A circulating nurse is planning care for a client who is scheduled for surgery and has a latex
allergy. Which of the following actions should the nurse include in the plan of care?
A. Schedule the client fr the last surgery of the day
B. Place monitoring cords and tubes in a stockinet
C. Choose rubber injection ports for fluid administration
D. Ensure phenytoin IV is readily available - ANS-B. Place monitoring cords and tubes in a
stockinet
A nurse administered digoxin immune fab to a client who received the incorrect dose of digoxin
over a period of 3 days. The nurse should identify that which of the following findings indicates
the antidote was effective?
A. Normal sinus rhythm
B. Digoxin level of 2.5 mg/mL
C. Decrease in blood pressure
D. Potassium level of 3.2 mEq.L - ANS-A. Normal sinus rhythm
A nurse administers ceftazidime to a client who has severe penicillin allergy. The nurse should
identify which of the following client findings as an indication that she should complete an
incident report?
A. The client reports shortness of breath
B. The client is also taking lisinopril
C. The client's pulse rate is 60/min
D. The client's WBC is 14,000/mm3 - ANS-A. The client reports shortness of breath
A nurse contacts a client's provider on the telephone to obtain a prescription for pain
medication. Which of the following actions should the nurse take?
A. Write the order on a prescription pad designed for the client's provider
B. Have the provider spell out the unfamiliar medication names
C. Read the prescription back to the provider using avvreviations
D. Consult with a second nurse for any questions regarding dosage - ANS-B. Have the provider
spell out the unfamiliar medication names
A nurse in a clinic is caring for a client who is taking aspirin for the treatment of arthritis. The
nurse should identify which of the following findings as an indication that the client is beginning
to exhibit salicylism?
A. Gastric distress
B. Oliguria
C. Excessive bruising
, D. Tinnitus - ANS-D. Tinnitus
A nurse in a provider's office is assessing a client who has been taking aspirin daily for the past
year. For which of the following findings should the nurse notify the provider immediately?
A. Hyperventilation
B. Heart burn
C. Anorexia
D. Swollen ankles - ANS-A. Hyperventilation
A nurse is administering baclofen for a client who has a spinal chord injury. Which of the
following findings should the nurse document as a therapeutic outcome?
A. Increase in seizure threshold
B. Decrease in flexor and extendosor spasticity
C. Increase in cognitive function
D. Decrease in paralysis of the extremities - ANS-B. Decrease in flexor and extendosor
spasticity
A nurse is administering cefotetan via intermittent IV bolus to a client who suddenly develops
dyspnea and widespread hives. Which of the following actions should the nurse take first?
A. Administer epinephrine 0.5mL via IV bolus
B. Discontinue the medication IV infusion
C. Elevate the client's legs above the level of the heart
D. Collect a blood specimen for ABG'd - ANS-B. Discontinue the medication IV infusion
A nurse is administering diazepam to a client who is having a colonoscopy. Which of the
following actions should the nurse take"
A. Ensure flumazenil is available to administer for toxicity management
B. Monitor the client for an increase in blood pressure
C. Expect the client to become unconscious within 30 seconds
D. Measure the capnography level every hour until the client is awake and oriented - ANS-A.
Ensure flumazenil is available to administer for toxicity management
A nurse is assessing a client who has received atropine eye drops during an eye examination.
Which of the following findings should the nurse expect as an effect of the medication?
A. Difficulty seeing in the dark
B. Pinpoint pupils
C. Blurred vision
D. Excessive tearing - ANS-C. Blurred vision
A nurse is assessing a client who is receiving epoetin alfa to treat anemia. Which of the
following findings should the nurse monitor?
A. Paresthesia
B. Increased blood pressure
C. Fever
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