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. ●
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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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Position the client with the head elevated 30-45 degrees. ● Anticipated. Elevating the head of the bed helps reduce the risk of aspiration and promotes respiratory function after surgery. Administer subcutaneous heparin. ● Anticipated. Prophylactic administration of anticoagulants such as heparin is common after surgery to prevent deep vein thrombosis (DVT) and pulmonary embolism (PE).
The nurse is planning education for a client with gastroesophageal reflux disease (GERD). Which statement should the nurse include in the teaching regarding the treatment goal of GERD? A "Treatment is aimed to reduce acid production in the stomach." B "Treatment is focused on reducing the rate of gastric emptying." C "Treatment will relax the lower esophageal sphincter." D "Treatment will reduce the frequency of belching." Answers: A -D The statement that the nurse should include in the teaching regarding the treatment goal of GERD is: A) "Treatment is aimed to reduce acid production in the stomach." A nurse is caring for a client with a stage IV pressure ulcer and a history of methicillin-resistant staphylococcus aureus (MRSA). Which finding should the nurse report to the healthcare provider immediately? Answers: A - D A Temperature of 100.9° F B Respiratory rate of 20 breaths per minute C Heart rate of 102 beats per minute D Blood pressure of 100/62 mmHg The finding that the nurse should report to the healthcare provider immediately is: A) Temperature of 100.9°F A nurse is caring for a client with suspected inflammatory bowel disease. Which finding would suggest ulcerative colitis, rather than Crohn's disease? Answers: A-D A Many episodes of bloody diarrhea B Decreased albumin level C Abdominal pain and cramping D Significant inflammation in the small intestine The finding that would suggest ulcerative colitis, rather than Crohn's disease, is: A) Many episodes of bloody diarrhea. A client presents to the emergency department with pain and ankle swelling following a soccer injury. Which action should the nurse implement first? २ A
Provide morphine 2 mg IV push. B Contact the radiology department to arrange an ankle x-ray. C Administer ibuprofen PO. D Elevate the leg and apply an ice pack. Answers: A -D The action the nurse should implement first is: D) Elevate the leg and apply an ice pack. A nurse is caring for a client with renal failure and a hemoglobin of 8.1 g/dL. Which medication should the nurse expect to administer? Answers: A - D A Erythropoietin B Vitamin B12 C Vitamin K D Folate supplement The medication the nurse should expect to administer for a client with renal failure and a hemoglobin of 8.1 g/dL is: A) Erythropoietin A client reports pain in the right foot one day after a right below-the-knee amputation. Which is the nurse's best action? A Contact the healthcare provider to inquire about mirror therapy. B Explain that the brain does not yet understand the limb is no longer there. C Remove and re-wrap the compression bandage. D Provide intravenous pain medication. Answers: A - D The nurse's best action in this situation is: C) Remove and re-wrap the compression bandage. A nurse is administering an antibiotic infusion. Ten minutes into the infusion, the client reports pruritis and dyspnea. What should the nurse do first? A Administer 2 L of oxygen via nasal cannula and administer diphenhydramine. B Auscultate lung sounds and count respiration rate. C Contact the health care provider and charge nurse. D Elevate the head of the bed and discontinue the infusion. Answers: A-D\ The nurse's first action should be: D) Elevate the head of the bed and discontinue the infusion. A nurse is caring for a client with a platelet count of 19,000/mcL. Which is the priority action by the nurse? Answers: A -D A Initiate bleeding precautions. B