Nokea
A nurse is reviewing a client's 0800 laboratory values at 1100. The nurse notes that the client received heparin at 1000. Which of the following laboratory values warrants an incident report?
- A. ePTT 90 seconds
- B. Hgb 16 g/dL
- C. INR 1.6
- D. WBC 6,000/mm3
Correct Answer: A
Rationale: The correct answer is A: ePTT 90 seconds. This value indicates a higher than normal clotting time, which could potentially lead to bleeding complications due to excessive anticoagulation from heparin. The other values (B, C, D) are within normal ranges and do not indicate an immediate risk or adverse outcome related to heparin administration. An incident report is necessary to document and address the elevated ePTT to ensure appropriate interventions are taken to prevent harm to the patient.
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A nurse is reviewing the medical record of a client who has sinusitis and a new prescription for cefuroxime. Which of the following client information is the priority for the nurse to report to the provider?
- A. The client has a BUN of 18 mg/dL
- B. The client takes an aspirin daily
- C. The client has a history of a severe penicillin allergy
- D. The client reports a history of nausea with cefuroxime
Correct Answer: C
Rationale: The correct answer is C: The client has a history of a severe penicillin allergy. This is the priority for the nurse to report because cefuroxime belongs to the cephalosporin class of antibiotics, which has a cross-reactivity with penicillins. Individuals with a history of severe penicillin allergy are at an increased risk of also being allergic to cephalosporins like cefuroxime. This can lead to potentially life-threatening allergic reactions. Reporting this information to the provider is crucial to avoid prescribing a medication that could harm the client.
Choice A (BUN of 18 mg/dL) is not directly related to the prescription of cefuroxime for sinusitis. Choice B (client takes an aspirin daily) is important but not as critical as the potential allergic reaction to cefuroxime. Choice D (client reports a history of nausea with cefuroxime) is relevant but does not pose an
A nurse is caring for a client who has a prescription for amoxicillin. Which of the following findings indicates the client is experiencing an allergic reaction?
- A. Nausea
- B. Cardiac dysrhythmia
- C. Laryngeal edema
- D. Insomnia
Correct Answer: C
Rationale: The correct answer is C: Laryngeal edema. Laryngeal edema is a severe allergic reaction symptom that can lead to airway obstruction and respiratory distress. This is a life-threatening condition that requires immediate intervention. Nausea (A) and insomnia (D) are common side effects of amoxicillin but not indicative of an allergic reaction. Cardiac dysrhythmia (B) is not a typical allergic reaction symptom to amoxicillin.
A nurse is assessing a client who is receiving a peripheral IV infusion and notes infiltration of fluid into the tissue surrounding the insertion site. Which of the following actions should the nurse take?
- A. Flush the IV catheter
- B. Apply pressure to the IV site
- C. Elevate the extremity
- D. Slow the infusion rate
Correct Answer: C
Rationale: The correct action is to elevate the extremity. Elevating the extremity above the level of the heart helps to reduce swelling and prevent further fluid infiltration into the surrounding tissue. This promotes proper circulation and limits potential complications. Flushing the IV catheter (choice A) would not address the infiltration issue. Applying pressure to the IV site (choice B) could cause further damage to the tissue. Slowing the infusion rate (choice D) may not be sufficient to prevent further infiltration.
For each of the following client statements, click to specify whether the statement indicates an understanding or no understanding of the teaching.
- A. If I experience black stools, I should notify my provider.
- B. I should rinse my mouth after taking this medication.
- C. I should avoid taking antacids while on this medication.
- D. I should take this medication with orange juice.
- E. I should take my medication on an empty stomach.
Correct Answer: D
Rationale: [1, 0, 0, 0]
The correct answer is D. Taking medication with orange juice is often mentioned for specific medications that require acidic environments for absorption. This statement demonstrates an understanding of the medication regimen. Choices A, B, and C are incorrect as they do not directly relate to the medication instructions. Choice E is also incorrect as it contradicts the specific instruction provided in choice D.
A nurse is caring for a client who is 12 hr postpartum and has a third-degree perineal laceration. The client reports not having a bowel movement
for 4 days. Which of the following medications should the nurse administer?
- A. Bisacodyl 10 mg per rectum
- B. Magnesium hydroxide 30 mL PO
- C. Famotidine 20 mg PO
- D. Loperamide 4 mg PO
Correct Answer: A
Rationale: The correct answer is A: Bisacodyl 10 mg per rectum. Bisacodyl is a stimulant laxative that helps stimulate bowel movements. Given the client's situation of not having a bowel movement for 4 days postpartum with a third-degree perineal laceration, prompt relief is needed to prevent complications such as constipation or increased pressure on the perineal area. Administering Bisacodyl per rectum will provide a faster onset of action compared to oral medications, ensuring timely relief for the client.
Choice B: Magnesium hydroxide is a laxative used for constipation but may not provide immediate relief for the client in this urgent situation.
Choice C: Famotidine is a histamine-2 blocker used for managing stomach acid but is not indicated for addressing constipation.
Choice D: Loperamide is an antidiarrheal medication and is contraindicated in this scenario as it can worsen constipation.