Module 3 Flashcards
An 87 year old man is admitted to the hospital for cellulitis of the left arm. He ambulates with a walker and takes a diuretic medication to control symptoms of fluid retention. What intervention is most important to protect him from injury
provide a bedside commode
A mother and her 3 year old live at home built in 1932. What NANDA RN Dx is the most applicable for the child?
Risk for poisoning
A 75 year old client, hospitalized with a CVA becomes disoriented at times and tries to get out of bed, but is unable to ambulate without help. What is the most appropriate safety measure?
Use a bed exit safety monitoring device
What RN intervention is the highest in priority for a client at risk for falls in a hospital setting?
Place the bed in the lowest position
When planning to teach healthcare topics to a group of male adolescents, what topic is the highest priority
Guns are the most frequently used weapon for adolescent suicide
A client tells the nurse “This pill is a different color than the one that I usually take at home.” What is the best response by the nurse?
I will recheck your medication orders
What is missing from this order:
Codeine q4-6 hours, PO. PRN for pain
dosage is missing
PCP ordered 5 mL of a med to be given IM to a 40 year old female who weighs 135 and is 5’7” tall. What is an appropriate method of administration
Two 3mL syringes, #20-#23 gauge, 1 1/2 inch needle
An older client with renal insufficiency is to receive a cardiac med. What is the nurse most likely to administer
decreased dosage
Proper administration of an otic med to a 2 year old client includes
pull the ear down and back
what client is at greater risk for experiencing sensory overload
An 80 year old client admitted for emergency surgery
An alert 80 year old client is transferred to a LTC facility. On the 2nd night he becomes confused and agitated. What are 2 RN Dx?
Acute confusion
Disturbed sensory perception
The RN Dx risk Risk for Impaired Skin Integrity R/T sensory-perception disturbance would best fit a client who…
uses a W/C due to paraplegia
What does this statement indicate about a client’s needs:
“I can’t hear the doorbell.”
client needs a sensory aid
A hospitalized client is disoriented and believes she is in a train station. What response from the nurse is most appropriate?
“It may seem like a train station sometimes but, this is Valley Hospital.”
A PCP writes a prescription for 0.15 mg of digoxin IV every day. The med is available in a concentration of 400 mcg/mL. How many mL will the RN administer?
~0.38 mL
A RN student is preparing to administer insulin to a client with diabetes. What’s the correct order for the administration of this drug? (8)
- Mix the insulins
- Assess the skin for the injection
- Cleanse the site with alcohol
- Pinch the skin lightly
- Insert the needle quickly into the SubQ tissue
- Inject the medication
- Count to 5
- Remove the syringe
A client with impaired vision is admitted to the hospital. What interventions are most appropriate to meet the clients needs? (3)
- Identify yourself by name
- Stay in the clients field of vision
- Explain the sounds in the environment
Medication errors can place the client at significant risk. What practices will help decrease the possibility of errors
Establish a reporting system for “near misses
Communicate effectively
Create a culture of trust
The RN, at shift change, learns that one of the clients in his care has bilateral soft wrist restraints. The client is confused, trying to get out of bed, and pulled out the IV line which was subsequently reinserted. What actions by the RN is appropriate?
Document the behaviors that require continued use of the restraints
Provide ROM when restraints are removed
Orient the client
Assess the tightness of the restraints
The RN is to administer 0.75 mL of meds SQ in the upper arm to a 300 lb pt. the RN can grasp approx 2 inches of the clients tissue. What needle is most appropriate?
2 mL syringe, #25 gauge, 5/8 needle
The RN is to administer a TB test to a client who is 6 ft tall and weighs 180 lbs. what is the most appropriate needle for the RN to use?
TB syringe, #25-27 gauge, 1 1/2 inch needle
A client is exhibiting S/S of acute confusion/delirium. What strategy should the nurse implement to promote a therapeutic environment?
Keep the room organized and clean
A client is at risk for sensory deprivation. What 3 clinical signs would the RN observe?
Deceased attention span
Excessive sleeping
Crying, depression
