42. The nurse is to inject Vitamin B intramuscularly to another
elderly client. Before injecting, the nurse explained that the
client may feel some discomfort. This is an example of

1 Answer

Answer :

C. Anticipatory response

Related questions

Description : 77. Nurse Kristine is to inject Demerol 75 mg to a post-TURP (transurethral resection of the prostate) client who is in pain. When she checked the narcotic cabinet, she found out a ... next Demerol vial is available. The action of the nurse violates which of the following ethical principles?

Last Answer : A. Justice

Description : 51. Albert came to the hospital with chest pain and fever. After a thorough assessment by the doctor, he was admitted for pericarditis management. The nurse positions the client to reduce pain and discomfort. Describe this position.

Last Answer : C. Sit the client upright and lean forward

Description : 41. For a client complaining of mild musculoskeletal pain, the nurse will anticipate that the treatment for this client’s level of discomfort will include which of the following?

Last Answer : B. Acetaminophen

Description : In assessing the appropriateness of removing a suprapubic catheter, the nurse recognizes that the patient's residual urine must be less than which of the following amounts on two separate occasions ... urine that is greater than 100 cc indicates that the suprapubic catheter cannot be discontinued.

Last Answer : a) 100 cc If the patient complains of discomfort or pain, however, the suprapubic catheter is usually left in place until the patient can void successfully.

Description : 88. When the nurse ensures that the client has plan for continuous care after leaving the health care facility and assists from the transition from one environment to another, she is doing a

Last Answer : A. Discharge plan

Description : 79. A scrub nurse is assisting an emergency Cesarian section on a 39-year-old laundry woman. Before closing the peritoneum, the surgeon asks, How old is the client? Holding the fallopian ... there is no signed consent for tubal ligation. The nurse just demonstrated which of the following?

Last Answer : C. Advocacy

Description : 69. When Marina checked the capillary blood glucose of the client at 6 PM before meals as instructed by the senior nurse, the result showed 65 mg/dl. Which of the following will Marina do first?

Last Answer : C. Check the physician’s order in case CBG is below 70 mg/dl

Description : 62. A 30-year-old client had cholesterol blood test before admission to the hospital. The nurse in charge would teach the family and significant others that the client should exercise to help keep the total cholesterol to a desired level of

Last Answer : A. 140 mg/dl

Description : When the intern-in-charge did the skin prep and catheterized the client, the circulating nurse noticed when the intern withdrew the catheter from the vagina. What is your appropriate and ... . Offer to change the catheter C. Alcoholize the tip of the catheter before reinserting the catheter

Last Answer : B. Offer to change the catheter

Description : The nurse reading the physician's report of an elderly patient's physical examination knows a notation that the patient demonstrates xanthelasma refers to a) yellowish waxy deposits on upper eyelids. The change is ... red moles. Cherry angioma is the term that is used to describe a bright red mole.

Last Answer : a) yellowish waxy deposits on upper eyelids. The change is a common, benign manifestation of aging skin or it can sometimes signal hyperlipidemia.

Description : When the female client reports a frothy yellow-brown vaginal discharge, the nurse suspects the client has a vaginal infection caused by a) trichomonas vaginalis. Trichomonas vaginalis causes a ... the external vulva and vaginal walls. d) chlamydia. Chlamydia causes a profuse purulent discharge.

Last Answer : a) trichomonas vaginalis. Trichomonas vaginalis causes a frothy yellow-white or yellow-brown vaginal discharge.

Description : 99. The companion asks why the client was advised to avoid iron supplements or vitamins. The correct response of the nurse would be

Last Answer : A. “These supplements enhance the production of RBC.”

Description : 76. A client is being positioned for radical vulvectomy and a couple of clinical clerks wanted to come in to watch the surgery. The circulating nurse advise them to enter the OR suite later. Foremost, this decision of the nurse is directed towards

Last Answer : D. Preserving privacy

Description : 72. The client is to have surgery in 10 days. Lugol’s solution 4 gtts po was prescribed in 10 days. The client asked the nurse for the purpose of the drug. Which response of the nurse is correct?

