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A nurse is assessing a client who is receiving intravenous therapy. The nurse
should identify which of the following findings as a manifestation of fluid
volume excess?
a. Decreased bowel
sounds b. Distended
neck veins
c. Bilateral muscle weakness
d. Thread pulse
A nurse is assessing a client who is receiving heparin IV continuous IV. The
client has an PPT of 90 seconds. They should monitor the client for which of
the following changes in their vital signs?
a. Decreased temperature
b. Increased pulse rate
c. Decreased respiratory
rate d. Increased blood
pressure
A nurse is preparing to administer medication to a client and discovers a
medication error. The nurse should recognize that which of the following staff
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members is responsible for completing an incident report?
a. The quality improvement
committee b. The nurse who
identifies the error
c. The nurse who caused the error
d. The charge nurse
A nurse is planning care for a client who is receiving morphine via
continuous epidural infusion. The nurse should monitor the client for
which of the following?
a. Pruritus
b. Cough
c. Tachypnea
d. Gastric bleeding
A nurse is reviewing the medical record of a client who has sinusitis and a new
prescription for cefuroxime. Which of the following client information is the
priority for the nurse to report to the provider?
a. The client has a BUN of 18 mg/dL
b. The client takes an aspirin daily
c. The client has a history of a severe penicillin allergy
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d. The client reports a history of nausea with cefuroxime
A nurse is assessing a client who has hypermagnesemia. Which of the
following medications should the nurse prepare to administer?
a. Protamine sulfate
b.Acetylcysteine
c. Calcium gluconate
d. Flumazenil
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A nurse is assessing a client following the administration of ondansetron
(Zofran). Which of the following findings should indicate to the nurse that the
ondansetron has been effective?
a. Client reports a decrease in
pain b. Client reports a
decrease in nausea
c. Client reports a decrease in coughing
d. Client reports a decrease in diarrhea
A nurse manager is planning an in-service about pain management with
opioids for client who has cancer. Which of the following information
should the nurse manager include? a. IM administration is recommended if
PO opioids are ineffective
b. Respiratory depression decreases as opioid tolerance develops
c. Meperidine is the opioid of choice for treating chronic pain
d. Withhold PRN pain medication for the client who is receiving opioids every 6 hr
A nurse is reviewing the list of current medication for a client who is to start
prescription for carbamazepine. The nurse should identify that which of the
following medications interacts with carbamazepine?
a. Nicotine transdermal system
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