Saving Grace 1

A client who had a small bowel resection acquired methicillin-resistant staphylococcus aureus (MRSA) while hospitalized. He treated and released but is readmitted today because of diarrhea and dehydration. It si important for the nurse to implement which intervention?

Maintain contact transmission precautions

The nurse notes the client receiving heparin infusion labeled, Heparin Na 25,000 Units in 5% Dextrose injection 500 ml at 50ml/hr. What dose of Heparin is the client receiving per hour?

2,500 units

An unlicensed assistant personnel UAP leaves the unit without notifying the staff. In what order should the unit manager implement this intervention to address the UAPs behavior?

Discuss the issue privately with UAP.

The nurse mixes 250 mg of debutamine in 250ml of D5W and plans to administer the solution at rate 15mcg/kg/minute a client weighing 110 pounds. The nurse should set the infusion pump to administer how many ml per hour only. If rounding is required, round to the nearest whole number.)

45 ml

An older adult client admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CVA). Which intervention should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.)

Measure neurological vital signs every 4hours
Encourage family to participate in the client's care
Play classical music in room while client is awake

The nurse should expect a client diagnosis with regional enteritis (Crohn's disease) to exhibit what initial symptoms?

Diarrhea, abdominal pain, and weight loss

The nurse is planning to assess a client's oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client has a bilateral below-the-knee amputation and pedal pulses that are weak and threaty. What action should the nurse take?

Place the oximeter clip on the ear lobe to obtain the oxygen saturation reading.

A client is receiving lactulose (Portalac) for signs of hepatic encephalopathy. to evaluate the client's therapeutic response to this medication, which assessment should the nurse obtain?

Level of consciousness (LOC)

While changing a client's chest tube dressing, the nurse notes a crackling sensation when gentle pressure is applied to the skin at the insertion site. What is the best action fo the nurse to take?

Measure the area of swelling and crackling.

During discharge teaching, the nurse discusses the parameters for weight monitoring awith a client who was recently diagnossed with heart failure (HF). Which information is most important for the client to acknowlege?

Report weight gain of 2 pounds (0.9kg) in 24 hours

Which intervention should the nurse implement during the administration of vesicant chemotherapeutic agent via an IV site in the client's arm?

Assess IV site frequently for signs of extravasation

A client is being discharged home after being treated for heart failure (HF). What instructions should the nurse include in this client's discharge teaching plan?

Weigh every morning

An older adult male is admitted with complications to chronic obstructive pulmonary disease (COPD). He reports progressive dyspnea that worsens on exertion and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide?

Restrict daily fluid intake

An older male client arrives at the clinic complaining that his bladder always feels full. He complains of weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating his urine system. Which action should the nurse implement?

Palpate the client's suprapubic area for distention

The nurse is preparing an older client for discharge following cataract extraction. Which instruction should be include in the discharge teaching?

Avoid straining at stool, bending, or lifting heavy objects

A client with osteoporosis related to long-term corticosteroid therapy receives a prescription for calcium carbonate. Which client's serum laboratory values requires intervention by the nurse?

Creatine 4mg/dl (354 micromol/L SI)

After receiving report, the nurse can most safely plan to asess which client last? the client with....

No postoperative drainage in the Jackson-Pratt drain with the bulb compressed.

A female nurse who took drugs from the unit for personal use was temporarily released from duty. After completion of mandatory counseling, the nurse has asked administration to allow her to return to work. When the nurse with the impaired nurse request, which action is best for the charge nurse to take?

Allow the impaired nurse to return to work and monitor medication administration

The nurse is teaching a male adolescent recently diagnosed with type 1 diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate the effectiveness of the teaching?

Observe his as he demonstrates self-injection techniques in another diabetic adolescent

The nurse is assessing a postpartum client who is 36 hours post-delivery. Which finding should the nurse report to the healthcare provider?

Oral temperature of 100.6 F

An insulin infusion for a client with diabetes mellitus who is experiencing hyperglycemic hyperosmolar in addition to the client's glucose, which laboratory value is most important for the nurse to monitor?

Serum portassium

The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse report to the health care provider?

Elevated liver function test\`

Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma?

Intravenous administration of thyroid hormones

While assessing a client's chest tube (CT), the nurse discovers bubbling in the water seal chamber of the chest tube collection device. The client's vital signs are: blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32 breaths/minute, oxygen saturation 88%. Which interventions should the nurse implement? (Select all that apply)

-Provide supplemental oxygen
-Auscultate bilateral lung fields
-Reinforce occlusive CT dressing

The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts?

Begin to show signs of improvement in affect

The RN is assigned to care for four surgical clients. After receiving report, which should the nurse see first? The client who is....

