Nokea
A client has received thrombolytic therapy, and the physician has ordered meperidine (Demerol) IM for pain. Before administering the injection, the nurse should
- A. confirm that all lab work has been completed.
- B. verify the order with the physician.
- C. check the client's PTT.
- D. determine that all of the thrombolytic agent has infused.
Correct Answer: B
Rationale: implementation, complications of thrombolytic therapy include bleeding, which can occur with intramuscular injections; nurse should confer with the physician about the appropriateness of the order
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The nurse is caring for a client with a history of type 2 diabetes who is receiving glipizide (Glucotrol) 5 mg PO daily. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue.
- B. Sweating and shakiness.
- C. Occasional thirst.
- D. Mild headache.
Correct Answer: B
Rationale: Sweating and shakiness indicate hypoglycemia, a serious glipizide side effect. Options A, C, and D are less urgent.
A 5-year-old boy is brought to the emergency room after ingesting a bottle of baby aspirin. The nurse should observe the boy for which of the following signs and symptoms?
- A. Nausea and vertigo.
- B. Epistaxis and paralysis.
- C. Dysrhythmia and hypoventilation.
- D. Tinnitus and gastric distress.
Correct Answer: D
Rationale: symptoms of overdose
The nurse would identify which of the following clients as being at the highest risk for developing a pulmonary embolus?
- A. A 19-year-old four days postpartum with an obstetrical history of placenta previa.
- B. An obese 40-year-old man with multiple pelvic fractures from an auto accident two days ago.
- C. A 65-year-old woman who had a fractured hip repaired 10 days ago and who is in physical therapy daily.
- D. A 22-year-old leukemic client with a platelet count of 120,000/mm³ and a hemoglobin level of 9.0 g.
Correct Answer: B
Rationale: obesity, immobility, and pooling of blood in the pelvic cavity contribute to development of pulmonary emboli
The nurse is caring for a client with a history of anxiety who is receiving lorazepam (Ativan) 0.5 mg PO tid. Which of the following findings should the nurse report immediately?
- A. Mild sedation.
- B. Dry mouth.
- C. Dizziness upon standing.
- D. Insomnia.
Correct Answer: C
Rationale: Dizziness upon standing suggests orthostatic hypotension, a serious lorazepam side effect. Options A, B, and D are common.
A nurse is the first on the scene of a motor vehicle accident. The victim has sucking sounds with respirations at a chest wound site and tracheal deviation toward the uninjured side. Until others arrive, the priority nursing action would be to
- A. loosely cover the wound, preferably with a sterile dressing.
- B. place a sandbag over the wound.
- C. monitor chest wound drainage.
- D. place a firm, airtight, sterile dressing over the wound.
Correct Answer: A
Rationale: implementation, in an open pneumothorax, air enters the pleural cavity through an open wound; placing a sterile dressing loosely over the wound allows air to escape but not reenter the pleural space