Nokea
A client has developed a hospital-acquired pneumonia. When preparing to administer cephalexin (Keflex) 500 mg, the nurse notices that the pharmacy sent cefazolin (Kefzol). What should the nurse do? Select all that apply.
- A. Administer the cefazolin (Kefzol).
- B. Verify the medication order as written by the physician.
- C. Contact the pharmacy and speak to a pharmacist.
- D. Request that cephalexin (Keflex) be sent promptly.
- E. Return the cefazolin (Kefzol) to the pharmacy.
Correct Answer: B,C,D,E
Rationale: The nurse should verify the order (B), contact the pharmacy (C), request the correct medication (D), and return the incorrect drug (E). Administering cefazolin (A) risks a medication error.
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A client expresses concern about how a hypophysectomy will affect his sexual function. Which of the following statements provides the most accurate information about the physiologic effects of hypophysectomy?
- A. Removing the source of excess hormone should restore the client's libido, erectile function, and fertility.'
- B. Potency will be restored, but the client will remain infertile.'
- C. Fertility will be restored, but impotence and decreased libido will persist.'
- D. Exogenous hormones will be needed to restore erectile function after the adenoma is removed.'
Correct Answer: D
Rationale: Hypophysectomy may disrupt pituitary hormone production, including those affecting sexual function. Exogenous hormones (e.g., testosterone) are often needed to restore erectile function.
When assessing a client for early septic shock, the nurse observes for which of the following?
- A. Cool, clammy skin.
- B. Warm, flushed skin.
- C. Decreased systolic blood pressure.
- D. Hemorrhage.
Correct Answer: B
Rationale: Early septic shock is characterized by vasodilation and increased cardiac output, leading to warm, flushed skin. Cool, clammy skin and decreased blood pressure occur in later stages, and hemorrhage is not a feature of septic shock.
The nurse learns that a client who is scheduled for a tonsillectomy has been taking 40 mg of oral prednisone daily for the last week for poison ivy on his leg. What is the nurse's best action?
- A. Document the prednisone with current medications.
- B. Notify the surgeon of the poison ivy.
- C. Notify the anesthesiologist of the prednisone administration.
- D. Send the client to surgery.
Correct Answer: C
Rationale: Prednisone use affects adrenal function and stress response, increasing risks during anesthesia. Notifying the anesthesiologist ensures proper perioperative management, such as stress-dose steroids.
The nurse is caring for an older adult in the emergency department with moderate hypothermia. Which of the following actions should the nurse take? Select all that apply.
- A. Apply external heat with a heating blanket to the client's trunk.
- B. Actively rewarm the extremities first, followed by the client's trunk.
- C. Use extracorporeal rewarming methods such as cardiopulmonary bypass or hemodialysis.
- D. Monitor for fluid, electrolyte, and metabolic abnormalities.
- E. Administer ordered medications at spaced longer intervals.
- F. Administer room temperature intravenous (IV) fluids for core rewarming.
Correct Answer: A,D,F
Rationale: Applying heat to the trunk (A), monitoring electrolytes (D), and using room-temperature IV fluids (F) are appropriate for moderate hypothermia. Rewarming extremities first (B) risks core afterdrop, extracorporeal methods (C) are for severe cases, and altering medication intervals (E) lacks evidence.
The family members caring for a 72-year-old client who is near death from colon cancer are concerned about dehydration. What should the nurse tell them about dehydration at end of life?
- A. The physician will make the decision regarding hydration therapy.
- B. Dehydration may prolong the dying process.
- C. Hydration is used only in extreme situations of dehydration.
- D. Dehydration is expected during the dying process.
Correct Answer: D
Rationale: Dehydration is a natural part of the dying process and is often not treated aggressively in hospice care, as it may not cause discomfort and can reduce symptoms like edema.