nursing IV

8/22/2019 nursing IV

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NURSING PRACTICE I

1. The nurse is to administer 25 mg ofpromethazine (Phenergan) IM to a 150-pound client. The nurse no!s that thismedication should "e gi#en into a deep

large muscle mass. The preferred site ofin$ection for this client !ould "e !hich of thefollo!ing%

&. 'eltoid. 'orsogluteal. *astus lateralis'. *entrogluteal

2. To administer 1ml of a flu #accineintramuscularl+ (IM) to an o"ese adult in thedeltoid area +ou !ould use !hat sizeneedle%

&. 5, inch. 1 inch. 1 inch'. 2 inch

/. The nurse is caring for se#eral clients !ithcentral #enous catheters. hile changingthe tu"ing on the central lines the nurse!ould not need to instruct the client toperform a *alsal#as maneu#er !hen theclient has !hich of the follo!ing catheters%

&. The 3roshong catheter. 4ingle-lumen catheter. Percutaneous catheter'. &ccessed su"cutaneous #enous port

. hen communicating !ith a culturall+di#erse client !ho speas a differentlanguage the "est practice for the nurse isto6

&. 4pea loudl+ and slo!l+.. 4tand dose to the client and spea

loudl+.. &rrange for an interpreter !hen

communicating !ith the client.'. 4pea to the client and famil+ together

to increase the chances that the topic!ill "e understood.

5. The client !ith m+asthenia gra#is is ha#ingdifficult+ speaing. The speech is d+sarthricand has a nasal tone. The nurse !oulda#oid using !hich of the follo!ingcommunication strategies !hen !oring !iththis client%

&. 7ncouraging the client to spea 8uicl+. &sing +es and no 8uestions !hen a"le. 9sing a communication "oard !hen

necessar+'. :epeating !hat the client said to #erif+

the message

;. & client admitted to the mental health unit ise


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'. izarre affect

10. & +oung male client tentati#el+ diagnosed!ith a "orderline personalit+ disorder sa+s tothe nurse @I donBt no! !h+ I got m+ tattooit !as for me. >H% 4ometimes I do thesethings to get m+ parents mad andsometimes I do them "ecause IBm "ored.ThatBs !hat happened the night I crashedthe famil+ car. I !asnBt drun or suicidal oran+thing lie the police thought. It !as $ustfor icsD@ hich of the follo!ing is theappropriate nursing response%

&. @Ce


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1G. & left atrial catheter is inserted into a clientduring cardiac surger+. The nurse ismonitoring the left atrial pressure (L&P) anddocuments that the pressure is normal if!hich of the follo!ing L&P #alues is noted%

&. mm Kg. 15mmKg. 25mmKg '. /2mmKg

20. & nurse is performing an assessment on achild !ith a head in$ur+. The nurse notes ana"normal flence the client is sta"ilized the nurse"egins discharge teaching. The nurse !ould"e especiall+ #igilant to include informationa"out compl+ing !ith medication therap+ ifthe clientBs "aseline theoph+lline le#el !as6

&. 10 mcg,mL. 12 mcg,mL. 15 mcg,mL'. 1 mcg,mL

2. The nurse is conducting a dietar+assessment on a client !ho is on a #egandiet. The nurse plans to pro#ide dietar+

teaching focusing on foods high in !hich#itamin that ma+ "e lacing in a #egan diet%&. *ilamin &. *ilamin 12. *ilamin '. *ilamin 7

2G. & nurse is planning to teach a client !ithmala"sorption s+ndrome a"out thenecessit+ of follo!ing a lo!-fat diet. Thenurse de#elops a list of high-fat foods toa#oid and includes !hich food item on thelist%

&. >ranges. roccoli. ream cheese


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'. roiled haddoc

/0. & nurse is preparing a 2-+ear-old child !ithsuspected nephrotic s+ndrome fordiagnostic tests to confirm the diagnosis.The mother ass the nurse if the child !ille#er loo thin again. The nurse mostappropriatel+ responds "+ telling the mother6

