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Hesi rn foundation of nursing
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Showing 10 questions, Sign in for moreThe palliative care nurse receives a consult for a terminally ill client in the intensive care unit. The client is weak, mouth breathing, and refusing anything to eat or drink. Which intervention should the nurse include in the plan of care?
The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a I-JAP understands gloving procedures?
The healthcare provider prescribes streptomycin 200 mg intramusculary every 12 hours. The vial is labeled, "Streptomycin I gram/2.5 mL". How many milliliters should the nurse administer? (Enter numerical value only. (If rounding is required, round to the nearest tenth.)
Explanation
Convert grams to milligrams: 1 gram = 1000 milligrams. So, the vial contains 1000 mg of streptomycin in 2.5 mL.
Determine the concentration: The concentration of the solution is 1000 mg / 2.5 mL.
Calculate the volume to administer: To administer 200 mg, you can set up a proportion:
(1000 mg / 2.5 mL) = (200 mg / x mL)
Cross-multiply: 1000x = 200 * 2.5
Solve for x: x = (200 * 2.5) / 1000 = 500 / 1000 = 0.5 mL
Therefore, the nurse should administer 0.5 mL.
The electronic medication system alerts the nurse that the medication dose scanned for the client is two times higher than the dose prescribed. Which action should the nurse implement?
The nurse is preparing a client for surgery and notices that the signed consent form has an error. The form states that the client is to have the left leg amputated. However, the client's right leg is marked for the surgery. The nurse administered the preoperative opioid medication 10 minutes ago and there are no family members present. Which action should the nurse implement?
The nurse enters a client's room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?
A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?
The client is a 74-year-old female with a history of type 2 diabetes mellitus. She is in the hospital recovering from pneumonia.
Nurses' Notes
Urinalysis
|
Laboratory Test |
Result |
Reference Range |
|
pH |
6.0 |
4.6 to 8 |
|
Protein |
Negative |
Negative |
|
Ketones |
Negative |
Negative |
|
Blood |
Negative |
Negative |
Patient Data
Complete the diagram by dragging from the choices area condition the client is most likely experiencing. two take to address that condition, and two parameters the to assess the client's progress.
Explanation
Potential Condition: Nocturia
The client is a 74-year-old female with type 2 diabetes mellitus, which increases the risk of nocturia (frequent nighttime urination) due to poor glycemic control, diuretic effects of hyperglycemia, and age-related changes in bladder function. No ketones or protein in the urine suggests no active diabetic ketoacidosis (DKA) or nephropathy. No blood in the urine, ruling out hematuria.
Actions to Take:
Review home medications: Some medications, such as diuretics, may contribute to nocturia. Certain diabetes medications, like SGLT2 inhibitors (e.g., empagliflozin, canagliflozin), promote glucose excretion in the urine, leading to increased urination.
Implement fall precautions: Elderly clients waking up frequently at night to urinate are at a high risk of falls, especially if they have neuropathy from diabetes. Ensuring proper lighting, accessible pathways, and bedside commodes can help prevent falls.
Parameters to Monitor:
Intake and output (I&O): Tracking urinary output can help determine the severity of nocturia and assess for potential fluid imbalances. Helps monitor the effectiveness of interventions.
Blood glucose: Hyperglycemia causes osmotic diuresis, increasing urine production and contributing to nocturia. Good glycemic control can help reduce nocturia episodes.
The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?
A child has experienced several episodes of vomiting. After the nurse reviews the need to provide only clear liquids, the parent of the child reports making clear liquid popsicles out of flavored gelatin for the child. Which information should the nurse obtain about the popsicles?
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