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Low levels of __are associated with malnutrition.
- Albumin
A client is in the radiology department at 0900 when the prescription
levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The
client returns to the unit at 1300. What is the best intervention for the nurse to
implement?
A. Contact the healthcare provider and complete a medication variance form.
B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning.
C. Notify the charge nurse and complete an incident report to explain the missed
dose.
D. Give the missed dose at 1300 and change the schedule to administer daily at
1300.
D. Give the missed dose at 1300 and change the schedule to administer daily at
1300.
,While instructing a male client's wife in the performance of passive range-of-
motion exercises to his contracted shoulder, the nurse observes that she is
holding his arm above and below the elbow. What nursing action should the
nurse implement?
A. Acknowledge that she is supporting the arm correctly.
B. Encourage her to keep the joint covered to maintain warmth.
C. Reinforce the need to grip directly under the joint for better support.
D. Instruct her to grip directly over the joint for better motion
A. Acknowledge that she is supporting the arm correctly.
What is the most important reason for starting intravenous infusions in the upper
extremities rather than the lower extremities of adults?
A. It is more difficult to find a superficial vein in the feet and ankles.
B. A decreased flow rate could result in the formation of a thrombosis.
C. A cannulated extremity is more difficult to move when the leg or foot is used.
D. Veins are located deep in the feet and ankles, resulting in a more painful
procedure.
B. A decreased flow rate could result in the formation of a thrombosis.
The nurse observes an unlicensed assistive personnel (UAP) taking a client's
blood pressure with a cuff that is too small, but the blood pressure reading
obtained is within the client's usual range. What action is most important for
the nurse to implement?
A. Tell the UAP to use a larger cuff at the next scheduled assessment.
B. Reassess the client's blood pressure using a larger cuff.
C. Have the unit educator review this procedure with the UAPs.
D. Teach the UAP the correct technique for assessing blood pressure.
B. Reassess the client's blood pressure using a larger cuff.
,A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation
arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to
administer the IVPB dose over 20 minutes. For how many ml/hr should the
infusion pump be set to deliver the secondary infusion?
150 mL/hr
Twenty minutes after beginning a heat application, the client states that the
heating pad no longer feels warm enough. What is the best response by the
nurse?
A. That means you have derived the maximum benefit, and the heat can be
removed.
B. Your blood vessels are becoming dilated and removing the heat from the site.
C. We will increase the temperature 5 degrees when the pad no longer feels
warm.
D. The body's receptors adapt over time as they are exposed to heat.
D. The body's receptors adapt over time as they are exposed to heat.
The nurse is instructing a client with high cholesterol about diet and lifestyle
modification. What comment from the client indicates that the teaching has
been effective?
A. If I exercise at least two times weekly for one hour, I will lower my cholesterol.
B. I need to avoid eating proteins, including red meat.
C. I will limit my intake of beef to 4 ounces per week.
D. My blood level of low density lipoproteins needs to increase.
C. I will limit my intake of beef to 4 ounces per week.
, The UAPs working on a chronic neuro unit ask the nurse to help them
determine the safest way to transfer an elderly client with left-sided
weakness from the bed to the chair. What method describes the correct
transfer procedure for this client?
A. Place the chair at a right angle to the bed on the client's left side before
moving.
B. Assist the client to a standing position, then place the right hand on the
armrest.
C. Have the client place the left foot next to the chair and pivot to the left before
sitting.
D. Move the chair parallel to the right side of the bed, and stand the client on
the right foot.
D. Move the chair parallel to the right side of the bed, and stand the client on
the right foot.
An unlicensed assistive personnel (UAP) places a client in a left lateral position
prior to administering a soap suds enema. Which instruction should the nurse
provide the UAP?
A. Position the client on the right side of the bed in reverse Trendelenburg.
B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap.
C. Reposition in a Sim's position with the client's weight on the anterior ilium.
D. Raise the side rails on both sides of the bed and elevate the bed to waist level.
C. Reposition in a Sim's position with the client's weight on the anterior ilium.
A client who is a Jehovah's Witness is admitted to the nursing unit. Which
concern should the nurse have for planning care in terms of the client's
beliefs?
A. Autopsy of the body is prohibited.
B. Blood transfusions are forbidden.
C. Alcohol use in any form is not allowed.
D. A vegetarian diet must be followed.
B. Blood transfusions are forbidden.