&. @>h +ou feel guilt+ "ecause +ou didnBtnotice the !eight gain%@

. @hen children are little itBs en remo#ing the dressing from theleg ulcer the nurse notes that the ulcer ispale and deep and that the surroundingtissue is cool to touch. The nurse should

document that these findings identif+ !hicht+pe of ulcer%

&. & #ascular ulcer. & #enous stasis ulcer. &n arterial ulcer'. & stage 1 ulcer

//. The nurse is tr+ing to communicate !ith aclient !ith "rain attac (stroe) and aphasia.hich of the follo!ing actions "+ the nurse!ould "e least helpful to the client%

&. 4peaing to Ihe client at a slo!er rate. &llo!ing plent+ of time for the client to

respond. ompleting the sentences that the clientcannot finish

'. Looing directl+ at the client duringattempts at speech

/. & nurse o"tains an order from a ph+sician torestrain a client "+ using a $acet restraintand instructs a nursing assistant to appl+ therestraint to the client. hich o"ser#ation "+the nurse indicates inappropriate applicationof the restraint "+ the nursing assistant%

&. & safel+ not in the restraint straps. :estraint straps that are safel+ secured

to the side rails

. Jacet restraint straps that do nottighten !hen force is applied againstthem

'. Jacet restraint secured so that t!ofingers can slide easil+ "et!een therestraint and the clientBs sin

/5. & nurse is gi#ing a report to a nursingassistant !ho !ill "e caring for a client !hohas hand restraints. The nurse instructs thenursing assistant to assess the sin integrit+of the restrained hands e#er+6

&. 2 hours. / hours. hours'. /0 minutes

/;. The nurse is teaching the client !ho has had

a lar+ngectom+ for lar+ngeal cancer ho! touse an artificial lar+n


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. & form of "iofeed"ac to enhance"earing-do!n efforts during deli#er+

. Light stroing of the a"domen tofacilitate rela


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&. Immediatel+ "efore s!imming. 15 minutes "efore e


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!hich item does not need to "e limited oreliminated !ith this disease%

&. ine. offee. =resh fruit'. aed chicen

;0. The nurse instructs the ileostom+ client toinclude !hich action as part of essentialcare of the stoma%

&. Massage the area "elo! the stoma.. Limit fluid intae to pre#ent diarrhea.. Tae in high-fi"er foods such as nuts.'. leanse the peristomal sin

meticulousl+.

;1. The client !ith a ne! colostom+ isconcerned a"out the odor from stool in theostom+ drainage "ag. The nurse teachesthe client to include !hich food in the diet to

reduce odor%&. 7ggs. Aogurt. roccoli'. ucum"ers

;2. The nurse has gi#en instructions to the client!ith an ileostom+ a"out foods to eat tothicen the stool. The nurse determines thatthe client needs further instructions if theclient states that !hich food maes the stoolless !ater+%

&. ran

. Pasta. oiled rice'. Lo!-fat cheese

;/. The client !ith chronic pancreatitis needsinformation on dietar+ modification tomanage the health pro"lem. The nurseteaches the client to limit !hich item in thediet%

&. =at. Protein. ar"oh+drate'. ater-solu"le #itamins

;. The nurse is participating in a healthscreening clinic and is preparing teachingmaterials a"out colorectal cancer. hichris factor for colorectal cancer should thenurse include%

&. &ge older lhan /0 +ears. Kigh-fi"er lo!-fat diet. 'istant relati#e !ith colorectal cancer'. Personal histor+ of ulcerati#e colitis or

gastrointestinal pol+ps

;5. & nurse instructs a client to use the pursed-lip method of "reathing and the client assthe nurse a"out the purpose of this t+pe of"reathing. The nurse responds no!ing that

the primar+ purpose of pursed-lip "reathingis to6

&. Promote o"tain s+ringes !ith *,i-inch needles

from the pharmac+.

