A nurse is preparing to administer protamine to a client. Which of the following therapeutic effects should the nurse expect to document in the client’s medical record? a. Increased heart rate b. Decreased clotting time c. Increase urine output d. Decreased pain 2. A nurse is caring for a client who is 2 days postoperative following an above- the- knee amputation. Which of the following actions should the nurse take to promote progression toward independence and mobility for the client? a. Maintain abduction of the client’s residual limb with pillow. b. Encourage the client to use the over bed trapeze c. Caution the client to avoid a prone position while in bed d. Keep a loose, absorbent dressing over the client’s surgical site. 3. A nurse at a pediatric clinic is checking the vital signs of a 2 months old infant prior to administering immunizations. The nurse should recognize that a respiratory rate of 30/min indicates which of the following findings? a. The respiratory rate is a manifestation of respiratory depression. b. The respiratory rate is a manifestation of respiratory infection. c. The respiratory rate is most likely a result of cold stress. d. The respiratory rate is within the expected reference range.
1. When a nurse preparing to administer protamine, she can expect to document decreased clotting time. Protamine is the antidote of Heparin. The action of protamine is to decrease clotting time.
2. Encourage the patient to use the over bed trapeze. This action will promote the amputated patient to move independently on the bed.
3. The respiratory rate 30/min for a 2 months old infant is within the expected reference range. The expected respiratory rate for 2 months old infant is 30 to 50 breaths per minute .
A nurse is preparing to administer protamine to a client. Which of the following therapeutic effects...
A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging in the IV pump. Which of the following actions should the nurse take first? Label the pump with a defective equipment sticker. Unplug the pump. Obtain a replacement pump. Notify the biomedical department to fix the pump. A nurse is caring for a client who has a surgical wound. Which of the following laboratory values places the client at risk for poor wound...
A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client’s coccyx and abrasions around both wrists. Which of the following actions should the nurse take to address suspicions of elder abuse? Contact the family regarding the client’s condition. Notify risk management. Privately interview the client about her condition. Inform the transferring agency of the client’s condition. A nurse is caring for a client who is experiencing expressive asphasia...
1. The nurse is preparing a consent form for a client to sign before a procedure. Which of the following statement explains a characteristic of informed consent ? a. The client does not need autonomy to give consent. b. Minors are permitted to give consent c. The client does not need to give consent if the situation is an emergency d. If the client is of legal age, he or she does not need to cognitive ability to understand 2....
A nurse is inserting an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse take to verify proper placement of the tube? Place the end of the NG tube in water to observe for bubbling. Auscultate 2.5 cm (1 in) above the umbilicus while injecting 15 mL of sterile water. Assess the client for a gag reflex. Measure the pH of the gastric aspirate A nurse is caring for a client who...
A nurse is preparing to administer digoxin 225 mcg for a pediatric Client who has a heart rate above 90/min. Which of the following actions should the nurse take to ensure administration of the right dose? Select all that apply? a) Validate that the dose is within the safe range. b)Confirm the medication amount is appropriate for the child. c) Verify that the medication is not expired. d) Check the client's heart rate prior to administration. e) Document the administration...
A nurse in the emergency department is assessing a client who has major depressive disorder. Which of the following actions should the nurse take first? (Exhibit) Encourage the client to verbalize feelings. Implement seizure precaution for the client. Administer ondansetron to the client for nausea. Obtain the client’s weight. A home health nurse is completing screenings for elder abuse during client visits. Which of the following findings should the nurse identify as an indication of potential elder abuse? A client...
A nurse is assessing a client whose therapy has included bed rest for several weeks. Which of the following findings should the nurse identify as the priority? Musculoskeletal weakness Loss of appetite Increase heart rate during physical activity Left lower extremity tenderness A nurse is assessing a client’s ability to balance. Which of the following actions is appropriate when the nurse conducts a Romberg test? Ask the client to extend her arms in front of her body. Ask the client...
A nurse is collecting data from an adolescent client who has experienced sexual abuse. Which of the following statements by the client should the nurse recognized as the use of the use of defense mechanism of suppression? I drink beer as often as I can so that I don’t have to think about all of the times it happened. My mother is the real reason for it all because she doesn’t live in the real world. Sometimes I get angry...
15-The nurse is assessing a client with suspected endometriosis. Which of the following findings would support a diagnosis of endometriosis? dyspareunia hot flashes. Weight gain amenorrhea 16-The nurse has been made aware of the following client situation. The nurse should first assess the client with 1. heart failure who has a productive cough and is anxious 2. original enteritis (Crohn's disease) who is reporting cramping abdominal pain and diarrhea. 3. idiopathic thrombocytopenic purperia (ITP) who has petechia on the...
1. A nurse is caring for a client who is intubated and receiving mechanical ventilation. Which of the following findings should indicate to the nurse that the client's airway requires suctioning? a. Pulse ox saturation of 94% b. Rhonchi noted upon auscultation c. decreased peak airway inspiratory pressure d. low pressure alarm sounding on the ventilator 2. The nurse is teaching a client about PICC line. Which of the following statements by the nurse is correct? a. The procedure will...