Study guides, Class notes & Summaries

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A client arrives for a vaccination at an influenza prevention clinic. A nursing assessment identifies a current febrile illness with a cough. The nurse should: a. Give the vaccine b. Administer aspirin with the vaccine c. Hold the vaccine and notify the health care provider d. Reschedule administration of the vaccine for the next month : D! The appropriate response is to delay the administration of the vaccine until the client is healthy. Vaccines should not be administered during a fe...

Potassium chloride intravenously is prescribed for a client with hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply. 1. Obtain an intravenous (IV) infusion pump. 2.Monitor urine output during administration. 3.Prepare the medication for bolus administration. 4.Monitor the IV site for signs of infiltration or phlebitis. 5.Ensure that the medication is diluted in the appropriate volume of fluid. 6.Ensure tha...

The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? a. observe the appearance of the skin under the ice pack b. instruct the client regarding the need for the covering c. reapply the covering after filling with fresh ice d. ask the client how long the ice was applied to the skin : Answer: a. observe the appearance of the skin under the ice pack Rationale: the first action taken by the nurse sho...

In planning care for a 6 month-old infant, what must the nurse provide to assist in the development of trust? A) Food B) Warmth C) Security D) Comfort : C) Security A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication? A) "I cannot give this medication as it is written. I have no idea of what you mean." B) "Would you please clarify what you have written so I am sure I am reading it correctly?" C) "I am having ...

The nurse is completing the admission assessment of a 3-year old who is admitted with bacterial meningitis and hydrocephalus. Which assessment finding is evidence that the child is experiencing increased intracranial pressure (ICP)? A. Tachycardia and tachypnea B. Sluggish and unequal pupillary responses C. Increased head circumference and bulging fontanels D. Blood pressure fluctuations and syncope : B. Sluggish and unequal pupillary responses A client with acute pancreatitis is admit...

1. The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which nursing intervention is appropriate for this child? A) Make certain the child is maintained in correct body alignment. B) Be sure the traction weights touch the end of the bed. C) Adjust the head and foot of the bed for the child's comfort D) Release the traction for 15-20 minutes every 6 hours PRN. : A: Make certain the child is maintained in correct body alignment. 2. The nurse is assessing a hea...

Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication? A) Checking the client's blood pressure B) checking the client's peripheral pulses C) checking the most recent potassium level D) checking the client's intake and output record for the last 24 hours : A) Checking the client's blood pressure Rationale--enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used t...

The nurse has completed giving discharge instructions to a client who has had a total joint replacement (TJR) of the knee with a metal prosthetic system. The nurse determines that the client understands the instructions if the client makes which statement? 1."Changes in the shape of the knee are expected." 2."Fever, redness, and increased pain are expected." 3."All caregivers should be told about the metal implant." 4."Bleeding gums or black stools may occur, but this is normal...

A morbidly obese client is scheduled for gastric bypass surgery. The client completes the required preoperative nutritional counseling and signs the operative permit. To promote effective discharge planning, which intervention is most important for the nurse to implement? : Discuss small, low fat, low sugar meal preparation techniques. A client who was splashed with a chemical has both eyes covered with bandages. When assisting the client with eating, which intervention should the nurs...

The nurse has completed giving discharge instructions to a client who has had a total joint replacement (TJR) of the knee with a metal prosthetic system. The nurse determines that the client understands the instructions if the client makes which statement? 1."Changes in the shape of the knee are expected." 2."Fever, redness, and increased pain are expected." 3."All caregivers should be told about the metal implant." 4."Bleeding gums or black stools may occur, but this is normal...