Answers
/. A client is receiving a continuous half strength tube feeding at 50ml/hour. To prepare
enough of the solution for eight hours, how many ml of full strength feeding will the
nurse need? (Enter numeric value only.) - Answer-✅200ml . 25 ml of full strength
feeding mixed with 25ml of water provided 50ml of half strength. 25ml × 8 hours= 200ml
/.An elderly male client is experiencing urinary incontinence. What is the best initial
nursing action? - Answer-✅Apply an external condom catheter
/.3. A male Muslim client with pneumonia is scheduled to receive a dose of an
intravenous antibiotic but refuses to allow the nurse to begin the medication, stating he
cannot allow fluids to enter his body once he is cleansed for prayer. What action should
the nurse implement? - Answer-✅Reschedule administration of the antibiotic until after
he completes his prayers
/.UAP using a hand sanitzers that is alcohol for 2 minutes - Answer-✅tell that hand
sanitizer use is less > 2min
/.5.A child is to receive vancomycin (Vancocin) 40 mg/kg IV one hour before a
scheduled procedure. The child weighs 44 pounds. How many mg of the medication
should the nurse administer - Answer-✅Answer: 800 Rationale: First, convert the child's
weight to kg: 44 pounds divided by
2.2pound/kg = 20 kg. Next calculate the mg/kg/dose, 40 mg x 20 kg = 800mg
/.6. While assisting a postpartum client with perineal care, the nurse notes that her
vaginal bleeding spurts rather than trickles from the vagina. The uterine fundus is firm
and the client's vital signs are pulse 88 beats/minute; respiratory rate, 21
breaths/minute; and blood pressure, 104/68 mmHg. What action should the nurse take
next? - Answer-✅Compare current vital signs with previous vital signs
/.A 6-year old boy was hit with a bat while playing at school. He has a splinter of wood
imbedded in his eye. Which action should the school nurse take? - Answer-✅Have the
parent take the child for emergency help
/.Within four weeks of childbirth, a client is admitted to the hospital for disorganized
speech bizarre behavior, and strange thoughts about her infant being possessed by
demons. The nurse identifies a nursing diagnosis of "Altered thought processes,
secondary to" what condition? - Answer-✅Postpartum psychosis
, /.The nurse identifies a priority diagnosis of, "Altered comfort related to menstrual
cramps" for a 25-year-old female client. Which self-care activity should the nurse
emphasize in the client's teaching plan? - Answer-✅Regular aerobic exercise.
/.Psych/Alcohol/Tylenol overdose antidote - Answer-✅Give Mucomyst
/.Medical Surgical/Laxative abuses - Answer-✅Patient -taking Milk of Magnesium
/.Spiritual/Documentation - Answer-✅Native American - Allow pt's family to stay in the
room
/.Leadership- Interpreter informed consent - Answer-✅Pt should sign the consent
/.Geriatrics/Emergency Rib fractures fall - Answer-✅Pulmonary embolism
/.A client diagnosed with major depression is being allowed a weekend pass from the
psychiatric unit. Which instruction should the nurse provide to the client's family? -
Answer-✅Involve the client in usual at home activities
/.Upon assessment, the nurse discovers that a postpartum client has persistent red
lochia.
Which of the following does this assessment finding suggest to the nurse? - Answer-
✅Coagulation disorders
/.The healthcare provider performs peritoneal dialysis on a client, after which 2 liters of
fluid is drained. What action should the nurse complete first? - Answer-✅Assess vital
signs.
/.After administering a medication through a nasogastric tube connected to suction,
what action should the nurse take first? - Answer-✅Clamp the tube
/.The nurse is caring for four clients: Client A 94% o2 saturation, Client B, hemoglobin of
8.;
Client C, potassium level of 3.8 and Client D appendectomy who has a white blood cell
count of 15,000. What
should the nurse implement? - Answer-✅Determine if Client B has two units of packed
cells available in the blood bank.
/.Triage question with a train wreck The psychiatric nurse is called to a train derailment
that was likely caused by a terrorist bomb. In triaging those in need of immediate care,
what is the priority ranking for these cases?
(arrange these cases in order or priority with the top item requiring the most immediate
care and the bottom item requiring the least priority care) - Answer-✅A mother and
father have just arrived on the .