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?

1 Answer

Answer :

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

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 : 70. The senior nurse observes that Marina occasionally does not follow agreed upon interventions. The senior nurse reports that Marina should improve in which of the following?

Last Answer : C. Compliance to standards

Description : 68. The senior asked Marina to list nursing interventions for the nursing diagnosis “Ineffective tissue perfusion: peripheral”. From the following list, which intervention will the senior nurse consider to be contraindicated?

Last Answer : D. Maintain both extremities in a dependent position

Description : A staff nurse was found charting blood glucose result without actually doing the procedure. What is the appropriate initial action of the senior nurse? A. Write and submit an explanation and reprimand as necessary B. Go on leave without pay C. Write an incident report D. Explain to the patient

Last Answer : A. Write and submit an explanation and reprimand as necessary

Description : The nurse teaches the patient with gastroesophageal reflux disease (GERD) which of the following measures to manage his disease? a) Avoid eating or drinking 2 hours before bedtime. The patient should not ... blocks. d) Eat a low carbohydrate diet The patient is instructed to eat a low-fat diet

Last Answer : a) Avoid eating or drinking 2 hours before bedtime. The patient should not recline with a full stomach.

Description : If a case of smallpox is suspected, the nurse should a) Call the CDC Emergency Preparedness Office. Anyone suspecting a case of smallpox should call the CDC Emergency Preparedness Office ... very different from that of chickenpox. With chickenpox, lesions appear at different developmental stages.

Last Answer : a) Call the CDC Emergency Preparedness Office. Anyone suspecting a case of smallpox should call the CDC Emergency Preparedness Office at 770-488-7100. The CDC will respond by immmediate provision ... with negative pressure, and maintain thorough lists of all those who have contact with the patient.

Description : 98. Phlebotomy was ordered as part of the therapy. You instructed the client and emphasized that the procedure can be repeated. The client inquired, “What is the primary aim of the procedure?” Your appropriate response is

Last Answer : D. “It keeps the hematocrit within normal range.”

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 : 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 : The normal serum value for potassium is a) 3.5-5.5 mEq/L. Serum potassium must be within normal limits to prevent cardiac dysrhythmias. b) 135-145 mEq/L. Normal serum sodium is 135-145 mEq/L. c) 96-106 mEq/L. ... is 96-106 mEq/L. d) 8.5-10.5 mg/dL. Normal total serum calcium is 8.5-10.5mg/dL.

Last Answer : a) 3.5-5.5 mEq/L. Serum potassium must be within normal limits to prevent cardiac dysrhythmias.

Description : If tube feeding is continuous, the placement of the feeding tube should be checked a) every shift. Each nurse caring for the patient is responsible for verifying that the tube is located ... is unnecessary to check placement. Even though the feedings are continuous, the placement must be assessed.

Last Answer : a) every shift. Each nurse caring for the patient is responsible for verifying that the tube is located in the proper area for continuous feeding.

Description : The charge nurse reported to the chief nurse that the Demerol 50 cc vial inventory has been incorrect for the last 24 hours. The most appropriate action of the narcotic nurse is: A. Log ... by the narcotic nurse D. Review endorsement of clients who received Demerol within the last 24 hours

Last Answer : D. Review endorsement of clients who received Demerol within the last 24 hours

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 : 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

Last Answer : C. Anticipatory response

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 : 78. Nurse Nora is assigned on PM shift for the month of June. She requested the head nurse if she can be on night or morning instead to be able to tutor her 2 sons in the elementary. The head ... it is her turn to go on PM duty. The action of the head nurse exemplifies which of the following?

Last Answer : A. Authority

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 : The nurse teaches the patient about diabetes including which of the following statements? a) Elevated blood glucose levels contribute to complications of diabetes, such as diminished vision. When blood ... be able to resume previous methods for control of diabetes when the stress is resolved.

Last Answer : a) Elevated blood glucose levels contribute to complications of diabetes, such as diminished vision. When blood glucose levels are well controlled, the potential for complications of diabetes is reduced.

Description : When the patient's eosinophil count is 50-90% of blood leukocytes, the nurse interprets the result as a) indicative of idiopathic hypereosinophilic syndrome. When eosinophils make up 50-90% of white cell ... d) normal. Eosinophils normally make up 1-3% of the total number of white blood cells.

Last Answer : a) indicative of idiopathic hypereosinophilic syndrome. When eosinophils make up 50-90% of white cell count, the patient is demonstrating severe eosinophilia.

Description : When assisting the patient to interpret a negative HIV test result, the nurse informs the patient that the results mean a) his body has not produced antibodies to the AIDS virus. A negative test ... When antibodies to the AIDS virus are detected in the blood, the test is interpreted as positive.

Last Answer : a) his body has not produced antibodies to the AIDS virus. A negative test result indicates that antibodies to the AIDS virus are not present in the blood at the time the blood sample for the test is drawn.

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 : 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 : 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 : 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

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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 : 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 : 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 : 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 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 : Bladder retraining following removal of an indwelling catheter begins with instructing the patient to follow a 2-3 hour timed voiding schedule. Immediately after the removal of the indwelling ... in the bladder after voiding, straight catheterization may be performed for complete bladder emptying.

Last Answer : a) encouraging the patient to void immediately. Immediate voiding is not usually encouraged. The patient is commonly placed on a timed voiding schedule, usually within two to three hours.

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 : When the nurse observes that the patient has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the patient's ... rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.

Last Answer : a) decerebrate. Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing.

Description : The nurse teaches the patient whose surgery will result in a sigmoid colostomy that the feces expelled through the colostomy will be a) solid. With a sigmoid colostomy, the feces are solid. b) semi- ... colostomy, the feces are mushy. d) fluid. With an ascending colostomy, the feces are fluid.

Last Answer : a) solid. With a sigmoid colostomy, the feces are solid.

Description : Which of the following observations regarding ulcer formation on the patient's lower extremity indicate to the nurse that the ulcer is a result of venous insufficiency? a) The border of the ... d) The ulcer is deep, involving the joint space. Venous insufficiency ulcers are usually superficial.

Last Answer : a) The border of the ulcer is irregular. The border of an ulcer caused by arterial insufficiency is circular.

Description : When the post-cardiac surgical patient demonstrates vasodilation, hypotension, hyporeflexia, slow gastrointestinal motility (hypoactive bowel sounds), lethargy, and respiratory depression, the nurse suspects ... and QT intervals, broad flat T waves), disorientation, depression, and hypotension.

Last Answer : a) Hypermagnesemia Untreated hypomagnesemia may result in coma, apnea, cardiac arrest.

Description : When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods? a) 10-15 seconds In general ... suction for 0-5 seconds would provide too little time for effective suctioning of secretions.

Last Answer : a) 10-15 seconds In general, the nurse should apply suction no longer than 10-15 seconds because hypoxia and dysrhythmias may develop, leading to cardiac arrest.

Description : When assessing the older adult, the nurse anticipates increase in which of the follow components of respiratory status? a) Residual lung volume As a result, patient experience fatigue ... ) Cough efficiency The nurse anticipates difficulty coughing up secretions due to decreased cough efficiency.

Last Answer : a) Residual lung volume As a result, patient experience fatigue and breathlessness with sustained activity.

Description : If blood pressure can now be checked electronically, why do nurses still need stethoscopes?

Last Answer : Yes, we still need and use stethoscopes. Sometimes, the machines are unable to get a reading. Also, checking it manually is more accurate. We also use our stethoscopes for other things, like listening to your heart, lungs, and abdomen.