Last Answer : A. It decreases the risk of bleeding

Description : 64. The client was placed on a low sodium diet. The wife asks the nurse which foods to include in the client’s diet while at home. The nurse should instruct to include which of these?

Last Answer : C. Fruits and vegetables

Description : 61. A client with gout asks the nurse what food must be avoided so that the family can provide support. Which food has the highest in purine content and must be excluded from the dietary plan?

Last Answer : D. Liver

Description : 57. The client was prescribed Ocreotide acetate (Sandostatin). Nurse Carla would monitor for which of the following side effects?

Last Answer : A. Abdominal pain

Description : 55. The nurse wants to know if the client is aware of the side effects of NSAID. What would be the most appropriate question of the nurse?

Last Answer : B. “Have you ever vomited blood or noticed very black stools?”

Description : 40. The nurse should ensure that all components of medications are documented. Identify all these components. 1. Dosage, route and frequency 2. Name of client and medication 3. Date and time ... and strength 5. Physician's signature and specialty 6. Physician's signature and PRC license number

Last Answer : C. All except 5 and 6

Description : 38. A nurse encounters a client who refuses to take a prescribed medication. What is the appropriate action of the nurse?

Last Answer : C. Explore the possible reason why the client refuses the prescribed medication

Description : Reviewing the laboratory findings of the client, the nurse would found which findings are elevated? 1. White blood cell count 2. Total serum bilirubin 3. Alkaline phosphate 4. Red blood cell count 5. Cholesterol 6. Serum amylase A. 1, 2, and 3 B. 2, 3, and 4 C. 3, 5, and 6 D. 1, 2, and 6

Last Answer : A. 1, 2, and 3

Description : To confirm the diagnosis of cholecystitis, the attending physician ordered a procedure that can detect gallstones as small as 1 - 2 cm and inflammation. The nurse would prepare ... specific diagnostic procedure? A. Cholangiography B. Ultrasonography C. Gall bladder series D. Oral cholecystogram

Last Answer : B. Ultrasonography

Description : The Code of Ethics states that the nurse's primary commitment is to the client whether an individual of family, group or community. Which nursing activity would best demonstrate the ethical ... is least considered D. The nurse's providing care to maximize health according to available resources

Last Answer : A. The nurse providing care on a “first come – first served” basis

Description : The client complained of abdominal pain, nausea and vomiting with abdominal distention. The nurse anticipates which of the following priority management after referring to the surgeon? A. Gastric decompression B. Possible surgery C. Endoscopy D. Rectal tube insertion

Last Answer : A. Gastric decompression

Description : As the nurse monitors the client, she notices a bright red spot on the dressings which measures 4cm in diameter. The nurse should initially do which appropriate nursing intervention? A. Change the ... C. Notify the clients surgeon of a potential hemorrhage D. Assess the presence of a drain

Last Answer : D. Assess the presence of a drain

Description : The nurse instructs the nursing attendant to perform cleansing enema until the return flow is clear. The nursing attendant understood the instruction when she says, I will A. Call you when the return flow is ... flow D. Put the client in left Sim's position to achieve the desired return flow.

Last Answer : A. Call you when the return flow is clear”

Description : In the immediate post-operative period, the nurse assesses coarse, high-pitched sound on inspiration by listening over the trachea with a stethoscope. The nurse should immediately A. Position client to ... the client that he is doing fine C. Suction the tracheostomy tube D. Report to the surgeon

Last Answer : Which of the following expected outcomes for the patient is most relevant for the nursing diagnosis “At risk for imbalanced nutrition related to impaired swallowing”? A. Appropriate body weight maintained B. Fear of choking relieved C. Oral intake increased D. Swallowing of soft foods facilitated

Description : Pre-operatively, the nurse identified the nursing dagnosis, Knowledge Deficit: Post-operative communication strategies . Which of the following is a relevant nursing intervention? A. ... uses an alternative form of verbal communication D. Illustrate means of communicating post- operatively

Last Answer : D. Illustrate means of communicating post- operatively

Description : Which of the following terms refers to failure of fragments of a fractured bone to heal together? a) Nonunion When nonunion occurs, the patient complains of persistent discomfort and movement at the ... growth of the fragments of a fractured bone in a faulty position, forming an imperfect union.

