cheehoo Flashcards
A nurse is assessing a client who is receiving intravenous therapy. The nurse should identify which of the following findings is a manifestation of fluid volume excess?
- Decreased bowel sounds
- Distended neck veins
- Bilateral muscle weakness
- Thready pulse
Distended Neck Veins
A nurse is caring for a client with hyponatremia and is receiving an infusion of a prescribed hypertonic solution. Which of the following findings should indicate to the nurse that the treatment is effective?
- Absent Chvostek’s sign
- Improved cognition
- Decreased vomiting
- Cardiac arrhythmias absent
Improved Cognition
A nurse is teaching a client who has a new prescription for a nitroglycerin transdermal patch. Which of the following instructions should the nurse include?
“Discontinue the patch if you experience a headache.”
“Apply a new patch if you have chest pain.”
“Cover the patch with dry gauze when taking a shower.”
“Remove the patch prior to going to bed.”
“Remove the patch prior to going to bed.”
A nurse reviews the laboratory results of a client who has a prescription for sodium polystyrene sulfonate (Kayexalate) every six hours. Which of the following should the nurse report to the provider?
Creatinine 0.72 mg/dL
Sodium 138 mEq/L
Magnesium 2 mEq/L
Potassium 5.2 mEq/L
Potassium 5.2 mEq/L
Hyperkalemia (serum potassium level greater than 5.0 mEq/L) increases the client’s risk for fatal cardiac dysrhythmias. Kayexalate is used to decrease the serum potassium level
A nurse is caring for a client who has tuberculosis and is taking isoniazid and rifampin. Which of the following outcomes indicates that the client is adhering to the medication regimen?
The client has a negative sputum culture
The client tests negative for HIV
The client has a positive purified protein derivative test
The client’s liver function test results are within the expected reference range
The client has a negative sputum culture
A client is caring for a client who develops an anaphylactic reaction to IV administration. After assessing the client’s respiratory status and stopping the medication infusion. Which of the following actions should the nurse take next?
Replace the infusion with 0.9% sodium chloride
Give diphenhydramine IM
Elevate the client’s legs and feet
Administer epinephrine IM
Administer epinephrine IM
A nurse is caring for a client taking sertraline and reports a desire to begin taking supplements. Which of the following supplements should the nurse advise the client to avoid?
- St. John’s Wort
- Ginger root
- Black cohosh
- Coenzyme Q10
- St. John’s Wort
A nurse is caring for a client who has heart failure and a new prescription for lisinopril. For which of the following adverse effects should the nurse monitor when administering lisinopril?
- Bradycardia
- Hypokalemia
- Tinnitus
- Hypotension
- Hypotension
A nurse is assessing a client who is receiving heparin IV continuous IV. The client has a PPT of 90 seconds. They should monitor the client for which of the following changes in their vital signs?
Decreased temperature
Increased pulse rate
Decreased respiratory rate
Increased blood pressure
Increased blood pressure
A nurse is preparing to administer medication to a client and discovers a medication error. The nurse should recognize that which of the following staff members is responsible for completing an incident report?
The quality improvement committee
The nurse who identifies the error
The nurse who caused the error
The charge nurse
The nurse who identifies the error
A nurse is planning care for a client who is receiving morphine via continuous epidural infusion. The nurse should monitor the client for which of the following?
* Pruritus
* Cough
* Tachypnea
* Gastric bleeding
Pruritus – Sign of allergic reaction to morphine
A nurse is preparing to administer digoxin orally to a client. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
-Document administration of the medication
-Obtain the client’s apical heart rate
-Open the medication package
-Remove the medication from the dispensing system
-Compare the client’s wristband to the medication administration record
1.-Obtain the client’s apical heart rate
2.-Remove the medication from the dispensing system
3.-Open the medication package
4.-Compare the client’s wristband to the medication administration record
5.-Document administration of the medication
A nurse is reviewing the medical record of an adult client who has a fever and a prescription for acetaminophen. Which of the following findings should the nurse identify as a contraindication for receiving this medication?
Alcohol use disorder
Chronic kidney disease
Hepatitis B vaccine within the last week
Diabetes mellitus
Chronic kidney disease
A home health nurse is visiting a client who has heart failure and a prescription for furosemide. The nurse identified that the client had gained 2.5 kg (5 lb.) since the last visit two days ago. Which of the following actions should the nurse take first?
Encourage the client to dangle the legs while sitting in a chair
Teach the client about foods low in sodium
Determine medication adherence by the client
Notify the provider of the client’s weight gain
Determine medication adherence by the client
A nurse is preparing to administer the initial dose of penicillin G IM to a client. The nurse should monitor for which of the following indicate an allergic reaction following the injection?
Urticaria (rash)
Bradycardia
Pallor
Dyspepsia
Urticaria
