A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT) protocol that includes methotrexate (Mexate, Trexal, MIX), an
... [Show More] antimetabolite. Which information should the nurse
provide the parents about caring for their child? - Use sunblock or protective clothing when outdoors.
A 6 -years-old who has asthma is demonstrating a prolonged expiratory phase and wheezing, and has 35% personal best peak expiratory flow rate (PEFR). Based on these finding, which action should the nurse implement first? - Administer a prescribed bronchodilator.
Rationale: If the PEFR is below 50% in as asthmatic child, there is severe narrowing of the airway, and a bronchodilator should be administered immediately. Be should be implemented after A. C will not alleviate the symptoms and D is not a priority.
A 12 year old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50 ml/hour. The client's urine specific gravity is 1.035. What action should the nurse implement? - Evaluate postural blood pressure measurements
Obtain specimen for uranalysis
Encourage popsicles and fluids of choice
Assess bowel sounds in all quadrants
Rationale: specific gravity of urine is a measurement of hydration status (normal range of 1.010 to 1.025)
which is indicative of fluid volume deficit when Sp Gr increases as urine becomes more concentrated.
A 13 years-old client with non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. The healthcare provider collects home aspirate specimens for culture and sensitivity and applies a cast
to the adolescent's lower leg. What action should the nurse implement next? - Administer antiemetic agents
Bivalve the cast for distal compromise
Provide high- calorie, high-protein diet
Begin parenteral antibiotic therapy
Rationale: The standard of treatment for osteomyelitis is antibiotic therapy and immobilization. After bond
and blood aspirate specimens are obtained for culture and sensitivity, the nurse should initiate parenteral
antibiotics as prescribed.
A 16-year-old adolescent with meningococcal meningitis is receiving a continuous IV infusion of penicillin G, which is prescribed as 20 million units in a total volume of 2 liters of normal saline every 24 hr. The pharmacy delivers 10 million units/ liters of normal saline. How many ml/hr should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.) - Answer 83
Rationale: 1000 ml-----12hr.
Xml ---------1hr.
1000/12 = 83.33 = 83.
A 56-years-old man shares with the nurse that he is having difficulty making decision about terminating life support for his wife. What is the best initial action by the nurse? - Provide an opportunity for him to clarify his values related to the decision
Encourage him to share memories about his life with his wife and family
Advise him to seek several opinions before making decision
Offer to contact the hospital chaplain or social worker to offer support.
Rationale: When a client is faced with a decisional conflict, the nurse should first provide opportunities for
the client to clarify values important in the decision. The rest may also be beneficial once the client as
clarified the values that are important to him in the decision-making process.
A 60-year-old female client asks the nurse about hormones replacement therapy (HRT) as a means preventing osteoporosis. Which factor in the client's history is a possible contraindication for the use of HRT? - Her mother and sister have a history of breast cancer
A 350-bed acute care hospital declares an internal disaster because the emergency generators malfunctioned during a city-wide power failure. The UAPs working on a general medical unit ask the
charge nurse what they should do first. What instruction should the charge nurse provide to these UAPs? - Tell all their assigned clients to stay in their rooms.
A child is admitted to the pediatric unit diagnosed with sickle cell crisis. When the nurse walks into the room, the unlicensed assistive personnel (UAP) is encouraging the child to stay in bed in the supine
position. Which action should the nurse implement? - Reposition the client with the head of the bed elevated.
A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge? - Instructions about how much fluid the child should drink daily.
Rationale: It is essential that the child and family understands the importance of adequate hydration in preventing the stasis-thrombosis-ischemia cycle of a crisis that has a specific plan for hydration is developed so that a crisis can be delayed. Other choices listed are not the most important topics to include in the discharge teaching.
A child with heart failure is receiving the diuretic furosemide (Lasix) and has serum potassium level 3.0 mEq/L. Which assessment is most important for the nurse to obtain? - Cardiac rhythm and heart rate.
Daily intake of foods rich in potassium.
Hourly urinary output
Thirst ad skin turgor.
A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first? - Establish a structured routine for the client to follow.
A client arrives on the surgical floor after major abdominal surgery. What intervention should the nurse perform first? - Determine the client's vital sign.
A client at 30 week gestation is admitted due to preterm labor. A prescription of terbutaline sulfate 8.35 mg is gives subcutaneously. Based on which finding should the nurse withhold the next dose of this drug? - Maternal pulse rate of 162 beats per min
A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide (Amphogel) is scheduled to begin at 0730. Which client medication should the nurse bring to
the healthcare provider's attention? - Allopurinol (Zyloprim)
Aspirin, low dose
Furosemide (lasix)
Enalapril (vasote)
A client experiencing withdrawal from the benzodiazepines alprazolam (Xanax) is demonstrating severe agitation and tremors. What is the best initial nursing action? - Administer naloxone (Narcan) per PNR protocol
Initiate seizure precautions
Obtain a serum drug screen
Instruct the family about withdrawal symptoms.
Rationale: Withdrawal of CNS depressants, such as Xanax, results in rebound over-excitation of the
CNS. Since the client exhibiting tremors, the nurse should anticipate seizure activity and protect the
client.
A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose? - Current diagnosis of hepatitis B. [Show Less]