administer IVIG transfusion at a constant rate monitor vital signs within 15 minutes prior to administration and within 30 minutes after starting the infusion administer IVIG at room temperature should chills occur during the infusion, continue the infusion and provide the client with a blanket
The nurse is preparing to administer regular and NPH insulin to the client. He knows to do which of the following steps?
insert air first into the regular insulin insert air first into the NPH insulin draw up regular insulin first draw up NPH insulin first
The nurse plans on administering a medication using the Z-track intramuscular technique. The nurse knows the following steps are required during the procedure.
Draw 0.2 – 0.5 cc of air after aspirating the prescribed medication. Use the vastus lateralis muscle. Replace the needle used for medication withdrawal with a new one prior to injection. Insert the needle at 45-degree angle.
The clinic nurse is seeing a client who suffers from caregiver strain due to caring for her elderly parents who have dementia and live with her. Which action by the nurse during the assessment is most important?
ask the client about her support systems ask the client what she does for relaxation ask if her parents’ insurance covers adult day care for them offer to give her a list of nursing homes to care for her parents
The nurse is caring for a client who has verbalized the desire to commit suicide. He has a detailed, concrete plan in place. The nurse places the client on suicide precautions, which include assigning the client a 24-hour sitter. The client becomes angry and refuses the sitter. Which action by the nurse is the most appropriate?
place the client in soft wrist restraints have security sit outside the client’s door assign a sitter despite the client’s refusal allow the client to leave against medical advice (AMA) tell the client that a friend can come sit with him instead
An elderly adult has been admitted with a diagnosis of hypertension with a history of dementia. Which of the following nursing diagnoses has the highest priority for this client?
ineffective coping activity intolerance ineffective tissue perfusion risk for injury
A nurse is preparing to lift a client up in bed. Which of the following should the nurse do to help avoid injuring his back?
keep his feet together instruct the client to not help tighten his stomach and leg muscles elevate the head of the bed to about 30 degrees, if the client can tolerate it
The nurse has just administered an IM injection to a client. In which of the following ways should the nurse dispose of the needle?
re-cap the needle and discard it in the nearest puncture-resistant container break the needle and discard it in the nearest puncture-resistant container discard the needle in a puncture-resistant container in the central medication area discard the needle in a puncture-resistant container in the client’s room
A nurse on the orthopedics floor is asked by another nurse to witness her waste 1 mg of morphine. The nurse draws the full 2 mg dose of morphine into the syringe and tells the first nurse, “This client does not get enough pain relief with 1 mg of morphine, so I just go ahead and give 2 mg to keep him comfortable because the doctor won’t change the dose.” Which is the correct action by the first nurse?
tell the other nurse to call the doctor back and request an increase in the dosage refuse to sign off on the waste and report the incident to the charge nurse or unit manager sign off the waste, and suggest that the nurse give it over two separate doses 30 minutes apart sign off the…
The nurse is admitting a new client to the medical unit. When asked about advance directives, the client says, “I’m not really sure what that is, but I trust my doctor to do whatever he thinks I need.” Which is the correct action by the nurse?
tell the client not to worry about it, because the client can always add the advance directives later tell the client that she can pay her lawyer to draw one up and have a copy sent to the hospital explain what advance directives are and how they benefit the client, and offer to give the…