1. The nurse, planning care for a mechanically ventilated client, would plan to administer pantoprazole. The nurse understands this medication is to
... [Show More] prevent the onset of which of the following complications?
Thrombophlebitis
Hypertension
Hyperglycemia
Stress Ulcers
2. A client is diagnosed with cardiogenic shock. The nurse should plan immediate interventions to address which of the following complications of this disorder?
Pulmonary Embolism
Deep vein thrombosis
Acute renal failure
Disseminated intravascular coagulation
3. A patient in the emergency department is experiencing a hemorrhagic stroke. The nurse anticipates which of the following symptoms may have been present at the onset? SATA
Vomiting
Limited mobility worse in the morning
Severe, sudden headache
Increased appetite
Change in mental status
4. A nurse is caring for an end-of-life terminally ill client, experiencing very shallow and rapid breathing with periods of apnea. After evaluating the client, which action by the nurse would be most appropriate?
Reduce the number of people in the client's room
Reorient the client as needed
Place the client in supine position
Elevate the clients HOB
5. A nurse is admitted to the hospital with an infected postoperative surgical wound. The practitioner orders vancomycin IV. Order: Vancomycin 1 gram in 500 ml dextrose 5% water (D5W) to infuse over 2 hours via infusion pump. Calculate the flow rate in ml/hr. 250
6. A nurse assesses a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first?
Palpate the clients head for the presence of fractures
Assess the drainage from eyes and ears
Assess the drainage and test the drainage to rule out cerebral spinal fluid
Ask the client to keep their head elevate
7. An emergency department nurse triages a client with diabetes mellitus who has fractured her wrist. Which action would the nurse take first?
Remove the medical alert bracelet from the fractured arm
Place the client in a supine position with a warm blanket
Cover any open areas with a sterile dressing
Immobilize the arm by splinting the fracture
8. A nurse cares for a client who has obstructive jaundice. The client asks, " Why is my skin so itchy?" How would the nurse respond?
"Bile salts accumulate in the skin and cause the itching."
"Toxins released from an inflamed gallbladder lead to itching."
"Itching is caused by the release of calcium into the skin."
"Itching is caused by a hypersensitivity reaction [Show Less]