A nurse is preparing to administer diazepam 2 mg twice daily via NG tube. Available is diazepam oral
solution 5 mg/1 mL. How many mL should th nurse
... [Show More] administer with each dose? (Use a leading zero if it
applies. Do not use a trailing zero. Round th answer to th nearest tenth.)
0.4
A nurse in a long-term care facility is planning to use thrapeutic touch for a group of selected clients who
have chronic pain. Th nurse should identify that th use of thrapeutic touch is contraindicated for whch ofth
following clients?
A client who has chronic back pain and a history of being physically abused
Thrapeutic touch consists of using th nurse's hands to harmonize energy fields and to facilitate relief of painor
anxiety, such as for a client who has chronic back pain. Th nurse can touch th client with thir palms or move th
palms near, but not touching th client's body. Prior physical maltreatment and some mental health disorders
are contraindications for thrapeutic touch, because touch or near touch could cause severe anxiety.
A nurse in a rehabilitation unit is assessing a group of clients who have traumatic brain injuries. Th nurse
should identify that whch of th following clients requires a priority referral?
A client who coughs after drinking liquids
Th greatest risk to this client is injury from aspiration. Threfore, this is th client th nurse should address first. Th
priority referral th nurse should make is to a speech-language pathologist because a client who coughs after
drinking liquids is at risk for aspiration. Manifestations of dysphagia include changes in voice tone,coughing,
delayed swallowing, pocketing of food, and occasional silent aspiration, whch can occur if a client is
experiencing a decrease in sensation.
A nurse is assisting a client to move up in bed. Whch of th following actions should th nurse take?
Raise th height of th bed to th level of th nurse's elbows.
A nurse is caring for a client who is at risk for pressure ulcer formation due to immobility. Th nurse should
place th client in whch of th following positions to reduce pressure on th client's bony prominences?
30° lateral
Th 30° lateral position, along with positioning devices, can prevent pressure directly over th client's most
vulnerable bony prominences. This position can, however, cause pressure on th shoulder, ankle, anterior iliac
spine, and trochanter. Threfore, th nurse should ensure th client's head is midline and supported, rotation ofth
spine is avoided, and position changes are implemented every 1 to 2 hr
A nurse is preparing to administer vancomycin 500 mg by intermittent IV infusion every 6 hr. Available is
vancomycin 500 mg in 0.9% sodium chloride 100 mL to infuse over 2 hr. Th nurse should set th IV pump to
deliver how many mL/hr? (Round th answer to th nearest whole number. Use a leading zero if applicable. Do
not use a trailing zero.)
50
A nurse is admitting a client who is to undergo a surgical procedure. Under th Patient Self-DeterminationAct
(PSDA), whch of th following actions is th nurse's responsibility regarding th client's advance directives?
Ask th client whethr he has created advance directives.
A nurse is assessing a client who has hypokalemia. Whch of th following manifestations should th nurse
expect?
Decreased bowel sounds
Decreased bowel sounds are an indication of hypokalemia because of decreased excitability of cells, resulting
in less responsiveness to normal stimuli in nerves and muscles.
A nurse is planning care for a client who has an endotracheal tube and is receiving mechanical ventilation.
Whch of th following interventions should th nurse include to reduce th client's risk for ventilatorassociated pneumonia?
Swab th client's mouth with chlorhexidine solution.
A nurse is providing teaching to a client following a thoracentesis. Whch of th following actions should th
nurse take?
Position th client on her unaffected side.
Th nurse should position th client on th unaffected side to help facilitate expansion of th affected lung
A nurse is completing a neurological assessment of an older adult client and notes that th client has become
increasingly confused and agitated in th last 48 hr. Whch of th following conditions is th priority assessment
by th nurse?
Infection
A nurse is assessing a client who is receiving intermittent cathter irrigation following a transurethral
resection of th prostate (TURP). Whch of th following manifestations is th priority for th nurse to reportto.......................................................................CONTINUED [Show Less]