2. A client who is admitted to the care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which
... [Show More] intervention should the nurse implement first?
A) Patch one eye. B) Evaluate swallow.
C) Reorient often.
D) Range of motion.
3. The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendations should the nurse provide this client? (Select all that apply)
A) Wash the stump with soap and water.
B) Avoid range of motion exercise.
C) Apply alcohol to the stump after bathing. D) Inspect skin for redness.
E) Use a residual limb shrinker.
4. After 2 days treatment for dehydration, a child continues to vomit and have diarrhea. Normal saline is infusing and the child’s urine output is 50ml/hour. During morning assessment, the nurse determines that the child is lethargic and difficult to arouse. Which should the nurse implement?
A) Increase the IV fluid flow rate.
B) Review 24-hour intake and output.
C) Obtain arterial blood gases.
D) Perform a finger stick glucose test.
5. A client with bleeding esophageal varices receives vasopressin IV. What should the nurse monitor for during the IV infusion of this medication?
A) Vasodilatation of the extremities. B) Chest pain and dysrhythmia.
C) Hypotension and tachycardia.
D) Decreasing GI cramping and nausea.
6. A male client with an antisocial personality disorder is admitted to an inpatient mental health unit for multiple substance dependency. When providing a history, the client justifies to the nurse his use of illicit drugs. Based on this pattern of behavior, this client’s history is most likely to include which finding?
A) Multiple convictions for misdemeanors and Class B felonies.
B) Delusions of grandiosity and persecution.
C) Suicidal ideations and multiple attempts.
D) Photos and panic attacks when confronted by authority figures.
A) Administer low molecular weight heparin as prescribed.
B) Teach client to use incentive spirometer every 2 hours while awake. C) Remove urinary catheter as soon as possible and encourage voiding.
D) Maintain sequential compression devices while in bed.
E) Assess pain level and medicate PRN as prescribed.
8. The nurse is preparing a 50 ml dose of 50% Dextrose IV for a client with insulin shock. How should the nurse administer the medication?
A. Dilute the dextrose in one liter of 0.9% Normal Saline solution. B. Push undiluted slowly though the currently infusing IV.
C. Mix the dextrose in a 50 ml piggyback for a total volume of 100 ml.
D. Ask the pharmacist to add the Dextrose to a TPN solution.
9. A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor?
A) Serum Calcium.
B) Erythrocyte sedimentation rate.
C) Osmolality.
D) Hemoglobin.
11. A client peptic ulcer disease receives a prescription for intermittent suction via a SalemSump nasogastric tube (NGT). After inserting the NGT and obtaining coffee- ground gastric contents, the nurse clamps the NGT because the client must leave the unit for diagnostic studies. Upon return to the unit, the client complains of nausea. What action should the nurse implement first?
A) Administering a prescribed antiemetic agent.
B) Provide oral suction using a Yankauer tip.
C) Connect the NGT to low intermittent suction.
D) Irrigate the NGT with sterile normal saline.
12. The healthcare provider prescribes a fluid challenge of 0.9% sodium chloride 1,000 ml to be influenced over 4 hours. The IV administration set delivers 10 gtt/ml. How many gtt/minute should the nurse regulate the infusion? ( round the nearest whole number.)
Flow rate(gtt/min) = volume(ml)/ time(min) × drop factor(gtt/mL). Flow rate=1000ml/240min×10gtt/ml.
Flow rate = 41.667gtt/min. 42
13. At 40-week gestation, a laboring client who is lying is a supine position tells the nurse that she has finally found a comfortable position. What action should the nurse take?
A) Place a pillow under the client’s head and knees. B) Place a wedge under the client’s right hip.
C) Encourage the client to turn on her left side.
D) Explain to the client that her position is not safe.
14. A family member reports that the client who is bedridden has not been turned or repositioned all night and is sleeping on a special air mattress with no sheets. What information should the nurse provide to the family member?
A) Clarify that an aerated support surface does not use sheets that often cause skin breakdown.
B) Described the night staff’s plan of care to ensure the client’s sleep is not disturbed.
C) Explained that turning is only necessary to reposition the client during waking hours.
D) Suggest that a family member turn the [Show Less]