When making IV rounds, the nurse finds redness, swelling, and warmth at a client's IV site. The client states the IV "hurts and burns." The nurse's first action is to
a. culture the IV site and cannula. c. document the IV site appearance and
client statements.
b. follow the facility's protocol. d. teach the client to notify her at the first
sign of discomfort or swelling.
ANS: b
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A patient's family is asking how to administer rivastigmine (Exelon) to their parent, who has Alzheimer's disease. The nurse should provide the patient and family with which of the follow-ing instructions?
a. "The drug should be given every morning on an empty stomach." b. "The drug should be administered twice daily with food." c. "Give the drug nightly before bed." d. "Give the drug four times a day at least 2 hours after each meal."
To prevent possible complications from cardioversion, before administering the shock, the nurse would ensure that the (Select all that apply)
a. emergency equipment is nearby and in working order. b. joules are set to 50-100 joules initially on a monophasic machine. c. machine is set to synchronize with the client's QRS complex. d. the Code Blue team has arrived and is prepared.
Which of the following is the most valid criterion for determining the status of a patient's anxiety at discharge? The patient:
a. Has a relaxed facial expression b. Reports that he feels more relaxed today c. Shows no physiological signs of anxiety (e.g., pallor) d. Asks no further questions about home care
The client receiving an intravenous infusion of morphine sulphate begins to experience respiratory depression and decreased urine output. How is this effect described?
a. Therapeutic b. Toxic c. Idiosyncratic d. Allergic