Adult Health
The nurse is planning care for a client with a hemoglobin of 6.0 g/dL. Which action should the nurse anticipate including in the plan of care? A Alternate periods of rest and activity. ✓ B Increase the client's dietary vitamin K intake. C Place the client on neutropenic precautions. D Administer heparin subcutaneously.
The correct answer is A) Alternate periods of rest and activity.
The nurse is caring for a client with a tibial fracture. Which prescription does the nurse know is used to prevent complications of immobility? A Ondansetron 4mg IV push. B Fentanyl 25 mcg IV push. C Ibuprofen 600 mg PO. D Heparin 5,000 units subcutaneously. Answers: A -D
The correct answer is D) Heparin 5,000 units subcutaneously.
The nurse is caring for a client being treated for primary polycythemia vera. Which healthcare provider order should the nurse anticipate? Answers: A -D A Phlebotomy. B Fluid restriction C Iron supplementation D Platelet infusion
The correct answer is A) Phlebotomy.
A nurse is caring for a client with a platelet level of 18,000/mcL. Which finding requires immediate action? Answers: A-D A Petechiae on the lower legs. B Lethargy on assessment. C Bruising around the IV site. D Oozing of blood from the nose.
The finding that requires immediate action due to the client's low platelet count is:
D) Oozing of blood from the nose.
A nurse is caring for a client admitted with an exacerbation of ulcerative colitis. Which nursing action should be included in the plan of care? Answers: A-D A Monitor stools for blood B Increase dietary fiber intake C Decrease fluid intake D Administer ibuprofen for pain
The appropriate nursing action to include in the plan of care for a client admitted with an exacerbation of ulcerative colitis is:
A) Monitor stools for blood.
The nurse has received handoff shift report at the human immunodeficiency virus (HIV) clinic. Which client should the nurse assess first? A A client reporting
having a cough, congestion, and chills for the last 24 hours. B A client whose rapid HIV antibody test is positive. C A client whose latest CD4+ count has dropped to 300 uL. D A client reporting having a headache from prescribed antiretroviral medications. Answers: A - D
The client the nurse should assess first is:
A) A client reporting having a cough, congestion, and chills for the last 24 hours.
A nurse is planning education for a client with rheumatoid arthritis about joint preservation strategies. Which activity should the nurse include in the teaching? A Avoid activity and rest in bed as much as possible. B Perform all household chores in one day. C Stand during meal preparation to keep joints loose. D Use the strongest joint for any task or activity. Answers: A-D
The activity the nurse should include in the teaching for joint preservation strategies for a client with rheumatoid arthritis is:
C) Stand during meal preparation to keep joints loose.
The nurse is planning to educate a client with Crohn's disease about pernicious anemia. What should the nurse include in the education? Answers: A -D A Iron dextran infusions B Routine blood transfusions C Oral ferrous sulfate tablets D Cobalamin (B12) injections
The nurse should include the following in the education about pernicious anemia for a client with Crohn's disease:
D) Cobalamin (B12) injections.
A nurse is preparing to administer vancomycin 500 mg PO daily divided into four equal doses. The amount available is vancomycin 125 mg capsules. How many capsule(s) should the nurse administer with each dose? 1 capsule(s) (If needed, round the answer to the nearest whole number.)
To administer vancomycin 500 mg PO daily divided into four equal doses, you would divide the total daily dose (500 mg) by the number of doses (4).
500 mg / 4 doses = 125 mg per dose.
Since the available capsules are 125 mg each, the nurse would administer: 125 mg per dose / 125 mg per capsule = 1 capsule per dose.
So, the nurse should administer 1 capsule with each dose.
A nurse prepares to administer gentamycin 800 mg in 100 mL of dextrose 5% in water (D5W) to infuse over 1 hr. The drop factor of the tubing is 15 gtt/ml. At what rate will the nurse set the infusion? 1 gtt/min (If needed, round the answer to the nearest whole number.)
To calculate the infusion rate in drops per minute (gtt/min), we need to use the formula:
Infusion rate (gtt/min) = (Volume to be infused × Drop factor) / Time of infusion (in minutes)
First, let's convert the volume to be infused from mL to drops:
Volume to be infused = 100 mL × 15 gtt/mL = 1500 gtt
Now, we can calculate the infusion rate:
Infusion rate (gtt/min) = (1500 gtt × 1 min) / 60 min = 25 gtt/min
Therefore, the nurse should set the infusion rate to 25 gtt/min.
The nurse is planning care for a client after a Roux-en-Y gastric bypass (RYGB) surgery. For each potential healthcare provider order, indicate if it is anticipated or not anticipated in the care of this client. Action Not Anticipated Anticipated Place the client on a liquid diet. Maintain total bedrest for 24 hours. Provide 30 mL of fruit juice every two hours. Position the client with the head elevated 3045 degrees. Administer subcutaneous heparin.
● Place the client on a liquid diet.
● Anticipated. After Roux-en-Y gastric bypass surgery, clients typically start with a liquid diet and gradually progress to solid foods.
● Maintain total bedrest for 24 hours.
● Not Anticipated. While the client may have restrictions on physical activity immediately after surgery, total bedrest for 24 hours is not typically required.
● Provide 30 mL of fruit juice every two hours.
● Anticipated. Fluid intake is important after surgery to prevent dehydration and promote healing. Fruit juice can provide calories and hydration.
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