QUESTIONS WITH SOLUTIONS GRADED A+
◉ A nurse is caring for a client who has thrombophlebitis and is
receiving heparin by continuous IV infusion. The client asks the nurse
how long it will take for the heparin to dissolve the clot. Which of the
following responses should the nurse give? Answer: Heparin does not
dissolve clots. It stop new clots from forming.
◉ A nurse is providing education to a client who is in labor and has a
prescription for a continuous IV infusion of oxytocin. Which of the
information should the nurse include? Answer: Your contractions will
become stronger and more frequent."
Oxytocin is diluted with sodium chloride and administered IV via an
infusion pump device to induce or strengthen uterine contractions during
labor. The client who is receiving an oxytocin drip is closely monitored
to promote a safe delivery and prevent maternal and/or fetal
complications. The desired concentration of oxytocin medication is
determined by the desired labor contraction pattern that should increase
in frequency, duration, and intensity. The nurse closely monitors risks of
continuous IV infusion of oxytocin to determine when to discontinue the
medication. Risks include fetal distress (fetal bradycardia) caused by
hyper-stimulation of the uterus compromising blood flow to the fetus.
Uterine contractions lasting longer than 90 seconds should prompt the
nurse to discontinue the medication.
,◉ A client's IV bag of total parenteral nutrition (TPN) is empty, and the
new bag has not arrived from the pharmacy. Which of the following is
the most appropriate intervention for the nurse to make? Answer: Hang a
bag of dextrose 10% in water (D10W) until the new bag of TPN is
delivered.
If TPN runs out or is not available to hang, then the protocol requires
that D10W is infused. D10W is a hypertonic solution that will maintain
glucose level and prevent rebound hypoglycemia.
◉ A nurse is caring for a client who is receiving heparin by continuous
IV infusion. Which of the following medications should the nurse plan
to administer in the event of an overdose? Answer: Protamine
Protamine reverses the effects of heparin and is used in the event of an
overdose.
◉ A nurse gives a client morphine sulfate 2 mg IV push after the client
reports pain. The nurse evaluates the client 15 min after the injection.
Which of the following findings represent an adverse effect? Answer:
espiratory rate of 8 breaths per minute.(
The nurse's evaluation of the client's displaying respiratory depression of
8 per minutes represents an adverse effect of the morphine.
◉ A nurse is preparing to administer hydromorphone 2.5 mg. The
amount available is 5 mg/5 mL elixir. How many mL should the nurse
,administer? (Round the answer to the nearest tenth. Use a leading zero if
it applies. Do not use a trailing zero.). Answer: 2.5
◉ A postoperative client is receiving hydromorphone HCL (Dilaudid)
via a PCA pump and reports continuous pain. Which of the following
should be the nurse's initial action? Answer: Check the display on the
PCA pump.
The nurse needs to assess the display to determine how much medication
has been administered. Some clients are fearful of developing an
addiction to narcotics and may be reluctant to use the PCA.
◉ A nurse is preparing to administer insulin lispro (Humalog) to a client
who has type 1 diabetes mellitus. Which of the following nursing actions
is appropriate? Answer: Inject the insulin 15 min before a meal.
MY ANSWER
The appropriate nursing action is to administer the insulin 15 min before
a meal because insulin lispro is a rapid-acting insulin and the client may
develop hypoglycemia quickly if they don't eat.
◉ A client who has been taking losartan (Cozaar) has a hoarse voice,
swollen lips and tongue. (Move the nursing actions into the box on the
right, placing them in the selected order of performance. All steps must
be used.). Answer: Maintaining an adequate airway and oxygen status is
critical in any ACE or ARB treated patient experiencing angioedema.
Continuous pulse oximetry should be applied to the client, and oxygen
administered as indicated by pulse oximetry status. Intubation or
tracheotomy should be considered if adequate oxygenation cannot be
, maintained.After oxygenation status and airway have been evaluated,
the nurse should administer SQ epinephrine at 1:1000 (usually 0.3 to 0.5
ml). This dose may be repeated one time if no response is achieved.After
initiation of an IV access and isotonic IV fluids at a keep vein open rate,
IV antihistamines and corticosteroids should be administered.
Antihistamines are generally administered first as onset of action takes a
bit longer. By administering the antihistamines first, then followed by IV
corticosteroids (which have an onset of action of generally less than 10
min), the antihistamines have begun to work while immediate relief is
being offered by the corticosteroids. If no response is seen at this time,
fresh frozen plasma (FFP) may be administered to help reverse the
angioedema. FFP has been shown to substantially improve outcomes
associate with angioedema.After stabilization, the causative agent should
be permanently discontinued, and the client transferred to a monitored
bed as applicable. Most clients who have experienced angioedema will
remain hospitalized for 12 to 24 hr post event, and the nurse should
transfer the client upon stabilization to the critical care unit.
◉ A nurse is preparing to administer total parental nutrition (TPN) 1800
mL to infuse over 24 hr. The nurse should set the IV pump to deliver
how many mL/hr? (Round the answer to the nearest whole number. Use
a leading zero if it applies. Do not use a trailing zero.). Answer: 75
◉ A nurse in a substance abuse clinic is assessing a client who recently
started taking disulfiram. The client reports having discontinued the
medication after experiencing severe nausea and vomiting. Which of the
following reasons should the nurse suspect to be a likely cause of the
client's distress? Answer: The client consumed alcohol while taking the
medication.