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A nurse is caring for an 84-year-old male client in the medical unit. The client was admitted from a provider’s office with complaints of fatigue, dizziness, and shortness of breath. The nurse reviews the client’s medical records to prepare the client’s plan of care. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
- A. Teach the client about the condition.
- B. Encourage intake of low-sodium diet.
- C. Administer prescribed medications.
- D. Monitor vital signs regularly.
- E. Schedule a follow-up appointment with a specialist.
- F. Anemia
- G. Blood pressure
Correct Answer: A,C,D,E
Rationale: The correct answer is A,C,D,E. Firstly, the client is likely experiencing anemia based on the symptoms of fatigue, dizziness, and shortness of breath. Therefore, administering prescribed medications (C) to address the anemia is crucial. Teaching the client about the condition (A) helps improve understanding and compliance. Monitoring vital signs (D) is essential to track the client's response to treatment. Scheduling a follow-up appointment with a specialist (E) ensures ongoing evaluation and management. Encouraging intake of a low-sodium diet (B) is not directly related to anemia and may not be the priority in this case. Blood pressure (G) monitoring is important but not specific to anemia.
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A nurse is preparing to administer ziprasidone 10 mg IM every 6 hr. Available is ziprasidone 20 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 0.5
Rationale: The correct answer is 0.5 mL. To calculate this, first determine the total dose needed per administration (10 mg). Then, divide the total dose by the concentration of the medication (20 mg/mL) to find the volume to administer per dose (10 mg ÷ 20 mg/mL = 0.5 mL). This ensures the patient receives the correct amount of medication. Other choices are incorrect because they do not accurately calculate the volume needed for the specified dose. For example, choosing a higher volume would result in overdosing the patient, while choosing a lower volume would underdose the patient. The correct calculation is essential to ensure the patient's safety and therapeutic effectiveness.
A nurse is caring for a client who is cognitively impaired and repeatedly pulls on his NG tube. Which of the following actions should the nurse take before requesting a prescription for restraints? (Select all that apply.)
- A. Provide diversionary activities for the client.
- B. Assist the client with toileting at frequent intervals.
- C. Involve the family in the client’s care.
- D. Explain to the client that he will be restrained if he does not stop pulling on his NG tube.
- E. Use an electronic bed alarm device.
Correct Answer: A,B,C,E
Rationale: The correct actions are A, B, C, and E. A) Providing diversionary activities can distract the client from pulling on the NG tube. B) Assisting with toileting at frequent intervals helps address any discomfort or restlessness that may be contributing to the behavior. C) Involving the family can provide additional support and understanding of the client's needs. E) Using an electronic bed alarm device can alert the nurse when the client is attempting to pull on the NG tube, allowing for timely intervention. These actions focus on addressing the underlying reasons for the behavior and ensuring the client's safety without resorting to restraints, which should be a last resort due to ethical and legal considerations.
A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites?
- A. Serosanguineous drainage.
- B. Mild erythema.
- C. Warmth.
- D. Fever.
Correct Answer: D
Rationale: The correct answer is D: Fever. Infection at the pin sites in skeletal traction can lead to systemic signs such as fever. Fever is a common indicator of infection as the body responds to pathogens by increasing its temperature. Serosanguineous drainage, mild erythema, and warmth can be normal findings in the early stages of healing or due to inflammation, but fever indicates a more serious underlying issue like infection. Therefore, the nurse should prioritize monitoring for fever to promptly identify and address any potential infection.
A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes?
- A. To limit the amount of bleeding and clots from the surgical site.
- B. To eliminate the need for wound irrigations.
- C. To prevent drainage from accumulating in the wound.
- D. To provide a means for medication administration.
Correct Answer: C
Rationale: Rationale:
The correct answer is C: To prevent drainage from accumulating in the wound. A Jackson-Pratt drain is used to remove excess fluids (such as blood or serous fluid) from a surgical site to prevent accumulation, which can lead to infection or delayed healing. The drain creates negative pressure, allowing drainage to be collected in a bulb or reservoir outside the body. This promotes wound healing by preventing the buildup of fluid.
Incorrect choices:
A: To limit bleeding - While a JP drain may indirectly help limit bleeding by removing excess fluid, its primary purpose is to prevent fluid accumulation.
B: To eliminate wound irrigations - JP drains do not eliminate the need for wound irrigations; they are used for drainage removal.
D: Medication administration - JP drains do not provide a means for medication administration; they are specifically for drainage removal.
A nurse in an emergency department is caring for a client who has burns on the front and back of both arms. Using the rule of nines, the nurse should document burns to which percentage of the client’s total body surface area (TBSA)?
- A. 9 percent.
- B. 18 percent.
- C. 36 percent.
- D. 54 percent.
Correct Answer: B
Rationale: The correct answer is B (18 percent). The rule of nines is used to estimate the percentage of total body surface area (TBSA) affected by burns. According to this rule, each arm represents 9% of the TBSA (9% front + 9% back = 18%). Therefore, burns on both front and back of both arms would total 18% TBSA. Choices A, C, and D are incorrect because they do not accurately reflect the TBSA affected by burns on both arms. Choice A (9 percent) represents the TBSA of one arm, not both. Choices C (36 percent) and D (54 percent) overestimate the TBSA since they do not consider the rule of nines for the arms.