question

The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the nurse administer?

answer

0.5 ml.

question

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?

answer

After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.

question

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?

answer

Give the missed dose at 1300 and change the schedule to administer daily at 1300.

question

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?

answer

Give an around-the-clock schedule for administration of analgesics.

question

After completing an assessment and determining that a client has a problem, which action should the nurse perform next?

answer

determine the etiology of the problem

question

What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults?

answer

A decreased flow rate could result in the formation of a thrombosis.

question

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?

answer

Continue asking the mother questions about the child.

question

Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention?

answer

Assess for bladder distention.

question

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?

answer

Blood transfusions are forbidden.

question

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?

answer

Acknowledge that she is supporting the arm correctly.

question

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?

answer

Fowler's.

question

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?

answer

It is important that you continue your medication while learning to meditate.

question

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?

answer

150

question

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?

answer

Frontal lobe

question

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?

answer

Initiate an alternate site for the IV infusion of the medication.

question

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?

answer

Request and document the name of the certified translator.

question

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?

answer

Place a pillow between your knees while lying in bed to prevent hip dislocation.

question

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?

answer

Notify the healthcare provider of the family's request.

question

A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first?

answer

Nutritional history.

question

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?

answer

21

question

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?

answer

Instruct the client that the stoma will become smaller when the initial swelling diminishes.

question

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?

answer

1.5ml

question

Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube?

answer

Examining a chest x-ray obtained after the tubing was inserted.

question

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?

answer

124 gtt/min.

question

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?

answer

It is OK if you don't want to talk about your surgery. I will be available when you are ready.

question

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?

answer

Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter.

question

The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan?

answer

Avoid any types of sprays, powders, and perfumes.

question

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?

answer

Assist the ambulating client back to the bed.

question

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?

answer

During the inhalation

question

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?

answer

I will limit my intake of beef to 4 ounces per week.

question

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?

answer

Loosen the right wrist restraint.

question

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?

answer

8 a.m., 4 p.m., and midnight.

question

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?

answer

180

question

An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment?

answer

The nurse who transferred the client to the chair when the fall occurred.

question

The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility?

answer

The client voluntarily signed the form.

question

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?

answer

Flush the tube with water.

question

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?

answer

Be sure to have a complete physical examination before beginning your planned exercise program.

question

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

answer

upper torso

question

Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent?

answer

upper arm circumference

question

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?

answer

Degree of flexion and extension of the client's knee joint.

question

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?

answer

What vitamin and mineral supplements do you take?

question

An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care?

answer

Gently lift the client when moving into a desired position.

question

During a physical assessment, a female client begins to cry. Which action is best for the nurse to take?

answer

Acknowledge the client's distress and tell her it is all right to cry.

question

Which action is most important for the nurse to implement when donning sterile gloves?

answer

Keep gloved hands above the elbows.

question

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?

answer

Skim milk, turkey salad, roll, and vanilla ice cream.

question

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?

answer

Reposition in a Sim's position with the client's weight on the anterior ilium.

question

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?

answer

Inquire about the source and type of pain

question

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

answer

demonstrates the wound care procedure correctly.

question

The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP?

answer

Report the results of the vital signs to the nurse.

question

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?

answer

Reassess the client's blood pressure using a larger cuff.

question

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

answer

1½ tablets

question

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?

answer

Ensure the accuracy of the blood type match.

question

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?

answer

Hot remedies restore balance after surgery, which is considered a "cold" condition.

question

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?

answer

Measure the pulse volume and capillary refill distal to the infiltration.

question

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?

answer

Reposition the client on her side

question

The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein?

answer

A lactating woman nursing her 3-day-old infant.

question

In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly

answer

often follows relocation to new surroundings.

question

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?

answer

Observe the appearance of the skin under the ice pack.

question

A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse take?

answer

Commend the client for selecting a high biologic value protein.

question

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?

answer

Many complimentary healing practices can be used in conjunction with conventional practices.

question

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

answer

Fowler's.

question

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?

answer

11,000 units

question

Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status?

answer

Chocolate pudding.

question

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?

answer

Re-oxygenate the client before attempting to suction again.

question

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?

answer

Note which actions were not implemented.

question

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?

answer

Your blood vessels are becoming dilated and removing the heat from the site.

question

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?

answer

is disoriented to place and time.

question

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?

