NURS 125 MONDAY CLINICAL JUDGMENT
For which assessment finding will the nurse intervene first when providing postoperative care to a patient who returned to the nursing unit 2 hours after receiving succinylcholine?
Temperature 40 degrees C (104 degrees F)
A parent calls the clinic to report their 9-month-old infant has had 5 soft to loose stools today, has a decreased appetite, but is alert and playing. Which advice is most appropriate for the nurse to give the parent?
"Continue your infant's normal feedings."
A client is receiving anakinra as treatment for arthritis. The nurse understands that this drug acts in which manner?
Blocks interleukin-1
Prior to administering an opioid prescribed for pain management, the nurse assesses the client using the Pasero Opioid-Induced Sedation Scale (POSS) (see chart). The nurse assigns a score of 3 based on assessment criteria for the scale. What should the nurse do next?
Contact the health care provider (HCP) to request a decreased dose of the medication.
For which client would the use of standard precautions alone be appropriate?
an incontinent client in a nursing home who has diarrhea
What should a nurse recognize as a property of ibuprofen/Motrin? (Select all that apply.)
Analgesic Anti-inflammatory Antipyretic
The patient is being prescribed epoetin alfa for the treatment of anemia related to the renal failure. The patient also has a history of diabetes mellitus, uncontrolled hypertension, osteoarthritis, and hypothyroidism. Which of these conditions should the nurse bring to the physician's attention prior to administering the medication?
Uncontrolled hypertension
Before a transesophageal echocardiogram, a nurse gives a client an oral topical anesthetic spray. When the client returns from the procedure, the nurse observes that the client has no active gag reflex. What is the next action by the nurse?
Withhold food and fluids.
The nurse knows that acetaminophen should not be used in older adults with which condition?
cirrhosis
What is the nursing diagnosis the framework for?
nursing interventions
The client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. The nurse monitors blood chemistry test results and urinary output for
renal complications related to acyclovir therapy.
crawling or sitting with support. How should the nurse respond?
"This is a concern. Let's be sure the physician is aware of this change
The nurse cares for a client who receives continuous parenteral nutrition (PN) through a Hickman catheter and notices that the client's solution has run out. No PN solution is currently available from the pharmacy. What should the nurse do?
hang 10% dextrose and water
A mental health nurse is interviewing a child for suspected abuse. The parent states that the child is having disciplinary problems at school and stutters when approached. From the listed behavioral indicators, the nurse would suspect which type of abuse?
Emotional
An oncology nurse is caring for a client who relates that certain tastes have changed. The client states that "meat tastes bad." What nursing intervention can be used to increase protein intake for a client with taste changes?
Encourage eating cheese, eggs, and legumes
to administer morphine sulfate 4 mg I.V. What is available is morphine sulfate 10 mg/mL. How many mL will the nurse need to administer? Round to the nearest tenth
0.4
husband yesterday. The practitioner observes the client for which of the following?
Dysrhythmias
Ms. Quinn is admitted to the surgical intensive care unit after open heart surgery. The health care provider prescribes IV nitroglycerin, according to a hospital protocol for titration of the drug. Which factor would be most important when determining increases or decreases in the dose?
Current blood pressure
A client with Parkinson disease who is scheduled for physiotherapy is experiencing nausea and weakness. What is the most appropriate action by the nurse?
Assess the nausea and weakness, and call physiotherapy to cancel or reschedule the appointment.
fistula are cold to the touch and the capillary refill time is greater than 3 seconds. What is the priority action by the nurse?
Contact the healthcare provider.
An older adult client is admitted with polyuria, severe constipation, significant postural hypotension, and showing signs of alkalosis. While awaiting the lab results, what action by the nurse would be most appropriate?
Facilitate a STAT ECG.
The nurse is completing an initial assessment on an elderly client with impaired mobility. When asked about urinary patterns, the client states, "I can never get to the bathroom in time." The nurse documents this as which type of incontinence?
Functional incontinence
The nurse is caring for a client with a history of renal insufficiency and type 2 diabetes. Which prescription, if noted in the client's chart, would alert the nurse to discuss with the health care practitioner?
