1
Nursing MISC Hesi
Fundamentals Exam
Which drug does a nurse anticipate may be prescribed to produce diuresis and inhibit
formation of aqueous humor
... [Show More] for a client with glaucoma?
Chlorothiazide (Diuril)
Acetazolamide (Diamox)
Bendroflumethiazide (Naturetin)
Demecarium bromide (Humorsol)
A client receiving steroid therapy states, "I have difficulty controlling my temper which is so
unlike me, and I don't know why this is happening." What is the nurse's best response?
Tell the client it is nothing to worry about.
Talk with the client further to identify the specific cause of the problem.
Instruct the client to attempt to avoid situations that cause irritation.
Interview the client to determine whether other mood swings are being experienced.
A client receiving steroid therapy states, "I have difficulty controlling my temper which is so
unlike me, and I don't know why this is happening." What is the nurse's best response?
Tell the client it is nothing to worry about.
Talk with the client further to identify the specific cause of the problem.
Instruct the client to attempt to avoid situations that cause irritation.
Interview the client to determine whether other mood swings are being experienced.
The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit. The nurse
applies a cooling blanket and administers an antipyretic medication. The nurse explains that
the rationale for these interventions is to:
Promote equalization of osmotic pressures.
Prevent hypoxia associated with diaphoresis.
Promote integrity of intracerebral neurons.
Reduce brain metabolism and limit hypoxia.
A health care provider prescribes 500 mg of an antibiotic intravenous piggyback (IVPB) every
12 hours. The vial of antibiotic contains 1 g and indicates that the addition of 2.5 mL of sterile
water will yield 3 mL of reconstituted solution. How many milliliters of the antibiotic should be
added to the 50 mL IVPB bag? Record your answer using one decimal place. mL
1.5
The nurse is caring for a non-ambulatory client with a reddened sacrum that is unrelieved by
repositioning. What nursing diagnosis should be included on the client's plan of care?
Risk for pressure ulcer
Risk for impaired skin integrity
Impaired skin integrity, related to infrequent turning and repositioning
Impaired skin integrity, related to the effects of pressure and shearing force2
A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue
down to the underlying fascia. The nurse should document the assessment finding as which
stage of pressure ulcer?
Stage I
Stage II
Stage III
Unstageable
A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the
wound can be staged. A stage I pressure ulcer is defined as an area of persistent redness with no
break in skin integrity. A stage II pressure ulcer is a partial-thickness wound with skin loss involving
the epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion, blister, or
shallow crater. A stage III pressure ulcer involves full thickness tissue loss with visible subcutaneous
fat. Bone, tendon, and muscle are not exposed.
A client is being admitted for a total hip replacement. When is it necessary for the nurse to
ensure that a medication reconciliation is completed? Select all that apply.
After reporting severe pain
On admission to the hospital
Upon entering the operating room
Before transfer to a rehabilitation facility
At time of scheduling for the surgical procedure
Medication reconciliation involves the creation of a list of all medications the client is taking and
comparing it to the health care provider's prescriptions on admission or when there is a transfer to a
different setting or service, or discharge. A change in status does not require medication
reconciliation. A medication reconciliation should be completed long before entering the operating
room. Total hip replacement is elective surgery, and scheduling takes place before admission;
medication reconciliation takes place when the client is admitted.
A client is taking lithium sodium (Lithium). The nurse should notify the health care provider for
which of the following laboratory values?
White blood cell (WBC) count of 15,000 mm3
Negative protein in the urine
Blood urea nitrogen (BUN) of 20 mg/dL
Prothrombin of 12.0 seconds
White cell counts can increase with this drug. The expected range of the WBC count is 5000 to
10,000 mm3 for a healthy adult. Urinalysis, BUN, and prothrombin are not necessary and these are
normal values.
Often when a family member is dying, the client and the family are at different stages of
grieving. During which stage of a client's grieving is the family likely to require more
emotional nursing care than the client?
Anger
Denial3
Depression
Acceptance
In the stage of acceptance, the client frequently detaches from the environment and may become
indifferent to family members. In addition, the family may take longer to accept the inevitable death
than does the client. Although the family may not understand the anger, dealing with the resultant
behavior may serve as a diversion. Denial often is exhibited by the client and family members at the
same time. During depression, the family often is able to offer emotional support, which meets their
needs.
The client asks the nurse to recommend foods that might be included in a diet for diverticular
disease. Which foods would be appropriate to include in the teaching plan? Select all that
apply.
