5. Nurse Jamie is administering the initial total parenteral nutrition solution to a client. Which of the following assessments requires the nurse’s immediate attention? A. Temperature of 37.5 degrees Celsius. B. Urine output of 300 cc in 4 hours. C. Poor skin turgor. D. Blood glucose of 350 mg/dl.
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5. Nurse Jamie is administering the initial total parenteral nutrition solution to a client. Which of the following assessments requires the nurse’s immediate attention?
A. Temperature of 37.5 degrees Celsius.
B. Urine output of 300 cc in 4 hours.
C. Poor skin turgor.
D. Blood glucose of 350 mg/dl.
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- An older adult arrives at the emergency department with reports of severe nausea and vomiting large amounts of liquid brown emesis at home. The client's vital signs are a temperature of 96.4 'F, heart rate 124 beats/minute, respirations of 16 beats/minute, and blood pressure of 75/38 mmHg. Which intervention is the most important for the nurse to implement? A. Maintain strict intake and output B. Monitor blood glucose level C. Keep the head of the bed 45 degrees D. Assess warmth of extremetiesAn elderly patient is receiving antihistamine therapy. What interventions specific to this medication does the nurse implement? (Select all that apply). A. Assess the patient for delirium, confusion and dizziness. B. Auscultate the patient's breath sounds C. Provide a low residue diet. D. Encourage the patient to ambulate E. Monitor the patient's urine outputThe nurse weighs the client who is on an infusion of lactated Ringer’s postoperatively and finds that there has been a weight gain of 1.5 kg since the previous day. What would be the nurse’s next highest priority? a. Check with the client to determine whether there have been any dietary changes in the last few days. b. Assess the client for signs of edema and BP for possible hypertension. c. Contact dietary to change the client’s diet to reduced sodium. d. Request a diuretic from the client’s provider. Explain the answer and why the remaining options are bot correct
- A nurse is reviewing the medical records of 4 clients. The nurse should identify which of the following clients as requiring follow-up care? a. a client who received a Mantoux test 48 hr ago and has an induration b. a client who is scheduled for a colonoscopy and is taking sodium phosphate c. a client who is taking warfarin and has an INR 1.8 d. a client who is taking bumetanide and has a potassium level of 3.6 mEq/L Give typing answer with explanation and conclusion1. A nurse is caring for an adolescent who is 1 hour post-operative followingan appendectomy. Which of the following findings should the nurse report to theprovider?a. Heart rate 63 / minuteb. muscle rigidityc. temperature 36.4 Celsius (97.5 Fahrenheit)d. abdominal painA nurse is providing foot care for patients in a long-term carefacility. Which actions are recommended guidelines for thisprocedure? Select all that apply.a. Bathe the feet thoroughly in a mild soap and tepid watersolution.b. Soak the feet in warm water and bath oil.c. Dry feet thoroughly, including the area between the toes.d. Use an alcohol rub if the feet are dry.e. Use an antifungal foot powder if necessary to preventfungal infections.f. Cut the toenails at the lateral corners when trimmingthe nail.
- 1. To palpate for presence of inguinal hernia in a male client, the nurse needs to instruct the client to: a.Take a deep breath and hold for a moment b.Bear down or cough out c.Flex the hips and knee d.Exhale forcibly and hold for a moment 2. A client has just had an inguinal herniorrhaphy. Which of the following instructions would be MOST appropriate to include in his discharge plan? a.Maintain a high Fowler’s position while resting. b.Turning, coughing and deep breathing every 2 hours. c.Applying a truss before the client ambulates. d.Applying an ice bag to the scrotum. 3. Mr. Diaz a 50-year-old taxi driver was admitted to the medical- surgical unit with rectal bleeding and severe rectal pain. He was diagnosed with hemorrhoids for which he will be treated medically. This treatment will MOST likely include which of the following? a.A high fiber diet. b.A drink of one glass of water with each meal. c.A daily laxative regimen d.A well-balanced diet with cooked vegetables and fruits.…After receiving the third dose of a new oral anticoagulant prescription, Which action should the nurse implement? Select all A. Obtain a soft Bristol toothbrush B. Provide a PRN NSAID for gum discomfort C. Review most recent coagulation lab values D. Complete a medication variance report E. Report findings to healthcare providerA responsibility of the nurse is the administration of preop-erative medications to patients. Which statements describe the action of these medications? Select all that apply.a. Diazepam is given to alleviate anxiety.b. Ranitidine is given to facilitate patient sedation.c. Atropine is given to decrease oral secretions.d. Morphine is given to depress respiratory function.e. Cimetidine is given to prevent laryngospasm.f. Fentanyl citrate–droperidol is given to facilitate a senseof calm.
- The nurse is caring for a toddler with large, unrepaired ventricular septal defect and heart failure. Which assessment findings should the nurse expect? A. Hypotension B. Tachycardia 45) @ She 46) Am to I U 9 В states that when she kisses her baby, the intants skin taste saltv. 2 C. Pulse oximetry reading within defined limits. D. Blood pressure variance across extremities #3 L 54 $ R 07 2⁰ % 5 T 6 are Y & U in * 00 ( -O Tics PASSIA client is scheduled to receive phenytoin (Dilantin) 100 mg orally at 6 PM but is having difficulty swallowing capsules. What method should the nurse use to help the client take the medication? a. Sprinkle the powder from the capsule into a cup of water b. Administer 4 mL of phenytoin suspension containing 125 mg/5 mL c. Obtain a change in the administration route to allow an IM injection d. Insert a rectal suppository containing 100mg of phenytoinA hospitalized pre-school boy recovering from surgery refuses to drink fluids. Which intervention is best for the practical nurse (PN) to implement? A Tell the child he can go outside after he drinks a full glass of water. B Make a game of seeing who can finish a glass of water first-the nurse or the child. C Offer the child a popsicle and allow him to pick the flavor he prefers. D Ask the parents to participate in encouraging the child's fluid intake.