Nokea
The nurse is caring for a client with schizophrenia who is experiencing auditory hallucinations and has a new prescription for an oral antipsychotic. Which of the following actions should the nurse take?
- A. Provide music for the client
- B. Use gentle touch to calm the client
- C. Instruct the client to ignore the hallucinations
- D. Tell the client the medication will alleviate the hallucinations within a few hours
Correct Answer: C
Rationale: Instructing the client to ignore hallucinations helps them manage symptoms by redirecting focus, a practical coping strategy. Music or touch may exacerbate distress, and antipsychotics typically take days to weeks to reduce hallucinations, not hours.
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The nurse is working with unlicensed assistive personnel (UAP). Which task can the nurse safely assign to UAP?
- A. Assisting a 2-day postoperative hip arthroplasty client with morning care
- B. Collecting a urine specimen for culture and sensitivity from a client with a Foley catheter
- C. Irrigating colostomy of a 2-day postoperative colostomy client who is stable
- D. Refilling the empty enteral feeding container with tube feeding
Correct Answer: B
Rationale: Collecting a urine specimen from a Foley catheter is within the UAP's scope, as it involves a straightforward procedure with proper training. Colostomy irrigation and refilling enteral feeding containers require nursing judgment and are not safe for UAP to perform.
The nurse is preparing to administer an acetaminophen suppository to a 4-year-old client. Which of the following actions should the nurse take? Select all that apply.
- A. Place the client in the side-lying position.
- B. Guide the suppository along the rectal wall.
- C. Use a gloved index finger to insert the suppository.
- D. Advance the suppository no further than the external sphincter.
- E. Hold the client's buttocks together firmly after inserting the suppository.
Correct Answer: A,C,E
Rationale: The side-lying position facilitates insertion, a gloved finger ensures hygiene, and holding buttocks prevents expulsion. Guiding along the rectal wall is unnecessary, and the suppository should be inserted beyond the external sphincter for absorption.
The nurse is caring for a newborn 12 hours after an uncomplicated vaginal birth at 39 weeks gestation. Which of the following findings would require follow up? Select all that apply.
- A. Plantar creases are present over the entire soles of the feet
- B. Skin on the forehead blanches to a yellowish hue
- C. Toes fan outward as the sole of the foot is stroked upward
- D. Umbilical cord has one artery and one vein
- E. White, pearl-like cysts are present on the gum margins
Correct Answer: B,D
Rationale: Yellowish skin suggests jaundice, which requires monitoring for bilirubin levels. An umbilical cord with one artery (instead of two) and one vein may indicate congenital anomalies, needing further evaluation. Plantar creases are normal at 39 weeks, the Babinski reflex (toes fanning) is expected, and gum cysts (Epstein pearls) are benign.
A new nurse on the unit notes that the nurse manager seems to be highly respected by the nursing staff. The new nurse is surprised when one of the nurses states: 'The manager makes all decisions and rarely asks for our input.' The best description of the nurse manager's management style is
- A. Participative or democratic
- B. Ultraliberal or communicative
- C. Autocratic or authoritarian
- D. Laissez faire or permissive
Correct Answer: C
Rationale: Autocratic or authoritarian. The manager’s decision-making without staff input indicates an autocratic leadership style.
The physician orders the antibiotics ampicillin (Omnipen) and gentamicin (Garamycin) for a newly admitted client with an infection. The nurse should:
- A. administer both medications simultaneously.
- B. give the medications sequentially, and flush well between them.
- C. ask the physician or pharmacy which medication to give first and how long to wait before giving the other drug.
- D. start one medication now and begin the other medication in 2-4 hours.
Correct Answer: B
Rationale: Ampicillin and gentamicin are pH-incompatible, so they must be given sequentially with thorough flushing to prevent precipitation in the IV line. Simultaneous or delayed administration is inappropriate. Pharmacological Therapies