Ch. 26
A surgeon prescribes heparin 2,500 mEq intramuscularly (IM) every 12 hours (q12hr). What is the nurse’s best action?
Clarify the dose and route with the surgeon.
The nurse should contact the surgeon to clarify the dosage and route of administration. Heparin is measured in units and administered either subcutaneously or intravenously.
A client’s vital signs at the beginning of the shift are as follows: oral temperature 99.3°F (37°C), heart rate 82 beats/min, respiratory rate 14 breaths/min, and blood pressure 118/76 mm Hg. Four hours later, the client’s oral temperature is 102.3°F (39.1°C). Based on the temperature change, the nurse should anticipate the client’s heart rate would be how many beats/min?
1. 62
2. 82
3. 112
4. 132
3. 112
Heart rate would have increased from 82 to 112 beats/min. Temperature increased by 3°C (3 × 10 = 30; 82 + 30 = 112). Heart rate increases about 10 beats/min for each degree Fahrenheit of temperature to meet increased metabolic needs and compensate for peripheral dilation.
Which aspect of restraint use can the nurse delegate to the unlicensed assistive personnel (UAP)?
1. Assessing the patient’s status
2. Determining the need for restraint
3. Evaluating the patient’s response to restraints
4. Applying and removing the restraint
4
The nurse can delegate applying and removing the restraints, skin care, and checking for skin breakdown.
What position should the female patient assume before the nurse inserts an indwelling urinary catheter?
1. Modified Trendelenburg
2. Prone
3. Dorsal recumbent
4. Semi-Fowler’s
3
The nurse should have the patient lie supine with knees flexed, feet flat on the bed (dorsal recumbent position). If the patient is unable to assume this position, the nurse should help the patient to a side-lying position.
ring for a patient who has a continent ileostomy. Which intervention will the nurse add to the plan of care?
1. Change the ostomy appliance as needed.
2. Place a bedside commode by the patient’s bed.
3. Keep the collection device below the bladder.
4. Insert a tube into the stoma to drain the pouch.
4.
To drain the pouch, the patient inserts a tube through the external stoma into the pouch several times per day.
Administering medications in the same site over prolonged periods of time can cause ____ _____ and _____ ______, which will interfere with absorption and thus hinder the effectiveness of the medication.
fat deposits and skin lumps
The nurse is assessing vital signs for a client after a surgical procedure on the left leg. Intravenous (IV) fluids are infusing. Which action would be most important for the nurse to take?
1. Compare the left pedal pulse with the right pedal pulse.
2. Count the client’s respiratory rate for 1 full minute.
3. Take blood pressure in the arm without an IV line.
4. Obtain oral temperature with an electronic thermometer.
1.
For a client having surgery on the leg, the most important data would be whether the circulation has been compromised because of the surgery. This assessment can be made only by comparing one leg with the other.
h is the most commonly reported incident in hospitals?
1. Equipment malfunction
2. Patient falls
3. Laboratory specimen errors
4. Treatment delays
2
patient falls are by far the most common incident reported in hospitals and long-term care facilities.
Which intervention should the nurse take first to promote micturition in a patient who is having difficulty voiding?
1. Insert an indwelling urinary catheter.
2. Notify the healthcare provider immediately.
3. Obtain an intermittent, straight catheter.
4. Pour warm water over the patient’s perineum.
4
The nurse should first perform independent nursing measures, such as pouring warm water over the patient’s perineum. Least invasive measures are tried first.
A patient with cancer is started on morphine for excruciating pain. Which diagnosis should the nurse add to the patient’s care plan?
1. Risk for Constipation
2. Constipation
3. Perceived Constipation
4. Chronic Constipation
1
Risk for Constipation is an appropriate diagnosis for patients at increased risk because of bedrest, medications such as opioids, or surgery. The nurse might use this diagnosis for a patient with a condition or taking medications known to decrease peristalsis, like morphine.
The nurse administered the narcotic meperidine, 50 mg orally (PO) at 1400 to a patient with nausea, vomiting, and pain rated as 9 on a 0-to-10 scale. At 1430, the patient stated that the medication was not working and requested to have intravenous (IV) morphine, which the provider had prescribed for severe pain. What is the nurse’s best evaluation of this situation?
Administering meperidine PO was not the best nursing intervention in this situation
The nurse hears rhonchi when auscultating a client’s lungs. Which nursing intervention would be appropriate for the nurse to implement before reassessing lung sounds?
1. Have the client take several deep breaths.
2. Ask the client to take a deep breath and cough.
3. Take the client’s blood pressure and apical pulse readings.
4. Count the client’s respiratory rate for 1 minute.
2
Rhonchi are caused by secretions in the large airways and may clear with coughing. This is how the nurse differentiates between rhonchi and other adventitious sounds.
Teratogenic drugs should be avoided in which patient population?
Pregnant women
Drugs that are known to cause developmental defects are termed teratogenic. These drugs are contraindicated during pregnancy because of the likelihood of adverse effects in the embryo or fetus.
A patient who sustained a spinal cord injury will perform intermittent self-catheterization after discharge. After discharge teaching, which statement by the patient would indicate correct understanding of the procedure?
1. “I will need to replace the catheter monthly.”
2. “I will use clean, rather than sterile, technique at home.”
3. “I will remember to inflate the catheter balloon after insertion.”
4. “I will dispose of the catheter after use and get a new one each time.”
