Nokea
A nurse is caring for 4 clients. Which prescription by the health care provider would the nurse question and seek further clarification before administering?
- A. 0.45% sodium chloride solution for a client with severe gastroenteritis who had 12 episodes of diarrhea and vomiting in the past 4 hours
- B. IV bolus of 1000 mL 0.9% sodium chloride solution for a client in anaphylaxis due to a food allergy
- C. IV bolus of 1000 mL 0.9% sodium chloride solution for a client with diabetic ketoacidosis who has a serum glucose level of 650 mg/dL (36.1 mmol/L)
- D. IV mannitol 25% solution for a client with a closed head injury who is exhibiting signs of increased intracranial pressure
Correct Answer: C
Rationale: 0.45% saline is appropriate for gastroenteritis to replace fluids. 0.9% saline bolus treats anaphylactic shock. Mannitol reduces intracranial pressure. A 1000 mL bolus for DKA is excessive; smaller boluses (e.g., 250-500 mL) are safer to avoid fluid overload.
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The nurse is reinforcing postpartum discharge instructions to a client. Which instruction should the nurse include to promote newborn safety?
- A. Avoid using blankets to position the newborn in the car seat
- B. Place the newborn in the prone position in bed while sleeping
- C. Position the newborn's car seat in the back seat facing forward
- D. Remove pillows and loose blankets from the newborn's crib
Correct Answer: D
Rationale: Removing pillows and blankets from the crib reduces SIDS risk. Blankets in car seats are unsafe, prone sleeping increases SIDS risk, and forward-facing car seats are incorrect for newborns.
The nurse is caring for an adult who had a cerebrovascular accident. The nurse gives the client a washcloth and encourages the client to wash her face. The client looks at the washcloth as though she does not know what to do with it. The nurse knows that this indicates that the client has which of the following?
- A. Apraxia
- B. Aphasia
- C. Agnosia
- D. Dysarthria
Correct Answer: C
Rationale: Agnosia is the inability to recognize objects, like a washcloth, despite intact sensory function, common post-CVA, unlike apraxia (motor planning), aphasia (language), or dysarthria (speech articulation).
The nurse is about to medicate a client who is to have surgery today. The client says, 'I do not understand what the doctor is going to do,' and asks the nurse to explain specific details of the surgery. The client has already signed an operative permit. What is the best action for the nurse to take at this time?
- A. Attempt to answer the client's questions
- B. Notify the physician of the client's concerns prior to medicating the client
- C. Reassure the client that the physician is well respected and very competent
- D. Suggest that the client ask the physician her questions when in the operating room
Correct Answer: B
Rationale: The client's lack of understanding indicates a need for clarification before proceeding. Notifying the physician ensures informed consent is valid, delaying medication that may impair judgment.
A hospitalized client with thyrotoxicosis receives atenolol 50 mg PO daily. Which statement by the nurse accurately reinforces the client's understanding of this medication's purpose?
- A. Atenolol is an iodine-based medication that blocks the release of thyroid hormones.
- B. It is used to treat some of the symptoms of hyperthyroidism, such as increased heart rate.
- C. This medication is radioactive and damages or destroys the thyroid tissue.
- D. This first-line antithyroid drug inhibits the synthesis of thyroid hormones
Correct Answer: B
Rationale: Atenolol is a beta-blocker that controls hyperthyroidism symptoms like tachycardia. It is not iodine-based , radioactive , or an antithyroid drug .
The nurse is reinforcing teaching of proper technique for colostomy irrigation for the home health client. Which client action indicates that further instruction is required?
- A. Attaches an enema set to the irrigation bag, lubricates it, gently inserts it into the stoma, and holds it in place
- B. Fills irrigation container with 500-1000 mL of lukewarm tap water and flushes the irrigation tubing
- C. Hangs the irrigation container on a hook at the level of the shoulder approximately 18-24 inches above the stoma
- D. Slowly opens the roller clamp, allowing the irrigation solution to flow, but clamps the tubing when cramping occurs
Correct Answer: A
Rationale: Using an enema set is incorrect; a cone-tipped irrigator is required for safe colostomy irrigation. Water volume , height , and clamping are correct.