Whole grains
Cooked fruit and vegetables
Nuts and seeds
Lean red meats
Milk and eggs
With diverticular disease the patient should avoid foods that may obstruct the diverticuli. Therefore
the fiber should be digestible, such as whole grains, and cooked fruits and vegetables. Milk and eggs
have no fiber content but are good sources of protein. In clients with diverticular disease, nuts and
seeds are contraindicated as they may be retained and cause inflammation and infection, which is
known as diverticulitis. The client should also decrease intake of fats and red meats.
A nurse is obtaining a health history from the newly admitted client who has chronic pain in
the knee. What should the nurse include in the pain assessment? Select all that apply.
Pain history, including location, intensity, and quality of pain
Client's purposeful body movement in arranging the papers on the bedside table
Pain pattern, including precipitating and alleviating factors
Vital signs such as increased blood pressure and heart rate
The client's family statement about increases in pain with ambulation
Accurate pain assessment includes pain history with the client's identification of pain location,
intensity, and quality and helps the nurse to identify what pain means to the client. The pattern of pain
includes time of onset, duration, and recurrence of pain and its assessment helps the nurse anticipate
and meet the needs of the client. Assessment of the precipitating factors helps the nurse prevent the
pain and determine it cause. Purposeless movements such as tossing and turning or involuntary
movements such as a reflexive jerking may indicate pain. Physiological responses such as elevated
blood pressure and heart rate are most likely to be absent in the client with chronic pain. Pain is a
subjective experience and therefore the nurse has to ask the client directly instead of accepting
statement of the family members.
While undergoing a soapsuds enema, the client reports abdominal cramping. What action
should the nurse take?4
Immediately stop the infusion.
Lower the height of the enema bag.
Advance the enema tubing 2 to 3 inches.
Clamp the tube for 2 minutes, then restart the infusion.
Abdominal cramping during a soapsuds enema may be due to too rapid administration of the enema
solution. Lowering the height of the enema bag slows the flow and allows the bowel time to adapt to
the distention without causing excessive discomfort. Stopping the infusion is not necessary.
Advancing the enema tubing is not appropriate. Clamping the tube for several minutes then restarting
the infusion may be attempted if slowing the infusion does not relieve the cramps.
During the initial physical assessment of a newly admitted client with a pressure ulcer, a nurse
observes that the client's skin is dry and scaly. The nurse applies emollients and reinforces
the dressing on the pressure ulcer. Legally, were the nurse's actions adequate?
The nurse also should have instituted a plan to increase activity.
The nurse provided supportive nursing care for the well-being of the client.
Debridement of the pressure ulcer should have been done before the dressing was applied
Treatment should not have been instituted until the health care provider's prescriptions were received.
According to the Nurse Practice Act, a nurse may independently treat human responses to actual or
potential health problems. An activity level is prescribed by a health care provider; this is a dependent
function of the nurse. There is not enough information to come to the conclusion that debridement
should have been done before the dressing was applied. Application of an emollient and reinforcing a
dressing are independent nursing functions.
A visitor comes to the nursing station and tells the nurse that a client and his relative had a
fight and that the client is now lying unconscious on the floor. What is the most important
action the nurse needs to take?
Ask the client if he is okay.
Call security from the room.
Find out if there is anyone else in the room.
Ask security to make sure the room is safe
Safety is the first priority when responding to a presumably violent situation. The nurse needs to have
security enter the room to ensure it is safe. Then it can be determined if the client is okay and make
sure that any other people in the room are safe
To ensure the safety of a client who is receiving a continuous intravenous normal saline
infusion, the nurse should change the administration set every:
4 to 8 hours
12 to 24 hours
24 to 48 hours
72 to 96 hours
Best practice guidelines recommend replacing administration sets no more frequently than 72 to 965
hours after initiation of use in patients not receiving blood, blood products, or fat emulsions. This
evidence-based practice is safe and cost effective. Changing the administration set every 4 to 48
hours is not a cost-effective practice
A nurse is taking care of a client who has severe back pain as a result of a work injury. What
nursing considerations should be made when determining the client's plan of care? Select all
that apply.
Ask the client what is the client's acceptable level of pain.
Eliminate all activities that precipitate the pain.
Administer the pain medications regularly around the clock.
Use a different pain scale each time to promote patient education.
