A nurse is caring for a client who has a potassium level of 5.4 mEq\L. The nurse should assess the client for?
A) Hypotension
B)
... [Show More] Polyuria
C)Constipation
D)ECG changes
ECG changes
A nurse is implementing a bladder training program. Which of the following actions by the assistive personnel who is assisting in the clients care indicates a need for further instruction?
A) assist the client to the bathroom every two hours
B) encourages oral fluid, intake during waking hours
C) offers the opportunity to void 15 mins before bathing
D) instructs the client to void whenever the urge occurs
instructs the client to void whenever the urge occurs
A nurse is caring for an older adult client who is Asian and is recovering from a bowel obstruction. The client is on a clear liquid diet and asks the nurse for a cup of hot Ginger tea. The nurse should recognize that this request is?
A)contraindicated for this clients diet prescription
B) A traditional ethnic remedy
C) intended to promote sleep
D) cleanse the body
A traditional ethnic remedy
A nurse is calculating a clients intake and output during the shift. The client's intake includes 1000 ml normal saline, one cup of coffee, 6 oz of water, 1 bowel of soup, 3 oz of flavored Gelatin and 3 oz of ice cream.
1780 ml
A nurse if preparing a sterile field. Which of the following actions should the nurse perform first?
A) grasp outer edge of inner most flap and lay it on the table
B) center the sterile pack on the work surface
C) open outer most flap away from the body while arm is outstretched
D) Grasp side flap by outer edge and lay on the table
Center the sterile pack on the work surface
A nurse is creating a plan of care for a client who is receiving enteral feedings via a gastrotomy tube. Which of the following is the first action the nurse should take when administering enteral feedings?
A) aspirate and measure stomach contents
B) administer the bolus feeding
C) elevate the head of bed at least 30 degrees
D) warm the feeding to room temperature
Elevate the head of the bed at least 30 degree
A nurse is caring for a toddler in contact isolation. Which of the following is an appropriate toy to offer the toddler?
A) plush stuffed animal
B) Chapter book
C) plastic building blocks
D) puzzle
plastic building blocks
A nurse if removing an isolation gown. After caring for a client who requires contact precautions. Which of the following steps should the nurse take to properly remove the isolation gown that has ties in the front?
A) untie the neck strings, remove gloves and until waist strings
B) untie front waist strings, remove gloves and untie neck ties
C) remove gloves, wash hands, untie waist
D) remove gloves, untie neck strings, untie waist strings
untie waist strings, remove gloves, untie neck ties
A nurse is developing a plan of care for a client who has an ileostomy and application of stoma bag care. Based on the nurses understanding, which of the following are appropriate concepts.
A) facilitate ring adhesion with pectin flange
B) apply an aspirin to decrease odor
C) limit the use of skin barriers
D) expect firm fecal content
facilitate ring adhesion with pectin flange
A nurse is preparing to exit the room of a client who has a draining wound infected with MRSA and requires contact isolation precautions. identify the sequence the nurse should follow to remove PPE.
remove gloves
remove protective eyewear
remove gown
remove mask
perform hand hygiene
A nurse is caring for a client following the surgical placement of a colostomy. Which of the following statements indicates the client understands the dietary teaching?
A) eating yogurt can help decrease the amount of gas
B) I should eliminate pasta from my diet so that I don't have many loose stools
C) My largest meal of the day should be in the evening
D) carbonated beverages can help control odor
eating yogurt can help decrease the amount of gas
A client who is taking nitrofurantoin (Macrodantin) for a UTI voices a concern to the clinic nurse about voiding brown colored urine. Which of the following is an appropriate response by the nurse?
A) drinking more fluid will prevent your urine from becoming brown
B) the provider will change your medication because your infection is not resolving with the nitrofurantoin
C) an increase of RBC destruction in your blood can result in brown colored urine
D) brown colored urine is a harmless side effect of the medication.
brown colored urine is a harmless side effect of the medication
Stem: a nurse in a provider's office is re-enforcing teaching for a client who is to collect a 24 hour specimen. Which of the following should the nurse include in the instructions?
A) at the beginning of the collection time, void and discard the urine
B) at the beginning of the collection time, void and save the urine
C) at the end of the collection time, void and discard the urine
D) at the end of the collection time, void and save the urine in a separate container.
at the beginning of the collection time, void and discard the urine
A client has not voided for 8 hours following the removal of an indwelling bladder catheter. Which of the following should be the nurse's priority action?
A) increase fluids
B) perform bladder scan
C) place indwelling catheter
D) provide assistance to the bathroom
perform bladder scan
A nurse is caring for a client who is one day post operative following a transurethral resection of the prostate (TURP) and has a continuous bladder irrigation in place. Which of the following are appropriate nursing actions.
add the amount of bladder irrigation to the total output
-use sterile technique when preparing the irrigation solution
-ensure the drainage tubing is patent and without obstruction
-contact the surgeon if the client reports the continual need to void
-notify the surgeon if the urine is bright red in appearance or has large clots
-use sterile technique when preparing the irrigation solution
-ensure the drainage tubing is patent and without obstruction
-notify the surgeon if the urine is bright red in appearance or has large clots
A nurse is caring for an older adult client who was admitted to the hospital with confusion and weakness. Based on the client's laboratory findings which of the following actions should the nurse take? Select all that apply. Hematocrit 53%, BUN at 25 mg / dl, urine specific gravity at 1.032
-restrict fluid intake
- monitor I & O
- weigh client daily
-instruct the client to sit on the side of the bed for a few mins before standing
- check orientation to person, place and time regularly
-monitor I & O
- weigh client daily
-instruct the client to sit on the side of the bed for a few mins before standing
- check orientation to person, place and time regularly
A 0900 the nurse begins the care of a patient who has just been transferred from the post anesthesia care unit. The patient has a new liter of D5\0.9 % NS infusing at 125 ml\per hour. The client has an indwelling urinary catheter with continuous bladder irrigation of NS infusing at 75 ml per hour, to keep the catheter free of clots. At 1500 the nurse empties 1575 ml from the urinary catheter. Consider the patient's I & O starting at 0900 and ending at 1500 and calculate the number of positive or negative mL.
375 ml [Show Less]