Exam 4: Fundamentals

The health care provider writes a prescription for hydromorphone 10 mg intravenous push every 2 hours prn for the post-operative client.  The usual recommended dose is 0.2-1 mg every 2-3 hours prn.  What action should the nurse initially take?

The nurse prepares to administer a cleansing enema to a client with constipation.  Which interventions are appropriate?  Select all that apply.

The nurse teaches a client with newly diagnosed Sjögren's syndrome how to self-administer ophthalmic lubricating ointment medication.  Which statement that the client makes indicates the need for further teaching?

A 2-year-old who swallowed an overdose of adult cough syrup is being discharged from the emergency department.  The parent says to the nurse, "From now on, I'm going to store all medicines in my top dresser drawer."  Which is the best response by the nurse?

The student nurse verbalizes the procedure for obtaining a wound culture to the nurse preceptor.  Which of the following statements by the student indicate a correct understanding?  Select all that apply.

A nurse has received report from the off-going shift that a client is confused and has been identified as a high risk for falls.  The nurse shares this information with the unlicensed assistive personnel (UAP).  Which finding by the nurse requires intervention?

The nurse is caring for a client with bacterial meningitis, identified as Neisseria meningitidis who has a stage 4 pressure injury.  What personal protective equipment is most appropriate for the nurse to wear when performing a dressing change?  Select all that apply.

The nurse on the IV therapy team is making rounds in the intensive care unit on clients with central venous catheters.  Which central line should be removed earliest to prevent infection?

An elderly war veteran with prostate cancer and coronary artery disease is hospitalized for urosepsis.  The client becomes angry with the unlicensed assistive personnel (UAP), who is trying to help the client bathe.  Later, the UAP expresses frustration with the client to the registered nurse.  Which statement would be the most appropriate response?

The nurse is preparing to give a heparin injection to a client who is malnourished and cachectic.  Which method of injection would be appropriate for this client?

The health care provider prescribes intravenous fluid resuscitation for a client in hypovolemic shock.  The nurse should anticipate the rapid infusion of which intravenous solution initially?

A comatose client in the intensive care unit has an indwelling urinary catheter.  Which action(s) should the nurse implement to reduce the incidence of catheter-associated urinary tract infections (UTIs)?  Select all that apply.

Ten minutes after an infusion of packed red blood cells (PRBCs) is initiated through a central venous catheter (CVC), the client has shortness of breath and slight chest tightness.  What initial actions would be appropriate for the nurse to complete?  Select all that apply.

The nurse performs tracheostomy care for a client with a disposable inner cannula and tracheostomy dressing.  Place the steps in the correct order.  All options must be used.

A student nurse assesses and obtains a urine specimen from a client with methicillin-resistant Staphylococcus aureus (MRSA) who is on contact precautions.  The registered nurse intervenes when the student performs which action?

A nurse is making a home visit when a fire starts in the client's kitchen trash can.  The client has a fire extinguisher.  The nurse should take which actions to properly operate the fire extinguisher?  Select all that apply.

The nurse is preparing to administer a continuous enteral feeding for a client with a nasogastric tube.  Place the steps in the correct order.  All options must be used.

The charge nurse in the cardiac intensive care unit responds to a client room where a resuscitation effort is in progress.  The client's immediate family member refuses to leave the room.  How should the charge nurse handle this situation?

A client of the Orthodox Jewish faith with a history of type 2 diabetes mellitus is hospitalized, recovering from a total right hip arthroplasty.  At noon, the client consumed a lean roast beef sandwich with lettuce and mustard, carrot and celery sticks, and fresh fruit.  What would be the most appropriate 2:00 PM snack for this client?

The nurse teaches a parent how to administer an oral liquid medication to a 2-month-old client.  The nurse knows that the parent understands the teaching when the parent does which of the following?