Nokea
A 19-year-old female is admitted to the psychiatric floor after a suicide attempt 3 days ago. With client safety a priority, the nurse should
- A. assign the patient to the room closest to the nursing station.
- B. assign the patient to an open room with a roommate.
- C. assign the patient to a secluded, isolated room.
- D. assign a staff member to stay with the client at all times.
Correct Answer: A
Rationale: Placing the client near the nursing station allows close monitoring without isolation, balancing safety and autonomy. Constant staff presence is resource-intensive and not always necessary.
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Heparin has been ordered for a client with pulmonary embolis. Which statement, if made by the graduate nurse, indicates a lack of understanding of the medication?
- A. I will administer the medication 1-2 inches away from the umbilicus.'
- B. I will administer the medication in the abdomen.'
- C. I will check the PTT before administering the medication.'
- D. I will need to aspirate when I give Heparin.'
Correct Answer: D
Rationale: Aspirating during heparin injection is incorrect, as it increases the risk of hematoma formation in subcutaneous administration.
The nurse is caring for a client with systemic lupus erythematosis (SLE). The major complication associated with systemic lupus erythematosis is:
- A. Nephritis
- B. Cardiomegaly
- C. Desquamation
- D. Meningitis
Correct Answer: A
Rationale: Nephritis is the major complication of SLE due to immune complex deposition in the kidneys, leading to lupus nephritis, which can cause renal failure if untreated.
A client with Crohn's disease requires TPN to provide adequate nutrition. The nurse finds the TPN bag empty. What fluid would the nurse select to hang until another bag is prepared in the pharmacy?
- A. Lactated Ringers
- B. Normal saline
- C. D10W
- D. Normosol R
Correct Answer: C
Rationale: D10W provides dextrose to prevent hypoglycemia, a risk when TPN (high in glucose) is abruptly stopped. Saline or other fluids don't provide necessary glucose.
The physician has ordered an infusion of Osmitrol (mannitol) for a client with increased intracranial pressure. Which finding indicates the direct effectiveness of the drug?
- A. Increased pulse rate
- B. Increased urinary output
- C. Decreased diastolic blood pressure
- D. Increased pupil size
Correct Answer: B
Rationale: Mannitol is an osmotic diuretic that reduces intracranial pressure by increasing urinary output, drawing fluid out of the brain tissue.
The nurse is caring for a client who is postoperative day 2 following a total knee replacement. The client reports pain at the surgical site and has a temperature of 100.8°F (38.2°C). Which of the following actions should the nurse take FIRST?
- A. Administer an analgesic as ordered.
- B. Notify the physician.
- C. Apply a cold pack to the surgical site.
- D. Assess the surgical site for signs of infection.
Correct Answer: D
Rationale: assessing the surgical site for signs of infection is the first step to determine the cause of the fever and pain