Three days postoperative colon resection receiving transfusion of packed RBCs.

The nurse ends the assessment of a client by performing a mental status exam. Which statement correctly describes the purpose of the mental status exam?'s

Evaluate the client's mood, cognition and orientation

The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection?

Moderate amount of foul-smelling lochia

The home health nurse is assessing a male client who has started peritoneal dialysis (PD) 5 days ago. Which assessment finding warrants immediate intervention by the nurse?

Orthopnea

A client with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client's laboratory values include; sodium 129 mEq/l (129mmol/l SI), glucose 54 mg/dl (2.97mmol/l SI) and potassium 5.3 mmol/l SI). When reporting the findings to the HCP, the nurse anticipates a prescription for which intravenous medications?

Hydrocortisone

A young adult female with chronic kidney disease (CKD) due to recurring pyelonephritis is hospitalized with basilar crackles and peripheral edema. She is complaining of severe nausea and the cardiac monitor indicates sinus tachycardia with frequent premature ventricular contraction. Her blood pressure is 200/110 mm Hg, and her temperature is 101 F which PRN medication should the nurse administers first?

Furosemide

A child with heart failure (HF) is taking digitalis. Which signs indicates to the nurse that the child may be experiencing digitalis toxicity?

Vomiting

A client is admitted to a mental health unit after attempting suicide by taking a handful of medications. In developing a plan of care for the client, which goal has the highest priority?

Signs a no self-harm contract.

The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. Which client with which change in status is best to assign to the PN?

Viral meningitis whose temperature changed from 101 F (38.3 C) to 102 F (38.9C).

A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely?

Hypokalemia

What intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an IV site in the client's arm?

Assess IV site frequently for signs of extravasation

When preparing a client for a discharge from the hospital a cystectomy and urinary diversion to treat bladder cancer, which instruction is most important for the nurse to include in the client's discharge teaching plan?

Report any signs of cloudy urine output.

A male client approaches the nurse with an angry expression on his face and raises his voice, saying, "My roommate is the most selfish, self-centered, angry person I have ever met. If the loses his temper one more time with me, I am going to punch him out" The nurse recognizes that the client is using which defense mechanism?

Projection

An older male client arrives at the clinic complaining that his bladder always feels full. He complains of a weak urine flow frequent dribbling after voiding and increasing nocturia with difficulty initiating his urine stream action. What should the nurse implement?

Palpate the client's suprapubic area for distention

A client with pneumonia has arterial blood gases levels at: pH 7.33, PaCO2 49 mm/Hg, HC03 25 mEq/L, PaO2 95. What intervention should the nurse implement based on these results?

Institute coughing and deep breathing protocols

Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD)

Mental status

The mother of a school age child calls the school to ask when her daughter can return to school after treatment for Pediculosis capitis. What is the nurse's best response?

After the treatment kills all the live lice

When assessing a client with acute asthma, the nurse is most likely to obtain which finding?

Cough and musical breath sound on expiration

Which intervention should the nurse include in the plan of care for a patient with tetanus?

Minimize the amount of stimuli in the room

Following morning care, a client with C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implement first?

Relieve any kinks or obstruction in the client's Foley tubin

The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. What action should the nurse implement immediately?

Test fluid on the dressing for glucose

After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?

Ask the client about gastrointestinal pain

A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client's plan of care?

Observe for bleeding side effects related to heparin therapy

What is the primary focus of postoperative nursing care for the client with colon trauma?

Observation for and prevention of fistulas

After years of struggling with weight management, a middle-aged man is evaluated for gastroplasty. He has experienced difficulty with managing his diabetes mellitus and hypertension, but has it's been approved for surgery. Which intervention is most important for the nurse to include in this client plan of care?

Apply sequential compression stockings

After receiving report on an inpatient acute care unit, which client should the nurse assess first?

The client with bowel obstruction due to a volvulus who is experiencing abdominal rigidity

A continuous infusion of nitroglycerin is prescribed for an adult male admitted with an acute myocardial infarction. The client is experiencing active chest pain that he describes as 8 out of 10. Which intervention is most important for the nurse to implement?

Administer infusion via an infusion pump

The nurse is caring for a client with a tracheostomy. Which action should the nurse perform when suctioning the tracheostomy tube?

Insert the suction catheter into the trachea, and apply intermittent suction with removal catheter.

The nurse is preparing to administer suspension ampicillin labeled, 250mg/5ml, to a 12 year old child with impetigo. The prescription is for 500 mg QID. How many ml shoud the child receive per day?