Gentamicin 70 mg intramuscular (IM) every 8 hours
The nurse is performing the history and physical examination on a client who is being admitted for anorexia nervosa. The client, a 23-year-old, is 5 feet 2 inches, and weighs 88 pounds. The nurse assesses the client's history of weight gain and loss, typical daily food intake, electrolyte and other blood studies, and elimination patterns. The nurse observes typical physical findings such as dry skin, lanugo, and brittle hair and nails. Which factor is a priority for the nurse to assess next?
Heart rate and rhythm
A nurse practitioner (NP) orders an antibiotic to which the client is allergic. The nurse preparing the medication notices the allergy alert and contacts the NP by phone. The NP does not return the call and the first dose is due to be given. Which action by the nurse is the best solution?
Hold the medication until speaking with the NP
A nurse is caring for a patient who is being administered penicillin. What are the common adverse reactions to penicillin a nurse should assess for?
Inflammation of the tongue and mouth
Which action will the nurse include in the plan of care for a client admitted with acute decompensated heart failure (ADHF) who is receiving milrinone?
Monitor blood pressure frequently
A client with acquired immune deficiency syndrome (AIDS) is exhibiting shortness of breath, cough, and fever. What type of infection will the nurse most likely suspect?
Pneumocystis jiroveci
An 80-year-old woman is receiving treatment with oral fluconazole for a fungal infection Following yesterday's and today's dose, she reports an upset stomach to the charge nurse. How should the nurse at the facility best respond to the woman's report?
Provide food along with the fluconazole when administering it in the future.
A client comes into the emergency department with severe back pain radiating to the left lower groin. The healthcare provider prescribes morphine sulfate 5-10 mg IV every 2 hours. One hour after receiving 10 mg of morphine, the client is restless and distressed, reporting the pain is still at 8 of 10. What action will the nurse take?
Reassess the client's pain and associated symptoms, and report findings to the healthcare provider to advocate for better pain control.
The mother of a 9-month-old child reports her child's eyes are often crossed. The nurse confirms this during the examination. What action is indicated?
Report the findings to the physician.
A client with type I diabetes is learning how to inject themselves with insulin. Place the steps for self-injection of insulin in order. All options must be used.
Stabilize the skin with one hand. Pick up the syringe with the other hand. Insert the needle straight into the skin. Push the plunger all the way into the skin. Pull the needle out of the skin. Press cotton ball over injection site for several seconds
A patient is prescribed daily doses of phenytoin for seizures. The nurse knows that a single dose should not be missed during the course of treatment. Which condition could result if a dose is missed?
Status epilepticus
A 33-year-old male client returns to the medical-surgical unit following a thyroidectomy. Which assessment finding requires an immediate intervention by the nurse?
The client makes noises when he breathes.
The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel?
The client with continuous pulse oximetry who requires pharyngeal suctioning.
The home care nurse visited a newly assigned primigravida client with preeclampsia. When conducting the assessment and teaching, the client continued to cry and state she was in disbelief this was happening to her. When should the nurse schedule the second visit with the client?
The next day; the client is not coping well.
The patient has just received a central venous catheter placed by the physician. Which of the following should the nurse anticipate next?
The patient will have an X-ray to confirm placement of the device.
A nurse is providing care for a patient who suffered extensive burns to the extremities during a recent industrial accident. Topical lidocaine gel has been ordered to be applied to the surfaces of all the burns in order to achieve adequate pain control. When considering this order, the nurse should be aware that:
there is a risk of systemic absorption of the lidocaine through the patient's traumatized skin.
Just prior to administering lorazepam 2 mg I.V. to an agitated client, the client knocks the medication to the floor. After retrieving the medication, what is the best action by the nurse?
Ask another nurse to witness the waste of the medication.
A nurse provides evening care for a client wearing a continuous telemetry monitor. While the nurse is giving the client a back rub, the client 's monitor alarm sounds and the nurse notes a flat line on the bedside monitor system. What is the nurse's first response?
Assess the client and monitor leads.