Assess the client's pain every 15 minutes
The nurse works together with the client in order to determine the tolerable level of pain. Considering
that the client has chronic, not acute pain, the goal of the pain management is to decrease pain to the
tolerable level instead of eliminating pain completely. Administration of pain medications around the
clock will provide the stable level of pain medication in the blood and relieve the pain. Elimination of
all activities that precipitate the client's pain is not possible even though the nurse will try to minimize
such activities.
The same pain scale should be used for assessment of the client's pain level helps to ensure
consistency and accuracy in the pain assessment. Only management of acute pain such as
postoperative pain requires the pain assessment at frequent intervals.
The nurse is preparing to administer eardrops to a client that has impacted cerumen. Before
administering the drops, the nurse will assess the client for which contraindications? Select
all that apply.
Allergy to the medication
Itching in the ear canal
Drainage from the ear canal
Tympanic membrane rupture
Partial hearing loss in the affected ear
Contraindications to eardrops include allergy to the medication, drainage from the ear canal, and
tympanic membrane rupture. Partial hearing loss may occur with impacted cerumen and is not a
contraindication to the use of eardrops. Itching may occur with some ear conditions and is not a
contraindication to the use of eardrops.
What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select
all that apply.
Tetany
Seizures
Diarrhea
Weakness
Dysrhythmias
Tetany is caused by hypocalcemia. Seizures caused by electrolyte imbalances are associated with6
low calcium or sodium levels. Because of potassium's role in the sodium/potassium pump,
hyperkalemia will cause diarrhea, weakness, and cardiac dysrhythmias.
A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction
should the nurse give the client about this medication?
Prolonged use can cause dark concentrated urine.
The medication is best absorbed when taken on an empty stomach.
Take the medication with aluminum hydroxide to minimize GI upset.
Albumin
Globulin
Thrombin
Hemoglobin
The gamma-globulin fraction in the plasma is the fraction that includes the antibodies. Albumin helps
regulate fluid shifts by maintaining plasma oncotic pressure. Thrombin is involved with clotting.
Hemoglobin carries oxygen.
A nurse discusses the philosophy of Alcoholics Anonymous (AA) with the client who has a
history of alcoholism. What need must self-help groups such as AA meet to be successful?
Trust
Growth
Belonging
Independence
Self-help groups are successful because they support a basic human need for acceptance. A feeling
of comfort and safety and a sense of belonging may be achieved in a nonjudgmental, supportive,
sharing experience with others. AA meets dependency needs rather than focusing on independence,
trust, and growth.
What type of interview is most appropriate when a nurse admits a client to a clinic?
Directive
Exploratory
Problem solving
Information giving
The first step in the problem-solving process is data collection so that client needs can be identified.
During the initial interview a direct approach obtains specific information, such as allergies, current
medications, and health history. The exploratory approach is too broad because in a nondirective
interview the client controls the subject matter. Problem solving and information giving are premature
at the initial visit.19
What is a basic concept associated with rehabilitation that the nurse should consider when
formulating discharge plans for clients?
Rehabilitation needs are met best by the client's family and community resources.
Rehabilitation is a specialty area with unique methods for meeting clients' needs.
Immediate or potential rehabilitation needs are exhibited by clients with health problems.
Clients who are returning to their usual activities following hospitalization do not require rehabilitation.
Rehabilitation refers to a process that assists clients to obtain optimal functioning. Care should be
initiated immediately when a health problem exists to avoid complications and facilitate recuperation.
All resources that can be beneficial to client rehabilitation, including the private health care provider
and acute care facilities, should be used. Rehabilitation is a commonality in all areas of nursing
practice. Rehabilitation is necessary to help clients return to a previous or optimal level of functioning.
A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should
monitor for what clinical manifestations of the electrolyte deficiency? Select all that apply.
Diplopia
Skin rash
Leg cramps
Tachycardia
Muscle weakness
Leg cramps occur with hypokalemia because of potassium deficit. Muscle weakness occurs with
hypokalemia because of the alteration in the sodium potassium pump mechanism. Diplopia does not
indicate an electrolyte deficit. A skin rash does not indicate an electrolyte deficit. Tachycardia is not
associated with hypokalemia, bradycardia is.
A nurse in the surgical intensive care unit is caring for a client with a large surgical incision.
The nurse reviews a list of vitamins and expects that which medication will be prescribed
because of its major role in wound healing?