40 ml

A client with a severe prostatic infection that caused a blocked urethra is 3 days post-surgical urinary diversion. The healthcare provider directs the nurse to remove the suprapubic catheter to allow the client to void normally. Which intervention should the nurse implement first?

Clamp catheter until a client voids naturally

A client morning assessment incudes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for the nurse to include in this client's plan of care?

Administer prescribed diuretic

In preparing a nursing care plan for a client admitted with a diagnosis of Fuillain- Barre syndrome, which nursing problem has the highest priority?

Ineffective breathing pattern related to ascending paralysis.

A client is admitted with the diagnosis of Wernicke's syndrome. What assessment finding should the nurse use in planning the client's care?

Confusion

A client with complaints of shortness of breath and abdominal pain 1 week after bariatric surgery is admitted for follow-up evaluation. Which assessment finding warrants immediate intervention by the nurse?

Blood pressure of 88/50 mmHg

A client with prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement?

The client's need for pain medication should be determined

An older male client is admitted to the mental health unit with a sudden onset of global disorientation and is continuously conversing with his mother, who died 50 years ago. The nurse reviews the multiple prescriptions the client is currently taking and assesses his urine specimen, which is cloudy, dark yellow, and has a foul odor. These findings suggest that this client is experiencing which condition?

Delirium

While changing the pressure ulcer dressing of a client who is immobile, the nurse notes that the boundary edges of the wound have increased. Before reporting this finding to the healthcare provider, the nurse should review which of the client's serum laboratory values?

Albumin

A nurse assesses a client whose hand begins to spasm when the blood pressure cuff is inflated. The client complains of paresthesia in the fingers and toes. Which serum laboratory finding should the nurse expect to find?

Low serum calcium

The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse repond?

Encourage the parents to allow the child to continue attending swimming lesson with supervision.

In performing the admission assessment for a client experiencing complications of long-term Parkinson's disease, which question by the nurse provides the best information about disease progression?

"Have you ever been frozen to a spot and unable to move?"

After successful resuscitation, a client is given propranolol and transferred to the intensive Coronary Care Unit (ICCU). ON admission, magnesium sulfate 4 grams IV in 250 ml D5 W at one gram/hour. Which assessment findings require immediate intervention by the nurse?

Respiratory rate of 10 breaths per minute and pulse oximetry of 90%.

After receiving the morning report at 0700 on a postpartum unit, which client should the nurse assess first? The client who is...

Complaining of IV site pain whose IV antibiotic is due at 0800.

The nurse observes unlicensed assistive personnel (UAP) applying an alcohol-based hand rub while leaving a client's room after taking vital signs. What action should the nurse take?

Remind the UAP to continue rubbing the hands together until they dry.

While transferring a client with a chest tube from the bed to a stretcher, the chest becomes disconnected from the water-seal drainage container. The nurse immediately immerses the end of the tube in a container of sterile water. What action should the nurse implement next?

Prepare a new water seal system and reattach the chest tube.

The nurse is performing a peritoneal dialysis exchange on a client with chronic kidney disease (CKD). Which assessment finding should the nurse report ot the healthcare provider?

The appearance of the returning dialysate fluid is cloudy.

In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths/minute. What action should the nurse implement?

Document the assessment data

One week after an above-the-knee-amputation (AKA) of the left leg, a male client seems upset and reports that his left foot fells "numb". What action should the nurse implement?

Assess wound for signs of inflammation of drainage.

The nurse is preparing to administer 1.6 ml of medication IM to a 4 month old infant. Which action should the nurse include?

Divide the medication into two injections with volumes under 1ml.

A male client with diabetes-mellitus type 2, who is taking pioglitazone PO daily, reports to the nurse the recent onset of nausea, accompanied by dark-colored urine, and a yellowish cast to his skin. What instructions should the nurse provide?

"You need to seek immediate medical assistance to evaluate the cause of these symptoms".

An older client is referred to a rehabilitation facility following a cerebrovascular accident (CVA). The client is aphasic with left-sided paresis and having difficulty swallowing. Which intervention is most important to include in the client's plan of care?

Facilitate a consultation for speech therapy

When assessing a multigravida, the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreaths above the umbilicus. What action should the nurse implement first?

Check for a destined bladder.

The nurse is assigning care of a client with prostatitis to a practical nurse (PN). What instruction should the nurse provide the PN regarding care of this client?

Avoid urinary catherization.

A male client with a history of heavy alcohol intake is admitted with acute pancreatitis. The client reports severe abdominal pain, radiating to the back. IN positioning the client, which instruction should the nurse provide the unlicensed assistive personnel (UAP)?

Assist client to his side with his knees bent to his chest.

