When preparing to administer a prescribed medication to a homeless client at a
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community psychiatric clinic. The client tells the nurse that the usual dosage taken is
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different from the dose the nurse is giving. Which action should the nurse take?
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A) Inform the client that he may refuse the medication and document whether or not the
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client takes it.
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B) Withhold the medication until the dosage can be confirmed.
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C) Explain to the client that the dosage has been changed.
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D) Tell the client to take the medication then verify the dosage at the next healthcare team
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meeting. - ANS-B) Withhold the medication until the dosage can be confirmed.
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The charge nurse is making assignments for one practical nurse and three registered
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nurses who are caring for neurologically compromised clients. Which client with which
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change in status is best to assign to the PN?
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A) Subdural hematoma whose blood pressure changed from 150/80 to 170/60.
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,B) Viral meningitis whose temperature change from 101 S to 102F.
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C) Diabetic keto acidosis who is Glasgow coma scale score changed from 10 to 7.
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D) Myxedema, whose blood pressure change from 80/50 to 70/40. - ANS-B) Viral
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meningitis whose temperature change from 101 S to 102F.
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The nurse is caring for a client with pneumonia who now develops initial signs of septic
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shock and multi organ failure. The healthcare provider prescribes a sepsis protocol.
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Which intervention is most important for the nurse to include in the plan of care?
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A) Maintain strict intake and output.
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B) Keep head of bed raised 45°.
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C) Excess warmth of extremities.
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D) Monitor blood glucose level. - ANS-A) Maintain strict intake and output.
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And adolescent client is admitted to the hospital because of writing a suicide note to a
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teacher at school. On the second day of hospitalization, the nurse asked the client to meet
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with the treatment team. After the team meeting, the client leaves in tears and goes to
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their room. Which nursing intervention is best?
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A) Let the client rest quietly in their room for a while.
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B) Explore the clients goals and desire for treatment.
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C) Ask the treatment team about the clients behavior.
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,D) Go to the clients room and ask what happened. - ANS-D) Go to the clients room and ask
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what happened.
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The healthcare provider prescribes dalteparin 200 units per kilogram subcutaneous once
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a day for a client who weighs 154 pounds. The medication is available and 25,000 units
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per milliliter vial. How many milliliters should the nurse administer? (Enter numerical
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value only. If rounding is required, round to the nearest 10th.) - ANS-0.6
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NGN: The client is a 49-year-old male who reports flu like symptoms including fever and
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chest congestion for four days. He came to the emergency department last night when he
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was having more difficulty breathing he has a history of 1/2 pack a day cigarette smoking
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for 20 years. He has no significant medical or surgical history.
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Which two orders should the nurse complete first?
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A) Sputum culture.
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B) Start oxygen 3 L per minute via nasal cannula.
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C) Place the client on a cardio respiratory monitor.
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D) Chest x-ray.
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E) Acetominophen 350 mg PO every six hours for temperature control.
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F) Run 0.9% sodium chloride IV infusion at 150 mL per hour.
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G) Start peripheral IV.
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H) NPO. - ANS-B) Start oxygen 3 L per minute via nasal cannula.
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C) Place the client on a cardio respiratory monitor.
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, NGN: 0330: place the client on a cardio respiratory monitor, NPO, sputum culture, start a
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peripheral IV infusion, start oxygen 3 L per minute via nasal cannula, begin 0.9% sodium
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chloride IV infusion at 150 mL per hour, acetaminophen 350 mg PO every six hours for
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temperature.
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To start the client on oxygen as ordered which items should the nurse collects from the
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supply room? SATA
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A) humidifier bottle.
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B)Suction canister. h h
C)Sterile water. h h
D) Nasal cannula.
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E) Flow meter.
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F) Lambs wool.
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G) Tape. - ANS-D) Nasal cannula.
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E) Flow meter.
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NGN: states, I am feeling extremely anxious right now. The client has decreased breath
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sounds in the left lower low. His mucus membranes are dry. He has a productive cough
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with thick, yellow secretions. His capillary refill is four seconds. Vital signs, temperature
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100.2. Heart rate 101 bpm, respiratory rate 28 breaths per minute, blood pressure
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145/89, oxygen saturation 90% on room air.
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(for each body system click to specify the assessment findings that indicates hypoxia)
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