A seventy three-year-old girl client had a hemiarthroplasty of the left hip the previous day
because of a fracture resulting from a fall. In reviewing hip precautions with the purchaser,
which instruction have to the nurse consist of in this patron's coaching plan?
A. "In 8 weeks you will be capable of bend at the waist to attain items at the ground."
B. "Place a pillow among your knees even as mendacity in bed to save you hip dislocation."
C. "It is secure to use a walker to get off the bed, but you want assistance while strolling."
D. "Take pain medicinal drug 30 minutes after your bodily therapy periods." - ANS-B. "Place a
pillow among your knees whilst lying in mattress to save you hip dislocation."
(The client's affected hip joint following a hemiarthroplasty (partial hip alternative) is susceptible
to dislocation for 6 months to a 12 months following the procedure. Hip precautions to prevent
dislocation include setting a pillow among the knees to hold abduction of the hips (B). Clients
must be informed to keep away from bending on the waist (A), to searching for assistance for
each standing and on foot until they're strong on a walker or cane (C), and to take ache
medicine 20 to 30 minutes prior to bodily remedy classes, as opposed to ready until the pain
degree is excessive after their remedy.)
A purchaser is within the radiology branch at 0900 whilst the prescription levofloxacin
(Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at
1300. What is the high-quality intervention for the nurse to enforce?
A. Contact the healthcare provider and whole a medicinal drug variance shape.
B. Administer the Levaquin at 1300 and resume the 0900 time table inside the morning.
C. Notify the charge nurse and complete an incident document to give an explanation for the
neglected dose.
D. Give the missed dose at 1300 and exchange the agenda to manage every day at 1300. -
ANS-D. Give the neglected dose at 1300 and exchange the schedule to administer each day at
1300.
(To make certain that a therapeutic stage of medication is maintained, the nurse ought to
administer dose as quickly as viable, and revise the administration schedule for this reason to
prevent dangerously growing the extent of medication within the bloodstream (D). The nurse
ought to record the reason for the past due dose, however (A and C) are not warranted. (B)
could bring about multiplied blood levels of the drug.)
A purchaser is receiving a cephalosporin antibiotic IV and complains of pain and infection on the
infusion website. The nurse observes erythema, swelling, and a pink streak alongside the
vessel above the IV get right of entry to website. Which motion have to the nurse take
presently?
A. Administer the drugs extra rapidly the use of the same IV website.
B. Initiate an change website for the IV infusion of the drugs.
C. Notify the HCP earlier than administering the following dose.
D. Give the client a PRN dose of aspirin even as the medication infuses. - ANS-B. Initiate an
change web site for the IV infusion of the medication.
,(A cephalosporin antibiotic that is administered IV may additionally cause vessel irritation.
Rotating the infusion website online minimizes the chance of thrombophlebitis, so an trade
infusion web page ought to be initiated (B) before administering the next dose. Rapid
management (A) of intravenous cephalosporins can potentiate vessel infection and boom the
danger of thrombophlebitis. (C) isn't always important to provoke an alternate IV web page.
Although aspirin has antiinflammatory actions, (D) isn't always indicated.)
A customer is to get hold of 10 mEq of KCl diluted in 250 mL of ordinary saline over 4 hours. At
what charge should the nurse set the customer's intravenous infusion pump? - ANS-63 mL/hr
A customer who has been NPO for three days is receiving an infusion of D5W zero.45 regular
saline (NS) with potassium chloride (KCl) 20 mEq at eighty three mL/hour. The customer's
eight-hour urine output is four hundred mL, BUN is 15 mg/dL, and the serum potassium is
three.7 mEq/L. Which motion is most crucial for the nurse to implement?
A. Notify HCP and request to alternate the IV infusion to hypertonic D10W
B. Decrease within the infusion fee of the present day IV and file to the HCP
C. Document in the scientific file that these ordinary findings are predicted effects
D. Obtain potassium chloride 20 mEq in anticipation of prescription to to offer IV - ANS-C.
Document within the medical report that those normal findings are anticipated outcomes..
A consumer who is 5 'five" tall and weighs two hundred kilos is scheduled for surgical procedure
day after today. What query is most crucial for the nurse to consist of at some point of the
preoperative assessment?