The healthcare provider prescribes amoxicillin 1.5 grams PO daily, in equally divided doses to be administered every 8 hours. The medication is available in a bottle labeled. "Amoxicillin suspension 200mg/5ml." How many ml should the nurse administer every 8 hours?

37.5

A male client notifies the nurse that he feels short of breath and has chest pressure radiating down his left arm. A STAT 12-lead electrocardiogram (ECG) is obtained and shows ST segment elevation in leads ll, ll, aVF, and V4R. The nurse collects blood samples and gives a normal saline bolus. What action is most important for the nurse to implement?

Assess for contraindications for thrombolytic therapy.

A client with rapid respirations and audible rhonchi is admitted to the intensive care unit because of a pulmonary embolism (PE). Low-flow oxygen by nasal cannula and weight-based heparin protocol is initiated. Which intervention is most important for the nurse to include in this client's plan of care?

Evaluate daily blood clotting factors.

The nurse enters a client's room to administer scheduled daily medications and observes the client leaning forward and using pursed lip breathing. Which action is most important for the nurse to implement first?

Evaluate the oxygen saturation.

The healthcare provider prescribes a low-dose heparin protocol at 18 units/kg/hr. For a client with a possible pulmonary embolism. This client weighs 144 pounds. The available solution is labeled, Heparin Sodium 25,000 units in 5% dextrose 250ml. the nurse should program the pump to deliver how many ml/hr?

12 ml

The nurse is caring for a client who arrives to the emergency department with reports of dizziness and difficulty walking to the bathroom The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action?

Start two large-bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.

Dopamine 5mcg/kg/minute IV is prescribed for a client who weighs 132. The pharmacy dispensed a 500mL IV solution of 0.95 normal saline with 1500 mg. The nurse should prepare the infusion pump to deliver how may mL/hour?

5.6 mL/hr

A client who is hypotensive is receiving dopamine, an adrenergic agonist IV at eh rate of 8mcg/kg. Which intervention should the nurse implement with assessing the medication?

Initiate seizure precaution.

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

Watery diarrhea

When is it important for the nurse to assess a pregnant client's deep tension reflexes (DTRs)?

If the client has an elevated blood pressure.

A male client reports to the on-call clinic nurse that he took Tadalaf 10mg by mouth two hours ago and his skin now feels flushed. He reports a history of cardiac angina, but denies experiencing any chest pain. Which action should the nurse take?

Tell the client to have someone bring him to an emergency department immediately.

A client is receiving continuous ambulatory peritoneal dialysis since the arteriovenous (AV) graft in the right arm is no longer available to use for hemodialysis. The client has lost weight, has increasing peripheral edema, and has a serum albumin level of 1.5 g/dL (15g/L). Which intervention is the priority for the nurse to implement?

Ensure the client receives frequent small meals containing complete proteins.

A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin 500mg PO twice daily. Which information should the nurse include in the client's teaching plan?

-Recognizing signs and symptoms of hypoglycemia.
-Take metformin with the morning and evening meal
-Report persistent polyuria to the healthcare provider.

A 6 -week-old infant with pyloric stenosis is scheduled for a pylonmyectomy. Which pre-operative nursing action has highest priority?

Initiate a continuous infusion of IV fluids per prescription.

Which environmental factor is most significant when planning care for a client with osteomalacia?

Adequate sunlight

A client with pancreatitis complains of severe epigastric pain. sot eh nurse administers a prescribed narcotic analgesic. Ten minutes late, the client insists on sitting up and leaning forward. Which intervention should the nurse implement?

Position bedside table so the client can lean across it.

An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full-thickness burns to all surfaces of both lower extremities Which percentage of body surface area should the nurse document in the electronic medical record (EMR)?

36%

The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection indicate to the nurse the client understands the prescribed diet?

Roasted turkey, canned vegetables

Five days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspects that the client may have a pulmonary embolism. Which action should the nurse take first?

Provide supplemental oxygen.

An adult male client reports that he recently experienced an episode of chest pressure and breathlessness when he goes jogging. The client expresses concern because both of his parents had heart disease and his father had diabetes. He lives with his male partner, is a vegetarian, and takes steroid which maintains his blood pressure at 130/84 mm Hg. Which of the following should the nurse explore further with the client? (Select all that apply)

-History of hypertension
-Family health history

What action should the school nurse implement to provide secondary prevention for school-aged children?

Initiate a hearing and vision screening program for first graders.

A client is admitted to the hospital after experiencing a stroke or cerebral vascular accident (CVA). The nurse should request a referral speech therapy if the client exhibits which finding?

Persistent coughing while drinking.