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The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the nurse administer?
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take?
After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement?
Give the missed dose at 1300 and change the schedule to administer daily at 1300.
A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement?
Give an around-the-clock schedule for administration of analgesics.
After completing an assessment and determining that a client has a problem, which action should the nurse perform next?
determine the etiology of the problem
What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults?
A decreased flow rate could result in the formation of a thrombosis.
The nurse notices that the mother of a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take?
Continue asking the mother questions about the child.
Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention?
Assess for bladder distention.
A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs?
Blood transfusions are forbidden.
While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement?
Acknowledge that she is supporting the arm correctly.
An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings?
An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response?
It is important that you continue your medication while learning to meditate.
A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how many ml/hr should the infusion pump be set to deliver the secondary infusion?
The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions?
A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time?
Initiate an alternate site for the IV infusion of the medication.
A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take?
Request and document the name of the certified translator.
A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan?
Place a pillow between your knees while lying in bed to prevent hip dislocation.
An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first?
Notify the healthcare provider of the family's request.
A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first?
The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute?
Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse?
Instruct the client that the stoma will become smaller when the initial swelling diminishes.
The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the nurse administer?
Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube?
Examining a chest x-ray obtained after the tubing was inserted.
The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive?
At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence?
It is OK if you don't want to talk about your surgery. I will be available when you are ready.
Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding?
Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter.
The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan?
Avoid any types of sprays, powders, and perfumes.
A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first?
Assist the ambulating client back to the bed.
The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler?
During the inhalation
The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective?
I will limit my intake of beef to 4 ounces per week.
When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?
Loosen the right wrist restraint.
A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow?
8 a.m., 4 p.m., and midnight.
An IV infusion terbutaline sulfate 5 mg in 500 ml of D5W, is infusing at a rate of 30 mcg/min prescribed for a client in premature labor. How many ml/hr should the nurse set the infusion pump?
An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment?
The nurse who transferred the client to the chair when the fall occurred.
The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility?
The client voluntarily signed the form.
The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next?
Flush the tube with water.
An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide?
Be sure to have a complete physical examination before beginning your planned exercise program.
When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the
Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent?
upper arm circumference
During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure?
Degree of flexion and extension of the client's knee joint.
A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment?
What vitamin and mineral supplements do you take?
An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care?
Gently lift the client when moving into a desired position.
During a physical assessment, a female client begins to cry. Which action is best for the nurse to take?
Acknowledge the client's distress and tell her it is all right to cry.
Which action is most important for the nurse to implement when donning sterile gloves?
Keep gloved hands above the elbows.
The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions?
Skim milk, turkey salad, roll, and vanilla ice cream.
An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP?
Reposition in a Sim's position with the client's weight on the anterior ilium.
An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct?
Inquire about the source and type of pain
A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client
demonstrates the wound care procedure correctly.
The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP?
Report the results of the vital signs to the nurse.
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement?
Reassess the client's blood pressure using a larger cuff.
The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the nurse plan to
A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement?
Ensure the accuracy of the blood type match.
The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior?
Hot remedies restore balance after surgery, which is considered a "cold" condition.
A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications." What initial action is most important for the nurse to take?
Measure the pulse volume and capillary refill distal to the infiltration.
A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first?
Reposition the client on her side
The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein?
A lactating woman nursing her 3-day-old infant.
In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly
often follows relocation to new surroundings.
The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first?
Observe the appearance of the skin under the ice pack.
A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse take?
Commend the client for selecting a high biologic value protein.
When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices?
Many complimentary healing practices can be used in conjunction with conventional practices.
An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The nurse knows that the best position for this client during administration of the feedings is
Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received?
Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status?
The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next?
Re-oxygenate the client before attempting to suction again.
When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action will the nurse implement first?
Note which actions were not implemented.
Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse?
Your blood vessels are becoming dilated and removing the heat from the site.
A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate?
is disoriented to place and time.
Seconal 0.1 gram PRN at bedtime is prescribed to a client for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the nurse plan to administer?
The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min?
During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement?
Encourage additional oral intake of juices and water
The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take?
Infuse 10 percent dextrose and water at 54 ml/hr.
A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump?
The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client?
Move the chair parallel to the right side of the bed, and stand the client on the right foot.
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