?0. & client has a fi"erglass (nonplaster) castapplied to the lo!er leg. The client ass thenurse !hen the client !ill "e a"le to !alusing the casted leg. The nurse replies thatthe client !ill "e a"le to "ear !eight on thecasted leg6

&. In hours. In 2 hours. In a"out hours'. ithin 20 to /0 minutes of application

?1. & client !ith right-sided !eaness needs tolearn ho! to use a cane !hile am"ulating.The nurse plans to teach the client toposition the cane "+ holding it !ith the6


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&. Left hand and placing Ihe cane in frontof the left foot

. :ight hand and placing the cane in frontof the right foot

. Left hand and mo#ing it for!ard 12inches. ; inches lateral to the left foot

'. :ight hand and mo#ing it for!ard 12inches. ; inches lateral to the right foot

?2. The ph+sician orders a 2-hour urinecollection for *M& (#anill+lmandelic acid).The communit+ health nurse #isits the clientat home and instructs the client in theprocedure for the collection of the urine.hich statement if made "+ the client!ould indicate a need for further instruction%

&. @I !ill start the collection in 2 da+s.4tarting no!. I cannot eat or drin an+tea chocolate #anilla or fruit until thetest is completed.@

. Bhen I start the collection I !ill urinateand discard that specimen.@

. @I !ill pour the urine in the collection"ottle each time I urinate and refrigeratethe urine.@

'. @I can tae medication if I need to duringthe collection.B

?/. The maternit+ nurse is descri"ing theo#arian c+cle to a group of nursing students.The instructor ass a nursing student toidentif+ the phases of the c+cle. hich of thefollo!ing if identified as a phase of the c+cle

"+ the nursing student indicates a need tofurther research this area%

&. =ollicular phase. >#ulator+ phase. Luteal phase'. Proliferati#e phase

?. & client is seen in the health care clinic andis diagnosed !ith mild anemia. The anemiais "elie#ed to "e a result of the menstrualperiod. The !oman ass the nurse ho!much "lood is lost during a menstrualperiod. The nurse plans to respond "+

stating !hich of the follo!ing amounts of"lood is lost during this time%&. 0mL. ;0 mL. 0 mL'. 100 mL

?5. & nursing assistant collects a urinespecimen from a client and is planning todeli#er the specimen to the la"orator+ aftercompleting morning care for other assignedclients. The registered nurse instructs thenursing assistant to place the collectedspecimen in the unit la"orator+ refrigerator.The nursing assistant ass the registerednurse a"out the reason that the urine needs

refrigeration. The registered nurse "ases theresponse on the fact that !hen urine isallo!ed to stand un refrigerated6

&. The urine "ecomes more acidic.. acteria and !hite "lood cells (s)

decompose.. The urine clumps.'. The pK decreases.

?;. & registered nurse is instructing a ne!nursing graduate a"out hemodial+sis. hichstatement if made "+ the ne! nursinggraduate !ould indicate an inaccurateunderstanding of the procedure forhemodial+sis%

&. @4terile dlal+sate must "e used.@. Barming the dial+sale increases the

efficienc+ of diffusion.@. @Keparin sodium is administered during

dial+sis.@

'. @'ial+sis cleanses the ood fromaccumulated !aste products.@

??. & client "eing discharged to home afterrenal transplantation has a nursingdiagnosis of ris for infection related toimmunosuppressi#e medication therap+.The nurse determines that the client needsfurther instruction on measures to pre#entand control infection if the client states to6

&. Tae an oral temperature dail+.. 9se good hand-!ashing techni8ue.. Tae all scheduled medications e


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'. Tilting the clientBs head slightl+ a!a+and holding the otoscope upside do!n"efore inserting the speculum

0. & clinic nurse conducting a health screeningclinic is performing hearing assessments onclients !ho attend the clinic. 4enior nursingstudents are assisting the nurse !ith theassessments. The clinic nurse instructs thestudents to perform a #oice test and teachesthe students to6

&. 4tand 1 to 2 feet a!a+ from the clientand as the client to "loc one e


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'. 4inoatrial (4&) node

G0. & male client !ho is "eginning an e

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nursing IV