groups for relatives of military personnel discussing effective ways to express justifiable anger strategizing about ways to increase a personal sense of security recommending an antiwar advocacy group
teaching stress management and relaxation techniques identifying community groups for relatives of military personnel discussing effective ways to express justifiable anger strategizing about ways to increase a personal sense of security
To determine the I.V. drip rate, a nurse must know the drip factor, which is the number of drops in one milliliter. the number of milliliters in one drop. the number of drops per hour to be infused. the number of drops per minute to be infused.
the number of drops in one milliliter.
A nurse is helping a physician insert a subclavian central line. After the physician has gained access to the subclavian vein, the physician connects a 10-ml syringe to the catheter and withdraws a sample of blood. The physician then disconnects the syringe from the port. Suddenly, the client becomes confused, disoriented, and pale. The nurse suspects an air embolus. The nurse should place the client in high-Fowler's position and administer supplemental oxygen. position the client in the shock position with legs elevated. turn the client on the left side and place the bed in Trendelenburg's position. place the client in a supine position and prepare to perform cardiopulmonary resuscitation.
turn the client on the left side and place the bed in Trendelenburg's position.
On admission to the inpatient psychiatric unit, a client's facial expression indicates severe panic. The client repeatedly states, "I know the police are going to shoot me. They found out that I'm the child of the devil." What should the nurse say to initiate a therapeutic relationship with this client? "You certainly look stressed. Can you tell me about the upsetting events that have occurred in your life recently?" "You're having very frightening thoughts. I'll help you find ways to cope with this scary thinking." "Hello, ___. I'm going to be caring for you while I'm on duty. You look very frightened, but I'm sure you'll feel better by tomorrow." "Hello, my name is ___. I'm a nurse, and I'll care for you when I'm on duty. Should I call you ___, or do you prefer something else?"
"Hello, my name is ___. I'm a nurse, and I'll care for you when I'm on duty. Should I call you ___, or do you prefer something else?"
A nurse is caring for a client who is an employee in the hospital. The client has recently received a diagnosis of genital herpes and is being treated for a urinary tract infection (UTI). A co-worker asked the nurse how the employee is doing. What is the nurse's best response? "The client is upset that everyone knows about the herpes." "The antibiotics are really helping with the UTI." "If you look at the medical record you can see what is going on." "I'll be sure to tell the client you said hello"
"I'll be sure to tell the client you said hello"
The mother tells the nurse that the diagnosis of colic upsets her because she knows her infant will continue to have colicky pain. Which response by the nurse would be most appropriate? "It can be difficult to listen to your baby cry so loud and so long, so try to make sure that you get some free time." "The next 3 months will be a difficult time for you, but your baby will outgrow the colic by this time." "I know that your baby's crying upsets you, but she needs your undivided attention for the next few months." "It must be distressing to see your baby in pain, but at least she does not have an intestinal obstruction."
"It can be difficult to listen to your baby cry so loud and so long, so try to make sure that you get some free time."
The parents of a child who requires skeletal traction are unable to visit their child for more than 1 hour a day because there are five other children at home and both parents work outside of the home. The nurse recognizes expressions of guilt in both parents. To help alleviate this guilt, the nurse should make which statement? "It is important that you visit even for 1 hour." "I am sure you feel guilty about not being able to visit often." "Perhaps you could take turns visiting for a bit longer." "Not all parents can stay all the time."
"It is important that you visit even for 1 hour."
An adolescent client is admitted to a psychiatric day treatment program due to severe lower back pain since her mother's death 3 years ago. Medical examinations have not discovered a physical cause for her pain. She cares for her four younger siblings after school and on weekends because of her father's long work hours. Which predischarge statement indicates that treatment for her condition has been successful? "I just need more rest and relaxation and then my back will feel fine." "I do not want to talk about my family. It is my back that is hurting." "My back pain is worse on weekends with more responsibility and homework." "I understand now why my father spends so much time away from home."
"My back pain is worse on weekends with more responsibility and homework."
When teaching about prevention of infection to a client with a long-term venous catheter, the nurse determines that the client has understood discharge instructions when the client makes which statement? "My husband will change the dressing three times per week, using sterile technique. "I will monitor my temperature once every other day." "I won't remove the dressing until I return to the clinic next week." "I know it's very important to wash my hands after irrigating the catheter."
