Question

Please answer and give rationale

1. The nurse has a prescription for zofran 4 mg IV bolus. Identify the sequence the nurse should follow to prepare to administer the medication

a. select the injection port of the IV tubing closes to the client

b. cleanse the inject port with an antiseptic swab

c. perform hand hygiene and apply gloves

d. release the tubing and inject the medication

e. occlude the IV lin by pinching the tubing above the injection port

2. A nurse in the ER is admitting a client who reports a visual disturbance in the left eye. The client reports that it begun with a flash of light followed by partial loss of vision. The nurse should recognize that this clinical manifestation is indicative of which of the following?

a. corneal laceration

b. retinal detachment

c. conjunctival hemorrhage

d. optic neuritis

3. A nurse is caring for a client who has a radial arterial line. Which of the following is the priority assessment for the client?

a. integrity of the arterial wave form

b. pressure of the fluid in the hemodynamic system

c. temperature of and sensation in the client's hand

d. level of the client' hemodynamic system transducer

4. A nurse is caring for a client who has been transferred from the PACU to medsug unit following a surgical procedure under general anesthesia. Which of the following assessment findings requires immediate intervention by the nurse?

a. respiratory rate of 10/min

b. oxygen saturation of 92%

c. cyanosis of the lips

d. hypoactive bowel sounds

5. A nurse is caring for a client who is receiving peritoneal dialysis. Upon assessment, the nurse notes a temperature of 102^oF and abdominal distension. Which ofo the following actions should the nurse take? Select all that apply

a. monitor the access site for drainage

b. check the peritoneal catheter for patency

c. assess the color and amount of dialysate outflow

d. ensure the outflow bag is above the client' abdomen

e. auscultate bowel sounds

6. A nurse is caring for an older adult client. Which of the following should the nurse recognize as a sign that the client may need a hearing aid?

a. The client does not respond when the speaker is standing behind her

b. The client reports that she may have cerumen buildup in her ears

c. The client turns off the television when the nurse speaks to her

d. the client reports that she is sensitive to high pitched sounds

7. A nurse is providing about smoking cessation to a client. Which of the following statements by the client indicates the need for further teaching?

a. I should be able to maintain my current weight

b. I will seek support from a friend who wants to stop smoking

c. I will set a specific date to stop smoke

d. I will find new ways to occupy the time I used to spend smoking

Answer 1

Ans) 1) c,a,b,d,e

Explaination:

Steps will be as follows:

Perform hand hygiene and apply gloves.

Select the injection port of the IV tubing closes to the client.

Cleanse the inject port with an antiseptic swab.

Release the tubing and inject the medication

Occlude the IV lin by pinching the tubing above the injection port.

2) b. Retinal detachment

Explaination:

- Retinal detachment is an emergency. Tissue at the back of the eye pulls away from a layer of blood vessels that provide necessary oxygen and nourishment.

3) c. temperature of and sensation in the client's hand

Explaination:

- More commonly, it is used to assess collateral flow to the hand through the ulnar artery when the radial artery is going to be used for arterial punctures for drawing blood gases, cannulation for placement of arterial lines, catheterizations or radial artery harvest for bypass surgeries.

4) c. Cyanosis of lips

Explaination:

- If a person's skin or lips turn blue, it's usually a sign of low blood oxygen levels or poor circulation. If a person's skin or lips turn blue, it's usually caused by low blood oxygen levels or poor circulation. It can be a sign of a serious problem, so it's important to seek medical advice.