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Evolve Final

Question	Answer
Which action should the nurse implement when administering a prescription drug that should be given on an empty stomach?	Give one hour before or two hours after a meal. Average transit time from stomach to duodenum is 2 hours.
The nurse is caring for a client who is unable to void. The plan of care establishes an objective for the client to ingest 1000ml of fluid between 7am and 3pm. Which client response should the nurse document that indicates a sucessful outcome?	Drinks 240ml of fluid five times during the shift.
A client with metastatic cancer is preparing to make decisions about end of life issues. When the nurse explains a durable power of attorney for health care, which description is accurate?	It will identify someone that can make decisions for your health care if you are in a coma or vegetative state.
The nurse caring for the daughter of a local politician approaches a man reading names on the doors, IDs himself as a reporter for the local newspaper and requests information about the pts status. Which standard of nsg practice should the nurse use?	Confidentiality
A client with acute hemorrhagic anemia is to receive four units of packed RBC's (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement?	Ensure the accuracy of the blood type match.
A male client who had abdominal surgery has a nasogastric tube to suction, oxygen per nasal cannula, and complains of dry mouth. Which action should the nurse implement?	Apply a water soluble lubricant to the lips, oral mucosa, and nares. Petroleum based products are flammable.
A client with chronic renal failure selects a scramble egg for his breakfast. Which action should the nurse take?	Commend the client for selecting a high biologic value protein.
The nurse is administering meds through a NG tube which is connected to suction. After ensuring correct tube placement, what action should the nurse take next?	Flush the tube with water. NGT should be flushed before, after, and in between each med administered.
The nurse notices that the mother of a 9 year old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take?	Continue asking the mother questions about the child.
When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?	Loosen the right wrist restraint.
A client who is 5'5 tall and weighs 200lbs is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment?	What vitamin and mineral supplements do you take? Vitamins affect meds.
An african american grandmother tells the nurse that 4 year old grandson is suffering with miseries. Based on this statement, which focused assessment should the nurse conduct?	Inquire about the source and type of pain. Different cultural have different words.
In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly?	Often follows relocation to new surroundings.
The nurse is instructing a client with high cholesterol about diet and lifestyle modification. What comment from the client indicates that the teaching has been effective?	I will limit my intake of beef to 4 ounces per week. saturated fat from animal > cholesterol
The nurse is interviewing a female client whose spouse is present. During the interview, the spouse answers most of the questions for the client. Which action is best for the nurse to implement?	Ask the spouse to step out for a few minutes.
A young mother of three complains of increased anxiety during her annual physical exam. What information should the nurse obtain first?	Nutritional history
RN takes a female pt to the examination room and asks her to remove her clothes and put on an examination gown with the front open. The woman states "I have special undergarments that I do not remove for religious reasons." How should the nurse respond?	Tell me about your undergarments so we can discuss how you can have your examination comfortably.
The nurse determines that a client's body weight is 105% above the standardized height-weight scale. Which related factor should the nurse include in the nursing diagnosis, "Imbalanced nutrition: more than body requirements?	Inadequate lifestyle changes in diet and exercise.
A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge?	The client Demonstrates the wound care procedure correctly
An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings?	Fowlers' (Semi-sitting)
The nurse plans a teaching session with a client but postpones the planned session based on which nursing diagnosis?	Activity intolerance related to postoperative pain.
The nurse is preparing to adminster IV fluid to a client with a strict fluid restriction. IV tubing with which feature is most important for the nurse to select?	Buterol attachment
An elderly pt of a LTC facility is no longer able to perform ADLs and is progressively weaker. The pt previously requested that no resuscitative efforts be performed, and the family requests hospice care. WHat action should the nurse implement first?	Notify the healthcare provider of the family's request.
Prior to transferring a client to a chair using a mechanical lift, what is the most important client characteristic the nurse should assess?	Tolerance of exertion.
Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status?	Chocolate pudding
A pt is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The prep arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The RN plans to administer the IVPB dose over 20m. How many ml/hr should the infusion pump be set to deliver the secondary infusion?	150 ml/hr
The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the nurse administer?	1.5 ml.
The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility?	The client voluntarily signed the form.
The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan?	Avoid any types of sprays, powders, and perfumes.
Obese male pt discusses with RN plans to begin a LT wt loss regimen. With dietary changes, he plans to begin an aerobic exercise program 3-4x/w and stress mgmt classes. P/ praising pt for his decision, which info is most important for the RN to give?	Be sure to have a complete physical examination before beginning your planned exercise program.
The RN observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement?	Reassess the client's blood pressure using a larger cuff.
When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the?	Upper torso.
A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement?	Give an around-the-clock schedule for administration of analgesics.
An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP?	Reposition in a Sim's position with the client's weight on the anterior ilium.
A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first?	Assist the ambulating client back to the bed.
A pts infusion of NS infiltrated earlier today, and approx 500 ml of NS infused into the SQ tissue. The client is now c/o of excruciating arm pain and demanding “stronger pain medications.” What initial action is most important for the nurse to take?	Measure the pulse volume and capillary refill distal to the infiltration.
What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults?	A decreased flow rate could result in the formation of a thrombosis.
Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received?	11,000 units.
Seconal 0.1 gram PRN at bedtime is prescribed to a client for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the nurse plan to administer?	1 tablet.
