Bundle (Mental Health, Leadership, Med
Surg, Maternity, Nursing Care Of
Children, Community Health,
Pharmacology, Pediatrics,
Fundamentals) 269 Versions, Exam
A nurse is monitoring a client who is receiving a transfusion of packed RBC's.
The client's temp increases to 102.4 F. Which of the following actions should
the nurse take first?
Stop the transfusion (The greatest risk to this client is injury from an elevated
temperature; therefore, the first action the nurse should take is to stop the
transfusion)
A nurse is reinforcing teaching about benzodiazepine withdrawal with an older
adult client who discontinued taking lorazpam after taking it for 3 months.
Which of the following instructions should the nurse include?
Have someone assist you with ADL's (The client who has lorazepam withdrawal
can manifest tremors and dizziness, making ADLs difficult to perform)
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A nurse is reviewing the lab results of a client who takes insulin for the
management of diabetes mellitus. Which of the following findings should
indicates to the nurse the medication is effective?
Fasting BG 100 mg/dL (The expected reference range for a fasting blood
glucose level is 70 to 110 mg/dL so the nurse should identify that a client who
has a fasting blood glucose level of 100 mg/dL is effectively managing diabetes
mellitus)
A nurse is reinforcing teaching with a client who has seizures and a new
prescription for valproic acid. The nurse should instruct the client to report
which of the following adverse effects of valproic acid immediately to the
provider?
Abdominal pain (The greatest risk to the client is hepatotoxicity and
pancreatitis, which can cause abdominal pain. Therefore, the client should
notify the provider immediately if experiencing a decrease in appetite, nausea,
abdominal pain, or yellowing of the skin)
A nurse is reinforcing teaching with a client who has a prescription for
alendronate. Which of the following client responses indicates to the nurse an
understanding of the teaching?
"I will take the medication with 8 ounces of water" (The client should take
alendronate on an empty stomach with 240 mL (8 oz) of water to ensure it
does not lodge in the esophagus, which can result in esophageal ulcerations)
A nurse is reinforcing teaching with a client who has a new prescription for
etanercept to treat rheumatoid arthritis. Which of the following instructions
about self-administering this med should the nurse include?