135. A resident of a long-term care facility, who has moderate dementia, is having difficulty eating in the dining room. The client becomes frustrated
... [Show More] when dropping utensils on the floor and then refuses to eat. What action should the nurse implement?
• Encourage the client to eat finger foods.
136. While in the medical records department, the nurse observes several old medical records with names visible in waste container. What action should the nurse implement?
• Contact the medical records department supervisor.
137. 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.
138. While visiting a female client who has heart failure (HF) and osteoarthritis, the home health nurse determines that the client is having more difficulty getting in and out of the bed than she did previously. Which action should the nurse implement first?
• Submit a referral for an evaluation by a physical therapist.
139. A client has an intravenous fluid infusing in the right forearm. To determine the client’s distal pulse rate most accurately, which action should the nurse implement?
• Palpate at the radial pulse site with the pads of two or three fingers.
140. A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to child, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. What action should the nurse take?
• Ask the older brother how he felt during the incident.
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