Answers Verified 100% Correct
The nurse should withhold which medication if the client's serum potassium level is 6.2
mEq/? - ANSWER Spironolactone
A nurse receives a report on a pt who is four hours post-total abdominal hysterectomy.
The previous nurse reports that it was necessary to change the client's perineal pad
hourly and that it is again saturated. The previous nurse also reports that the client's
urinary output has decreased. Which action should the nurse implement first? -
ANSWER Assess for weakness or dizziness
A pt who is admitted for primary hypothyroidism has early signs of myxedema coma. In
assessing the pt, in which sequence should the nurse complete these actions? -
ANSWER -Observe breathing patterns
-assess blood pressure
-measure body temp
-palpate for pedal edema
The nurse is taking the blood pressure measurement of a client with Parkinson's
disease. Which information in the admission assessment is relevant to the nurse's plan
for taking the blood pressure reading? SATA - ANSWER Blurred Vision
Flat Affect
frequent syncope
After administering a proton pump inhibitor, which action should the nurse take to
evaluate the effectiveness of the medication? - ANSWER Ask the pt about
gastrointestinal pain
A pt is receiving enoxaparin 30 mg subcutaneously twice a day. In assessing for
adverse effects of the medication, which serum laboratory value most important for the
nurse to monitor - ANSWER platelet count
A pediatric client is taking the beta-adrenergic blocking agent propranolol. In
developing a teaching plan, the nurse should teach the parents to report which sign of
overdose? - ANSWER Bradycardia
The nurse is demonstrating correct transfer procedures to the unlicensed assistive
personnel working on a rehab unit. The UAP asks the nurse how to safely move a
physically disabled pt from the... wheelchair to the bed. Which action should the nurse
, recommend? - ANSWER Place the pt locked wheelchair on the pt strong side next to
the bed
The nurse has completed the diet teaching of a client who is being discharged
following tx of a leg wound. A high protein diet is encouraged to promote wound
healing. Which lunch choice by the pt indicates that the teaching was effective? -
ANSWER A tuna fish sandwich with chips and ice cream
When conducting diet teaching for a pt who was dx with a myocardial infarction, which
snack foods should the nurse encourage the pt to eat? SATA - ANSWER Fresh
Turkey slices and berries chick bouillon soup and toast
raw unsalted almonds and apples
A pt taking clopidogrel reports the onset of diarrhea. Which nursing action should the
nurse implement first? - ANSWER Observe the appearance of the stool
A pt is dx with Meniere's disease. Which problem should the nurse identify as most
important in the plan of care? - ANSWER Risk for injury related to vertigo
A new nurse preparing to irrigate an IV catheter is attaching a 24 gauge needle. Which
action should the charge nurse implement? - ANSWER Suggest the nurse use 20g
needle
A nurse working on an Endocrine Unit should see which client first? - ANSWER A pt
taking corticosteroids who has become disoriented in the last two hours.
After an older pt receives tx for drug toxicity the healthcare provider prescribes a 24 hr
creatinine clearance, the nurse notes that the pt serum creatinine is 0.3mg. Which
action should the nurse implement? - ANSWER Notify the healthcare provider of the
results
An older adult pt with Systemic inflammatory syndrome (SIRS) has a temp of 101.8, HR
of 110, and RR of 24 breaths/min. Which additional finding is most important to report to
the healthcare provider? - ANSWER Serum Creatinine of 2mg/dl
A pt in the third trimester of pregnancy reports that she feels some lumpy places in her
breasts and that her nipples sometimes leak a yellowish fluid. She has an appointment
with her healthcare provider in two weeks. What actions should the nurse take? -
ANSWER Explain that this is normal recreation and can be assessed at the next visit.
A pt presents to the labor and delivery unit with a report of leaking fluid that is greenish-
brown vaginal discharge. Which action should the nurse take first? - ANSWER begin
continuous fetal monitoring