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RN Hesi Exit
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Showing 20 questions, Sign in for moreThe nurse reviews the physician's orders for clonazepam and gives the medication as ordered. What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.
The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete intravenous antibiotic administration.
0900
Pain assessment completed. The client's pain is 2/10. The client requests sleeping medication for the night. She states that she has horrible thoughts and memories about the house collapsing all the time and that it is keeping her from falling asleep. She states, "I used to be so happy before
all of this happened. Now I can't seem to get out of this funk I am in." The client would also prefer to be in a quieter area of the unit as she is currently by the nurses' station and hears talking and alarms constantly.
1100
Noted that the client is using fantasy, isolation, and suppression as defense mechanisms. Notified the. Start clonazepam 0.25 mg PO every 12 hours
The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete intravenous antibiotic administration.
Patient Data
What other treatments might be helpful for this client? Select all that apply.
A client with a history of type 1 diabetes mellitus (DM) and asthma is readmitted to the unit for the third time in two months with a current fasting blood sugar (FBS) is 325 mg/dL (18 mmol/L). The client describes to the nurse of not understanding why the blood glucose level continues to be out of control. Which intervention(s) should the nurse implement? (Select all that apply.)
Reference Range
Blood Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]
A client who weighs 65 kg receives a prescription for lorazepam 44 mcg/kg intravenously to be administered 20 minutes before a scheduled procedure. The medication is available in 2 mg/mL vial. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)
Explanation
Calculate the total dosage required: 44 mcg/kg * 65 kg = 2860 mcg. Convert mcg to mg: 2860 mcg ÷ 1000 = 2.86 mg.
Divide by concentration: 2.86 mg ÷ 2 mg/mL = 1.43 mL.
Considering the vial contains 2 mg/mL, the nurse should administer around 1.43 mL, which can be rounded to 1.4 mL.
A client with leukemia who is receiving myelosuppressive chemotherapy has a platelet count of 25,000/mm3 (25 x 109/L). Which intervention is most important for the nurse to include in this client's plan of care?
Reference Range:
Platelet Count [150,000 to 400,000/mm3 (156 400 x 109/L)]
An infant who weighs 22 pounds receives a prescription for amoxicillin 20 mg/kg/day by mouth in divided doses every 8 hours. The bottle is labeled, "Amoxicillin for Oral Suspension, USP 250 mg per 5 mL." How many mL should the nurse administer with each dose? (Enter numerical value only. If rounding is necessary, round to the nearest tenth.)
Explanation
1. Convert the infant's weight from pounds to kilograms. We can use the conversion factor 1 kg
= 2.2 lb. So, 22 lb x (1 kg / 2.2 lb) = 10 kg.
2. Calculate the total daily dose of amoxicillin for the infant. We can use the formula D = d x W, where D is the total daily dose, d is the dose per kg per day, and W is the weight in kg. So, D = 20 mg x 10 kg = 200 mg.
3. Calculate the single dose of amoxicillin for the infant. We can divide the total daily dose by the number of doses per day. Since the prescription is for every 8 hours, there are 3 doses per day. So, 200 mg / 3 = 66.67 mg.
4. Calculate the volume of amoxicillin suspension for the single dose. We can use the ratio of the concentration of the suspension, which is 250 mg per 5 mL. So, 66.67 mg x (5 mL / 250 mg) =
1.33 mL.
5. Round the volume to the nearest tenth= 1.3 mL
An older client is taken to the clinic by the spouse, who appears extremely worried. The spouse reports to the nurse that the client started to not make any sense and asked to visit a brother who has been dead for many years. Which action(s) should the nurse take? (Select all that apply.)
The nurse is triaging several children as they present to the emergency room after a school bus accident. Which child requires the most immediate intervention by the nurse?
When the parents of a 6-year-old boy with a brain tumor are told that his condition is terminal, the mother shouts at the father, "This is your fault! It never would have happened if we had sought treatment sooner!" Which intervention is best for the nurse to implement?
When the nurse enters the room of a male client who was admitted for a fractured femur, his cardiac monitor displays a normal sinus rhythm (NSR), but he has no spontaneous respirations and his carotid pulse is not palpable. Which intervention should the nurse implement?
A client with persistent low back pain has received a prescription for an electronic stimulator (TENS) unit. After the nurse applies the electrodes and turns on the power, the client reports feeling a tingling sensation. How should the nurse respond?
The nurse implements a primary prevention program for sexually transmitted diseases in a nurse-managed health center. Which outcome Indicates that the program was effective?
An older client is admitted to the intensive care unit unconscious after several days of vomiting and diarrhea.
Vital Signs
Heart Rate-beats/minute- 110 Respirations - breathes/minute- 28 Blood Pressure – mmHG- 80/60
Arterial blood gases (ABGs)
Ph- 7.34
PaCO2- 34 mmHg
HCO3- 20 mmol/L
pO2- 90 mmHg
Electrolytes Results
Sodium
130 mEq/L(mmol/L) Potassium
2.5 mEq/L (mmol/L) Chloride
95 mEq/L (mmol/L)
Reference Range:
Sodium [136 to 145 mEq/L (136 to 145 mmol/L)]
Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]
Chloride [98 to 106 mEq/L (98 to 106 mmol/L)]
PaCO2 [35 to 45 mm Hg]
HCO, [21 to 28 mEq/L (21 to 28 mmol/L)] PaO2 [80 to 100 mm Hg)
The nurse inserts a urinary catheter and obtains a scant amount of dark amber output. Which intervention should the nurse implement first? (Please scroll and view each tab's information in the client's medical record before selecting the answer.)
The nurse implements a primary prevention program for sexually transmitted diseases in a nurse-managed health center. Which outcome Indicates that the program was effective?
The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client Indicates that the teaching was effective?
A client who is one day postpartum tells the nurse that her baby cannot latch onto the breast.
The nurse determines that the client's nipples are inverted. Which action should the nurse implement?
A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents?
The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?
In assessing a client at 34 weeks gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid, a hematocrit of 28% (0.28 volume fraction), a heart rate of 92 beats per minute, and a systolic murmur. Which finding requires follow-up?
Reference Range:
Hematocrit [37% to 47% (0.37 to 0.47 volume fraction)]
After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment finding(s) should the nurse report to the healthcare provider? (Select all that apply.)
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