"I feel God in this Chili’s tonight."
Sodium (Na)
136-145 mEq/L
A nurse is collecting data regarding the pain level of a 4-year-old client on the second postoperative day. Which of the following actions should the nurse take?
1. Ask the client what number the pain is on a scale from 1 to 10.
2. Tell the client to point to a face on a FACES Pain Rating Scale.
3. Have the parent report the pain level for the client.
4. Request an assistive personnel to evaluate the client's pain level.
2. Tell the client to point to a face on a FACES Pain Rating Scale.
The FACES Pain Rating Scale is an age appropriate pain assessment tool for a 4-year-old client.
A nurse is collecting data on four clients. Which of the following is the highest priority finding by the nurse?
A) Malaise
B) Anorexia
C) Headache
D) Diarrhea
D) Diarrhea
A client with a suspected brain tumor is scheduled for a CAT scan. When the procedure is explained, the client expresses fear of entering the enclosed space of the scanner. Which of the following responses by the nurse is appropriate?
a. "The procedure only takes a few minutes to complete."
b. "Let me review some breathing exercises with you."
c. "I can ask the doctor to prescribe a sedative for you."
d. "This is a routine test so there is no reason to worry."
b. "Let me review some breathing exercises with you."
During the implementation phase of the nursing process for medication administration, which procedure is considered essential?
a. Monitor the patient's response to the drug therapy
b. Following the five rights of medication administration
c. Establishing measurable and realistic outcomes
d. Use NANDA nursing dagnoses to plan care delivery
b. Following the five rights of medication administration
What is Michael’s username for the dating site?
Little Kid Lover.
What item of clothing does Michael always have dry cleaned?
His jeans.
A nurses caring for an older adult client who recently experienced the death of her partner. Which of the following is the priority need of the client?
A) establishing a sense of achievement
B) contributing to society
C) creating meaningful social relationships
D) enhancing self- confidence
Creating meaningful social relationships
A nurse is caring for a client with diabetes who is to receive hemodialysis. The client says to the nurse, "I don't even know why I'm doing this. There is no cure." Which of the following is an appropriate nursing response?
a. "It sounds as though you have given up."
b. "Dialysis will help you live longer."
c. "You shouldn't complain. You are fortunate to have this option available to you."
d. "There is always a chance that, through research, a cure will be found."
a. "It sounds as though you have given up."
- The nurse is using the therapeutic communication technique of restatement to encourage the expression of feelings.
Which of Angela’s cats does Dwight freeze?
Sprinkles.
Potassium
3.5-5.0 mg/L
A nurse is evaluating the morning laboratory reports of a client who has bipolar disorders. The laboratory report indicates a serum lithium level of 2 mEq/L. In responding to this report, which of the following actions should the nurse anticipate?
1. Continuing the medication as prescribed
2. Increasing the lithium dose because the level is sub-therapeutic
3. Monitoring the client for signs of lithium toxicity
4. May need a decreased dose since the level is at the upper limit of the expected reference range.
3. Monitoring the client for signs of lithium toxicity
This level indicates lithium toxicity. Lithium has a very narrow therapeutic range and should be kept below 1.5 mEq/L so serum lithium levels must be monitored at regular intervals. Even at slightly elevated levels, clients may exhibit signs of overdose or toxicity including gastrointestinal distress, muscle twitching, hyperreflexia, nystagmus, and confusion. Higher levels may cause seizures and eventually death.
A nurse is conducting therapeutic medication monitoring on four clients. Which of the findings should be immediately reported to the provider?
A) Lithium carbonate 0.8
B) Digoxin 3.0
C) Peak serum gentamicin 6 mcg/mL
D) Mag. Sulfate 4
Digoxin 3.0mg/mL
Who did Kevin get for his secret Santa?
Himself.
The nurse is drawing blood to evaluate the therapeutic levels of a drug dose. Which level indicates that maximum therapeutic response of the drug is achieved?
A. Onset level.
B. Trough level.
C. Random level.
D. Peak Level.
d. Peak level
Stomach pH
1.5-2.5
A nurse is planning care for a client who is newly diagnosed with myasthenia gravis. The nurse determines that which of the following is the highest priority concern when providing care to this client?
1. Impaired verbal communication
2. Impaired vision
3. Fatigue and muscle weakness
4. Ineffective breathing pattern
4. Ineffective breathing pattern
Myasthenia gravis (MG) is a chronic neuromuscular disease characterized by varying degrees of muscular weakness. MG is caused by a defect in the transmission of nerve impulses due to the body's inability to use the neurotransmitter acetylcholine at the neuromuscular junction. The classic manifestation of MG is muscle weakness that increases during periods of activity and improves after a period of rest.
A nurse is caring for a client who has a serum potassium level of 3.1 mEq/L. Which of the following actions should the nurse take first?
A) obtain an ECG.
B) Administer oral potassium
C) Encourage potassium-rich foods
D)Monitor I & O
A) Obtain an ECG
An emergency department nurse takes a telephone call from a client who reports "I have just taken 100 Elavil tablets to kill myself." The client is crying and says, "I want to die. I have no reason to live." Which of the following responses by the nurse is appropriate?
a. "Please stay on the phone with me so we can talk about your feelings."
b. "Why do you think you have no reason to live?"
c. "How do you feel about what you have just done?"
d. "I'm sure things are not as bad as they seem to you now."
a. "Please stay on the phone with me so we can talk about your feelings."
- This is a therapeutic response because the nurse has given the client opportunity to share his feelings. The nurse is also encouraging the client to stay on the phone so that emergency personnel can get to the client's home.
The nurse is preparing for an acute medication intervention, which route is understood to provide the most rapid delivery in to the circulation of blood?
Select one:
A. The parenteral route.
B. The topical route.
C. The enteral route.
D. Oral liquids.
a. The parenteral route
WBC
5000 -10,000
A nurse is caring for a client diagnosed with rheumatoid arthritis. When performing assisted range of motion on the client's joints, the nurse is likely to note the presence of which of the following?
1. Heberden's nodules
2. Tophi
3. Boutonniere deformity
4. Osteoma
3. Boutonniere deformity
Rheumatoid arthritis is a chronic, inflammatory autoimmune disorder which primarily affects the synovium (lining of the joints). Boutonniere deformity is a manifestation of rheumatoid arthritis in which a finger is flexed or bent inward towards the palm at the lowest joint (most proximal) and then extended outward away from the palm at the furthest joint (most distal). This deformity arises due to the loss of collagen (connective tissue) in the joints.
A nurse is collecting data on four clients. Which of the following findings is the most urgent?
A) bladder distension and urgency
B) pedal edema
C) warmth and pain in the calf
D) hypoactive bowel sounds
Warmth and pain in the calf
A nurse is caring for a client with leukemia. The client says to the nurse, "The doctor told me that my condition is too severe to be treated successfully, and I am no longer a candidate for chemotherapy. I guess I don't have long to live." Which of the following responses by the nurse is therapeutic?
a. "Having a positive attitude can help you."
b. "Let's talk about how you are feeling about this information."
c. "Have you considered getting a second opinion?"
d. "How long do you feel that you have left to live?"
b. "Let's talk about how you are feeling about this information."
- This is a therapeutic response because the nurse is using the exploring technique. This technique allows the client the opportunity to express his feelings regarding the prognosis.
A pregnant woman is prescribed a medication, while teaching the patient, the nurse explains that which pregnancy category drug would be the safest?
Select one:
A. "B"
B. "D"
C. "X"
D. "A"
D. "A"