1. The client had cholecystectomy this morning. The evening nurse after getting the report, find the client with pain 8/10 and hyperventilating. The vitals are
Temperature – 98F
Following are the result of ABG done by a respiratory therapist.
The following interventions are done by Nurse based on above results. (please choose more than one answer)
1. Give him pain medication
2. Give him a paper bag to breathe in
3. Start sodium bicarbonate Iv
4. Start Oxygen 2L
5. Put the patient flat on the bed
2. A client diagnosed with malignancy is on chemotherapy treatments right now. The following are the morning labs for this client
Platelets count- 80,000
Hct – 40
An RN taking care of this client should follow the following precautions (please choose more than one answer)
1. Allow him to only use an electric razor for a shave.
2. Eat more fresh fruits and vegetables
3. Do not give an intramuscular injection to client
4. Observe for Melena
5. Infuse blood transfusions
6. Put him in protective isolation
3. A newborn is attached to the apnea monitor. It was noticed that apnea monitor triggers alarm frequently. Please put the following action in order in which the nurse will be performing.
1. Document your assessment
2. Do focus assessment on a newborn
3. Check the respiratory rate for a full 1 minute.
4. Silence the alarm
5. Check monitor leads
4. In evaluating the effectiveness of Heparin therapy, the nurse would monitor which of these laboratory tests.
1. Prothrombin time
2. Partial Thromboplastin time
3. Red cell fragility
4. Platelet time
5.A client has angina pectoris. Which of the following statements by the client would indicate that he understands the necessary modifications in his lifestyle to prevent angina attack?
1.” I know that I will need to eat less so I will eat only one meal a day.”
2. “I will need to stay in bed all the time so I won’t have the pain.”
3. “I will stop what I am doing whenever I have pain and take the pill.”
4. “I will need to walk more slowly and rest frequently to avoid angina.’
6.Parent of a two-year child with cystic fibrosis planning to go vacation with a child. The nurse teaches the parent to avoid which of the following situation.
1. Give pancreatic enzymes with each food
2. Taking the child to sea beach during day time
3. Visiting museum.
4. Perform chest physiotherapy hour before food
7.A trauma client, admitted through the emergency room, has a urinary catheter inserted to monitor kidney function and assess for early signs of shock. The nurse would report which urinary output measurement as suggestive of cardiac failure or hypovolemia?
8. A patient with acute respiratory distress syndrome is being mechanically ventilated with positive end-expiratory pressure (PEEP). What should the nurse do to ensure an adequate cardiac output for this s patient? (Select all that apply.)
1. Assess the level of consciousness every 4 hours.
3. Assess lung sounds every shift.
4. Limit moving the patient.
5. Assess the apical pulse every 2 hours
9.A hospital patient with a diagnosis of type 1 diabetes has been administered a scheduled dose of regular insulin. Which of the following effects will result from the action of insulin?
1.initiation of glycogenolysis
2. Promotion of fat breakdown
3. Promotion of glucose uptake by target cells
4. Promotion of gluconeogenesis and protein synthesis
10.The dehydration leads to decreased perfusion. What is the reason for that 1. Decreased preload
2. Increased contractility
3. Decreased afterload
4. Increased cardiac output