"My husband will change the dressing three times per week, using sterile technique.
As a representative of the treatment team, a nurse is reviewing results of diagnostic studies with the family of an adolescent with anorexia nervosa. What explanation should the nurse give the family about the client's abnormal blood urea nitrogen (BUN) value? "The BUN is decreased because your daughter is hypertensive." "The BUN is elevated because your daughter is dehydrated." "The BUN is decreased because your daughter has developed hypothyroidism." "The BUN is elevated because your daughter has hypoglycemia."
"The BUN is elevated because your daughter is dehydrated."
After teaching the mother of a young girl about measures to help prevent urinary tract infections, which statement by the mother indicates successful teaching? "We'll make sure she takes a water bottle with her to afterschool events." "We'll try to get her not to go to the bathroom too frequently." "She'll love the idea of taking more bubble baths." "We'll let her soak in the bathtub for 30 minutes every day."
"We'll make sure she takes a water bottle with her to afterschool events."
A client who weighs 187 lb (85 kg) has an order to receive enoxaparin 1 mg/kg. This drug is available in a concentration of 30 mg/0.3 mL. What dose would the nurse administer in milliliters? Record your answer using two decimal places.
0.85
The neonate has a prescribed IV rate of 8 mL/h. Fluid totals are recorded every 2 hours on the even hours. There is a new prescription written at 1030 to decrease the IV rate to 6 mL/h. What is the fluid total to be infused and recorded at 1200? Record your answer using a whole number.
13
A client is receiving magnesium sulfate at 3 g/h intravenously. The bag of 1,000 mL normal saline contains 20 g of magnesium sulfate. At what rate (in mL/hour) should the nurse set the IV pump to deliver 3 g/h? Record your answer using a whole number.
150
An infusion of lidocaine hydrochloride is running at 30 mL/hour. The dilution is 1,000 mg/250 mL. What dosage is the client receiving per minute? Record your answer using a whole number.
2
A client admitted to the hospital with diabetic ketoacidosis is receiving a continuous infusion of regular insulin. The physician orders an I.V. containing 1 liter of dextrose 5% in water at 150 ml/hour to be started when the client's blood glucose level reaches [250 mg/dl (13.9 mmol/L)]. The drip factor of the I.V. tubing is 15 gtt/ml. What is the drip rate for this I.V. infusion in drops per minute? Record your answer using one decimal place.
37.5
A health care provider prescribes intravenous heparin 25,000 units in 250 ml of normal saline solution to infuse at 600 units/hour for a client who suffered an acute myocardial infarction (MI). After 6 hours of heparin therapy, the client's partial thromboplastin time is subtherapeutic. The health care provider orders the infusion to be increased to 800 units/hour. The nurse would set the infusion pump to deliver how many milliliters per hour? Record your answer using a whole number.
8
A nurse is caring for a 22-year-old female client with type 1 diabetes mellitus and toxic shock syndrome (TSS). Which action should the nurse perform first? Teach the client to use pads at night instead of tampons during her menstrual period. Administer 5% dextrose in half-normal saline solution at 150 mL/h IV. Administer 50 mg of meperidine IM every 4 hours as needed for pain. Administer 400 mg of ciprofloxacin IV every 12 hours infused over 1 hour.
Administer 5% dextrose in half-normal saline solution at 150 mL/h IV.
A nurse is reviewing arterial blood gas results on an assigned client. The pH is 7.32 with PCO2 of 49 mm Hg and a HCO3−of 28 mEq/L. The nurse reports to the physician which finding? metabolic alkalosis respiratory acidosis metabolic acidosis respiratory alkalosis
respiratory acidosis
Which finding is the best indication that fluid replacement for the client in hypovolemic shock is adequate? respiratory rate of 20 breaths/minute urine output greater than 30 ml/hour diastolic blood pressure greater than 90 mm Hg systolic blood pressure greater than 110 mm Hg
urine output greater than 30 ml/hour
A physician prescribes penicillin potassium oral suspension 56 mg/kg/day in four divided doses for a client with anorexia nervosa who weighs 25 kg. The medication dispensed by the pharmacy contains a dosage strength of 125 mg/5 mL. How many milliliters of solution should the nurse administer with each dose? Record your answer using a whole number.
