Questions and Answers | Latest 2021
1. A nurse is caring for a client who reports pain. When documenting the
quality of the clients pain on an initial pain assessment, the nurse should
record which of the following client statements?
-The pain is like a dull ache in my stomach
(The client is describing the quality of the pain, which is how the pain feels in the
client's own words.)
2. A client who is nonambulatory notifies the nurse that his trash can is on fire.
After the nurse confirms the presence of the fire, which of the following
actions should the nurse take next?
- Evacuate the client
(According to the RACE mnemonic, the first action in response to a fire is to
rescue the clients, moving them to a safe area.)
3. A nurse is completing an admission assessment for a client who reports
vomiting and diarrhea for the past 3 days. Which of the following findings
should the nurse expect?
- Rapid heart rate
(tachycardia indicates fluid volume deficit, which is an expected finding for a
client who has had vomiting and diarrhea for 3 days)
4. A nurse has accepted a verbal prescription “for three tenth of a milligram of
levothyroxine IV stat” for a client who has myxedema coma. How should
the nurse transcribe the dosage of this medication in the client’s medical
record?
- 0.3
(The use and placement of a decimal point can potentially cause a medication error
if documented incorrectly. A zero should precede a decimal point, as in 0.3 mg, but
should not follow a decimal point unless a whole number follows the zero, as in
2.05 mg.)
5. A nurse is preparing a heparin infusion for a client who was admitted to the
facility with deep-vein thrombosis. The prescription reads: 25,000 units of
heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr. At what
rate should the nurse set the infusion pump.
- 8 mL/hr
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, ( Step 1: What is the unit of measurement the nurse should calculate? mL/hr
Step 2: What is the dose the nurse should administer? Dose to administer = Desired
800 units/hr
Step 3: What is the dose available? Dose available = Have 25,000 units
Step 4: Should the nurse convert the units of measurement? No
Step 5: What is the quantity of the dose available? 250 mL
Step 6: Set up an equation and solve for X.
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https://www.coursehero.com/file/55189707/ATI-Form-Bdocx/