Vitamin A (Aquasol A)
Cyanocobalamin (Cobex)
Phytonadione (Mephyton)
Ascorbic acid (Ascorbicap)
Vitamin C (ascorbic acid) plays a major role in wound healing. It is necessary for the maintenance
and formation of collagen, the major protein of most connective tissues. Vitamin A is important for the
healing process; however, vitamin C is the priority because it cements the ground substance of
supportive tissue. Cyanocobalamin is a vitamin B12 preparation needed for red blood cell synthesis
and a healthy nervous system. Phytonadione is vitamin K, which plays a major role in blood
coagulation.
A client is receiving an intravenous (IV) infusion of 5% dextrose in water. The client loses
weight and develops a negative nitrogen balance. The nurse concludes that what likely
contributed to this client's weight loss?20
Excessive carbohydrate intake
Lack of protein supplementation
Insufficient intake of water-soluble vitamins
Increased concentration of electrolytes in cells
An infusion of dextrose in water does not provide proteins required for tissue growth, repair, and
maintenance; therefore, tissue breakdown occurs to supply the essential amino acids. Each liter
provides approximately 170 calories, which is insufficient to meet minimal energy requirements;
tissue breakdown will result. Weight loss is caused by insufficient nutrient intake; vitamins do not
prevent weight loss. An infusion of 5% dextrose in water may decrease electrolyte concentration.
A client has undergone a subtotal thyroidectomy. The client is being transferred from the post
anesthesia care unit/recovery area to the inpatient nursing unit. What emergency equipment is
most important for the nurse to have available for this client?
A defibrillator
An IV infusion pump
A tracheostomy tray
An electrocardiogram (ECG) monitor
The client who has undergone a subtotal thyroidectomy is at high risk for airway occlusion resulting
from postoperative edema. With this in mind, emergency airway equipment such as a tracheostomy
set and intubation supplies should be immediately available to the client. A defibrillator, an IV infusion
pump, and an electrocardiogram (ECG) monitor are all equipment items that should be available to all
postoperative clients.
The nurse reviews a medical record and is concerned that the client may develop
hyperkalemia. Which disease increases the risk of hyperkalemia?
Crohn's
Cushing's
End-stage renal
Gastroesophageal reflux
.
One of the kidneys' functions is to eliminate potassium from the body; diseases of the kidneys often
interfere with this function, and hyperkalemia may develop, necessitating dialysis. Clients with
Crohn's disease have diarrhea, resulting in potassium loss. Clients with Cushing's disease will retain
sodium and excrete potassium. Clients with gastroesophageal reflux disease are prone to vomiting
that may lead to sodium and chloride loss with minimal loss of potassium
A nurse assesses a client's serum electrolyte levels in the laboratory report. What electrolyte
in intracellular fluid should the nurse consider most important?
Sodium
Calcium
Chloride
Potassium21
The concentration of potassium is greater inside the cell and is important in establishing a membrane
potential, a critical factor in the cell's ability to function. Sodium is the most abundant cation of the
extracellular compartment, not the intracellular compartment. Calcium is the most abundant
electrolyte in the body; 99% is concentrated in the teeth and bones, and only 1% is available for
bodily functions. Chloride is an extracellular, not intracellular, anion.
What is the maximum length of time a nurse should allow an intravenous (IV) bag of solution
to infuse?
6 hours
12 hours
18 hours
24 hours
After 24 hours there is increased risk for contamination of the solution and the bag should be
changed. It is unnecessary to change the bag any less often.
An intravenous piggyback (IVPB) of cefazolin (Kefzol) 500 mg in 50 mL of 5% dextrose in water
is to be administered over a 20-minute period. The tubing has a drop factor of 15 drops/mL. At
what rate per minute should the nurse regulate the infusion to run? Record the answer using a
whole number. gtts/min
Solve the problem by using the following formula: Drops per minute = total number of drops /
total time in minutes Drops per minute = 50 mL x 15 (drop factor) / 20 mintes = 750 / 20 = 37.5.
Round the answer to 38 drops per minute. 38
Solve the problem by using the following formula: Drops per minute = total number of drops /
total time in minutes Drops per minute = 50 mL x 15 (drop factor) / 20 mintes = 750 / 20 = 37.5.
Round the answer to 38 drops per minute
The nurse manager is planning to assign an unlicensed assistive personnel (UAP) to care for
clients. What care can be delegated on a medical-surgical unit to a UAP? Select all that apply.