A. What is your every day calorie consumption?
B. What diet and mineral supplements do you take?"
C. "Do you sense that you are obese?"
D. "Will a clean liquid eating regimen be k after surgical treatment?" - ANS-B. "What vitamin and
mineral dietary supplements do you're taking?"
(Vitamin and mineral supplements (B) may effect medicinal drugs used during the operative
length. (A and C) are suitable questions for lengthy-term nutritional counseling. The nature of
the surgery and anesthesia will decide the want for a clean liquid weight loss program (D), in
preference to the consumer's desire.)
A customer who is a Jehovah's Witness is admitted to the nursing unit. Which situation need to
the nurse have for making plans care in terms of the patron's beliefs?
A. Autopsy of the frame is illegal.
B. Blood transfusions are forbidden.
C. Alcohol use in any shape isn't allowed.
D. A vegetarian food plan must be accompanied. - ANS-B. Blood transfusions are forbidden.
A customer who is in hospice care complains of increasing quantities of pain. The healthcare
company prescribes an analgesic every four hours as needed. Which movement need to the
nurse put into effect?
A. Give an round-the-clock schedule for administration of analgesics.
B. Administer analgesic remedy as needed while the ache is extreme.
C. Provide medicine to preserve the purchaser sedated and unaware of stimuli.
D. Offer a remedy-unfastened length so that the client can do daily activities. - ANS-A. Give an
around-the-clock schedule for administration of analgesics.
, (The most effective management of pain is achieved the usage of an round-the-clock time table
that offers analgesic medications on a normal basis (A) and in a timely way. Analgesics are
much less effective if pain persists until it's far severe, so an analgesic medicine need to be
administered earlier than the customer's pain peaks (B). Providing consolation is a priority for
the client who's loss of life, but sedation that impairs the purchaser's capability to engage and
revel in the time before lifestyles ends should be minimized (C). Offering a remedy-unfastened
period lets in the serum drug level to fall, which isn't an effective approach to control chronic
ache.)
A client with acute hemorrhagic anemia is to acquire four devices of packed RBCs as hastily as
possible. Which intervention is most crucial for the nurse to put in force?
A. Obtain the pre-transfusion hemoglobin level.
B. Prime the tubing and prepare a blood pump set-up
C. Monitor critical signs q 15 min for the primary hour.
D. Ensure the accuracy of the blood type match. - ANS-D. Ensure the accuracy of the blood
kind match.
(ALL interventions need to be implemented previous to administering blood, however (D) has
the highest priority. Any time blood is administered the nurse should make certain the accuracy
of the blood type suit so that it will prevent a probable hemolytic response.)
A client with persistent kidney ailment (CKD) selects a scrambled egg for his breakfast. What
movement should the nurse take?
A. Commend the client for choosing a excessive biologic cost protein.
B. Remind the consumer that protein inside the weight loss program need to be averted.
C. Suggest that the consumer additionally pick orange juice, to promote absorption.
D. Encourage the client to wait lessons on dietary management of CKD. - ANS-A. Commend the
customer for deciding on a high biologic fee protein. (Foods which includes eggs and milk (A)
are excessive biologic proteins which can be allowed because they're whole proteins and supply
the critical amino acids which are vital for increase and cellular restore. Orange juice is wealthy
in potassium and should no longer be advocated. The patron has made an excellent food plan
desire so (D) is not essential.)
A consumer with pneumonia has a decrease in oxygen saturation from ninety four% to 88% at
the same time as ambulating. Based on those findings, which intervention should the nurse
enforce first?
A. Assist the ambulating customer returned to the mattress
B. Encourage the customer to ambulate to solve pneumonia.
C. Obtain a prescription for transportable oxygen while ambulating.
D. Move the oximetry probe from the finger to the earlobe. - ANS-A. Assist the ambulating
customer again to the bed.
(An oxygen saturation underneath 90% shows insufficient oxygen. First, the consumer have to
be assisted to go back to mattress (A) to minimize oxygen demands. Ambulation increases
aeration of the lungs to save you pooling of respiratory secretions, however the consumer's
hobby right now is depleting oxygen saturation of the blood, so (B) is contraindicated. Increased
activity increases breathing attempt, and oxygen can be vital to hold ambulation (C), however
first the customer have to return to the mattress to rest. Oxygen saturation ranges at different
websites have to be evaluated AFTER the client returns to mattress (D). )
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