COMPLETE SOLUTIONS
◉ The nurse is preparing a client for surgery. Which finding
indicates that the client is ready to proceed to the operating room
(OR) for a scheduled surgical procedure? Answer: Hemoglobin 10.1
grams
◉ The nurse is preparing to administer an intramuscular injection in
the ventrogluteal site of a client who weighs 80 kg. What size needle
should the nurse select? Answer: 21-gauge, 1.5-inch needle
◉ A client at 38-weeks gestation is in active labor, and a vaginal
birth after Cesarean section (VBAC) is planned. Vaginal exam
indicates that the client is 6 cm dilated, 90% effaced, and at station 0
with intact membranes. As the client's contraction become stronger,
the fetal heart rate decelerates during the contractions but returns
to baseline. What action should the nurse take? Answer: Continue to
monitor the client's labor progress
◉ An elderly client with limited mobility reports frequent episodes
of nocturia. To reduce the risk for urinary incontinence, what action
should the nurse implement? Answer: Keep the call bell within the
client's reach
,◉ Which diagnostic tests are most important for the nurse to
monitor when providing care for a client with a bowel obstruction?
Answer: Serum electrolytes
◉ 28. A 72-year-old male client reports that he has felt depressed
since his wife died six months ago. What question is most important
for the nurse to ask this client? Answer: "Have you ever felt like
hurting yourself?"
◉ After administering the first dose of newly prescribed to four
clients within a thirty minute time frame, the nurse evaluates each
client for therapeutic responses or any adverse reactions. Which
medication should the nurse evaluate first? Answer:
HYdromorphone (Dilaudid)
◉ What is the most important symptom the nurse should monitor
the client for while assisting with the insertion of a subclavian
central venous catheter? Answer: Shortness of breath
◉ The nurse is developing a plan of care for a client who has a
prescription for the calcium channel-blocker nifedipine (Procardia)
to treat angina pectoris. What is the purpose for administration of
this medication? Answer: Decrease myocardial oxygen demands
◉ While transcribing a new prescription, the nurse notes that the
prescribed dosage is much lower than the recommended dosage
,listed in the drug reference guide. Which client data supports this
dosage reduction? Answer: Increased liver enzymes
◉ The nurse notes that a postoperative adult client's respiratory
rate is 10 breaths/minute. Which factor in the client's history is the
most likely explanation for
this finding? Answer: The PCA pump containing morphine sulfate
was discontinued 15 minutes before vital
signs were taken
◉ The charge nurse working on a postpartum unit is making
assignments for a staff consisting of a registered nurse (RN), a
practical nurse (PN), and two unlicensed assistive personnel (UAP).
Which client should the charge nurse assign to the registered
nurse? Answer: A primigravida who delivered an infant 6 hours ago
via vaginal delivery and is now complaining of seeing spots
◉ 35. A 13-year-old client with non-union of a comminuted fracture
of the tibia is admitted with osteomyelitis. The healthcare provider
collects bone aspirate specimens for culture and sensitivity and
applies a cast to the adolescent's lower leg. What action
should the nurse implement next? Answer: Initiate parenteral
antibiotic therapy
, ◉ A child with heart is receiving the diuretic furosemide (Lasix) and
has a serum potassium level 3.0 mEq/L. Which assessment is most
important for the nurse to
obtain? Answer: Heart rate and cardiac rhythm
◉ It is determined that a client with breast cancer has metastasis to
the liver. What is the most likely explanation for the client's risk of
developing hemorrhagic tendencies? Answer: The inability of the
liver to synthesize clotting factors
◉ The healthcare provider performs a paracentesis on a client with
ascites and 3 liters of fluid are removed. Which assessment
parameter is most critical for the nurse to monitor following the
procedure? Answer: Vital signs
◉ Which instruction should the nurse provide a client who is taking
the conventional antipsychotic medication chlorpromazine
(Thorazine) for schizophrenia? Answer: Immediately report rigidity
of the musculoskeletal system or a sudden high fever
◉ A client is receiving a continuous infusion of normal saline at 125
ml per hour. The nurse prepares to change the primary IV tubing
and hang a new bag of normal saline to maintain the prescription. In
which sequence should the nurse implement the procedure?
(Arrange with first on top and last on bottom) Answer: 1. Spike a
new bag of normal saline 1000ml using new tubing