An aged patron with a fractured left hip is on strict bedrest. Which nursing measure is important
to the client's nursing care?
A. Massage any reddened areas for at least 5 minutes.
B. Encourage active variety of motion sports on extremities.
C. Position the purchaser laterally, inclined, and dorsally in sequence.
D. Gently elevate the customer when entering into a preferred role.
D. Gently raise the patron whilst stepping into a desired function.
To keep away from shearing forces when repositioning, the consumer should be lifted gently
across a floor (D). Reddened regions have to now not be massaged (A) due to the fact this
could boom the harm to already traumatized pores and skin. To manipulate ache and muscle
spasms, lively variety of motion (B) may be constrained at the affected leg. The position
described in (C) is contraindicated for a purchaser with a fractured left hip.
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The nurse is administering medications through a nasogastric tube (NGT) which is connected to
suction. After ensuring accurate tube placement, what motion have to the nurse take
subsequent?
A. Clamp the tube for 20 mins.
B. Flush the tube with water.
C. Administer the medicines as prescribed.
D. Crush the tablets and dissolve in sterile water.
B. Flush the tube with water.
The NGT ought to be flushed before, after and in among every medication administered (B).
Once all medicines are administered, the NGT have to be clamped for 20 minutes (A). (C and
D) may be carried out handiest after the tubing has been flushed.
A customer who is in hospice care complains of growing quantities of ache. The healthcare
issuer prescribes an analgesic every four hours as wanted. Which action have to the nurse
implement?
,A. Give an round-the-clock time table for administration of analgesics.
B. Administer analgesic medicinal drug as needed while the pain is excessive.
C. Provide medicine to maintain the purchaser sedated and ignorant of stimuli.
D. Offer a medication-free length so that the customer can do each day activities.
A. Give an round-the-clock schedule for administration of analgesics.
The simplest control of ache is performed the use of an around-the-clock schedule that provides
analgesic medicines on a ordinary basis (A) and in a timely way. Analgesics are less powerful if
pain persists till it's far severe, so an analgesic medicine need to be administered earlier than
the customer's ache peaks (B). Providing consolation is a concern for the consumer who's
demise, however sedation that impairs the client's ability to have interaction and experience the
time before existence ends have to be minimized (C). Offering a remedy-loose length allows the
serum drug level to fall, which isn't an powerful approach to manipulate continual pain (D).
When assessing a patron with wrist restraints, the nurse observes that the palms on the proper
hand are blue. What motion must the nurse implement first?
A. Loosen the right wrist restraint.
B. Apply a pulse oximeter to the proper hand.
C. Compare hand coloration bilaterally.
D. Palpate the right radial pulse.
A. Loosen the proper wrist restraint.
The precedence nursing motion is to repair stream with the aid of loosening the restraint (A),
because blue hands (cyanosis) shows decreased move. (C and D) are also important nursing
interventions, however do now not have the priority of (A). Pulse oximetry (B) measures the
saturation of hemoglobin with oxygen and is not indicated in situations wherein the cyanosis is
associated with mechanical compression (the restraints).
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The nurse is assessing the nutritional status of numerous clients. Which client has the greatest
nutritional want for added intake of protein?
A. A university-age track runner with a sprained ankle.
B. A lactating woman nursing her three-day-vintage infant.
C. A faculty-aged toddler with Type 2 diabetes.
D. An aged man being handled for a peptic ulcer.
B. A lactating girl nursing her 3-day-antique toddler.
,A lactating girl (B) has the finest need for extra protein intake. (A, C, and D) are all situations
that require protein, however do now not have the expanded metabolic protein demands of
lactation.
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A customer is inside the radiology branch at 0900 while the prescription levofloxacin (Levaquin)
500 mg IV q24h is scheduled to be administered. The purchaser returns to the unit at 1300.
What is the exceptional intervention for the nurse to implement?
A. Contact the healthcare company and complete a remedy variance form.
B. Administer the Levaquin at 1300 and resume the 0900 agenda inside the morning.
C. Notify the rate nurse and entire an incident file to provide an explanation for the ignored
dose.
D. Give the neglected dose at 1300 and alternate the agenda to manage day by day at 1300.
D. Give the neglected dose at 1300 and exchange the agenda to administer each day at 1300.
To make sure that a therapeutic stage of medicine is maintained, the nurse ought to administer
the ignored dose as soon as viable, and revise the administration schedule hence to prevent
dangerously increasing the extent of the drugs in the bloodstream (D). The nurse have to report
the cause for the overdue dose, however (A and C) are not warranted. (B) ought to bring about
accelerated blood degrees of the drug.
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While teaching a male patron's wife inside the overall performance of passive
range-of-movement sporting activities to his shriveled shoulder, the nurse observes that she is
protecting his arm above and underneath the elbow. What nursing movement should the nurse
implement?
A. Acknowledge that she is assisting the arm successfully.
B. Encourage her to keep the joint blanketed to hold warmth.
C. Reinforce the need to grip immediately beneath the joint for better aid.
D. Instruct her to grip at once over the joint for higher movement.
A. Acknowledge that she is assisting the arm efficiently.
The wife is performing the passive ROM correctly, consequently the nurse need to renowned
this reality (A). The joint that is being exercised need to be exposed (B) whilst the rest of the
body have to stay covered for warmth and privateness. (C and D) do now not offer adequate
help to the joint while nevertheless allowing for joint movement.
, What is the most crucial reason for beginning intravenous infusions inside the top extremities in
place of the lower extremities of adults?
A. It is greater difficult to discover a superficial vein within the ft and ankles.
B. A decreased glide charge could result in the formation of a thrombosis.
C. A cannulated extremity is more hard to transport when the leg or foot is used.
D. Veins are placed deep within the ft and ankles, ensuing in a extra painful method.
B. A reduced drift price could result in the formation of a thrombosis.
Venous return is normally better inside the upper extremities. Cannulation of the veins inside the
lower extremities increases the danger of thrombus formation (B) which, if dislodged, will be
existence-threatening. Superficial veins are often very smooth (A) to locate inside the feet and
legs. Handling a leg or foot with an IV (C) is probably no longer any more hard than managing
an arm or hand. Even if the nurse did accept as true with moving a cannulated leg was more
hard, this isn't the most critical reason for the use of the higher extremities. Pain (D) is not a
attention.
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The nurse observes an unlicensed assistive personnel (UAP) taking a purchaser's blood stress
with a cuff this is too small, however the blood stress reading obtained is within the purchaser's
common variety. What motion is most vital for the nurse to implement?
A. Tell the UAP to apply a larger cuff at the next scheduled evaluation.
B. Reassess the client's blood strain the usage of a larger cuff.
C. Have the unit educator overview this method with the UAPs.
D. Teach the UAP the precise approach for assessing blood pressure.
B. Reassess the customer's blood stress the usage of a larger cuff.
The maximum important action is to make certain that an accurate BP analyzing is received.
The nurse need to reassess the BP with the proper size cuff (B). Reassessment ought to now
not be postponed (A). Though (C and D) are likely indicated, these actions do not have the
concern of (B).
Twenty mins after beginning a heat software, the purchaser states that the heating pad now not
feels heat sufficient. What is the first-rate reaction by way of the nurse?
A. That means you've got derived the most advantage, and the heat may be eliminated.
B. Your blood vessels are getting dilated and doing away with the heat from the site.
C. We will increase the temperature 5 stages whilst the pad no longer feels warm.
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