Therapies Part 1- Latest Update
The nurse receives a hand-off report for a client scheduled for dialysis in two hours.
After reviewing the electronic health record (EHR), which actions should the nurse take?
Select all that apply.
Hold the prescribed dose of lisinopril 20 mg by mouth daily.
Deliver the prescribed dose of NPH insulin 5 units subcutaneously.
Administer the first of 2 units of prescribed packed red blood cells.
Hold the prescribed IV antibiotic ordered every 6 hours, due now.
Hold the prescribed dose of sodium polystyrene sulfonate by mouth daily. - CORRECT
ANSWERS-Hold the prescribed dose of lisinopril 20 mg by mouth daily.
Deliver the prescribed dose of NPH insulin 5 units subcutaneously.
Hold the prescribed IV antibiotic ordered every 6 hours, due now.
Hold the prescribed dose of sodium polystyrene sulfonate by mouth daily.
The nurse reviews the electronic health record (EHR) of a 16-year-old client admitted to
the pediatric unit for treatment following an overdose of acetaminophen. In what order
should the nurse perform these prescriptions, from first to last? - CORRECT
ANSWERS-First, the nurse should insert the peripheral venous access device. The
normal saline bolus should be administered before N-acetylcysteine because that
medication will be delivered continuously over a longer period. A clear liquid diet is the
lowest priority after treatment of the client's condition has been initiated.
The nurse should also obtain acetaminophen level now and every eight hours.
For each potential nursing action, click to specify whether the intervention is indicated or
not indicated for the care of the client at this time.
Bolus the client with 4000 units of heparin
Turn off the IV pump
Instruct the lab to draw an anti-Xa level in 6 hours
Reprogram the pump to run at 17 mL/hour
Assess the client for petechiae and bruising
Administer protamine sulfate as an antidote
Ask the client if unilateral leg pain is present
Assess the integrity of the IV site - CORRECT ANSWERS-Not indicated
Not indicated
Indicated
Indicated
Indicated
Not indicated
Not indicated
Indicated
, The nurse cares for a client receiving chemotherapy for leukemia. What actions should
the nurse take when preparing and administering a vesicant agent? Select all that
apply.
Have a second qualified nurse verify the medication with the primary nurse.
Infuse an antiemetic medication through the same line as the chemotherapy.
Place absorbent pads underneath the lines when initiating the infusion.
Wear personal protective equipment when handling the lines.
Check for blood return prior to administration.
Place used supplies and protective equipment in the regular trash.
Use a central line instead of a peripheral line.
Monitor for erythema, pus, red streaks, or bruising at the line site. - CORRECT
ANSWERS-Have a second qualified nurse verify the medication with the primary nurse.
Place absorbent pads underneath the lines when initiating the infusion.
Wear personal protective equipment when handling the lines.
Check for blood return prior to administration.
Use a central line instead of a peripheral line.
Monitor for erythema, pus, red streaks, or bruising at the line site.
The nurse receives a client as a new admission. The client is experiencing a sickle cell
crisis. After reviewing the provider's prescriptions, select the row from the provider's
prescription that indicates the need to contact the healthcare provider for clarification. -
CORRECT ANSWERS-Morphine 1 mg by mouth every 4 hours as needed for pain
greater than 5/10
After reviewing the electronic health record (EHR), drag each word choice to fill in the
blank in each sentence.
The nurse knows that __________ is the priority concern for the client. The nurse
should administer ________ first. The nurse will question the healthcare provider about
the _______ prescription. - CORRECT ANSWERS-dehydration
0.9% NaCl
ampicillin 500 mg
The nurse has an IV pump that can be programmed to run rates in whole numbers. The
available heparin from the pharmacy is shown in the image.
(Heparin Sodium for Injection IV or Subcut use 10,000 units per mL)
(Heparin in 0.9% Sodium Chloride 25,000 units in 500 mL)
Verify the client's weight, allergies, and health history.
Request that the licensed practical/vocational nurse (LPN/LVN) perform a second check
of the medications prior to administration.
Label the tubing with the medication name and date the tubing needs to be changed.
Program the pump to run the bolus first and then start the heparin infusion.
Program the IV pump to run the heparin infusion at 34 mL/hr.
Set the volume to be infused (VTBI) on the pump to 500 mL.
Schedule the lab to draw the anti-Xa level 6 hours after starting the heparin infusion.
Ensure protamine sulfate is available on the unit. - CORRECT ANSWERS-Appropriate
Not appropriate