1. A male client who had a transurethral resection of the prostate (TURP) today has a continuous bladder irrigation (CBI). The client requests pain
... [Show More] medication for abdominal pain rated at “9“ on a scale of 1 to 10. What action should the nurse take first?
A. Administer prescribed PRN analgesic medication.
B. Position him on the left side and slow the irrigation rate.
C. Palpate his abdomen and check his urinary output. <
D. Assist him to ambulate to help pass flatus.
2. The mental health nurse takes several adolescent clients to the inpatient schoolroom. The teacher asks the nurse to stay and help one of the male clients who has attention-deficit hyperactivity disorder with his spelling assignment. Which goal is reasonable for this client to attain during this one-hour class?
A. Completes at least one page of spelling. <
B. Follows directions the first time they are given.
C. Sits quietly with peers and completes assignment.
D. Shares his problems with others in the class.
3. A client is receiving a standardized solution of heparin 25,000-units/250 ml of normal saline. The healthcare provider prescribes to increase the client’s current infusion rate of heparin to 700 units/hour. How many ml/hour should the nurse program the infusion pump? Enter the numerical value only.
Using formula, D/H x Q, 700 units/hour 25,000 units x 25o ml = 7 ml/hour
4. A client is receiving the intravenous adrenergic agonist dobutamine (Dobutrex). In evaluating the client’s reaction to the medication, which assessment finding indicates to the nurse that the medication is effective?
A. The client denies chest pain or discomfort.
B. The client had 160 ml urine output in 8 hours.
C. The client’s blood pressure is 110/70 mmHg. <
D. The client’s posterior tibial pulses are 1+.
5. A client misses breakfast because of a two-hour hand washing ritual that is performed daily. What plan is most therapeutic for the nurse to implement?
A. Meet with the client daily to discuss motivation for initiating the ritual.
B. Wake the client early so the ritual can be completed before breakfast. <
C. Set limits on amount of time the client is allowed to perform the ritual.
D. Socialize with the client during the ritual to demonstrate acceptance.
6. Which discharge instruction should the nurse provide a client with heart failure who is taking digoxin (Lanoxin)?
A. Avoid concurrent use of herbal products. <
B. Take Lanoxin with high-fiber foods.
C. Restrict fluid intake to equal urine output.
D. Check blood glucose level weekly.
7. The charge nurse in the Intensive Care Unit (ICU) needs to transfer a client to the medical unit so that a client from the Emergency Room can be admitted to ICU. Which client is best to consider?
A. A 38-year-old with a myocardial infarction who is having multifocal premature ventricular contractions.
B. A 66-year-old with congestive heart failure who has 2+ pitting edema and is short of breath on exertion. <
C. A 58-year-old diagnosed [Show Less]