Based upon the day 3 lab results, which order should the nurse bring to the provider’s attention?
Answer Choices:
Discontinue indwelling catheter
Potassium 10 mEq IV mini bag
Regular insulin 5 units subcutaneously
Warfarin 5 mg by mouth
Answer: Warfarin 5 mg by mouth
On day 3, the RN consults with the provider, who places an order for an arterial blood gas and serum lactate level. The ABG results are: pH 7.35, pCO2 30, pO2 74, HCO3 20. Based upon the results, what would the RN’s most appropriate action be?
Answer Choices:
Instruct the client to take slow deep breaths
Reposition the client in low Fowler’s position
Page the respiratory therapist to set up O2
Ask the unit secretary to call a Code Blue
Answer: Page the respiratory therapist to set up O2
A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion?
Answer Choices:
Anuria
Petechiae
Confusion
Blood pressure 84/50 mm Hg
Answer: Confusion
Based on the client record and Surviving Sepsis Campaign Bundle, the nurse should implement which intervention to restore adequate perfusion at this time?
Answer Choices:
Initiation of aggressive fluid resuscitation
Administration of acetaminophen
Administration of a vasopressor
Initiation of a blood transfusion
Answer: Initiation of aggressive fluid resuscitation
Which of the day 2 lab values would alert the RN that Mary might be experiencing systemic inflammatory response syndrome (SIRS)?
Answer Choices:
Potassium
INR
WBC
Blood glucose
Platelets
Hematocrit
Answer: WBC
Which interventions will decrease the client’s risk of developing a pulmonary embolism? (Select all that apply.)
Answer Choices:
Encourage client to do active leg exercises
Apply compression stockings
Maintain the head of the bed at 90 degrees
Administer aspirin and warfarin
Ambulate the client early
Answer: Encourage client to do active leg exercises, Apply compression stockings, Ambulate the client early
Considering the provider orders, which should the nurse monitor most closely for possible complications, given the client’s history and condition?
Answer Choices:
Famotidine 20 mg IV
Placement of sequential compression stockings
Lactated Ringer’s at 170 mL/hr
Cefepime 2 g IV every 12 hours
Answer: Lactated Ringer’s at 170 mL/hr
Select the 4 (four) orders that are priority.
Answer Choices:
Cefepime 2 grams IV every 12 hours
Stat lactate level
Fingerstick glucose every 6 hours
Obtain a set of blood cultures
Discontinue indwelling catheter
Discontinue Furosemide
1000 mL Lactated Ringer’s at 170 mL/hr
Answer: Cefepime 2 grams IV every 12 hours, Stat lactate level, Obtain a set of blood cultures, 1000 mL Lactated Ringer’s at 170 mL/hr
A nurse is teaching a client who has a new prescription for warfarin about foods that affect the INR. The nurse should include in the teaching that which of the following foods interacts with this medication?
Answer Choices:
Orange juice
Yogurt
Beef stew
Kale
Answer: Kale.
A nurse is caring for a client who has a new onset of hyperglycemic hyperosmolar state (HHS). Which of the following interventions by the nurse is the highest priority?
Answer Choices:
Administer insulin.
Teach the client about manifestations of HHS.
Measure the client’s urinary output.
Initiate IV fluid replacement.
Answer: Initiate IV fluid replacement.
A nurse is caring for a client who is experiencing anaphylactic shock in response to penicillin. Which medication should the nurse administer first?
Answer Choices:
Epinephrine
Furosemide
Methylprednisolone
Dobutamine
Answer: Epinephrine