Where do you find an adult apical pulse? - ANSWER Left 5th intercostal
rib mid clavicular
A patient initially weighs 200 lbs, but on the 2nd day of admission the
patient weighs 209 lbs, what should the nurse evaluate the patient for? -
ANSWER Fluid retention
In preparation for a rectal exam of non-ambulatory patient w/ arthritis in
both hips, the patient exam in which position? - ANSWER Sims position
Subjective data - ANSWER feelings, perceptions, and reported
symptoms
After assessing the patient and using 2 ID needed to provide headache
relief the nurse gives tylenol. What do you do after? - ANSWER
reassess again after 30 mins
Patient with high dose of opioid medication for severe pain, which
assessment finding do you find due to opioid toxicity - ANSWER
respiratory depression
Nurse caring for patientt with peripheral IV being used intermittently for
medications but not continuous infusion, what does that mean?what
should the nurse do for cleaning this? - ANSWER Flush with 0.9 saline
and lock it
The nurse completed a head to toe ax on patient. Which clinical sign
does the nurse find? - ANSWER Bilateral crackles
The nurse instruct the patient to void or empty the urinary drainage
collection container before administering a blood transfusion. T/F -
ANSWER True, due to fluid overload
rib mid clavicular
A patient initially weighs 200 lbs, but on the 2nd day of admission the
patient weighs 209 lbs, what should the nurse evaluate the patient for? -
ANSWER Fluid retention
In preparation for a rectal exam of non-ambulatory patient w/ arthritis in
both hips, the patient exam in which position? - ANSWER Sims position
Subjective data - ANSWER feelings, perceptions, and reported
symptoms
After assessing the patient and using 2 ID needed to provide headache
relief the nurse gives tylenol. What do you do after? - ANSWER
reassess again after 30 mins
Patient with high dose of opioid medication for severe pain, which
assessment finding do you find due to opioid toxicity - ANSWER
respiratory depression
Nurse caring for patientt with peripheral IV being used intermittently for
medications but not continuous infusion, what does that mean?what
should the nurse do for cleaning this? - ANSWER Flush with 0.9 saline
and lock it
The nurse completed a head to toe ax on patient. Which clinical sign
does the nurse find? - ANSWER Bilateral crackles
The nurse instruct the patient to void or empty the urinary drainage
collection container before administering a blood transfusion. T/F -
ANSWER True, due to fluid overload
