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Terms in this set (57)
Which serum laboratory value should the nurse monitor Sodium
carefully for a client who has a nasogastric (NG) tube to
suction for the past week? Rationale:
Monitoring serum sodium levels (D) for hyponatremia is indicated during prolonged
NG suctioning because of loss of fluids.
, When assisting a client from the bed to a chair, which With the nurse's feet spread apart and knees aligned with the client's knees, stand
procedure is best for the nurse to follow? and pivot the client into the chair.
Rationale:
(B) describes the correct positioning of the nurse and affords the nurse a wide base
of support while stabilizing the client's knees when assisting to a standing position.
The chair should be placed at a 45-degree angle to the bed, with the back of the
chair toward the head of the bed
The nurse assesses a 2-year-old who is admitted for Check for kinks in the tubing and raise the IV pole.
dehydration and finds that the peripheral IV rate by gravity
has slowed, even though the venous access site is Rationale:
healthy. What should the nurse do next? The nurse should first check the tubing and height of the bag on the IV pole (B),
which are common factors that may slow the rate. Gravity infusion rates are
influenced by the height of the bag, tubing clamp closure or kinks, needle size or
position, fluid viscosity, client blood pressure (crying in the pediatric client), and
infiltration.
The nurse is assessing several clients prior to surgery. Taking anticoagulants for the past year.
Which factor in a client's history poses the greatest threat
for complications to occur during surgery? Rationale:
Anticoagulants (B) increase the risk for bleeding during surgery, which can pose a
threat for the development of surgical complications. The health care provider
should be informed that the client is taking these drugs.
The nurse is administering the 0900 medications to a client "This is a new pill I have never taken before."
who was admitted during the night. Which client statement
indicates that the nurse should further assess the Rationale:
medication order? The client's recognition of a "new" pill requires further assessment (D) to verify that
the medication is correct, if it is a new prescription or a different manufacturer, or if
the client needs further instruction.
Which step(s) should the nurse take when administering Rationale:
ear drops to an adult client? (Select all that apply.) The correct answers (A and B) are the appropriate administration of ear drops. The
dropper should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should
be placed in the outermost canal (D). The auricle is pulled down and back for a child
A. younger than 3 years of age, but not an adult (E).
Place the client in a side-lying position.
B.
Pull the auricle upward and outward.
C.
Hold the dropper 6 cm above the ear canal.
D.
Place a cotton ball into the inner canal.
E.
Pull the auricle down and back
A client has a nursing diagnosis of Altered sleep patterns Rationale:
related to nocturia. Which client instruction is important for Nocturia is urination during the night. (A) is helpful to decrease the production of
the nurse to provide? urine, thus decreasing the need to void at night. (B) helps prevent bladder
infections. (C) may promote sleep, but the fluid will contribute to nocturia. (D) may
A. result in urinary incontinence if the client is sedated and does not awaken to void.
Decrease intake of fluids after the evening meal.
B.
Drink a glass of cranberry juice every day.
C.
Drink a glass of warm decaffeinated beverage at bedtime.
D.
Consult the health care provider about a sleeping pill.
H
E
S
I
F
U
N
D
A
M
E
N
T
A
L
S
S
T
U
D
Y
G
U
I
D
E
Students
also
studied
Terms in this set (57)
Which serum laboratory value should the nurse monitor Sodium
carefully for a client who has a nasogastric (NG) tube to
suction for the past week? Rationale:
Monitoring serum sodium levels (D) for hyponatremia is indicated during prolonged
NG suctioning because of loss of fluids.
, When assisting a client from the bed to a chair, which With the nurse's feet spread apart and knees aligned with the client's knees, stand
procedure is best for the nurse to follow? and pivot the client into the chair.
Rationale:
(B) describes the correct positioning of the nurse and affords the nurse a wide base
of support while stabilizing the client's knees when assisting to a standing position.
The chair should be placed at a 45-degree angle to the bed, with the back of the
chair toward the head of the bed
The nurse assesses a 2-year-old who is admitted for Check for kinks in the tubing and raise the IV pole.
dehydration and finds that the peripheral IV rate by gravity
has slowed, even though the venous access site is Rationale:
healthy. What should the nurse do next? The nurse should first check the tubing and height of the bag on the IV pole (B),
which are common factors that may slow the rate. Gravity infusion rates are
influenced by the height of the bag, tubing clamp closure or kinks, needle size or
position, fluid viscosity, client blood pressure (crying in the pediatric client), and
infiltration.
The nurse is assessing several clients prior to surgery. Taking anticoagulants for the past year.
Which factor in a client's history poses the greatest threat
for complications to occur during surgery? Rationale:
Anticoagulants (B) increase the risk for bleeding during surgery, which can pose a
threat for the development of surgical complications. The health care provider
should be informed that the client is taking these drugs.
The nurse is administering the 0900 medications to a client "This is a new pill I have never taken before."
who was admitted during the night. Which client statement
indicates that the nurse should further assess the Rationale:
medication order? The client's recognition of a "new" pill requires further assessment (D) to verify that
the medication is correct, if it is a new prescription or a different manufacturer, or if
the client needs further instruction.
Which step(s) should the nurse take when administering Rationale:
ear drops to an adult client? (Select all that apply.) The correct answers (A and B) are the appropriate administration of ear drops. The
dropper should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should
be placed in the outermost canal (D). The auricle is pulled down and back for a child
A. younger than 3 years of age, but not an adult (E).
Place the client in a side-lying position.
B.
Pull the auricle upward and outward.
C.
Hold the dropper 6 cm above the ear canal.
D.
Place a cotton ball into the inner canal.
E.
Pull the auricle down and back
A client has a nursing diagnosis of Altered sleep patterns Rationale:
related to nocturia. Which client instruction is important for Nocturia is urination during the night. (A) is helpful to decrease the production of
the nurse to provide? urine, thus decreasing the need to void at night. (B) helps prevent bladder
infections. (C) may promote sleep, but the fluid will contribute to nocturia. (D) may
A. result in urinary incontinence if the client is sedated and does not awaken to void.
Decrease intake of fluids after the evening meal.
B.
Drink a glass of cranberry juice every day.
C.
Drink a glass of warm decaffeinated beverage at bedtime.
D.
Consult the health care provider about a sleeping pill.
