order lab work. increase the dose of warfarin. discontinue the levothyroxine. decrease the dose of warfarin.
A 19-year-old male is rushed to the emergency room with a GI bleed after a car accident. The priority intervention is
asking the client what he remembers about the accident. obtaining a full set of vitals. completing a full abdominal assessment. administering ordered pain medication STAT.
A client is being treated with internal radiation (brachytherapy). The nurse explains to the client that
visitors should wear gown, gloves, and mask when coming in the room. visitors are not allowed until the client is no longer receiving radiation therapy. visitors must stay at least 6 feet away from the client. visitors should not bring any cards or gifts into the room because they can become radioactive.
The nurse is working on a discharge teaching plan for a client prescribed phenelzine (Nardil), a monoamine oxidase inhibitor (MAOI drug). The nurse knows teaching was successful if the client states
“I will not be able to have wine and aged cheese anymore.” “I should avoid all dairy products from now on.” “Taking this medication with vitamin K–containing foods is dangerous.” “I will need to decrease my dietary fiber now.”
What airborne precautions should the nurse anticipate when a client with measles is admitted to the hospital?
wear a surgical face mask upon entering client’s room require client to wear a face mask in the hallway during transport require client to be placed in a negative pressure airflow room wear a fit-tested N-95 respirator at all times when in client’s room have the client enter through the facility’s dedicated isolation entrance
An 80-year-old man with a decubitus ulcer has just been admitted to the floor. Upon assessment of the wound, the nurse notes that an area of skin under the wound extends and creates another opening in the skin 4 centimeters away. She would chart this as
tunneling. dehiscence. undermining. evisceration.
A nurse starts an IV medication for a client. It is ordered as IV push, and she pushes the medication slowly over two minutes. The client then becomes restless, complains of chest pain, has difficulty breathing, and becomes cyanotic. The nurse recognizes this is most likely caused by
an allergic reaction to the drug. pneumothorax. septic shock. pulmonary embolism.
An AIDS patient has developed a fungal Fusarium infection. The nurse anticipates the physician will order
lamivudine/zidovudine (Combivir). famciclovir (Famvir). ciprofloxacin (Cipro). voriconazole (Vfend)
A nurse is caring for an 84-year-old client who is malnourished. The nurse is concerned about all of the following complications of malnutrition EXCEPT
increased risk for falls. poor wound healing. chronic heart failure. increased risk of infections.
A 45-year-old female comes into the clinic for a yearly physical. The nurse calculates her body mass index (BMI) as 32. The nurse would chart this as
obese. underweight. overweight. healthy weight.