What treatment do you anticipate for M.D.?
What will be an ideal response?
Because M.D. has pneumonia, her treatment would include providing necessary respiratory support
and administration of humidified oxygen. You would obtain blood cultures and a sputum culture
with Gram stain and initiate intravenous (IV) antibiotics. Fluid support would be initiated. You would
monitor M.D.'s vital signs, pulse oximetry, neurologic status, and fluid and electrolyte balance.
Arterial blood gas (ABG) values might be obtained. You would initiate fluid support. Because she is
myelosuppressed, she will need neutropenia and bleeding precautions.
20 . The physician orders a 500-mL normal saline bolus now, with orders to infuse over 2 hours.
You decide to use M.D.'s implanted port for intravenous (IV) access. After you access the port
and connect the fluid, the infusion pump alarms that the line is occluded. What will you do?
First, assess the equipment and make sure the line is patent, without any kinks or blockages.
Have M.D. cough and deep breathe and raise her arm overhead. Reposition her. Then check for
blood return. If you meet resistance, do not continue to flush. If necessary, reaccess the port and
verify placement of the Huber needle. Try to infuse the saline again. If still not successful, notify
the provider. Chest x-ray results can be reviewed; you would follow agency policy regarding the
installation of an antithrombolytic agent and obtain venous access by another means. Note whether
M.D. has any discomfort or pain at the insertion site or in the shoulder, neck, or arm.
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Which of the following would the nurse most likely assess in a client with insufficient fluid volume?
1. Increased urine output, increased pulse, increased blood pressure, and flushed skin 2. Decreased urine output, decreased pulse, decreased blood pressure, and cool and clammy skin 3. Decreased urine output, increased pulse, decreased blood pressure, and cool and clammy skin 4. Increased urine output, decreased pulse, increased blood pressure, and flushed skin
A new nurse is interested in working a "weekend option.". Which of the following describes this pattern of scheduling?
a. Nurse works two 12-hour shifts on the weekend and is paid for either 36 or 40 hours a week. b. Nurse works five shifts a week with alternating weekends. c. Nurse works three shifts a week and alternates weekends. d. Nurse works alternating weekends and alternates shifts.
A nurse is preparing discharge planning papers for a child with a urinary tract infection. The instructions should include: (Select all that apply.)
1. Taking all of the medication until gone. 2. Scheduling a follow-up urinalysis. 3. Encouraging increased liquid intake. 4. Promoting regular voiding times. 5. Prophylactically treating the entire family.
The nurse is initiating a group for adolescent girls diagnosed with anorexia nervosa. Many of the clients in the group are irritable and resent having to attend
One of them comments, "This is a stupid waste of time!" Which of the response by the nurse would be most appropriate? A) "If you feel that way, then you can just leave." B) "You sound irritated; tell me about what is bothering you." C) "You were assigned to this group by your therapist, so you must participate." D) "Sit down and be quiet; your peers would appreciate some peace and quiet."