Blog

A client who has a history of chronic lung disease is admitted to the hospital with possible pneumonia. Respirations are shallow and breath sounds are diminished. Blood gases reveal: pH – 7.25, PCO2 – 70, HCO3- 24.  What acid-base imbalance is this client experiencing?

Place these nursing actions in order of proper sequence for preparing an IV solution and tubing when initiating an intravenous infusion.  When recording your answer below, enter the number only, that corresponds to your choice.  1. Clamp tubing, uncap spike, and insert spike into entry site on the solution bag as directed by the manufacturer 2. Verify the primary care providers orders, gather all supplies and wash your hands, identify the patient 3. Label tubing with date of initiation, due date to replace tubing, and name. 4. Maintain aseptic technique when opening sterile packages and IV solutions 5. Prime the tubing eliminate all air, by releasing the clamp that allows fluid to move through the tubing prior to initiating the infusion 6. Squeeze the drip chamber and allow it to fill one-half full or as indicated by the manufacturer and open the IV tubing clamp.

A nurse in the pediatric unit is caring for a 4-month-old infant with bronchiolitis. Which of the following findings would indicate that the infant is experiencing respiratory distress (Select all that apply).

The nurse is caring for a client with a sodium level of 152. What is an appropriate dietary choice for this client?

While assessing a client’s peripheral IV site, the nurse observes edema and coolness around the insertion site. How should the nurse document this observation?

The nurse is performing an admission assessment on a 79-year-old client newly admitted for end-stage liver disease. What principle should guide the nurse’s assessment of the client’s skin turgor?

Harriet, 30 years old, has been admitted to the burn treatment center with full-thickness burns over 30% of her upper body. Her diagnosis is consistent with extracellular fluid volume deficit.  What symptoms would indicate to the nurse that the patient may be experiencing fluid volume deficit.  (Select all that apply)

You are the nurse caring for a trauma patient who presents to the ER following an automobile accident. The primary care provider prescribes the nurse to start an IV with a large bore needle to infuse fluids rapidly. What gauge catheter is the best choice for this situation?

A 74-year old female is admitted to the Emergency room with increasing dyspnea, productive cough, and fatigue.   Nurses’ Notes       1000: Client arrives in Emergency Department with worsening shortness of breath over the past week, strong productive cough with green-tinged sputum, and fatigue. Client has a history of  chronic obstructive pulmonary disease -emphysema; has been using their “relief” inhaler at home with no relief of symptoms. Client lives independently at home and states they smoke approximately 1 pack of cigarettes per day. Ambulatory, alert and oriented x 4. Has coarse crackles auscultated in bilateral lower lung fields with a barrel chest appearance, using accessory muscles, expiratory wheeze on auscultation. Client states they have “less room” to take a deep breath. Clubbing noted in all digits bilaterally.   1015: Client has increasing dyspnea, prefers to be sitting up in the chair. Requesting “rescue inhaler.” The provider has been notified. IV started. Ipratropium bromide and albuterol nebulizer treatment started.   Vital Signs       Time  1000 1015   Oral Temp  99.0 F (37.2 C 99.0 F (37.2 C   Pulse 104 108   Respiratory Rate 27 30   Blood Pressure 157/86 159/88   Pulse oximeter  91% room air 90% room air   Pain  0 0     Provider ordered Medications (ER):     Medication Dosage/Frequency/ Route   Ipratropium bromide and albuterol  3mL(0.5mg ipratropium bromide 2.5 mg albuterol) nebulizer treatment 4 x a day. First dose now.   Acetaminophen 500 mg x 1 PO  PRN for moderate to severe back pain   Methylprednisolone sodium succinate 40 mg IV push x 1 dose now   Amoxicillin/clavulanate  875 mg/ 125 mg PO every 12 hours   Albuterol sulfate 2.5 mg/3 ml nebulizer every 4 hours PRN Which medication do you anticipate that the nurse will give first?

After 2 months of tuberculosis (TB) treatment with isoniazide (INH) and rifampin (Rifadin), pyrazinamide (PZA) and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action will the nurse take next?