Nokea
A 6-year-old child is seen in the emergency room after stepping on a rusty nail. He has received no immunizations. What should the nurse expect to give him immediately to prevent a tetanus infection?
- A. Tetanus toxoid
- B. DTaP
- C. Immune serum globulin
- D. Penicillin
Correct Answer: C
Rationale: Immune serum globulin provides immediate passive immunity against tetanus in an unimmunized child.
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A client newly diagnosed with Type I Diabetes Mellitus asks the purpose of the test measuring glycosylated hemoglobin. The nurse should explain that the purpose of this test is to determine:
- A. The presence of anemia often associated with Diabetes
- B. The oxygen carrying capacity of the client's red cells
- C. The average blood glucose for the past 2-3 months
- D. The client's risk for cardiac complications
Correct Answer: C
Rationale: The average blood glucose for the past 2-3 months. By testing the portion of the hemoglobin that absorbs glucose, it is possible to determine the average blood glucose over the life span of the red cell, 120 days.
The client received Narcan, a narcotic antagonist, following a colonoscopy. Which action by the nurse has the highest priority?
- A. Document the occurrence in the nurse's notes.
- B. Prepare to administer narcotic medication IV.
- C. Administer oxygen via nasal cannula.
- D. Assess the client every 15 to 30 minutes.
Correct Answer: D
Rationale: Narcan reverses opioids but has a short half-life; frequent assessment (15–30 min) monitors for re-sedation or respiratory depression, the priority.
The male client with a chronic urinary tract infection is prescribed trimethoprim-sulfamethoxazole (Bactrim). Which statement indicates the client needs more teaching?
- A. I will drink six (6) to eight (8) glasses of water a day.
- B. I am going to have to take this medication forever.
- C. I can stop taking this medication if there is no more burning.
- D. I may get diarrhea with this medication, but I can take Imodium.
Correct Answer: C
Rationale: Stopping Bactrim when symptoms resolve risks incomplete treatment and resistance; full course is needed. Hydration, duration, and diarrhea management are correct.
A nurse is caring for a client who is receiving methyldopa hydrochloride (Aldomet) intravenously. Which of the following assessment findings would indicate to the nurse that the client may be having an adverse reaction to the medication?
- A. Headache
- B. Mood changes
- C. Hyperkalemia
- D. Palpitations
Correct Answer: B
Rationale: Mood changes. The nurse should assess the client for alterations in mental status such as mood changes. These symptoms should be reported promptly.
The client in the intensive care department is receiving 2 mcg/kg/min of dopamine, an inotropic vasopressor. Which intervention should the nurse include in the plan of care?
- A. Monitor the client's blood pressure every two (2) hours.
- B. Assess the client's peripheral pulses every shift.
- C. Use a urometer to assess hourly output.
- D. Ensure the IV tubing is not exposed to the light.
Correct Answer: C
Rationale: Dopamine affects renal perfusion; hourly urine output via urometer monitors efficacy and prevents toxicity. BP, pulses, or light exposure are less critical.