Acid base balance and IV therapy
A client is being prescribed IV fluid for severe vomiting and dehydration. What is an example of isotonic solution or fluids?
Normal saline 0.9% or Lactated Ringers
A nurse is training a newly hired nurse about infection-control measures on the unit. It is crucial for the nurse to understand that which of the following is the most effective way to prevent the spread of pathogens during client care?
Hand Hygiene
A nurse is converting the dosage of a medication to a different unit in the metric system. The medication label specifies the drug as being 0.5 g per tablet. The order is for 500 mg. How many tablets will the nurse give?
1 tablet
Which activity should the nurse encourage first after surgery?
Ambulation
What should the nurse do first prior to beginning Tracheostomy care and suctioning
Do a focused assessment of the patient's respiratory system
A client has been vomiting for three days, which acid base imbalance should the nurse expect?
Metabolic Alkalosis
A nurse is preparing to administer medication to a client. Which two forms of client identification are the best?
Name and date of birth
A nurse is preparing to administer penicillin IM to an adult client. Which of the following angles should the nurse use for injection into the client's ventrogluteal muscle?
90 degree
A nurse received a client for surgery scheduled in 3 hours. Which action is most important to prevent aspiration?
Keep the patient on NPO status
Which of the following actions should the nurse perform when opening the sterile pack?
Open the outermost flap away from the body first
A nurse is caring for a 33-year-old patient who presents to the emergency department with acute anxiety and rapid breathing after a panic attack. The provider orders an arterial blood gas (ABG). The results are shown below: pH: 7.55 PaCO₂: 29 mm Hg HCO₃⁻: 24 mEq/L PaO₂: 99 mm Hg
Which acid–base imbalance should the nurse identify?
Respiratory Alkalosis
A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of personal protective equipment (PPE) should the nurse remove first?
Gloves
A clinic nurse is preparing for a tuberculosis screening. Knowing the injections will be administered intradermally, what size needles and syringes will the nurse prepare?
1 mL tuberculin syringe with a 25–27 gauge, ¼–½ inch needle
The post operative nurse measures client’s vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure?
Blood pressure
A client with a tracheostomy has coarse breath sounds and visible secretions in the tubing. Oxygen saturation is 92% on humidified oxygen. Which action should the nurse take first before suctioning?
Hyperoxygenate
A client with metabolic acidosis has ABGs showing pH 7.31 and HCO₃⁻ 16 mEq/L. Which intervention does the nurse anticipate?
Replace sodium bicarb via IV
A nurse is admitting a geriatric patient to the unit. Which four nursing actions would the nurse perform to reduce the client's risk for a fall?
Keep the bed in lowest position
Call bell light within reach
Apply Non-skid socks
Apply bed/ chair alarm
A nurse is preparing an injection by withdrawing the solution from a multidose vial. What is the first step necessary to facilitate withdrawing a medication from the vial?
Inject an equal amount of air into the vial.
A nurse is caring for a client in the PACU. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client’s pain?
The self report from the client
The nurse is providing postoperative tracheostomy care. Which actions reduce the risk of infection?
Perform sterile technique when cleaning and changing the tracheostomy dressing
Change soiled dressings promptly
Use sterile technique when suctioning
Do not reuse disposable inner cannulas
A client is admitted to the medical-surgical unit with prolonged vomiting and weakness. Laboratory results reveal pH 7.49 and HCO₃⁻ 33 mEq/L. The provider prescribes IV fluid therapy. Which IV fluid does the nurse anticipate administering to help correct this client’s metabolic alkalosis?
Normal saline 0.9%
A nurse on an oncology unit is preparing the medication dosage for a client. What must a nurse do each time medications are administered to ensure that medication errors do not occur?
Observe the three checks and five rights
A nurse is teaching a client newly diagnosed with diabetes administration of the subcutaneous medication called Humalog. Which of the following strategies should the nurse use to promote the client’s understanding?
Have the patient do a self demonstration
A postoperative client is receiving patient-controlled analgesia pump (PCA) with hydromorphone. Which three findings require immediate intervention?
Respiratory rate less than 12
Oxygen sat less than 90
Difficult to arouse/ decline in mental status from baseline
A nurse is performing a sterile dressing change. The nurse needs new sterile items on her sterile field, how can they be added to the sterile field?
With sterile forceps or hands wearing sterile gloves