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A nurse is reviewing a client’s orders and notes the following: Vital signs every 4 hours, regular diet, Cefazolin 1g IV every 8 hours for 5 days, Metformin 1,000 mg PO every 12 hours, and point of care blood glucose check every 4 hours. Which action should the nurse take?

Place the client on contact precautions.

Start a high-fiber diet.

Administer an oral steroid.

Make the client NPO.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Placing the client on contact precautions is not indicated based on the provided orders. Contact precautions are typically used for infections that are spread by direct or indirect contact, such as MRSA or C. difficile. The orders do not suggest the presence of such an infection.

Choice B rationale

Starting a high-fiber diet is not indicated. The client is already on a regular diet, and there is no mention of conditions that would necessitate a high-fiber diet, such as constipation or diverticulosis.

Choice C rationale

Administering an oral steroid is not indicated. The orders include Cefazolin, an antibiotic, and Metformin, an antidiabetic medication. There is no indication for an oral steroid, which is typically used for inflammatory conditions or autoimmune diseases.

Choice D rationale

Making the client NPO (nothing by mouth) is the correct action. This is likely due to the need for accurate blood glucose monitoring and the administration of IV antibiotics. Being NPO ensures that the client does not eat or drink anything that could interfere with these treatments.

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A. Decreased muscle tone, relaxed jaw muscles, sagging mouth. B. Urine output is clear yellow. C. Altered breathing (apnea, labored or irregular breathing, Cheyne-Stokes pattern). D. Congestion/increased pulmonary secretions; noisy respirations (death rattle).

Correct Answer is ["A","C","D"]

Explanation

Choice A rationale

Decreased muscle tone, relaxed jaw muscles, and a sagging mouth are common signs that indicate a client is near death. These changes occur as the body begins to shut down and muscle control diminishes.

Choice B rationale

Clear yellow urine output is not typically associated with the end-of-life stage. As death approaches, urine output usually decreases and may become darker in color.

Choice C rationale

Altered breathing patterns, such as apnea, labored or irregular breathing, and Cheyne-Stokes respiration, are common signs that a client is nearing death. These changes in breathing patterns are due to the body’s decreasing ability to regulate respiratory function.

Choice D rationale

Congestion and increased pulmonary secretions, often referred to as the “death rattle,” are common signs that a client is near death. These noisy respirations occur as the body’s ability to clear secretions diminishes.

A. Encourage increased fluid intake and measure urinary output every 8 hours. B. Provide comfort measures such as topical warm application and tactile massage. C. Determine client’s objective measure of pain using a numerical pain scale. D. Assist the client to ambulate as much as possible during waking hours. E. Implement a 24-hour schedule of routine administration of prescribed analgesics.

Correct Answer is ["B","C","E"]

Explanation

Choice A rationale

Encouraging increased fluid intake and measuring urinary output every 8 hours is not directly related to managing chronic pain. This intervention is more relevant for clients with conditions affecting fluid balance or renal function.

Choice B rationale

Providing comfort measures such as topical warm application and tactile massage can help alleviate chronic pain by promoting relaxation and improving blood circulation. These non- pharmacological interventions can be effective in managing pain and enhancing the client’s comfort.

Choice C rationale

Determining the client’s objective measure of pain using a numerical pain scale is essential for assessing the severity of pain and evaluating the effectiveness of pain management interventions. Accurate pain assessment is crucial for developing an appropriate plan of care.

Choice D rationale

Assisting the client to ambulate as much as possible during waking hours may not be feasible for clients with severe chronic pain. While physical activity is important, it should be balanced with the client’s pain levels and overall condition.

Choice E rationale

Implementing a 24-hour schedule of routine administration of prescribed analgesics ensures consistent pain relief and prevents breakthrough pain. Regular administration of analgesics is a key component of effectivepain management for clientswithchronic pain.

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A nurse is reviewing a client’s orders and notes the following: Vital signs every 4 hours, regular diet, Cefazolin 1g IV every 8 hours for 5 days, Metformin 1,000 mg PO every 12 hours, and point of care blood glucose check every 4 hours. Which action should the nurse take?

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Correct Answer is ["A","C","D"]

Explanation

Correct Answer is ["B","C","E"]

Explanation

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Take full exam for free A nurse is reviewing a client’s orders and notes the following: Vital signs every 4 hours, regular diet, Cefazolin 1g IV every 8 hours for 5 days, Metformin 1,000 mg PO every 12 hours, and point of care blood glucose check every 4 hours. Which action should the nurse take?

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A family requested a visit from a hospice nurse as they think the client appears to be nearing the end of life. The nurse assesses the client. Which of the following signs indicate that the client is near death?

Correct Answer is ["A","C","D"]

Explanation

The nurse is viewing the admission assessment of a client with chronic pain. What intervention(s) should the nurse include in the client’s plan of care? Select all that apply.

Correct Answer is ["B","C","E"]

Explanation

What times should the nurse measure vital signs? Select all that apply.

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The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client using a tympanic thermometer.The UAP pulls the client’s auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?

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A nurse is reviewing a client’s laboratory results and notes a blood glucose result of 104 mg/dL (5.8 mmol/L). The reference range is 74 to 106 mg/dL (4.1 to 5.9 mmol/L). Which action should the nurse take?

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