Four hours after administering promethazine to a male client, the PN measures his temperature.
When the client questions the PN about the purpose for taking his temperature, how should the PN
respond?
encourage the pt to share his concerns about
the plan of care
describe how the medication works to lower
body temperature.
explain the need to assess for side effects of
the medicine.
offer assurance that vital signs are routinely
,taken every 4 hours. - Answersexplain the need to assess for side effects of this medicine
After administering the 0730 ac dose of sliding scale regular insulin to a client with DM, what action
by the PN has the highest priority?
instruct the uap to take the client a breakfast tray.
measure the clients vital signs and oxygen
saturation.
notify the charge nurse of the dose of insulin
administered.
observe the client for pallor, diaphoresis, or
fatigue - Answersinstruct the uap to take the client a breakfast tray
Morphine sulfate via intravenous patient-controlled analgesia (PCA) pump is prescribed for a client
with severe chronic back pain. Thirty minutes after initiating the pea pump, the PN notes that the
client becomes lethargic. What action should the PN take?
determine the clients pain scale rating
measure the clients vital signs
check the iv insertion site for swelling
reinforce pca pump teaching - Answersmeasure the clients vital signs
The PN applies a preparation with keratolytic properties to both legs of a pt with psoriasis. What
findings indicate that the desired effect has been achieved.
affected areas are free of localized redness and
swelling.
scaley areas of the skin appear softer with less
peeling.
full range of motion without pain of lower
extremity joints.
no prudent drainage present from lesions on
, the legs. - Answersscaley areas of the skin appear softer with less peeling
The PN is administering lonidine (catapres) to a client with hypertension. What instruction should
the PN give the client?
"Do not abruptly stop the medication"
"Avoid milk products when taking this medication"
"Take your pulse before pressure taking the medication"
"Check your blood pressure monthly" - Answers"Do not abruptly stop the medication"
A 15 year old with asthma is to begin long-term therapy with both inhaled and oral corticosteroids.
The RN and PN collaborate on the plan of care. Which nursing diagnosis should receive the highest
priority when setting goals and planning interventions?
altered nutrition: more than body requirements
related to steroid use.
risk for infection: related to immunosuppression
secondary to steroid use.
body image disturbance (acne) related to
steroid use
altered family processes related to
exacerbations of asthma. - Answersrisk for infection: related to immunosuppression secondary to
steroid use
The PN is administering initial dose of furosemide (lasix) 40 mg daily to a client with hypertension.
The PN should monitor this client for which condition?
hypophosphatemia
hypercalemia
hyperchloremia
hypokalemia - Answershypokalemia
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