Client Manifestations
Name two s/s of pain in a nonverbal client.
guarding, grimacing, hypertension, tachycardia, moaning, clenched teeth, tightly squeezed eyes, crying.
The nursing field is held to an exceptionally high standard, as a profession. How many ethical principals are there that guide our profession?
7
Citrusy fruits are great, except for this specific fruit, that can cause adverse reactions to over 10 medication classes!
Grapefruit
ordered: levetiracetam 750 mg tab PO BID
on hand: levetiracetam 250 mg tab
What are you going to give?
3 tabs
Lifting something with your legs, with feet apart, with the object close to the body, is an example of what?
Proper body mechanics
Your client was inadvertently given too much fentanyl d/t the 6 rights of med administration not being followed. What would the nurse expect to see when assessing vital signs?
bradypnea - short, shallow breaths
A nurse accepting personal and professional consequences, both good and bad, of their actions or inactions is an example of what ethical principal?
Accountability
Rrrrrr. Your scurvy client presents with brittle hair, bleeding gums, and extremely irritable. What will you, the nurse, educate your patient to increase in their dietary intake?
Vitamin C
1 teaspoon = ___ mLs
1 oz = ___ mLs
5, 30
engage the safety mechanism
A client c/o dizziness and lightheadedness upon standing. What condition is most likely the culprit?
Orthostatic hypotension
Nurse Jackie is in a rush this morning, rushes through her med pass on all 5 patients, then performs her assessments. When she gets to her last patient, who is also a new admit, she finds him dead. Upon review, Nurse Jackie gave a med to the patient they were allergic to. What ethical principal did Nurse violate?
Vitamin C is super important! What supplement works best within the body when taken with a drink containing vitamin C?
Iron
DOUBLE POINTS
KCl 20 mEq/h in 250 mL to infuse over 4 hours is ordered for your client. The drop factor on the manual IV tubing is 40 gtt/mL. What is the gtt/min rate?
(Round to the nearest whole number)
250 mL/4 hr x 1 hr/60 min = 1 mL/min
40 gtt/mL x 1 mL/min = 40 gtt/min
You, the nurse, makes a goal for your patient to ambulate to the bathroom with stand-by assist two times throughout your shift. What part of the nursing process does this represent?
Planning
Under Maslow's Hierarchy of needs, what level do we typically see our clients at, as nurses?
1st level / base level / Physiological needs
Giving the client the option to undergo a life-saving procedure is an example of what ethical principal?
Autonomy
This multi-use supplement is better absorbed through food, but the supplement is ok too; can help with cholesterol levels; may help to lower blood pressure but will do little for heart disease; and may lessen the pain and inflammation of RA.
Omega-3 fatty acids
Your irate patient is experiencing a mental break. The MD orders Olanzapine 7.5 mg IM STAT.
On hand is Olanzapine 10 mg/2 mL vial. How much will you give?
1.5 mL
A doctor writes an order for Bupropion 150 mg BID. What aspect of this medication order is missing?
Route
DOUBLE POINTS
Who do you see first: client A - bleeding from the surgical site and on blood thinners. Client B - has pneumonia with s/s of tachypnea while short of breath. Client C - was eating lunch but now in visible distress and unable to speak.
Client C - Airway obstruction
Your client is 85 y/o F, A&O x3, with new diagnosis of stage IV glioblastoma. The family asks you, the nurse, to not tell the patient of her diagnosis and to tell her she just has a cold. What ethical principal would you be violating by lying to your client?
Veracity
Nutritional supplements are packed with vitamins and nutrients the client's body needs. Where will the nurse document this nutritional supplement?
fluid intake
Your liver failure client is ordered lactulose 40 mg solution PO TID.
On hand is 20 mg/30 mL solution. How many mLs are you giving your client?
60 mL
You are caring for a client with paraplegia and notice nonblanchable erythema 3 cm x 3 cm to the left heel. What does this indicate (including stage)?
stage I pressure injury