M/S skin
A nurse is planning to change an abdominal dressing for a client who has an incision with a drain. Which of the following actions should the nurse plan to take?
1. remove the entire dressing
2.loose the dressing
3.don clean gloves and remove dressing
4. open sterile supplies before removing dressing
What is Don clean gloved to remove the dressing
A nurse is reinforcing discharge teaching with a client who has AIDS. Which of the following statements should the nurse make regarding home infection control?
1) Burn soiled dressings
2) Measure temperature weekly.
3) Disinfect blood spills with a hydrogen peroxide solution.
4) Soak sponges used for cleaning in a bleach solution after use.
What is soak sponges used for cleaning in a bleach solution after use?
A nurse is preparing to administer dextrose 5% in water IV to infuse at 100 mL/60 min. The drop factor on the manual IV tubing is 60 gtt/mL. The nurse should set the IV flow rate to deliver how many gtt/min? (Round to the nearest whole number.)
What is 100 gtt/min
A nurse is preparing to administer morning insulin to a client who has a prescription for 14 units of regular insulin and 28 units of NPH insulin subcutaneous daily. What is the total number of units of insulin that the nurse should prepare in the insulin syringe?
What is 42 units?
A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood cells. The client develops itching and hives. Which of the following actions should the nurse take first?
1) Administer diphenhydramine.
2) Notify the registered nurse.
3) Stop the transfusion.
4) Obtain vital signs.
What is stop the transfusion?
A nurse is collecting data from a client who has skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites?
1) Fever
2) Warmth
3) Mild erythema
4) Serosanguineous drainage
What is Fever?
A nurse is caring for a client who has a diagnosis of acute glomerulonephritis. Which of the following should be reported immediately to the provider?
1) Urinary output of 280 mL during previous 8 hr
2) Blood pressure 162/90 mm Hg
3) Pedal edema
4) Hematuria
what is Blood pressure 162/90 mm Hg
A nurse is preparing to administer potassium chloride 20 mEq. The amount available is potassium chloride liquid 40 mEq/15 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth.)
What is 7.5mL?
A nurse is preparing to administer morphine 15 mg subcutaneously. The amount available is morphine injection 10 mg/mL. How many mL should the nurse administer? (Round to the nearest tenth.)
What is 1.5mL?
A nurse is assisting with the plan of care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan of care?
1) Keep dedicated equipment in the client's room.
2) Use a nasal cannula to administer oxygen at 2 L/min.
3) Monitor level of consciousness every 4 hr.
4) Restrict visitors.
What is monitor level of consciousness every 4 hr?
A nurse is caring for a client who is postoperative open reduction and internal fixation with placement of a wound drain to repair a hip fracture. Which of the following actions should the nurse take?
1) Empty the suction device every 4 hr.
2) Monitor circulation on the affected extremity every 2 hr for the first 12 hr.
3) Position the client’s hip so that it is internally rotated
4) Encourage foot exercises every 4 hr.
What is Empty the suction device every 4 hr.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The nurse should monitor the client for which of the following conditions as a complication TPN?
1) Stomatitis
2) Abdominal distention
3) Aspiration
4) Polyuria
What is polyuria?
A nurse is preparing to administer 0.9% sodium chloride 1 L IV to infuse over 8 hr. The drop factor of the manual IV tubing set is 15 gtts/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number.)
What is 31 gtt/min
A nurse is caring for a client who has chlamydia and a new prescription for azithromycin. Which of the following information should the nurse include when reinforcing teaching about this medication?
1) Notify your provider if you experience a sore throat or fever while taking this medication.
2) Urine that is dark yellow or orange is an expected adverse effect of this medication.
3) Take the medication with an antacid to decrease stomach upset.
4) You might experience bleeding gums while taking this medication.
What is notify your provider if you experience a sore throat or fever while taking this medication.
A nurse is administering nicardipine to a client who has a BP of 180/120 mm Hg. Which of the following actions should the nurse take first?
1) Check for orthostatic hypertension.
2) Instruct the client to restrict sodium intake.
3) Assist the client to make lifestyle changes.
4) Monitor the client’s BP every 5 minutes.
What is monitor the clients blood pressure every 5 mins
A nurse is planning preventive care for a client who is at risk for pressure ulcers and requires bed rest. Which of the following actions should the nurse take?
1) Keep the client’s skin moist.
2) Reposition the client at least every 2 hr.
3) Keep the head of the bed elevated.
4) Massage the client’s bony prominences.
What is Reposition the client at least every 2 hr.
A nurse is reviewing a client’s laboratory results. Which of the following findings should the nurse report to the provider?
1) Chloride 99 mEq/L
2) Magnesium 1.9 mg/dL
3) Potassium 3.6 mEq/L
4) Sodium 126 mEq/L
What is Sodium 126 mEq/L
A nurse is preparing to administer dextrose 5% in water (D5W) 100 mL to infuse over 1 hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number.)
What is 25 gtt/min
You need to calculate intake in mL for your patient. For lunch they had : 8 oz apple juice 7 tsp of chicken broth 1 cup of jello How much intake did your patient have in mL?
A nurse is reviewing data for a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?
1) Increased clotting factors.
2) Immediate sodium and fluid retention.
3) Progressive increase in platelet production.
4) Excessive thrombosis and bleeding.
What is excessive thrombosis and bleeding?
A nurse is collecting date on a client who has a major burn injury. The nurse should recognize which of the following findings as a priority?
1) The client has edema at the burn site.
2) The client produces black colored sputum.
3) The client has decreased sensation over the burn areas.
4) The client has large blistered areas over his chest.
What is client produces black colored sputum
A nurse is collecting data from a client while changing his ileostomy pouch. Which of the following data should the nurse report immediately?
1) The skin around the stoma is red.
2) The stoma is pale in color.
3) The ostomy is draining constantly.
4) The client last changed the ostomy pouch 10 days ago.
What is the stoma is pale in color?
A nurse is preparing to administer hydroxyzine HCL 50 mg PO. Available is hydroxyzine oral suspension 25 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number.)
What is 10mL?
Your 4 year old pediatric patient weight 40 pounds. She is febrile. You need to administer acetaminophen (Tylenol)15mg/kg. How many mg will you administer?
What is 35mL?
A nurse is caring for a client who experiences anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first?
1) Hydrocortisone sodium succinate
2) Diphenhydramine
3) Epinephrine
4) Albuterol
What is epinephrine?