IV
1. Contact the primary health care provider
2. Document findings in the electronic health record
3. Change the IV site to a new location
4. Stop the infusion of the drug
Stop the infusion of the drug
While making rounds the nurse finds a client with type 1 diabetes mellitus pale, sweaty, and slightly confused; the client can swallow. The client's blood glucose level check is 48mg/dL. What is the nurse's best first action to prevent harm?
1. Call the pharmacy and order a STAT dose of glucagon
2. Immediately give the client 30g of glucose orally
3. Start an IV and administer a small amount of a concentrated dextrose solution
4. Recheck the glucose level and call the rapid response team.
Immediately give the client 30g of glucose orally
A client has been diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following is NOT a priority nursing intervention for this client?
1. Increase fluid intake to at least 2L/day
2. Flush NG tube with normal saline rather than sterile water
3. Initiate seizure precautions
4. Encourage increased dietary intake of sodium
Increase fluid intake to at least 2L/day
A nurse prepares a dose of medication that is a controlled substance to give to a client for pain. When the nurse takes the medication into the room, the client refuses it. What action of the nurse is most appropriate?
1. Discard the medication according to facility policy and document the client's refusal
2. Encourage the client to take the medication and explain that it has already been signed out to him
3. Return the medication to its former packaging
4. Label the medication for use and return it to the locked cupboard so that someone else may use it
Discard the medication according to facility policy and document the client's refusal
An older adult client receiving an infusion 5% dextrose in 0.9% normal saline at 150mL/hr has developed shortness of breath with a decrease in oxygen saturation to 86%. What is the priority nursing intervention?
1. Notify the health care provider
2. Place the client on oxygen
3. Sit the client upright in bed
4. Assess the client's lung sounds
Sit the client upright in bed
The nurse is caring for client with type 2 diabetes. Which of the following are appropriate nursing interventions? Select all that apply.
1. Maintain a low protein diet
2. Give lipid lowering medications if indicated
3. Teach the client about the glycemic index
4. Encourage high caloric intake
5. Encourage aerobic exercise
Give lipid lowering medications if indicated
Teach the client about the glycemic index
Encourage aerobic exercise
A client who has suffered a traumatic brain injury (TBI) has developed diabetes insipidus. A home health nurse is seeing the client in his home to help him manage his care at home. Which of the following teaching points would the nurse offer to help prevent injury in this client?
1. Have the client ensure easy access to the bathroom or bedside commode
2. Reinforce keeping a fan on in the room next to the bed while sleeping
3. Encourage the client to wear socks and extra blankets when sleeping at night
4. Tell the client to reduce fluid intake and avoid drinks that contain caffeine
Have the client ensure easy access to the bathroom or bedside commode
According to the World Health Organization Pain Management Ladder, if a client has a pain intensity that is classified as moderate-to-severe pain which is persistent despite other interventions, which of the following medications could the client receive? Select all that apply.
1. Methadone
2. Fentanyl
3. Oxycodone with acetaminophen (Percocet)
4. Ibuprofen
5. Acetylsalicylic acid (Aspirin)
Methadone
Fentanyl
Oxycodone with acetaminophen (Percocet)
A patient with a peripheral IV has developed infiltration at the insertion site. Which of the following signs or symptoms would the nurse look for with IV infiltration? Select all that apply.
1. Swelling at the insertion site
2. Patient discomfort
3. Blanching of the skin
4. Skin breakdown around the IV dressing
5. Patient fever
Swelling at the insertion site
Patient discomfort
Blanching of the skin
When preparing to administer a prescribed subcutaneous dose of NPH insulin from an open vial taken from a medication drawer to a client with diabetes, the nurse notes the solution is cloudy. What action will the nurse perform to ensure client safety?
1. Warm the vial in a bowl of warm water until it reaches normal body temperature
2. Return the vial to the pharmacy and open a fresh vial of NPH insulin
3. Roll the vial between the hands until the insulin is clear
4. Check the expiration date and draw up the insulin dose
Check the expiration date and draw up the insulin dose
A client has developed hyponatremia as a result of syndrome of inappropriate anti-diuretic hormone. Which type of IV fluid would the nurse most likely administer?
