Please select 2 correct answers
“I should empty my ostomy pouch of urine when it is full.”
Please select 4 correct answers
Please refer to the text mode for the rationale.
Please select 2 correct answers
The three classic signs of preeclampsia are hypertension, generalized edema, and proteinuria. Increased respirations are not a sign of preeclampsia.
Please select 5 correct answers
When caring for a client receiving magnesium sulfate therapy, the nurse would monitor maternal vital signs, especially respirations, every 30-60 minutes and notify the physician if respirations are less than 12, because this would indicate respiratory depression. Calcium gluconate is kept on hand in case of magnesium sulfate overdose, because calcium gluconate is the antidote for magnesium sulfate toxicity. Deep tendon reflexes are assessed hourly. Cardiac and renal function is monitored closely. The urine output should be maintained at 30 ml per hour because the medication is eliminated through the kidneys.
Please select 3 correct answers
In a client who has had an ECG, the P wave represents the activation of the electrical impulse in the SA node, which is then transmitted to the AV node. In addition, the P wave represents atrial muscle depolarization, not ventricular depolarization. The normal duration of the P wave is 0.11 seconds or less in duration and 2.5 mm or more in height.
Please select 4 correct answers
A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. Having the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.
A small glass of milk relaxes the body and promotes sleep.
Please select 3 correct answers
These symptoms are often reported by clients with insomnia. Clients report nonrestorative sleep. Arising once at night to urinate (nocturia) is not in and of itself insomnia.
Please select 2 correct answers
Research demonstrate that the occurrence of SIDS is reduced with these two positions.
Benzodiazepines such as clonazepam and lorazepam are given to the client withdrawing from alcohol. Answer A is incorrect because methodone is given to the client withdrawing from opiates. Answer C is incorrect because naloxone is an antidote for narcotic overdose. Answer D is incorrect because disufiram is used in aversive therapy for alcohol addiction.
The client’s breakfast should be served within 30 minutes to coincide with the onset of the client’s regular insulin.
The nurse should administer 0.7mL of the medication. Answers A, B, and D are incorrect because the dosage is incorrect.
Tetracycline is contraindicated for use in infants and young children because it stains the teeth and arrests bone development. Answers B, C, and D are incorrect because they can be used to treat infections in infants and children.
The client with echolalia repeats words or phrases used by others. Answer A is incorrect because it refers to clang association. Answer C is incorrect because it refers to circumstantiality. Answer D is incorrect because it refers to neologisms.
Holding a cup of coffee or hot chocolate helps to relieve the pain and stiffness of the hands. Answers A, B, and D do not relieve the symptoms of rheumatoid arthritis; therefore, they are incorrect.
The infant’s birth weight should double by 6 months of age. Answers B, C, and D are incorrect because they are greater than the expected weight gain by 6 months of age.
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NCLEX Select All That Apply #8