2
the nurse should inform the patient that clean technique can be used after discharge.
The mother of a 3-month-old infant comes to emergency department and states, “My baby has been having severe diarrhea for 4 days. She is crying all the time.” In formulating the plan of care for diarrhea, the nurse focuses outcomes on which of the following? Select all that apply.
1. Fluid management
2. Electrolyte balance
3. Skin integrity
4. Excessive crying
5. Ease of stool passage
1, 2, 3
Feedback
1.
This is correct. Patients with diarrhea are at risk for fluid imbalance. Water loss is a primary concern. Infants, young children, and the frail elderly are most vulnerable and may require hospitalization and intravenous fluid replacement therapy.
2.
This is correct. Electrolyte imbalance, especially potassium, secondary to diarrhea is a high risk for infants, young children, and older adults.
3.
This is correct. Since the patient is an infant, skin integrity is an outcome for diarrhea, due to the irritating effects of feces in the diaper having direct contact with the infant’s skin. Because of the moisture and the activity of enzymes in the stool, infants with severe diarrhea need nursing care to prevent Skin Integrity Impairment.
4.
This is incorrect. Although crying distresses parents, managing the infant’s crying is not a priority at this time, and it will usually cease once the infant is feeling better and responding to treatment.
5.
This is incorrect. Ease of stool passage is an outcome for constipation, not diarrhea.
The nurse is preparing to administer a medication for a client with cystic fibrosis. The nurse is not familiar with the drug. Which is the best action that the nurse should take?
The Physician’s Desk Reference is a book commercially compiled by the pharmaceutical companies and is a standard resource for professionals prescribing and administering medication.
The nurse assesses the following changes in a client’s vital signs. Which client situation should be reported to the primary care provider?
1. Decreased blood pressure (BP) after standing up
2. Decreased temperature after a period of diaphoresis
3. Increased heart rate after walking down the hall
4. Increased respiratory rate when the heart rate increases
1
A decrease in the client’s blood pressure when standing indicates orthostatic hypotension, and the cause should be investigated.
While receiving an intravenous dose of an antibiotic, levofloxacin, a patient develops severe shortness of breath, wheezing, and severe hypotension. Which action should the nurse take first?
1. Administer epinephrine intramuscularly (IM).
2. Give a bolus dose of intravenous fluids.
3. Stop the infusion of medication.
4. Prepare for endotracheal intubation.
3
The patient is experiencing an anaphylactic reaction (severe shortness of breath, wheezing, and severe hypotension), a life-threatening allergic reaction. Therefore, the nurse should immediately discontinue the medication.
A patient is prescribed furosemide, a loop diuretic, for treatment of congestive heart failure. The nurse will monitor for which electrolyte loss?
1. Calcium
2. Potassium
3. Magnesium
4. Phosphorus
2
Furosemide is a loop diuretic, which causes potassium loss.
The primary care provider orders peak and trough levels for a patient who is receiving intravenous vancomycin every 12 hours. When should the nurse obtain a blood specimen to measure the trough?
1. With the morning routine laboratory studies
2. Approximately 30 minutes before the next dose
3. Two hours after the next dose infuses
4. While the drug is infusing
2
Trough levels are typically obtained approximately 30 minutes before administering the next dose of the drug.
A patient who just returned from the postanesthesia care unit is reporting severe incision pain. Which drug contained in the medication administration record will offer the patient the fastest relief?
1.Liquid acetaminophen with codeine
2.Intravenous morphine sulfate
3.Intramuscular meperidine
4.Oral oxycodone tablets
2.
This is the fastest. The onset of medication action takes place within seconds, so intravenous administration is especially useful in emergencies.
The client has an order for the drug digitalis, which has the effect of decreasing the heart rate. Which site should the nurse use to obtain a pulse rate prior to administering the medication?
1. Radial
2. Temporal
3. Apical
4. Brachial
3. Apical
The nurse should use count the pulse rate for 1 full minute using the apical site. It is the most accurate of any of the peripheral sites. When administering medications that affect the heart rate, an accurate rate is essential.
The physician prescribes warfarin 5 mg orally (PO) at 1800 for a patient. After administering the medication, the female nurse realizes that she administered a 10 mg tablet instead of the prescribed 5 mg PO. Which action by the nurse is appropriate?
1. No action is necessary because an extra 5 mg of warfarin is not harmful.
2. Call the prescriber and ask the order to be changed to 10 mg.
3. Document on the chart that the drug was given, and indicate the drug was given in error.
4. Complete an incident report according to the facility’s policy.
4
Complete an incident report according to the facility’s policy; submit the signed report to the nurse manager.
A patient’s catheter bag is empty 2 hours after it was last drained. The nurse’s first action is to:
1. Irrigate the catheter
2. Perform a bladder scan
3. Replace the catheter
4. Check for kinks or compression
4
The nurse should first check for kinks or compression. Kinks or compression of the catheter or tubing may impede flow of urine into the bag.
he nurse must administer ear drops to an infant. How should the nurse proceed?
1. Pull the pinna down and back before instilling the drops.
2. Position the pinna upward and outward before instilling the drops.
3. Instill the drops directly; no special positioning is necessary.
4. Position the patient supine with the head of the bed elevated 30°
1. Pull the pinna down and back before instilling the drops.
For a child younger than 3 years of age, the nurse should pull the pinna down and back. This straightens the ear canal for proper channeling of the medication.