The nurse is caring for a client who is experiencing pruritis. Which would be the most appropriate nursing intervention?
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Solution
Answer B is correct. Adding baby oil to the client’s bathwater could assist in soothing the itching. Answers A, C, and D would increase dryness and worsen the skin itching.
A client who is complaining of nausea, has an order for hydroxyzine hydrochloride (Vistaril) 75mg every 3–4 hours IM p.r.n. for nausea. The vial contains 100mg per 2mL. How many milliliters will you give?
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Solution
Answer B is correct. The desired dose is 75mg. The dose on hand is 100mg in 2mL, making the correct dose 1.5mL. The answers in A, C, and D are incorrect calculations.
The nurse is giving information to a client at high risk for the development of skin cancer. Which instruction should be included?
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Solution
Answer D is correct. Everyone should wear sunscreen when going outside, to protect them from the ultraviolet exposure. Answer A is not necessary. Answer C is incorrect because only moles that are suspicious require removal and biopsy. Answer B is the period of day when the sun rays are most detrimental to the skin.
A client is diagnosed with left subclavian artery obstruction. What additional findings would the nurse expect?
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Solution
Answer C is correct. Obstruction of the subclavian artery would show a decrease in radial heart rate on the side of the obstruction. Answers A, B, and D are related to neurological problems or deficits, which makes them incorrect.
The nurse has an order to administer meperidine (Demerol) 75 mg IM for pain. The drug available is Demerol 100mg in 2 mLs. How many mL(S) will the nurse administer?
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Solution
Answer C is correct. The correct calculation is 1.5 mL, which is calculated as follows: 75 mg?= 2mL/100mg= 150/100= 1.5 mL
Answers A, B, and D are incorrect calculations, so they are wrong.
Which of the following laboratory results would cause the most concern in the immunosuppressed client?
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Solution
Answer A is correct. Normal sodium is 135–145mEq, so this is a low blood level that should be reported. Answers B, C, and D are normal or near-normal readings.
An infant in the nursery is 48 hours old and has not passed meconium. The nurse suspects which of the following?
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Solution
Answer D is correct. A newborn who has not passed meconium in the first 24 hours could have cystic fibrosis. This is due to the thick secretions preventing passage of the meconium, resulting in obstruction of the bowel. Answers A and B are both cardiovascular problems that are not associated with meconium passage, so these are incorrect. Answer C is not associated with meconium and is evidenced by a yellow skin tone and an elevated serum bilirubin level.
Which of the following would the nurse perform when giving medication via an NG tube?
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Solution
Answer A is correct. Making sure that the tube is in the right location is an important first step. Clients should be positioned with the head elevated, the medication should be administered slowly, and the NG tube should be clamped for 20-30 minutes after medication administration; therefore, options B, C, and D are incorrect.
The nurse is discussing with parents the recommended activities for children with asthma. Which sports activity would the nurse include in the discussion?
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Solution
Answer B is correct. Because of the moisturized air inhaled with swimming, it is an ideal sport for children with respiratory conditions, so this is correct. Answers A, C, and D could trigger an attack with asthma and would not be recommended.
A client has pneumonia. Which assessment finding best indicates that the client’s respiratory efforts are currently adequate?
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Solution
Answer C is correct. The oxygen saturation is the best indicator of respiratory status because it is more objective. Answers A, B, and D are subjective and nonspecific, so they are incorrect.