Nokea
A client has an order for furosemide (Lasix) 40 mg IV push via a heparin lock. Which of the following nursing actions would be MOST appropriate?
- A. Use a 16- to 18-gauge 1-in needle for administration.
- B. Administer the medication over one to two minutes.
- C. One cc of 1:1,000 heparin flush should be administered before the medication.
- D. A primary IV should be started prior to medication administration.
Correct Answer: B
Rationale: furosemide (Lasix) given IV push should be administered slowly over one to two minutes
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The nurse is observing a student nurse auscultate the lungs of a client. The nurse knows that the student nurse is correctly auscultating the right middle lobe (RML) if the stethoscope is placed in which of the following positions?
- A. Posterior and anterior base of right side.
- B. Right anterior chest between the fourth and sixth intercostals.
- C. Left of the sternum, midclavicular, at right fifth intercostal.
- D. Posterior chest wall, midaxillary, right side.
Correct Answer: B
Rationale: RML is found in the right anterior chest between the fourth and sixth intercostal spaces
After receiving report, which of the following patients should the nurse see FIRST?
- A. A patient in sickle-cell crisis with an infiltrated IV.
- B. A patient with leukemia who has received one-half unit of packed cells.
- C. A patient scheduled for a bronchoscopy.
- D. A patient complaining of a leaky colostomy bag.
Correct Answer: A
Rationale: IV fluids are critical to reduce clotting and pain.
The nurse is receiving a bedside report from another nurse. The nurse giving the report begins to talk about another client. Which action by the nurse receiving the report is MOST appropriate?
- A. Ask the nurse to report on this client only.
- B. Ask the nurse to lower his/her voice.
- C. Ask the nurse to move to another part of the room.
- D. Ask the nurse to clarify which client s/he is reporting on.
Correct Answer: A
Rationale: client confidentiality is being violated, nurse should intervene to protect client
A client is admitted to the unit with pregnancy-induced hypertension (PIH).
Which of the following actions is the priority nursing action?
- A. Start an IV.
- B. Obtain the vital signs.
- C. Administer magnesium sulfate.
- D. Notify the lab to draw blood.
Correct Answer: B
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) implementation, not a priority action (2) correct-assessment, important to do a baseline assessment in order to successfully evaluate the treatment (3) implementation, not a priority action (4) implementation, not a priority action
The nurse notes that one of the staff members caring for clients has a watery discharge from the right eye and the eye appears red. Which of the following actions, if taken by the nurse, is BEST?
- A. Send the staff member home.
- B. Assess the staff member's compliance with standard precautions.
- C. Assign the staff member only to clients with chronic diseases.
- D. Re-assign the staff member to clean the supply closet.
Correct Answer: A
Rationale: extreme tearing, redness, foreign body sensation are symptoms of viral conjunctivitis, highly contagious; infected employees cannot work until symptoms have resolved in 3-7 days