1- A client who fell 20 feet from the roof of his home has multiple…

1- A client who fell 20 feet from the roof of his home has multiple… 1- A client who fell 20 feet from the roof of his home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). The nurse observes that the suction control chamber is bubbling at the-10 cm mark with fluctuation in the water seal, and over the past hour 75 mL of bright red blood is measured in the collection chamber. Which intervention should the nurse implement?A-Add sterile water to the suction control chamber.B-Increase wall suction to eliminate fluctuation in water seal.C-Give blood from the collection chamber as auto transfusionD-Manipulate blood in tubing to drain into chamber . 2-A group of nurses implement a pilot study to evaluate a proposed evidence-based change to providing client care. Evaluation indicates successful outcomes and the nurses want to integrate the change throughout the facility. Which actions should be taken? (Select all that apply)A-Submit a sentinel event report to the research committee.B-Arrange inservice training through the education department.C-Invite data review by the quality improvement departmentD-Propose clinical practice guidelines to the nursing committeeE-Obtain informed consent from clients who will receive care . 3- The nurse is caring for a client with the sexually transmitted infection (STI) human papillomavirus (HPV) The client reports having unprotected sex. Which response should the nurse provide?A-Remain non-judgmental and assure the client of confidentialityB-Discuss that partners without similar symptoms may not be infected.C-Notify that persons with STIs are reported to local health departments.D- Urge the client to have regular STI screening every two years 4- The nurse is preparing to send a client to the cardiac catheterization for angioplasty. Which client report is most important for the nurse to explore further prior to the start of procedure?A- Verbalizes a fear of being in a confined space.B-Experiences facial swelling after eating crabC-Reports left chest wall pain prior to admissionD-Drank a glass of water in the past 2 hours 5- The healthcare provider prescribes epinephrine (1:10,000) intravenously for a client with severe allergic reaction. To reduce the risk for overdose, which action should the take?A-Dilute the medication with 10 mL of normal saline solutionB- Confirm the dose and concentration with another nurseC- Use an auto-injection pen to control the rate of administrationD-Monitor the client closely for intravenous extravasation . 6- A 9 year old is receiving vancomycin 400mg / V * V every 6 hours for a methicillin-resistant (Beta-lactam-resistant) Staphylococci aureus (MRSA) infection. The medication is in a 100 bag of saline with instructions to infuse over one and a half hours.How many mL/hour should the nurse program the infusion pump? (Enter numeric value onlyrounding is round to the nearest whole number 7- The nurse includes assessment for fat embolism syndrome (FES) in the plan of care for a client with a fractured femur. Which findings should the nurse include that are often the earliest indication of FES?A-Tachycardia, fever.B-Petechial rash .C-Confusion, restlessness.D-Pulmonary crackles. 8- An older client presents to the emergency department with due to constipation. The nurse is providing list of high fiber foods to the client that the provider recommended. Which action should the nurse implement when reviewing the list of foods?A- Turn on overhead lights while giving instructions.B- Stand behind the client to avoid intimidation.C-Provide handouts written at a 12th grade reading level.D- Use background music to promote relaxation. 9-The healthcare provider prescribes a low dose heparin protocol at 18 units/kg/hour for a client with a possible pulmonary embolism. This client weighs 144 pounds. The available solution is labeled, Heparin Sodium 25,000 units in 5 percent dextrose injection 250 mL. The nurse should program the pump to deliver how many mL/hr? (enter numeric value only. If rounding is required, round to the nearest whole number.) 10- The nurse is conducting a visual screening of a group of older adults. Which finding should the nurse report to the healthcare provider immediately?A-Recent change in the ability to read and drive after dark.B- Gray-white circle around the iris of both eyes .C-Gradual onset of continuous eye pain and blurred vision.D-Cloudy opacity of the crystalline lens. 11- A client who experienced a blunt trauma to the abdomen is admitted to the intensive care unit following surgery for an exploratory laparotomy which revealed a contused right kidney and lacerated Which intervention most important for the nurse to include in the plan of care?A-Replace fluids intravenously based on intake and output.B-Record the amount of daily wound drainage .C-Turn every 2 hours around the clock from side-to-side.D- Assess skin condition and turgor for breakdown . 12-The nurse is assessing a client who received a hematopoietic stem cell transplant 4 weeks ago. Which assessment finding indicating graft-versus-host disease should the nurse report to the healthcare provider?A-Change in level of consciousness.B-Widespread maculopapular rash.C-High blood pressure .D-Decreased urinary output . 13- An older woman with advanced Alzheimer’s is admitted with nausea, vomiting, and diarrhea. The client’s caregiver tells the nurse that the client has history of irritable bowel syndrome, hepatitis A and Methicillin-resistant Staphylococcus aureus (MRSA).Which intervention is most important for the nurse to implement ?A- Perform hem occult test on a sample of the clients stoolB- Clarify with the caregiver the exact location of the MRSAC- Administer a prescribed PRN antimeticD- Utilize strict precautions when handling feces 14- A client who is receiving zidovudine reports the appearance of pinpoint, red, round spots on the skin. Which result should the nurse report to the healthcare provider ?A- Provide typed instructions for healthy diet selectionsB-Demonstrate specific strengthening exercisesC-Reinforce need for adequate hydrationD- Explain exercise daily regimen 15- The nurse is assessing a 3-month old infant who had a pylorotomy yesterday. The child should be medicated for pain based in which findings? (Select all that apply)A-Increased pulse rateB- Restlessness .C-Increased temperature.D-Clenched fists .E-Increased respiratory rate.F- Peripheral pallor of the skin . Health Science Science Nursing NUTR 4353 Share QuestionEmailCopy link Comments (0)

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