1. 0.9% NaCl
2. D5W
3. 0.45% NS
4. 3% Normal saline
3% Normal saline
A client who is dying of cancer tells the nurse that he is in extreme pain. Which of the following principle should the nurse adhere to when managing pain in a dying client? Select all that apply.
1. Determine if the client has developed drug tolerance
2. Withhold adequate pain relief until other curative attempts have failed
3. Provide an increased amount of pain medicine to sedate the client
4. Discuss increasing the dose of pain medication with the provider
5. Monitor for side effects of increasing opioid use
Determine if the client has developed drug tolerance
Discuss increasing the dose of pain medication with the provider
Monitor for side effects of increasing opioid use
A patient has taken 5000mg of tylenol within 12hrs to control their pain and is now overdose. Which drug would be administered to reverse the effects?
1. Naloxone (Narcan)
2. Acetylcesteine
3. Methadone
4. Furosemide
Acetylcesteine
A nurse has just restarted a client’s peripheral IV after the last one infiltrated. The nurse has determined that the IV is working and is in the correct position. Which principles should the nurse use when securing the IV site? Select all that apply.
1. Place a dressing over the IV site after it has been inserted
2. Consider placing a small piece of gauze under the cannula to reduce skin pressure
3. Use a 4x4 gauze over the top of the IV to keep it in place
4. The hub of the catheter may be taped in place using tape
5. Consider immobilizing the extremity if the IV is for a child
Place a dressing over the IV site after it has been inserted
The hub of the catheter may be taped in place using tape
Consider immobilizing the extremity if the IV is for a child
Which health promotion activity(ies) will the nurse recommend to prevent harm in a client with type 2 diabetes? Select all that apply.
1. Avoid all dietary carbohydrates and fat
2. Have your eyes and vision assessed by an ophthalmologist every year
3. Reduce your intake of animal fat and increase your intake of plant sterols
4. Be sure to take your antidiabetes drug right before you engage in any type of exercise
5. Keep your feet warm in cold weather by using either a hot water bottle or a heating pad
6. Avoid foot damage from shoe-rubbing by going barefoot or wearing flip-flops when you are at home
Have your eyes and vision assessed by an ophthalmologist every year
Reduce your intake of animal fat and increase your intake of plant sterols
A nurse suspects a client has diabetes insipidus. What are the priority interventions? Select all that apply.
1. Monitor neuro status
2. Monitor urine specific gravity
3. Monitor for hypernatremia
4. Monitor strict I&O
5. Monitor for hyponatremia
Monitor neuro status
Monitor urine specific gravity
Monitor for hypernatremia
Monitor strict I&O
A 50-year-old patient is recovering from abdominal surgery. He complains of pain that has been continuously rated at a 6 on a 0-10 scale despite the intervention of giving morphine Q4H PRN. Which implication must the nurse consider when controlling this patient’s pain?
1. Whether the patient would respond to a different type of medication
2. Whether the patient is becoming addicted to the medication
3. Whether the patient is experiencing an increased respiratory rate because of the medication
4. Whether the patient is allergic to the medication
Whether the patient would respond to a different type of medication
A nurse works in a busy healthcare unit of the hospital which includes care of clients with many different types of chronic illnesses. Which of the following actions should the nurse implement to help prevent the spread of infection among clients who have diabetes?
1. Maintain tight control of client blood glucose levels
2. Avoid touching items in the client rooms
3. Set aside syringes that are only used for diabetic clients
4. Cover all food trays with cling wrap before passing out meals
Maintain tight control of client blood glucose levels
A nurse is caring for a client who has been diagnosed with syndrome of inappropriate anti-diuretic hormone (SIADH). What type of electrolyte imbalance would the nurse most likely see in this situation? Select all that apply
1. Hyponatremia
2. Hypocalcemia
3. Hyperkalemia
4. Hypermagnesemia
Hyponatremia
A nurse has been ordered to give a patient an intravenous dose of an opioid pain medication following surgery. Which of the following describes a contraindication to using intravenous therapy? Select all that apply.
1. When the enteral route of administration would be just as effective
2. When the patient feels nauseous
3. When the patient has an electrolyte imbalance
4. When the patient's oxygen saturation is 84%
5. When the patency of the IV site is questionable
When the enteral route of administration would be just as effective
When the patient's oxygen saturation is 84%
When the patency of the IV site is questionable