Blog

A client who had a transurethral resection of the prostate (TURP) 1 day earlier now has a three-way Foley catheter inserted for continuous bladder irrigation. The Intake & Output (I&O) measurement is recorded each shift and is noted below. How much of the output is the true urine output for this client? IV 0.45 NaCl    1,000 mL CBI Irrigant      8,000 mL  PO intake            250 mL Total Output for 12 hours = 9,050 mL     

As the home health nurse, you are taking an admission history for a client who has deep vein thrombosis (DVT) and is taking warfarin 2 mg. daily. Which statement by the client is the best indicator that additional teaching about warfarin may be needed?

You are transferring a client with newly diagnosed Chronic Myeloid leukemia to an Extended Care Facility. Which information is most important to communicate to the Charge nurse at the Extended Care Facility? 

You are administering heparin and following the protocol below for a client weighing 189 lbs. The order is to administer an initial heparin bolus IV followed by a titrated IV infusion. Round to the tenths place. HEPARIN PROTOCOL Initial bolus- 50 units/kg Initial rate – 18 units/kg/hr Obtain a PTT every 6 hours, and adjust dosage and rate as follows: If  PTT is less than 35 secs:      Repeat bolus with 80 units/kg and increase the rate by 4 units/kg/hr. If  PTT is 36 to 44 seconds:       Repeat bolus with 40 units/kg and increase the rate by 2 units/kg/hr. If  PTT is 45 to 75 seconds:       Continue current rate. If  PTT is 76 to 90 seconds:       If  PTT is 76 to 90 seconds:          Decrease rate by 2 units/kg/hr. If  PTT is greater than 90 secs: Hold the heparin for 1 hour and decrease rate by 3 units/kg/hr. Available (for bolus)  – heparin 1,000 units/mLAvailable (for infusion) –  heparin 25,000 units in 250 mL D5W    How many mL of heparin will the client receive for the initial IV bolus?

For a client diagnosed with Immune Thrombocytopenia Purpura (ITP), which nursing intervention is appropriate? 

A nurse presenting an educational event for a local community group is addressing premenstrual syndrome (PMS). What treatment guidelines should the nurse teach this group? 

The nurse admits a 47-year-old client to the health care facility with suspected Acute Myeloid Leukemia (AML). The focused assessment for this client includes assessing for which three main consequences of AML?

A couple presents to the fertility clinic and report the inability to become pregnant. They report not using any contraception for the past 12 months. Diagnostic tests are planned for the woman to ascertain whether the uterus can support implantation. What test would the nurse expect to have ordered for this woman? 

The client diagnosed with leukemia is scheduled for a Human Stem Cell Transplant (HSCT).  In developing a post-op plan of care, which of the following interventions will need to be included. (SELECT ALL THAT APPLY).

A client presented to the emergency department after falling from a ladder. After the assessment the HCP prescribes the insertion of a urinary catheter. While preparing for the procedure, the nurse notes blood at the urinary meatus. The nurse should take which action first?