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Author Archives: Anonymous

The nurse is reviewing the following arterial blood gas resu…

The nurse is reviewing the following arterial blood gas results from a client admitted with pneumonia. pH: 7.31 PaCO2: 80 mm/Hg HCO3: 25 mEq/L PaO2: 70 mm/Hg The nurse realizes that these results necessitate which priority nursing intervention?

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A client with COPD tells a nurse that he feels short of brea…

A client with COPD tells a nurse that he feels short of breath. During the assessment, the nurse noted wheezing, RR 30, O2 sat of 86%, BP 130/88. The nurse calls the respiratory therapist to administer an ordered nebulizer treatment. The therapist says, “I have several more nebulizer treatments to do on the unit where I am now. As soon as I’m finished, I’ll come and assess the client.” What is the nurse’s most appropriate action?    

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A client with asthma is receiving albuterol.  When teaching…

A client with asthma is receiving albuterol.  When teaching the client about the use of albuterol it is most important that the nurse include which of the following?

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A client is receiving a transfusion of packed red blood cell…

A client is receiving a transfusion of packed red blood cells. Time BP Apical HR RR Temp 0800 90/50 100 bpm 20 bpm 98.0⁰ F 0815 92/54 110 bpm 18 bpm 100.0⁰ F What is the nurse’s priority intervention based on the client’s above assessment?  

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You are administering heparin and following the protocol bel…

You are administering heparin and following the protocol below for a client weighing 189 lbs. The order is to administer an initial heparin bolus IV followed by a titrated IV infusion. Round to the tenths place. HEPARIN PROTOCOL Initial bolus- 50 units/kg Initial rate – 18 units/kg/hr Obtain a PTT every 6 hours, and adjust dosage and rate as follows: If  PTT is less than 35 secs:      Repeat bolus with 80 units/kg and increase the rate by 4 units/kg/hr. If  PTT is 36 to 44 seconds:       Repeat bolus with 40 units/kg and increase the rate by 2 units/kg/hr. If  PTT is 45 to 75 seconds:       Continue current rate. If  PTT is 76 to 90 seconds:       If  PTT is 76 to 90 seconds:          Decrease rate by 2 units/kg/hr. If  PTT is greater than 90 secs: Hold the heparin for 1 hour and decrease rate by 3 units/kg/hr. Available (for bolus)  – heparin 1,000 units/mLAvailable (for infusion) –  heparin 25,000 units in 250 mL D5W    How many mL will the client receive for the repeat heparin IV bolus in response to the PTT of 40 secs?

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Identify which laboratory test should be ordered for each cl…

Identify which laboratory test should be ordered for each client complaint. Each laboratory test can only be used 1 time.

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A client is admitted to the hospital post MVA with history o…

A client is admitted to the hospital post MVA with history of hemophilia A and bleeding from a head laceration.  Which of these HCP orders is the priority to be administered? 

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A nurse was assigned to an outpatient infusion center to pro…

A nurse was assigned to an outpatient infusion center to provide treatment for a 55-year-old client who was recently diagnosed with Hodgkin Lymphoma. What do you anticipate is the best treatment goal for this client?

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A client is on neutropenic precautions following treatment f…

A client is on neutropenic precautions following treatment for acute lymphocytic leukemia and now presents with hypotension, tachycardia and an elevated temperature.  The nurse notifies the HCP. Which order from the HCP would be the nurse’s priority intervention?

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During a follow-up visit, a client who has been on estrogen…

During a follow-up visit, a client who has been on estrogen therapy reports daily use of cigarettes. The nurse explains to the client use of nicotine while on estrogen will increase the likelihood of which adverse event?

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