answer

1 tab

question

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?

answer

83 gtt/min.

question

During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement?

answer

Encourage additional oral intake of juices and water

question

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?

answer

Infuse 10 percent dextrose and water at 54 ml/hr.

question

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?

answer

63 ml/hour.

question

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?

answer

Move the chair parallel to the right side of the bed, and stand the client on the right foot.

question

On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse?

answer

) Battery Civil laws protect individual rights and include intentional torts, such as assault (an intentional threat to engage in harmful contact with another) or battery (unwanted touching). Performing any procedure against the client's wishes can potentially poise a legal issue, such as battery (B), even if the procedure is of questionable benefit to the client. (A, C, and D) are not examples against the client's request

question

A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record?

answer

Healthcare provider notified of client's refusal to have blood specimens collected for testing.

question

At the beginning of the shift, the nurse assesses a client who is admitted from the post-anesthesia care unit (PACU). When should the nurse document the client's findings?

answer

Immediately after the assessments are completed.

question

An Arab-American woman, who is a devout traditional Muslim, lives with her married son's family, which includes several adult children and their children. What is the best plan to obtain consent for surgery for this client?

answer

D) Tell the surgeon that the son will decide after explanation of the proposed surgery is provided. Traditional Muslim women live in a patriarchal family where decisions are made by men. Most likely, the son will make the decision for his mother, so

question

Which response by a client with a nursing diagnosis of Spiritual distress, indicates to the nurse that a desired outcome measure has been met?

answer

Accepts that punishment from God is not related to illness Acceptance that she is not being punished by God indicates a desired outcome

question

During shift change report, the nurse receives report that a client has abnormal heart sounds. Which placement of the stethoscope should the nurse use to hear the client's heart sounds?

answer

Use the stethoscope bell over the valvular areas of the anterior chest Abnormal heart sounds are best heard with the bell of the stethoscope, which picks up lower-pitched sounds, that is placed at points on the anterior chest

question

A nurse is preparing to give medications through a nasogastric feeding tube. Which nursing action should prevent complications during administration?

answer

A) Mix each medication individually Medications should be mixed separately (A) to prevent clumping.

question

During the admission interview, which technique is most efficient for the nurse to use when obtaining information about signs and symptoms of a client's primary health problem?

answer

Closed-ended questions Lay descriptors of health problems can be vague and nonspecific. To efficiently obtain specific information, the nurse should use closed-ended questions (C) that focus on common signs and symptoms about a client's health problem

question

An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers?

answer

Rashes in the axillary, groin, and skin fold regions Immobility, constant contact with bed clothing, and excessive heat and moisture in areas where air flow is limited contributes to bacterial and fungal growth, which increases the risk for rashes

question

A client who has been NPO for 3 days is receiving an infusion of D5W 0.45 normal saline (NS) with potassium chloride (KCl) 20 mEq at 83 ml/hour. The client's eight-hour urine output is 400 ml, blood urea nitrogen (BUN) is 15 mg/dl, lungs are clear bilaterally, serum glucose is 120 mg/dl, and the serum potassium is 3.7 mEq/L. Which action is most important for the nurse to implement?

answer

Document in the medical record that these normal findings are expected outcomes The results are all within normal range.(C) No changes are needed.

question

What action should the nurse implement when accessing an implanted infusion port for a client who receives long term IV medications?

answer

Insert a Huber-point needle into the port An implanted infusion port needs to be accessed using a Huber-point needle (B) (non-coring) to be prevent damage to the self-sealing septum of the port.

question

During the daily nursing assessment, a client begins to cry and states that the majority of family and friends have stopped calling and visiting. What action should the nurse take?

answer

Listen and show interest as the client expresses these feelings When a client begins to cry and express feelings, a therapeutic nursing intervention is to listen and show interest as the client expresses feelings

question

The nurse plans to obtain health assessment information from a primary source. Which option is a primary source for the completion of the health assessment?

answer

Client A primary source of information for a health assessment is the client (A). (B, C, and D) are considered secondary sources about the client's health history, but other details, such as subjective data, can only be provided directly from the client.

question

The nurse is using a genogram while conducting a client's health assessment and past medical history. What information should the genogram provide?

answer

Genetic and familial health disorders A genogram that is used during the health assessment process identifies genetic and familial health disorders (A). It may not identify the client's chronic health problems

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