A nurse is caring for a client who has a prescription for famotidine 160 mg PO
every 6 hr. Available is famotidine oral suspenision 40 mg/5 mL. How many
mL should the nurse administer per dose? Correct Ans - 20 mL
A nurse is collecting data from a client who has an iron deficiency anemia.
Which of the following findings should the nurse expect? Correct Ans -
Difficulty concentrating
*In clients who have iron deficiency anemia, body cells do not receive the
required oxygen because there is less hemoglobin for binding. The nurse
should recognize that impaired oxygenation of brain tissue can lead to
dizziness and difficulty concentrating.
A nurse manager is preparing to complete a performance analysis for a group
of assistive personnel (AP). The manager asks a staff nurse for feedback on
each AP's abilities. Which of the following actions should the staff nurse take?
Correct Ans - Discuss how each AP's actions measure against the job
description.
*To provide objective information, the staff nurse should compare the
behavior of each AP to the facility job description. The nurse can provide
specific information about how each AP either meets the standard or
demonstrates a need for improvement.
A nurse is reviewing a client's electronic medical record and kids that an
assistive personnel (AP) recorded the client's temperature as 35.5°C (95.5°F)
2 hr earlier. Which of the following actions should the nurse take first?
Correct Ans - Check the client's temperature
*According to the nursing process, the first action the nurse should take is to
collect data from the client. Therefore, the nurse should retake the client's
temperature.
A nurse on an acute care unit is collecting data from a school-age child who
has cystic fibrosis (CF). Which of the following findings is the priority for the
nurse to report to the provider? Correct Ans - Reports lack of appetite
, *The nurse should identify that the greatest risk to a child who has a
decreased appetite is pulmonary infection. Anorexia, along with other
manifestations, such as loss of weight and lethargy, are commonly seen in
children who have CF which an infection exacerbation. Typical manifestations
of pulmonary infection, such as fever and tachypnea, might now be seen in a
child who has CF. Additionally, a child who is anorexic is at increased risk for
diminished lung function.
A nurse in a long-term care facility is observing a newly licensed nurse who is
providing tracheostomy care for a client. The nurse identifies proper
performance of the procedure when the newly licensed nurse selects which of
the following solutions to clean the inner cannula? Correct Ans -
Hydrogen peroxide
*The nurse should identify that sterile hydrogen peroxide solution is used to
loosen secretions from the inner cannula during cleaning. If the client skin
becomes irritated, the nurse should choose 9% sodium chloride solution.
A nurse is reinforcing discharge teaching with a client who is postoperative
following an open radical prostatectomy. Which of the following instruction
should the nurse include in the teaching? Correct Ans - "Perform Kegel
exercises daily."
*The nurse should instruct the client to perform Keagle exercises to promote
the control of urine flow and reduce incontinence.
A nurse is reinforcing teaching with a group of clients about the Heimlich
maneuver during a first aid class. The nurse should include the teaching that
which of the following manifestations indicates the need for the Heimlich
maneuver to be performed? Correct Ans - Difficulty breathing
Coughing
Presence of stridor
*The Heimlich maneuver is performed when the airway is obstructed by
foreign body. A client who has an obstructed airway may exhibit
manifestation such as coughing, choking, gagging, difficulty breathing,
cyanosis, and stridor.