A nurse is preparing to give medications through a nasogastric feeding tube. Which
action should prevent complications during administration?
A. Mix each medication individually
B. Use sterile gloves for the procedure
C. Monitor vital signs before giving medications
D. Mix all medications together to facilitate administration
A. Mix each medication individually
(Medications should be mixed separately (A) to prevent clumping.)
The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN)
via a central line at 54 mL/hr. When initially assessing the client, the nurse notes that the
TPN solution has run out and the next TPN solution is not available. What immediate
,action should the nurse take?
A. Infuse normal saline at a keep vein open rate.
B. Discontinue the IV and flush the port with heparin.
C. Infuse 10% dextrose and water at 54 mL/hour.
D. Obtain a stat blood glucose level and notify the HCP.
C. Infuse 10% dextrose and water at 54 mL/hour.
(TPN is discontinued gradually to allow the client to adjust decreased levels of
glucose. Administering 10% dextrose in water at the prescribed rate (C) will
keep the client from experiencing hypoglycemia until the next TPN solution is
available. The client could experience a hypoglycemic reaction if the current
level of glucose (A) is not maintained or if the TPN is discontinued abruptly (B).
There is no reason to obtain a stat blood-glucose level (D) and the HCP
cannot do anything about this situation.)
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?
A. Complimentary healing practices interfere with the efficacy of the medical model of
treatment.
B. Conventional medications are likely to interact with folk remedies and cause adverse
effects.
C. Many complimentary healing practices can be used in conjunction with conventional
practices.
D. Conventional medical practices will ultimately replace the use of complimentary
healing practices.
, C. Many complimentary healing practices can be used in conjunction with
conventional practices. (Conventional approaches to health care can be
depersonalizing and often fail to take into consideration all aspects of an
individual, including body, mind, and spirit. Often complimentary healing
practices can be used in conjunction with conventional medical practices (C),
rather than interfering (A) with conventional practices, causing adverse effects
(B), or replacing conventional medical care (D). )
The nurse plans to obtain health assessment information from a primary source. Which
option is a primary source for the completion of the health assessment?
Give this one a try later!
CLIENT (HCP, fam, previous medical records-- secondary sources)
When evaluating a client's plan of care, the nurse determines that a desire outcome was
not achieved. Which action should the nurse implement first?
A. Establish a new nursing diagnosis.
B. Note which actions were not implemented.
C. Add additional nursing orders to the plan.
D. Collaborate with the HCP to make changes.
Give this one a try later!
B. Note which actions were not implemented.
(First, the nurse should review which actions in the original plan were not
implemented (B) in order to determine why the original plan did not produce
the desired outcome. Appropriate revisions can then be made, which may
include revising the expected outcome, or identifying a new nursing diagnosis
(A). (C) may be needed if the nursing actions were unsuccessful, or were
unable to be implemented. (D) other members of the healthcare team may be
, necessary to collaborate changes once the nurse determines why the original
plan did not produce the desired outcome.
The nurse observes that a male client has removed the covering from an ice park applied
to his knee. What action should the nurse take first?
A. Observe the appearance of the skin under the ice pack.
B. Instruct the client regarding the need for the covering.
C. Reapply the covering after filling with fresh ice.
D. Ask the client how long the ice was applied to the skin.
Give this one a try later!
Observe the appearance of the skin under the ice pack (The first action taken
by the nurse should be to assess the skin for any possible thermal injury. If no
injury to the skin has occurred, the nurse can take the other actions.)
A male client being discharged with a prescription for the bronchodilator theophylline
tells the nurse that he understands he is to take three doses of the medication each day.
Since, at the time of discharge, time-released capsules are not available, which dosing
schedule should the nurse advise the client to follow?
Give this one a try later!
8 AM, 4 PM, and midnight
(Theophylline should be administered on a regular around the clock schedule
to provide the best bronchodilating effect and reduce the potential for
adverse effects.)
action should prevent complications during administration?
A. Mix each medication individually
B. Use sterile gloves for the procedure
C. Monitor vital signs before giving medications
D. Mix all medications together to facilitate administration
A. Mix each medication individually
(Medications should be mixed separately (A) to prevent clumping.)
The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN)
via a central line at 54 mL/hr. When initially assessing the client, the nurse notes that the
TPN solution has run out and the next TPN solution is not available. What immediate
,action should the nurse take?
A. Infuse normal saline at a keep vein open rate.
B. Discontinue the IV and flush the port with heparin.
C. Infuse 10% dextrose and water at 54 mL/hour.
D. Obtain a stat blood glucose level and notify the HCP.
C. Infuse 10% dextrose and water at 54 mL/hour.
(TPN is discontinued gradually to allow the client to adjust decreased levels of
glucose. Administering 10% dextrose in water at the prescribed rate (C) will
keep the client from experiencing hypoglycemia until the next TPN solution is
available. The client could experience a hypoglycemic reaction if the current
level of glucose (A) is not maintained or if the TPN is discontinued abruptly (B).
There is no reason to obtain a stat blood-glucose level (D) and the HCP
cannot do anything about this situation.)
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?
A. Complimentary healing practices interfere with the efficacy of the medical model of
treatment.
B. Conventional medications are likely to interact with folk remedies and cause adverse
effects.
C. Many complimentary healing practices can be used in conjunction with conventional
practices.
D. Conventional medical practices will ultimately replace the use of complimentary
healing practices.
, C. Many complimentary healing practices can be used in conjunction with
conventional practices. (Conventional approaches to health care can be
depersonalizing and often fail to take into consideration all aspects of an
individual, including body, mind, and spirit. Often complimentary healing
practices can be used in conjunction with conventional medical practices (C),
rather than interfering (A) with conventional practices, causing adverse effects
(B), or replacing conventional medical care (D). )
The nurse plans to obtain health assessment information from a primary source. Which
option is a primary source for the completion of the health assessment?
Give this one a try later!
CLIENT (HCP, fam, previous medical records-- secondary sources)
When evaluating a client's plan of care, the nurse determines that a desire outcome was
not achieved. Which action should the nurse implement first?
A. Establish a new nursing diagnosis.
B. Note which actions were not implemented.
C. Add additional nursing orders to the plan.
D. Collaborate with the HCP to make changes.
Give this one a try later!
B. Note which actions were not implemented.
(First, the nurse should review which actions in the original plan were not
implemented (B) in order to determine why the original plan did not produce
the desired outcome. Appropriate revisions can then be made, which may
include revising the expected outcome, or identifying a new nursing diagnosis
(A). (C) may be needed if the nursing actions were unsuccessful, or were
unable to be implemented. (D) other members of the healthcare team may be
, necessary to collaborate changes once the nurse determines why the original
plan did not produce the desired outcome.
The nurse observes that a male client has removed the covering from an ice park applied
to his knee. What action should the nurse take first?
A. Observe the appearance of the skin under the ice pack.
B. Instruct the client regarding the need for the covering.
C. Reapply the covering after filling with fresh ice.
D. Ask the client how long the ice was applied to the skin.
Give this one a try later!
Observe the appearance of the skin under the ice pack (The first action taken
by the nurse should be to assess the skin for any possible thermal injury. If no
injury to the skin has occurred, the nurse can take the other actions.)
A male client being discharged with a prescription for the bronchodilator theophylline
tells the nurse that he understands he is to take three doses of the medication each day.
Since, at the time of discharge, time-released capsules are not available, which dosing
schedule should the nurse advise the client to follow?
Give this one a try later!
8 AM, 4 PM, and midnight
(Theophylline should be administered on a regular around the clock schedule
to provide the best bronchodilating effect and reduce the potential for
adverse effects.)
