A nurse is preparing to administer thrombolytic therapy to a client who had an ischemic stroke. Which of the following is an appropriate nursing
... [Show More] action?
-Start the therapy within 8 hrs. (within 6 hrs.)
-Insert an indwelling urinary catheter after therapy begins
-Monitor blood pressure every 30 minutes during infusion.
-Elevate the head of the bed between 25 and 30 degrees - -Elevate the head of the bed between 25 and 30 degrees
A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching?
-Place hands on the upper abdomen during inhalation.
-Exhale slowly through pursed lips.
-Hold breath about 3 to 5 seconds before exhaling.
-Position the mouthpiece 2.5 cm (1 in) from the mouth - -Hold breath about 3 to 5 seconds before exhaling.
A nurse is assessing a client who is 12 hr. postoperative following a colon resection. Which of the following findings should the nurse report to the surgeon?
-Heart rate 90/mm
-Hgb 8.2 g/dL
-Gastric ph of 3.0
-Absent bowel sounds - -Absent bowel sounds
Recall that bowel sounds are altered in patients with obstruction; absent bowel sounds imply
total obstruction. QSEN: Safety
A nurse is caring for a client who has diabetes insipidus. Which of the following medications should the nurse plan to administer?
-Regular Insulin
-Furosemide
-Desmopressin
-Lithium Carbonate - -Desmopressin
-Teach patients with diabetes insipidus the proper way to self-administer desmopressin orally or by nasal spray.
A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily for 3 years. Which of the following test should the nurse monitor?
-Stool occult blood
-Urine for white blood cells
-Fasting blood glucose
-Serum calcium - -Stool occult blood
A nurse in the emergency department is assessing a client. Which of the following actions should the nurse take first? (Click on the "Exhibit" button for additional information about the
client. There are three tabs that contain separate categories of data.)
-Obtain a sputum sample for culture.
-Prepare the client for a chest x-ray.
-Initiate airborne precautions
-Administer ondansetron. - -Initiate airborne precautions
A nurse is contacting the provider of a client who has cancer and is experiencing breakthrough pain. Which of the following prescriptions should the nurse anticipate?
-Intravenous dexamethasone
-Transmucosal fentanyl
-Oral acetaminophen- not strong enough
-Intramuscular meperidine - -Transmucosal fentanyl
A nurse is admitting a client who reports chest pain and has been placed on a telemetry monitor. Which of the following should the nurse analyze to determine whether the client is experiencing a myocardial infarction?
-QRS duration
-ST segment
-T-wave
PR interval - -ST segment
-Examine the ST segment. The normal ST segment begins at the isoelectric line. ST elevation
or depression is significant if displacement is 1 mm (one small box) or more above or below
the line and is seen in two or more leads. ST elevation may indicate problems such as
myocardial infarction, pericarditis, and hyperkalemia. ST depression is associated with
hypokalemia, myocardial infarction, or ventricular hypertrophy.
A nurse is teaching a client who has ovarian cancer about skin care following radiation treatment. Which of the following instructions should the nurse include?
-Apply over the counter moisturizer to the radiation site
-Cover the radiation site loosely with a gauze wrap before dressing
-Use a soft washcloth to clean the area around the radiation site
-Pat the skin on the radiation site to dry it. - -Pat the skin on the radiation site to dry it. [Show Less]