occult blood in the stool yellowing of the sclera vision loss enlarged abdomen
A 42-year-old female has thrombocytopenia with a platelet count of 75,000. The nurse should
monitor for bleeding. place the client on neutropenic precautions. limit visiting hours. encourage a diet high in iron.
The nurse is caring for a client with staphylococcus epidermidis. The client is on a vancomycin IV. What nursing consideration should the nurse be aware of regarding this medication?
The client should only order from the low-residue-diet menu. The nurse should assist the client to ambulate. The nurse will need to draw blood before administration to determine trough levels. The client should be monitored for cardiac arrhythmias.
A new graduate nurse is assigned to a 30-year-old female requiring NG tube feeding. The preceptor reminds the graduate nurse to check placement of the NG tube before administering the feeding. The best way to do this is by
verifying placement with an X-ray before each feeding. aspirating gastric contents and testing the contents on a pH paper. auscultating bowel sounds after administering a 30 cc air bolus. auscultating bowel sounds after administering the first 10 cc of tube feeding.
A nurse prepares to administer a transfusion of RBCs and takes the client’s vital signs. The client’s temperature is 102.7°F, but other vitals are within normal limits. The nurse should
transfuse the RBC as ordered. administer an antipyretic and transfuse the RBCs. transfuse the RBCs but monitor the temperature hourly. not transfuse the RBCs and instead contact the physician.
A client in the recovery ICU is on mechanical ventilation. The nurse notices the client has frothy secretions around his mouth, and the nurse hears adventitious breath sounds with the stethoscope. The nurse should
increase the oxygen level on the ventilator. suction the endotracheal tube. lower the head of the bed. call the rapid response team.
A client’s lab results have just come in. The nurse reviews the electrolytes and contacts the health care provider regarding which result?
chloride 167 mEq/L calcium 9.3 mg/dL phosphate 3.8 mg/dL sodium 141 mEq/L
Which of the following are risk factors for developing glaucoma? Select all that apply.
asthma pernicious anemia diabetes mellitus obesity hypertension
A 52-year-old female with mitral valve stenosis is admitted to the floor. She asks the nurse why she got this condition because it does not run in her family. The nurse explains most cases of mitral stenosis are due to a history of
right-sided heart failure. hypercholesterolemia. rheumatic fever. viral meningitis.
A 15-year-old male is brought into the emergency room after being hit by a car while riding his bicycle. The team quickly assesses him for injury and notes on the neurologic exam the client responds to external stimuli by arching back his head, extending and internally rotating the arms and legs, extending the elbows, pronating the wrists, and clenching his teeth. The team suspects injury to
the frontal lobe. the spinal column. the midbrain. the cerebral hemisphere.