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When preparing to administer a prescribed medication to a
homeless client at a community psychiatric clinic. The client tells
the nurse that the usual dosage taken is different from the dose
the nurse is giving. Which action should the nurse take?
A) Inform the client that he may refuse the medication and
document whether or not the client takes it.
B) Withhold the medication until the dosage can be confirmed.
C) Explain to the client that the dosage has been changed.
D) Tell the client to take the medication then verify the dosage at
the next healthcare team meeting. - answer B) Withhold the
medication until the dosage can be confirmed.
The charge nurse is making assignments for one practical nurse
and three registered nurses who are caring for neurologically
,compromised clients. Which client with which change in status is
best to assign to the PN?
A) Subdural hematoma whose blood pressure changed from
150/80 to 170/60.
B) Viral meningitis whose temperature change from 101 S to 102F.
C) Diabetic keto acidosis who is Glasgow coma scale score
changed from 10 to 7.
D) Myxedema, whose blood pressure change from 80/50 to
70/40. - answer B) Viral meningitis whose temperature change
from 101 S to 102F.
The nurse is caring for a client with pneumonia who now develops
initial signs of septic shock and multi organ failure. The
healthcare provider prescribes a sepsis protocol. Which
intervention is most important for the nurse to include in the plan
of care?
A) Maintain strict intake and output.
B) Keep head of bed raised 45°.
C) Excess warmth of extremities.
D) Monitor blood glucose level. - answer A) Maintain strict intake
and output.
,And adolescent client is admitted to the hospital because of
writing a suicide note to a teacher at school. On the second day of
hospitalization, the nurse asked the client to meet with the
treatment team. After the team meeting, the client leaves in tears
and goes to their room. Which nursing intervention is best?
A) Let the client rest quietly in their room for a while.
B) Explore the clients goals and desire for treatment.
C) Ask the treatment team about the clients behavior.
D) Go to the clients room and ask what happened. - answer D) Go
to the clients room and ask what happened.
The healthcare provider prescribes dalteparin 200 units per
kilogram subcutaneous once a day for a client who weighs 154
pounds. The medication is available and 25,000 units per
milliliter vial. How many milliliters should the nurse administer?
(Enter numerical value only. If rounding is required, round to the
nearest 10th.) - answer 0.6
NGN: The client is a 49-year-old male who reports flu like
symptoms including fever and chest congestion for four days. He
came to the emergency department last night when he was having
more difficulty breathing he has a history of 1/2 pack a day
, cigarette smoking for 20 years. He has no significant medical or
surgical history.
Which two orders should the nurse complete first?
A) Sputum culture.
B) Start oxygen 3 L per minute via nasal cannula.
C) Place the client on a cardio respiratory monitor.
D) Chest x-ray.
E) Acetominophen 350 mg PO every six hours for temperature
control.
F) Run 0.9% sodium chloride IV infusion at 150 mL per hour.
G) Start peripheral IV.
H) NPO. - answer B) Start oxygen 3 L per minute via nasal
cannula.
C) Place the client on a cardio respiratory monitor.
NGN: 0330: place the client on a cardio respiratory monitor,
NPO, sputum culture, start a peripheral IV infusion, start oxygen
3 L per minute via nasal cannula, begin 0.9% sodium chloride IV
infusion at 150 mL per hour, acetaminophen 350 mg PO every six
hours for temperature.
To start the client on oxygen as ordered which items should the
nurse collects from the supply room? SATA