Last Answer : a) Nonunion When nonunion occurs, the patient complains of persistent discomfort and movement at the fracture site.

Description : Antimicrobial barrier?Acticoat dressings used in the treatment of burn wounds can be left in place for five days. a) antimicrobial barrier dressings can be left in place for?Acticoat up to five days ... ) two days. antimicrobial barrier dressings can be left in?Acticoat place for up to five days.

Last Answer : a) antimicrobial barrier dressings can be left in place for?Acticoat up to five days thus helping to decrease discomfort to the patient, decrease costs of dressing supplies, and decrease nursing time involved in burn dressing changes.

Description : During which stage of pressure ulcer development does the ulcer extend into the underlying structures, including the muscle and possibly the bone? a) Stage IV A stage IV pressure ulcer ... area of nonblanchable erythema, tissue swelling, and congestion, and the patient complains of discomfort.

Last Answer : a) Stage IV A stage IV pressure ulcer extends into the underlying structure, including the muscle and possibly the bone.

Description : During which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue? a) Stage III Clinically, a deep crater with or without undermining of adjacent tissues is ... area of nonblanchable erythema, tissue swelling, and congestion, and the patient complains of discomfort.

Last Answer : a) Stage III Clinically, a deep crater with or without undermining of adjacent tissues is noted.

Description : The nurse teaches the patient with a high risk for osteoporosis about risk-lowering strategies including which of the following statements? a) Walk or perform weight-bearing exercises out ... alcohol and caffeine consumption in moderation, and performing a regular weight-bearing exercise regimen.

Last Answer : a) Walk or perform weight-bearing exercises out of doors. Risk-lowering strategies for osteoporosis include walking or exercising out of doors, performing a regular weight-bearing exercise ... and vitamin D intake, smoking cessation, and consuming alcohol and caffeine consumption in moderation.

Description : 89. A nurse has to attend a committee meeting for two hours. She delegates her work to another nurse. What primary consideration should be observed?

Last Answer : D. Competency to perform the given function

Description : Which of the following solutions should the nurse anticipate for fluid replacement in the male patient? a) Lactated Ringer's solution Replacement fluids may include isotonic electrolyte solutions and ... only to treat severe symptomatic hyponatremia and should be used only in intensive care units.

Last Answer : a) Lactated Ringer’s solution Replacement fluids may include isotonic electrolyte solutions and blood component therapy.

Description : In order to avoid hip dislocation after replacement surgery, the nurse teaches the patient which of the following guidelines? a) Never cross the affected leg when seated. Crossing the affected leg may result ... a chair. The patient should be taught to avoid bending forward when seated in a chair.

Last Answer : a) Never cross the affected leg when seated. Crossing the affected leg may result in dislocation of the hip joint after total hip replacement.

Description : A patient with fungal encephalitis receiving amphotericin B complaints of fever, chills, and body aches. The nurse knows that these symptoms a) may be controlled by the administration of ... and cerebral spinal fluid (CSF) cultures. Blood and CSF cultures help diagnosis fungal encephalitis.

Last Answer : a) may be controlled by the administration of diphenhydramine (Benedryl) and acetaminophen (Tylenol) approximately 30 minutes prior to administration of the amphotericin. Administration of amphotericin B ... 30 minutes prior to the administration of amphotericin B may prevent these side effects.

Description : When the nurse reviews the physician's progress notes for the patient who has sustained a head injury and sees that the physician observed Battle's sign when the patient was in the Emergency Department, the ... CSF) from the patient's nose. Escape of CSF from the patient's nose is termed rhinorrhea.

