A health care provider has ordered restraints for a older adult client who is delirious from the pain medication she was administered. Which guideline is appropriate for utilizing restraints?
a. The patient should be assessed every 1-2 hours. b. Chemical restraints should be used before physical r...
NUR 311L Final Exam Questions and
Correct Answers
A health care provider has ordered restraints for a older adult client who is delirious
from the pain medication she was administered. Which guideline is appropriate for
utilizing restraints?
a. The patient should be assessed every 1-2 hours.
b. Chemical restraints should be used before physical restraints
c. A PRN order should be obtained so the nurse can remove and replace the restraints
as the patient's mental status changes
d. The client's order for restraints must be renewed by the provider every 4 hours ✅a
The new graduate nurse is reviewing for her NCLEX. She understands that which of the
following lists contains an error?
a. QID = four times a day; QHS = at the hospital, IM = intramuscular
b. SL= Sublingual, BID = twice a day, RUQ = right upper quadrant
c. Q2 = every 2, SQ= subcutaneous, AD = right ear
d. PO = by mouth, AC = before meals, PRN = as needed ✅a
The nurse is administering a medication to a client with a PEG tube. Which action
should the nurse perform when administering medication using this route?
a. Use solid medications whenever possible.
b. Crush medications to a fine powder, if allowable, and mix with 15 to 30 mL of water
c. Avoid opening capsules to empty liquid
d. Administer a 30 to 60 mL water flush between each individual medication ✅b
The nurse is providing education about incentive spirometry to a postoperative patient
whose surgery took place earlier today. Which instruction should the nurse provide?
a. Hold your breath for 1 minute before using the spirometer.
b. Place the lips securely on the device and exhale slowly.
c. Inhale deeply slowly and deeply through the mouthpiece
d. Call for help if you feel the need to cough after using the device ✅c
The nurse is providing post-op skin care instructions to his discharging client. He knows
that the teaching has not been effective when the patient states...
a. I can submerge my incision for bathing, but not in a pool, lake, or hot tub
b. I can change my dressing as needed.
c. I should pat my incision dry rather than rubbing it.
, d. I should clean my incision gently with soap and water, then allow the water to run off.
✅a
The directions for reconstitution of oxacillin sodium for injection are on the drug label.
Directions read: "For IM use, add 5.7 mL sterile water for injection. Resulting solution
contains 250 mg oxacillin sodium per 1.5 mL. The vial contains oxacillin sodium
equivalent to 1g. Usual adult dosage is 250mg to 500mg IM every 4-6 hours." The client
is to receive 400mg IM every 6 hours. How many milliliters should the nurse administer
per dose?
a. 2.4 mL
b. 2.28 mL
c. 1.5 mL - 3 mL
d. 14.4 mL ✅a
The nurse is providing education to a newly diagnosed Type 1 diabetic. The nurse
knows that the teaching has not been effective when the patient states...
a. "It is important that I wash my feet daily and avoid open toe shoes.
b. "I should ensure that I properly understand carb counting and how it affects my
insulin needs at meal times."
c. "I did this to myself because I love pizza and sodas
d. "I should be cautious not to moisturize the areas between my toes." ✅c
A nurse is administering Ketorolac 30mg IM now into the patient's vastus lateralis. She
will find which landmarks?
a. The lateral femoral condyle and the iliac crest
b. The lateral femoral condyle and the greater trochanter
c. The greater trochanter and the anterior superior iliac spine
d. The greater trochanter with thumb toward the groin ✅b
The nurse has an order to draw blood specimens for his patient. In which order should
she draw them?
a. Anti-Xa (blue), BMP (yellow), and CBC (lavender), blood cultures
b. CBC (lavender), Anti-Xa (blue), BMP (yellow), blood cultures
c. Blood cultures, Anti-Xa (blue), BMP (yellow), CBC (lavender)
d. Blood cultures, BMP (yellow), Anti-Xa (blue), CBC (lavender) ✅c
A nurse is teaching a client how to use a walker. Which instruction should the nurse
NOT provide?
a. Keep your arms relaxed at each side of the walker.
b. Move the walker 12-18 inches with each step and set it down.
c. Step forward with either foot into the walker, then follow through with the other foot
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