Performing a bed bath for a client on bed rest
Evaluating the effectiveness of acetaminophen and codeine (Tylenol #3)
Obtaining an apical pulse rate before oral digoxin (Lanoxin) is administered
Assisting a client who has patient-controlled analgesia (PCA) to the bathroom
Assessing the wound integrity of a client recovering from an abdominal laparotomy
Performing a bed bath for a client on bed rest is within the scope of practice of the UAP. Assisting a
client who has PCA to the bathroom does not require professional nursing judgment and is within the
job description of the UAP. Evaluating human responses to medications requires the expertise of a
licensed professional nurse. Obtaining an apical pulse rate requires a professional nursing judgment
to determine whether or not the medication should be administered. Evaluating human responses to
health care interventions requires the expertise of a licensed professional nurse.
A client has an anaphylactic reaction after receiving intravenous penicillin. What does the
nurse conclude is the cause of this reaction?22
An acquired atopic sensitization occurred.
There was passive immunity to the penicillin allergen.
Antibodies to penicillin developed after a previous exposure.
Potent antibodies were produced when the infusion was instituted
Hypersensitivity results from the production of antibodies in response to exposure to certain foreign
substances (allergens). Earlier exposure is necessary for the development of these antibodies. This is
not a sensitivity reaction to penicillin; hay fever and asthma are atopic conditions. It is an active, not
passive, immune response. Antibodies developed when there was a previous, not current, exposure
to penicillin.
A nurse is providing care to a client eight hours after the client had surgery to correct an
upper urinary tract obstruction. Which assessment finding should the nurse report to the
surgeon?
Incisional pain
Absent bowel sounds
Urine output of 20 mL/hour
Serosanguineous drainage on the dressing
A urinary output of 50 mL/hr or greater is necessary to prevent stasis and consequent infections after
this type of surgery. The nurse should notify the surgeon of the assessment findings, since this may
indicate a urinary tract obstruction. Incisional pain, absent bowel sounds, and serosanguineous
drainage are acceptable assessment findings for this client after this procedure and require continued
monitoring but do not necessarily require reporting to the surgeon
A nurse is caring for an older adult who is taking acetaminophen (Tylenol) for the relief of
chronic pain. Which substance is most important for the nurse to determine if the client is
taking because it intensifies the most serious adverse effect of acetaminophen?
Alcohol
Caffeine
Saw palmetto
St. John's wort
Too much ingestion of alcohol can cause scarring and fibrosis of the liver. Eighty-five to 95% of
acetaminophen is metabolized by the liver. Acetaminophen and alcohol are both hepatotoxic
substances. Metabolites of acetaminophen along with alcohol can cause irreversible liver damage.
Caffeine affects (stimulates) the cardiovascular system, not the liver. In addition, caffeine does not
interact with acetaminophen. Saw palmetto is not associated with increased liver damage when
taking acetaminophen. It often is taken for benign prostatic hypertrophy because of its
antiinflammatory and antiproliferative properties in prostate tissue. St. John's wort is classified as an
antidepressant and is not associated with increased liver damage when taking acetaminophen.
However, it does decrease the effectiveness of acetaminophen.
An arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is
20 mEq/L. Which disturbance should the nurse identify based on these results?
1
Metabolic acidosis
2
Metabolic alkalosis23
3
Respiratory acidosis
4
Respiratory alkalosis
A low pH and low bicarbonate level are consistent with metabolic acidosis. The pH indicates acidosis.
The CO2 concentration is within normal limits, which is inconsistent with respiratory acidosis; it is
elevated with respiratory acidosis.
1 A
low pH and low bicarbonate level are consistent with metabolic acidosis. The pH indicates acidosis.
The CO2 concentration is within normal limits, which is inconsistent with respiratory acidosis; it is
elevated with respiratory acidosis.
Ph-7.35-7.45
PCO2 - 35-45
HCO3 - 22-30
Toxicity can result because the action of calcium ions is similar to that of digoxin. Calcium gluconate
cannot be added to a solution containing carbonate or phosphate because a dangerous precipitation
will occur. Calcium gluconate can be added to the IV solution the client is receiving. If calcium
infiltrates, sloughing of tissue will result.
A nurse is preparing to administer an oil-retention enema and understands that it works
primarily by:
Stimulating the urge to defecate.
Lubricating the sigmoid colon and rectum.
Dissolving the feces.
Softening the feces
The primary purpose of an oil-retention enema is to lubricate the sigmoid colon and rectum.
Secondary benefits of an oil-retention enema include stimulating the urge to defecate and softening
feces. An oil-retention enema does not dissolve feces.
After gastric surgery a client has a nasogastric tube in place. What should the nurse do when
caring for this client?
Monitor for signs of electrolyte imbalance.
Change the tube at least once every 48 hours.