14
A client is to receive 1 unit of packed red blood cells over 2 hours. There are 250 mL in the infusion bag. The IV administration infusion set delivers 10 gtt/mL. At what flow rate (in drops per minute) should the nurse run the infusion? Record your answer using a whole number.
21
A client is scheduled to have an elective mandibular osteotomy to correct a mandibular fracture sustained in an accident 6 months earlier. Which statement by the client indicates to the nurse that the client is having difficulty coping? "My wife will help me, but I don't think I'll need that much help." "I'll be glad to have my jaw fixed because my wife thinks I don't look like myself." "I'm ready to get this over with." "I'm somewhat afraid to have the surgery, but I feel OK about it."
"I'll be glad to have my jaw fixed because my wife thinks I don't look like myself."
Which client statement indicates that the client has coped effectively with a relationship problem? "I can understand how my wife and I see things differently." "My wife and I are talking about our likes and dislikes in activities." "My wife will be happy to know that I can spend less time at work now." "We are really listening to each other about our different view on issues."
"We are really listening to each other about our different view on issues."
The physician prescribes acetaminophen 650 mg by mouth every 4 hours for a client with a temperature of 102° F (38.8° C) who has a feeding tube in place. The nurse has acetaminophen solution on hand containing 160 mg/5 ml. How many milliliters of solution should the nurse administer? Record your answer using one decimal place.
20.3
A client with heart failure must be monitored closely after starting diuretic therapy. The best indicator for the nurse to monitor is urine specific gravity. weight. fluid intake and output. vital signs.
weight.
A client who is experiencing an exacerbation of ulcerative colitis is receiving IV fluids that are to be infused at 125 mL/h. The IV tubing delivers 15 gtt/mL. How quickly should the nurse infuse the fluids in drops per minute to infuse the fluids at the prescribed rate? Record your answer using a whole number.
31
The nurse is to administer chloramphenicol 50 mg IV in 100 mL of dextrose 5% in water over 30 minutes. The infusion set administers 10 gtt/mL. At what flow rate (in drops per minute) should the nurse set the infusion? Round to the nearest whole number.
33
A client with a deep vein thrombosis has heparin sodium infusing at 1,500 units/hour. The concentration of heparin is 25,000 units/500 mL. If the infusion remains at the same rate for a full 12 hour shift, how many milliliters of fluid will infuse? Record your answer using a whole number.
360
A true crisis state, involving a period of severe disorganization, is difficult to endure emotionally and physically. The nurse recognizes that a client will only be able to tolerate being in crisis for how long? 1 to 2 weeks 4 to 6 weeks 12 to 14 weeks 24 to 26 weeks
4 to 6 weeks
Prior to going to surgery, the client tells the nurse that it is not possible to hear without a hearing aid and asks to wear it to surgery and recovery. What is the nurse's best response? Explain to the client that it is policy not to take personal items to surgery because they may be lost or broken. Explain to the client that the premedication that will cause sleepiness and it will not be necessary to hear anything. Call the surgery unit to explain the client's concern, and ask if the client can wear the hearing aid to surgery. Tell the client that a nurse will bring the hearing aid to the postanesthesia care unit as soon as the client wakes up.
Call the surgery unit to explain the client's concern, and ask if the client can wear the hearing aid to surgery.
If a client's central venous catheter accidentally becomes disconnected, what should a nurse do first? Call the physician. Clamp the catheter. Apply a dry sterile dressing to the site. Tell the client to take and hold a deep breath.
Clamp the catheter.
A client is receiving spironolactone for treatment of bilateral lower extremity edema. The nurse should instruct the client to make which nutritional modification to prevent an electrolyte imbalance? Increase intake of milk and milk products. Increase foods high in sodium. Restrict fluid intake to 1,000 mL/day. Decrease foods high in potassium.
Decrease foods high in potassium.
A drug must enter the bloodstream before it can act within the body. Which parenteral administration route places a drug directly into the circulation, requiring no absorption? Intradermal I.M. I.V. Subcutaneous (subQ)
I.V.
