The nurse is caring for a client with congestive heart failure who is scheduled for the morning dose of digoxin 0.125 mg PO. The client’s apical pulse is 54. Which is the priority nursing action?
place the client on 2L of oxygen via nasal cannula hold the drug and notify the health care provider wait an hour and recheck the pulse; then administer the drug administer the drug and ask the unlicensed assistive personnel (UAP) to recheck the pulse in 30 minutes
The nurse is reviewing a new client’s medication orders. Which order would prompt the nurse to notify the health care provider?
allopurinol 300 mg PO daily potassium chloride 20 mEq PO daily warfarin (Coumadin) 50 mg PO daily metoprolol (Lopressor) 50 mg PO daily
The nurse is preparing to administer levofloxacin (Levaquin) 400 mg orally to a client with a urinary tract infection. Which statement by the client requires further teaching by the nurse?
“I will need to wear sunscreen if I am outdoors.” “I need to finish all the medication, even if my symptoms go away.” “I should take my antacid right before my pill so I don’t get heartburn.” “I need to check my pulse twice daily and call my doctor if I have new-onset irregular heartbeats.”
The nurse is preparing a middle-aged female for a total knee replacement (TKR) surgery on her left leg tomorrow. Which statement by the nurse is incorrect?
“Have you had a cold within the past 2 weeks?” “You will receive a dose of an antibiotic before surgery.” “When you need to urinate the first night you’ll need to use a fracture pan.” “You should ask for medication when you are in pain.”
The nurse is assisting a client who has experienced a left-sided cerebral vascular accident. The client requires assistance with personal hygiene. Which intervention should the nurse do initially ?
provide positive feedback place hygiene items on the client’s left side provide assistive devices assess abilities and level of deficit
The nurse is preparing an adult male for a transurethral resection of the prostate (TURP). Which statement by the client indicates a need for further teaching by the nurse?
“My urine may change color because of bleeding.” “I will need to drink water frequently.” “I will have a dressing where the surgeon cuts.” “I will have a catheter in place after surgery.”
The nurse is taking care of an elderly client with congestive heart failure. Which of the following are the most appropriate nursing interventions to reduce the workload of the heart and to promote comfort and rest? Select all that apply.
obtain daily weight provide assistance with self-care activities provide sensory stimulation check vital signs after activity
The nurse is caring for an adult who had an appendectomy 6 hours ago. Which intervention would the nurse expect to perform to promote rest and sleep? Select all that apply.
provide a substantial meal of meatloaf, mashed potatoes, corn, and milk offer Ambien 5 mg as ordered lower the temperature of the room change bed linen
The nurse is caring for a client who has just been diagnosed with ovarian cancer. The nurse is using silence as an effective therapeutic response. How is silence an effective therapeutic response?
It is not therapeutic; it implies that the nurse is not listening. It encourages the client to keep her feelings to herself. It allows the client time to think and reflect and lead the conversation. It allows the nurse to think about other tasks she needs to tackle to provide efficient care to all of…