Next Practice and Application 2

Question 1

A nurse is caring for a patient with heart failure who has gained 3 lbs in 24 hours. Which intervention is the priority?

Accepted Answer

Notify the provider immediately

Answer

A weight gain of 2 or more pounds in 24 hours signals fluid retention requiring prompt provider notification.

Question 2

When performing a sterile dressing change, the nurse accidentally touches the sterile field with an ungloved hand. What is the correct action?

Accepted Answer

Discard the contaminated supplies and start over

Answer

Once the sterile field is broken, all contaminated supplies must be discarded and the procedure restarted.

Question 3

A client is prescribed warfarin. Which laboratory value should the nurse monitor to evaluate therapeutic effectiveness?

Accepted Answer

INR

Answer

INR (International Normalized Ratio) is the standard measure used to monitor warfarin therapy.

Question 4

A nurse is teaching a newly diagnosed type 2 diabetes patient about foot care. Which instruction is most important?

Accepted Answer

Inspect feet every day for cuts or sores

Answer

Daily foot inspection allows early detection of wounds that the patient may not feel due to peripheral neuropathy.

Question 5

A nurse receives an order for morphine 4 mg IV. The vial reads morphine 10 mg/mL. How many mL should the nurse administer?

Accepted Answer

0.4 mL

Answer

4 mg ÷ 10 mg/mL = 0.4 mL is the correct dose calculation.

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