When caring for a client with a central venous line, which nursing actions should be implemented in the plan of care for chemotherapy administration? Select all that apply. Inspect the insertion site for swelling, erythema, or drainage. Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present. Contact the health care provider about verifying placement if the status is questionable. Verify patency of the line by the presence of a blood return at regular intervals. If unable to aspirate blood, reposition the client and encourage the client to cough.
Inspect the insertion site for swelling, erythema, or drainage. Contact the health care provider about verifying placement if the status is questionable. Verify patency of the line by the presence of a blood return at regular intervals. If unable to aspirate blood, reposition the client and encourage the client to cough.
Which serum electrolytes findings should the nurse expect to find in an infant with persistent vomiting? K+, 3.2; Cl-, 92; Na+, 120 K+, 3.4; Cl-, 120; Na+, 140 K+, 3.5; Cl-, 90; Na+, 145 K+, 5.5; Cl-, 110; Na+, 130
K+, 3.2; Cl-, 92; Na+, 120
A client is scheduled for an ileostomy. Which would be most helpful in preparing the client psychologically for the surgery? Invite a member of the ostomy association to visit the client. Encourage the client to ask questions about managing an ileostomy. Provide a brief, thorough explanation of all preoperative and postoperative procedures. Include family members in preoperative teaching sessions.
Provide a brief, thorough explanation of all preoperative and postoperative procedures
A week ago, a tornado destroyed the client's home and seriously injured her husband. The client has been walking around the hospital in a daze without any outward display of emotions. She tells the nurse that she feels like she is going crazy. Which intervention should the nurse use first? Explain the effects of stress on the mind and body. Reassure the client that her feelings are typical reactions to serious trauma. Reassure the client that her symptoms are temporary. Acknowledge the unfairness of the client's situation.
Reassure the client that her feelings are typical reactions to serious trauma
A client is receiving TPN administered through a central line. What should the nurse do to prevent complications associated with this infusion? Keep the client on strict bed rest. Cover the insertion site with a moisture-proof dressing. Secure all connections of the system. Use aseptic technique for dressing changes.
Secure all connections of the system.
The nurse finds an unopened bag of IV 50% dextrose in a sink on the nursing unit. What should the nurse do with the IV bag? Send it to the pharmacy. Discard it in a sharps container. File an incident report. Leave it where found and notify the charge nurse.
Send it to the pharmacy.
A client expresses to the nurse that they cannot get the mental support needed to prepare to undergo treatment for leukemia. Which nursing diagnosis is most appropriate for the client? Disturbed body image Anxiety Spiritual distress Ineffective coping
Spiritual distress
While collecting data from a client diagnosed with impulse-control disorder (and who displays violent, aggressive, and assaultive behavior), the nurse can expect to find which of the following? Select all that apply. The degree of aggression is disproportionate to the stressor. The client often uses a stressor to justify violent behavior. The client functions well in other areas of life. The client shows no remorse about the inability to control behavior. The client has a history of parental substance abuse or a chaotic, abusive family life.
The degree of aggression is disproportionate to the stressor. The client often uses a stressor to justify violent behavior. The client has a history of parental substance abuse or a chaotic, abusive family life.
A pregnant client in her third trimester asks why she needs to urinate frequently again, as she did during the first trimester. What should the nurse tell her? This symptom is a normal variation and is easily managed by limiting fluid intake. This symptom is abnormal and should subside after the presenting part of the fetus is engaged. This symptom is normal and results from the fetus exerting pressure on the bladder. This symptom is abnormal during the third trimester and may indicate a urinary tract infection.
This symptom is normal and results from the fetus exerting pressure on the bladder.
A client has a serum calcium level of 7.2 mg/dl (1.8 mmol/L). During the physical examination, the nurse expects to assess Homans' sign. Trousseau's sign. Goodell's sign. Hegar's sign.
Trousseau's sign
A client developed cardiogenic shock after a severe myocardial infarction and has now developed acute renal failure. The client's family asks the nurse why the client has developed acute renal failure. What should the nurse tell the family?Because of the cardiogenic shock, there is: an obstruction of urine flow from the kidneys. a decrease in the blood flow through the kidneys. a blood clot that formed in the kidneys. structural damage to the kidney.
a decrease in the blood flow through the kidneys.
Which finding is a risk factor for hypovolemic shock? gram-negative bacteria antigen-antibody reaction vasodilation hemorrhage
hemorrhage