The spouse brings a client to the emergency department due to erratic
behavior and expressions of despair. The emergency department is
extremely busy with many clients. When the triage nurse asks if the
client feels suicidal now, the client shrugs the shoulders. What initial
action should the triage nurse take? – ANSWER- Place the client in an
inside hallway with one-on-one observation.
The orthopedic health care provider instructs a client with a fractured
femur, who has been non-weight bearing for the past 5 weeks, to
progress to full weight bearing on the right leg. which advanced crutch
gait that most closely resembles normal walking should the office nurse
teach the client? – ANSWER- 4-point gait
- there are 5 crutch gaits: 2-, 3-, 4-point, swing-to, and swing-through
`A nurse administers an intramuscular (IM) injection using the Z-track
method technique. Place the steps in chronological order. All options
must be used. – ANSWER- 4. Pull the skin 1-1 1/2″ (2.5-3.5 cm)
laterally and away from the injection site.
- Hold the skin taut with non-dominant hand and insert needle at a 90-
degree angle. - Inject medication slowly with dominant hand while maintaining
traction - Wait 10 seconds after injecting the medication and withdraw the
needle.
Release the hold on the skin, allowing the layers to slide back to their
original position. - Apply gentle pressure at the injection site but do not massage.
The clinic nurse is teaching a client about levothyroxine, which the
health care provider has prescribed for newly diagnosed hypothyroidism.
Which statement made by the client indicates that further teaching is
needed? – ANSWER- “If this makes my stomach upset, I will take it
with an antacid.”
- will impair the absorption of levothyroxine (Synthroid). — Antacids,
calcium and iron preparations. - should take levothyroxine on an empty stomach, preferably in the
morning, separately from other medications
The nurse is reviewing laboratory results for several prenatal clients.
Which finding is most important to report to the health care provider? –
ANSWER- Client at 24 weeks gestation with hemoglobin of 9 g/dL (90
g/L) and hematocrit of 29% - during the second half of pregnancy, the fetus beings to store iron,
depleting maternal stores. Hemoglobin <11 g/dL in the first or third
trimester or <10.5 g/dL in the second trimester is considered low.
A client with obesity has just started taking orlistat. Which statement by
the client indicates a need for further teaching? – ANSWER- “I have
started taking a daily multivitamin with my dinner-time dose of
medication.” - Orlistat is a lipase inhibitor that prevents the breakdown and absorption
of fats from the intestine – interferes with fat-soluble vitamin uptake
The nurse on the medical-surgical unit receives report on assigned
clients. Which client warrants immediate attention? – ANSWER- Client
with epigastric pain after endoscopic retrograde
cholangiopancreatography. - Perforation or irritation of these areas during the procedure can cause
acute pancreatitis, a potentially life-threatening complication after an
ERCP: s/s – acute epigastric or left upper quadrant pain, often radiating
to the back, and a rapid rise in pancreatic enzymes (amylase. lipase)
The home health care nurse reviews the laboratory results for 4 clients.
Which laboratory value is most important for the nurse to report to the
health care provider? – ANSWER- Client with rheumatoid arthritis
taking adalimumab has a WBC count of 14,000/mm3
Which emergency department client would be allowed to leave against
medical advice after the risks are discussed with the primary health care
provider? – ANSWER- Client with coffee-ground emesis from chronic
use of high-dose aspirin. - Issues that can make a client ineligible to leave AMA include danger to
self or others, lack of consciousness, altered consciousness, mental
illness, being under chemical influence, or a court decision. Parents may
not refuse life-, limb-, or organ- saving treatment on behalf of their
minor child for religious or personal reasons: if the parents deny critical
treatments to the child, the hospital may seek protective custody
Which of the following are examples of medical battery? Select all that
apply. – ANSWER- 3. The nurse administers 2 mg of morphine PRN to
a difficult, alert client but tells the client it is saline.
- The nurse inserts a needed urinary catheter even though a competent
client refuses it
The nurse is preparing to administer a scheduled dose of
metoclopramide IV to a client with diabetic gastroparesis. Which
clinical finding causes the nurse to question the prescription? –
ANSWER- Sucking lip motions.
- Metoclopramide is a commonly used antiemetic medication that treats
nausea, vomiting, and gastroparesis by increasing gastrointestinal
motility and promoting stomach emptying. With extended use and/or
high doses, metoclopramide may lead to the development of tardive
dyskinesia, a movement disorder that is characterized by uncontrollable
motions and is often irreversible.
Clinical manifestations of tardive dyskinesia: Facial – ANSWER- – Lip
movement – smacking, sucking, puckering - tongue movement – protrusion, curling
- grimace
- brow furrow or twitch
- excess blinking
Clinical manifestations of tardive dyskinesia: extremities – ANSWER- –
foot tap - hand wringing
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