Lju4801 assignment questions
When evaluating a client's plan of care, the nurse determines that a desired outcome was not
achieved. Which action should the nurse implement first? Note which actions were not
implemented.
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with
a cuff that is too small, but the blood pressure reading obtained is within the client's usual range.
What action is most important for the nurse to implement? Reassess the client's blood pressure
using a larger cuff.
A client returns to the nursing unit from surgery with a prescription for Lactated Ringer's
solution 1000 mL to be infused over 10 hours. The IV administration set delivers 60 gtts/mL.
The nurse should regulate the infusion to deliver how many gtts/minute? 100
Examination of a client complaining of itching on his right arm reveals a rash made up of
multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse
record this finding? Localized red rash compromised of flat areas, pinpoint to 0.5 cm in
diameter.
In planning care for a client with an acute stroke resulting in right-sided hemiplegia, which
positioning should the nurse use to maintain optimal functioning? Left lateral, supine, brief
periods on the right side, and prone.
A college student who is diagnosed with a vaginal infection and vulva irritation describes the
vaginal discharge as having a "cottage-cheese" appearance. Which prescription should the nurse
implement FIRST? Instill the first dose of nystatin (Mycostatin) vaginally per applicator.
When conducting an admission assessment, the nurse should ask the client about the use of
complimentary healing practices. Which statement is accurate regarding the use of these
practices? Many complimentary healing practices can be used in conjunction with
conventional practices.
After a client has been pre-medicated for surgery with an opioid analgesic, the nurse discovers
that the operative permit has not been signed. What action should the nurse implement? Notify
the surgeon that the consent form has not been signed.
Prior to administering a newly prescribed medication to a client, the nurse reviews the adverse
effects of the medication listed in a drug reference guide and determines the priority risks to the
client. While performing this action, the nurse is engaged in which step of the nursing process?
Analysis
Rationale:
The nurse is analyzing data to establish and individualized nursing diagnosis, such as, "Risk for
injury related to side effects of drugs."
A client with a gastrostomy tube (GT) receives a prescription for a 250 mL bolus feeding of
Glucerna 60% enteral formula. The nurse should dilute the full-strength formula with how many
mL of water? 100
The nurse is caring for a client with a continuous feeding through a percutaneous endoscopic
gastrostomy (PEG) tube. Which intervention should the nurse include in the plan of care? Check
for tube placement and residual volume q4 hours.
When evaluating a client's plan of care, the nurse determines that a desired outcome was not
achieved. Which action should the nurse implement first? Note which actions were not
implemented.
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with
a cuff that is too small, but the blood pressure reading obtained is within the client's usual range.
What action is most important for the nurse to implement? Reassess the client's blood pressure
using a larger cuff.
A client returns to the nursing unit from surgery with a prescription for Lactated Ringer's
solution 1000 mL to be infused over 10 hours. The IV administration set delivers 60 gtts/mL.
The nurse should regulate the infusion to deliver how many gtts/minute? 100
Examination of a client complaining of itching on his right arm reveals a rash made up of
multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse
record this finding? Localized red rash compromised of flat areas, pinpoint to 0.5 cm in
diameter.
In planning care for a client with an acute stroke resulting in right-sided hemiplegia, which
positioning should the nurse use to maintain optimal functioning? Left lateral, supine, brief
periods on the right side, and prone.
A college student who is diagnosed with a vaginal infection and vulva irritation describes the
vaginal discharge as having a "cottage-cheese" appearance. Which prescription should the nurse
implement FIRST? Instill the first dose of nystatin (Mycostatin) vaginally per applicator.
When conducting an admission assessment, the nurse should ask the client about the use of
complimentary healing practices. Which statement is accurate regarding the use of these
practices? Many complimentary healing practices can be used in conjunction with
conventional practices.
After a client has been pre-medicated for surgery with an opioid analgesic, the nurse discovers
that the operative permit has not been signed. What action should the nurse implement? Notify
the surgeon that the consent form has not been signed.
Prior to administering a newly prescribed medication to a client, the nurse reviews the adverse
effects of the medication listed in a drug reference guide and determines the priority risks to the
client. While performing this action, the nurse is engaged in which step of the nursing process?
Analysis
Rationale:
The nurse is analyzing data to establish and individualized nursing diagnosis, such as, "Risk for
injury related to side effects of drugs."
A client with a gastrostomy tube (GT) receives a prescription for a 250 mL bolus feeding of
Glucerna 60% enteral formula. The nurse should dilute the full-strength formula with how many
mL of water? 100
The nurse is caring for a client with a continuous feeding through a percutaneous endoscopic
gastrostomy (PEG) tube. Which intervention should the nurse include in the plan of care? Check
for tube placement and residual volume q4 hours.
