Solutions
How much fluid should be consumed daily? - ANSWER 2,500- 3,000 mL
A nurse if caring for a client who requires a 24-hr urine collection. Which of the following
statements by the client indicates an understanding of the teaching?
A. "I had a bowel movement, but I was able to save the urine."
B. "I flushed what I urinated at 7:00 a.m. and have saved all urine since."
C. "I have a specimen in the bathroom from about 30 minutes ago."
D. "I drink a lot, so I will fill up the bottle and complete the test quickly." - ANSWER B.
discard the first voiding and save all the others
-Keep on ice/Refrigerator
-collection takes over a full 24 hr
A nurse is caring for a client who has herpes zoster and asks the nurse about the use of
complementary and alternative therapies for pain control. The nurse should inform the
client that his condition is a contraindication for which of the following therapies?
A. Feverfew
B. Biofeedback
C. Aloe
D. Acupuncture - ANSWER D. Could open the skin surface and lead to increase risk of
further infection
Feverfew should not be given to pt who are prescribed - ANSWER Warfarin or other
,blood thinners
Feverfew - ANSWER Alternative therapy for wound healing
Biofeedback - ANSWER Alternative therapy for stroke recover, smoking cessation,
headache disorders
-Mind-Body technique
A nurse is preparing to transfer a client who has right-sided weakness from the bed to a
chair. In what order should the nurse take the following actions to assist the client?
1. Position the chair of the left side of the bed
2. Use the stand-and-pivot technique to move the client to the chair
3. Ask the client if he can bear weight
4. Have the client sit and dangle his feet at the bedside - ANSWER 3.
1.
4.
2.
A nurse is preparing to administer an injection of an opioid medication to a client. The
nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions
should the nurse take?
A. Lock the remaining medication in the controlled substances cabinet.
B. Dispose of the vial with the remaining medication in a sharps container.
C. Ask another nurse to observe the medication wastage.
D. Notify the pharmacy when wasting the medication. - ANSWER C. A second nurse
must witness the disposal of any portion of a dose of a controlled substance
A nurse if preparing a heparin infusion for a client who was hospitalized with DVT. The
order reads 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800
units/hr. At what rate should the nurse set the infusion pump? - ANSWER Desired X
Amount/ Have= X mL
800 X 250mL/ 25,000 units = 8 mL
**Learn how to do medication calculations!!!! - ANSWER
, A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10
units of NPH insulin to mix together and administer SQ. Determine the correct order of
steps for this procedure.
1. Inject 5 units of air into the bottle of regular insulin
2. Withdraw the correct dose of NPH insulin from the bottle
3. Inject 10 units of air into the bottle of NPH insulin
4. Withdraw the correct dose of regular insulin from the bottle - ANSWER 3.
1.
4.
2.
Inject Cloudy, Inject Clear, Draw up Clear, Draw up Cloudy
A nurse is caring for a client who is postoperative and refuses to use an incentive
spirometer following major abdominal surgery. Which of the following is the nurse's
priority action?
A. Administer a pain medication to the client.
B. Determine the reasons why the client is refusing to use the incentive spirometer.
C. Request that a respiratory therapist discuss the technique for incentive spirometry.
D. Document the client's refusal to participate in health restorative activities. -
ANSWER B. Assess the client first always
ADPIE
Nursing Process - ANSWER ADPIE
Assessment
Diagnosis
Planning
Implementation
Evaluation
A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by
mouth every day." Which of the following components of the prescription should the
nurse question?