Connect the nasogastric tube to high continuous suction.
Assess placement by injecting 10 mL of water into the tube
Gastric secretions, which are electrolyte rich, are lost through the nasogastric tube; the imbalances
that result can be life threatening. Changing the nasogastric tube every 48 hours is unnecessary and
can damage the suture line. High continuous suction can cause trauma to the suture line. Injecting 10
mL of water into the nasogastric tube to test for placement is unsafe; if respiratory intubation has
occurred aspiration will result24
A nurse administers an intravenous solution of 0.45% sodium chloride. In what category of
fluids does this solution belong?
Isotonic
Isomeric
Hypotonic
Hypertonic
Hypotonic solutions are less concentrated (contain less than 0.85 g of sodium chloride in each 100
mL) than body fluids. Isotonic solutions are those that cause no change in the cellular volume or
pressure, because their concentration is equivalent to that of body fluid. This relates to two
compounds that possess the same molecular formula but that differ in their properties or in the
position of atoms in the molecules (isomers). Hypertonic solutions contain more than 0.85 g of solute
in each 100 mL.
The nurse is caring for a client that is on a low carbohydrate diet. With this diet, there is
decreased glucose available for energy, and fat is metabolized for energy resulting in an
increased production of which substance in the urine?
Protein
Glucose
Ketones
Uric Acid
As a result of fat metabolism, ketone bodies are formed and the kidneys attempt to decrease the
excess by filtration and excretion. Excessive ketones in the blood can cause metabolic acidosis. A low
carbohydrate diet does not cause increased protein, glucose, or uric acid in the urine.
Study Tip: The old standbys of enough sleep and adequate nutritional intake also help keep
excessive stress at bay. Although nursing students learn about the body's energy needs in anatomy
and physiology classes, somehow they tend to forget that glucose is necessary for brain cells to work.
Skipping breakfast or lunch or surviving on junk food puts the brain at a disadvantage.
What is a nurse's responsibility when administering prescribed opioid analgesics? Select all
that apply.
1
Count the client's respirations.
2
Document the intensity of the client's pain.
3
Withhold the medication if the client reports pruritus.
4
Verify the number of doses in the locked cabinet before administering the prescribed dose.
Opioid analgesics can cause respiratory depression; the nurse must monitor respirations. The
intensity of pain must be documented before and after administering an analgesic to evaluate its
effectiveness. Because of the potential for abuse, the nurse is legally required to verify an accurate
count of doses before taking a dose from the locked source and at the change of the shift. Pruritus is
a common side effect that can be managed with antihistamines. It is not an allergic response, so it25
does not preclude administration. The nurse should not discard an opioid in a client's room. Any
waste of an opioid must be witnessed by another nurse.
A client has been admitted with a urinary tract infection. The nurse receives a urine culture
and sensitivity report that reveals the client has vancomycin-resistant Entercoccus (VRE).
After notifying the physician, which action should the nurse take to decrease the risk of
transmission to others?
Insert a urinary catheter.
Initiate droplet precautions.
Move the client to a private room.
Use a high efficiency particulate air (HEPA) respirator during care.
Contact precautions are used for clients with known or suspected infections transmitted by direct
contact or contact with items in the environment; therefore infectious clients must be placed in a
private room. There is no need to insert an indwelling catheter, as this can increase the risk for
additional infection. Droplet precautions are used for clients known or suspected to have infections
transmitted by the droplet route. These infections are caused by organisms in droplets that may travel
3 feet, but are not suspended for long periods.
A client who had abdominal surgery is receiving patient-controlled analgesia (PCA)
intravenously to manage pain. The pump is programmed to deliver a basal dose and bolus
doses that can be accessed by the client with a lock-out time frame of 10 minutes. The nurse
assesses use of the pump during the last hour and identifies that the client attempted to selfadminister the analgesic 10 times. Further assessment reveals that the client is experiencing
pain still. What should the nurse do first?
1
Monitor the client's pain level for another hour.
2
Determine the integrity of the intravenous delivery system.
3
Reprogram the pump to deliver a bolus dose every eight minutes.
4
Arrange for the client to be evaluated by the health care provider.
Initially, integrity of the intravenous system should be verified to ensure that the client is receiving
medication. The intravenous tubing may be kinked or compressed, or the catheter may be dislodged.
Continued monitoring will result in the client experiencing unnecessary pain. The nurse may not
reprogram the pump to deliver larger or more frequent doses of medication without a health care
provider's prescription. The health care provider should be notified if the system is intact and the
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