A nurse is preparing to administer diazepam 2 mg twice daily via NG tube. Available is diazepam

oral solution 5 mg/1 mL. How many mL should the nurse administer with each dose? (Use a leading

zero if itapplies. Do not use a trailing zero. Round the answer to the nearest tenth.)

0.4

A nurse in a long-term care facility is planning to use therapeutic touch for a group of selected

clients who have chronic pain. The nurse should identify that the use of therapeutic touch is

contraindicated for which ofthe following clients?

A client who has chronic back pain and a history of being physically abused

Therapeutic touch consists of using the nurse's hands to harmonize energy fields and to

facilitate relief of painor anxiety, such as for a client who has chronic back pain. The nurse can

touch the client with their palms or move the palms near, but not touching the client's body.

Prior physical maltreatment and some mental health disorders are contraindications for

therapeutic touch, because touch or near touch could cause severe anxiety.

A nurse in a rehabilitation unit is assessing a group of clients who have traumatic brain injuries.

The nurseshould identify that which of the following clients requires a priority referral?

A client who coughs after drinking liquids

The greatest risk to this client is injury from aspiration. Therefore, this is the client the nurse

should address first. The priority referral the nurse should make is to a speech-language

pathologist because a client who coughs after drinking liquids is at risk for aspiration.

Manifestations of dysphagia include changes in voice tone,coughing, delayed swallowing,

pocketing of food, and occasional silent aspiration, which can occur if a client isexperiencing a

decrease in sensation.

A nurse is assisting a client to move up in bed. Which of the following actions should the nurse take?

Raise the height of the bed to the level of the nurse's elbows.

A nurse is caring for a client who is at risk for pressure ulcer formation due to immobility. The

nurse shouldplace the client in which of the following positions to reduce pressure on the client's

bony prominences?

30° lateral

The 30° lateral position, along with positioning devices, can prevent pressure directly over the

client's most vulnerable bony prominences. This position can, however, cause pressure on the

shoulder, ankle, anterior iliacspine, and trochanter. Therefore, the nurse should ensure the

client's head is midline and supported, rotation ofthe spine is avoided, and position changes are

implemented every 1 to 2 hr

A nurse is preparing to administer vancomycin 500 mg by intermittent IV infusion every 6 hr.

Available is vancomycin 500 mg in 0.9% sodium chloride 100 mL to infuse over 2 hr. The nurse

should set the IV pump todeliver how many mL/hr? (Round the answer to the nearest whole

number. Use a leading zero if applicable. Do not use a trailing zero.)

50

A nurse is admitting a client who is to undergo a surgical procedure. Under the Patient SelfDeterminationAct (PSDA), which of the following actions is the nurse's responsibility regarding

the client's advance directives?