Last Answer : a) an area of bruising over the mastoid bone. Battle’s sign may indicate skull fracture.

Description : Regarding emergency procedures at the burn scene, the nurse teaches which of the following guidelines? a) Never wrap burn victims in ice. Such procedure may worsen the tissue damage and lead to ... . Such procedures may worsen the tissue damage and lead to hypothermia in patients with large burns.

Last Answer : a) Never wrap burn victims in ice. Such procedure may worsen the tissue damage and lead to hypothermia in patients with large burns.

Description : The nurse notes that the patient demonstrates generalized pallor and recognizes that this finding may be indicative of a) anemia. In the light-skinned individual, generalized pallor is a ... . d) local arterial insufficiency. Local arterial insufficiency is characterized by marked localized pallor.

Last Answer : a) anemia. In the light-skinned individual, generalized pallor is a manifestation of anemia. In brown- and black-skinned individuals, anemia is demonstrated as a dull skin appearance.

Description : When the nurse observes diffuse swelling involving the deeper skin layers in the patient who has experienced an allergic reaction, the nurse records the finding as a) angioneurotic edema. ... the result of increased interstitial fluid and associated with disorders such as congestive heart failure.

Last Answer : a) angioneurotic edema. The area of skin demonstrating angioneurotic edema may appear normal but often has a reddish hue and does not pit.

Description : When the nurse administers intravenous gamma-globulin infusion, she recognizes that which of the following complaints, if reported by the patient, may indicate an adverse effect of the infusion? a) ... urination is a sign of urinary tract infection, not an adverse effect of gamma-globulin infusion.

Last Answer : a) Tightness in the chest Flank pain, tightness in the chest, or hypotension indicates adverse effects of gamma-globulin infusion.

Description : The nurse providing education regarding sexually transmitted diseases includes which of the following statements regarding herpes virus 2 (herpes genitalis)? a) In pregnant women with active herpes virus, babies ... very difficult to kill. Usually, the virus is killed at room temperature by drying.

Last Answer : a) In pregnant women with active herpes virus, babies delivered vaginally may become infected with the virus. Therefore, a cesarean delivery may be performed if the virus recurs near the time of delivery.

Description : When the nurse observes the patient's urine to be orange, she further assesses the patient for a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake ... white urine may indicate infection, pyruria, or in the female patient, the use of vaginal creams.

Last Answer : a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake of Dilantin or other medications. Orange to amber colored urine may also indicate concentrated urine due to dehydration or fever.

Description : The nurse recognizes that the patient with a duodenal ulcer will likely experience a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain ... patient with gastric ulcer. d) weight loss. The patient with a duodenal ulcer may experience weight gain.

Last Answer : a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain and ingestion of food brings relief.

Description : Which of the following statements accurately reflects a rule of thumb upon which the nurse may rely in assessing the patient's fluid balance? a) Minimal intake of 1.5 liters per day If food and fluids are ... 2 liters per day Minimal intake, as a rule of thumb, is less than 2 liters per day.

Last Answer : a) Minimal intake of 1.5 liters per day If food and fluids are withheld, IV fluids (3L/day) are usually prescribed.

Description : For which of the following medications must the nurse contact the pharmacist in consultation when the patient receives all oral medications by feeding tube? a) Enteric-coated tablets Enteric-coated ... make an opening in the capsule and squeeze out contents for administration by feeding tube.

Last Answer : a) Enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change of form of medication is required by patients with tube feedings.

Description : Regarding oral cancer, the nurse provides health teaching to inform the patient that a) many oral cancers produce no symptoms in the early stages. As the cancer progresses, the patient may complain of ... crater-like. A typical lesion in oral cancer is a painless hardened ulcer with raised edges.

Last Answer : a) many oral cancers produce no symptoms in the early stages. As the cancer progresses, the patient may complain of tenderness or difficulty in chewing, swallowing, or speaking.