The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first?	Observe the appearance of the skin under the ice pack.
A client who is a Jehovah’s Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client’s beliefs?	Blood transfusions are forbidden.
Which action is most important for the nurse to implement when donning sterile gloves?	Keep gloved hands above the elbows.
Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention?	Assess for bladder distention.
The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next?	Re-oxygenate the client before attempting to suction again.
The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler?	During the inhalation.
After completing an assessment and determining that a client has a problem, which action should the nurse perform next?	Determine the etiology of the problem.
The HCP prescribes 1,000 ml of RL with 30U of Pitocin to run in over 4h for a pt who has just delivered a 10lb infant by C section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min?	83 gtt/min.
The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the nurse administer?	0.5 ml.
An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response?	It is important that you continue your medication while learning to meditate.
While instructing a male client's wife in the performance of passive range of motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement?	Acknowledge that she is supporting the arm correctly.
When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action will the nurse implement first?	Note which actions were not implemented.
The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP?	Report the vital signs to the nurse.
During a visit to the outpatient clinic, the nurse assess a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure?	Degree of flexion and extension of the client's knee joint.
The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding?	Ptosis of the left eyelid.
A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take?	Request and document the name of the certified translator.
A pt is brought into the ED p/ a sudden cardiac arrest. A full code is started. 5m later family arrives with a durable POA signed by the pt requesting that no heroics be taken, including intubation, to save the pts life. What action should the RN take?	Stop the code immediately.
The nurse dons gown, mask with eyeshield, and gloves before entering a client's room that has airborne precautions. Upon leaving the client's room, in which sequence should the nurse remove the personal protective equipment?	Remove gloves, gown, mask, wash hands
When documenting assessment data, which statement should the nurse record in the narrative nursing notes?	S1 murmur auscultated in supine position: Objective data
A male pt being d/c with a rx for the bronchodilator theophylline tells the RN that he understands he is to take 3 doses/d. Since, at the time of dc, timed-release capsules aren't available, which dosing schedule should the RN advise the pt to follow?	8am, 4pm, 1200 midnight. q 8hrs
The nurse is preparing to administer a high volume saline enema to a client. Which information is most important for the nurse to obtain prior to administering the enema?	History of inflammatory bowel disorder S/S: diarhhea, hematuria, perforation
A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan?	Place a pillow between your knees while lying in bed to prevent hip dislocation.
A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement?	Give the missed dose at 1300 and change the schedule to administer daily at 1300.
A pt is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time?	Initiate an alternate site for the IV infusion of the medication.
A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump?	63 ml/hour.
A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement?	Ensure the accuracy of the blood type match.
A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first?	Reposition the client on her side
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take?	After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate?	is disoriented to place and time.
An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment?	The nurse who transferred the client to the chair when the fall occurred.
An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care?	Gently lift the client when moving into a desired position.
An elderly pt of a LTC facility is no longer able to perform ADLs and is becoming progressively weaker. The pt previously requested that no resuscitative efforts be performed, and the family requests hospice. What action should the nurse implement first?	Notify the healthcare provider of the family's request.
An IV infusion terbutaline sulfate 5 mg in 500 ml of D5W, is infusing at a rate of 30 mcg/min prescribed for a client in premature labor. How many ml/hr should the nurse set the infusion pump?	180
At the time of the first dressing change, the pt refuses to look at her mastectomy incision. The RN tells the pt that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence?	It is OK if you don't want to talk about your surgery. I will be available when you are ready.
During a physical assessment, a female client begins to cry. Which action is best for the nurse to take?	Acknowledge the client's distress and tell her it is all right to cry.
During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement?	Encourage additional oral intake of juices and water
Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding?	Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter.
The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the nurse plan to?	1½ tablets
The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein?	A lactating woman nursing her 3-day-old infant.
The RN is caring for a pt who is receiving 24h TPN via a central line at 54 ml/hr. When initially assessing the pt, the RN notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take?	Infuse 10 percent dextrose and water at 54 ml/hr.
The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions?	Frontal lobe
The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions?	Skim milk, turkey salad, roll, and vanilla ice cream.
The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive?	124 gtt/min.
The RN notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior?	Hot remedies restore balance after surgery, which is considered a "cold" condition.
The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute?	21
The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client?	Move the chair parallel to the right side of the bed, and stand the client on the right foot.
Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse?	Instruct the client that the stoma will become smaller when the initial swelling diminishes.
Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse?	Your blood vessels are becoming dilated and removing the heat from the site.
When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices?	Many complimentary healing practices can be used in conjunction with conventional practices.
When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action will the nurse implement first?	Note which actions were not implemented.
Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube?	Examining a chest x-ray obtained after the tubing was inserted.
Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent?	upper arm circumference

Created by: elizabethlaughlinlee

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