Exhibits

Review H and P, nurse's notes, laboratory results, flow sheet, and orders.

Click to mark whether the assessment finding represents a therapeutic result of the sodium bicarbonate administered, a non-therapeutic side-effect, or an unrelated finding.

The nurse admits a client with a diagnosis of stage 4 cancer. The client has a prescription to wear a subcutaneous morphine sulfate patch for pain. The client is short of breath and difficult to arouse. While performing a head to toe assessment, the nurse discovers four patches on the client's body. Which action should the nurse take first?

A client who is taking an oral contraceptive receives a new prescription for erythromycin. Which instruction should the nurse provide to the client?

The nurse administers naloxone to a client with opioid-induced respiratory depression. One hour later, nursing assessment reveals that the client has a respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and is unable to be aroused. Which action should the nurse implement?

A male client with a history of heart failure (HF) complains of heartburn when he lies down after dinner. The home health nurse should encourage the client to talk to the healthcare provider about using which over-the-counter medication to relieve this problem?

The nurse is planning the home care of a client who is receiving a mydriatic medication. Which environment is best for this client?

0730

• Admit to the surgical floor
• Dextrose 59% and 0.9% sodium chloride to infuse at 125 ml/hr
• Advance diet as tolerated
• Insulin glargine 12 units subcutaneous every 12 hours
• Ceftriaxone 2 g IV every 24 hours for 3 days, first dose given in surgery
• Insulin lispro 1 unit subcutaneously per 15 carbohydrates
• Insulin lispro sliding scale:

180-240 mg/dL (10-13.3 mmol/L)- 1 unit

241-300 mg/dl. (13.4-16.7 mmol/L)-2 units

300-360 mg/dL (16.7-30 mmol/L)-3 units

over 360 mg/dL (30 mmol/L)-call the physician

• Glucagon 1 syringe subcutaneously for blood glucose less than 60 mg/dL (3.3 mmol/L) and unresponsiveness

It is 1800, and the client has a schedule dose of insulin glargine due. The client has a regular diet tray ordered with 60 carbohydrates. The tray has not yet arrived in the room.

For each nursing action below, click to specify If the action is indicated, contraindicated or non-essential.

A client is receiving intravenous (1V) vancomycin and the nurse plans to draw blood for a peak a. trough to determine the serum level of the drug. Which collection times provide the best determination of these levels?

While assessing a client who takes acetaminophen for chronic pain, the nurse observes that the client's skin looks yellow in color. Which action should the nurse take in response to this finding?

The healthcare provider prescribes the antibiotic tetracycline HCI for an adult client that arrived at an outpatient clinic. Which instruction should the nurse include in the teaching plan for this client?

The nurse prepares to administer a scheduled dose of labetalol by mouth to a client with hypertension. The client's vital signs are temperature 99° F (37.2° C), heart rate 48 beats/minute, respirations 16 breaths/minute, and blood pressure (B/P) 150/90 mm Hg. Which action should the nurse take?