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
You may also like to solve these questions
An elderly man is admitted to an inpatient psychiatric unit with an initial diagnosis of psychotic depression. The INITIAL nursing priority is to
- A. clarify perceptual distortions.
- B. establish reality orientation.
- C. ensure client and milieu safety.
- D. increase self-esteem.
Correct Answer: C
Rationale: initial nursing priority for all psychiatric patients is to ensure their safety and the safety of all members of the milieu
A 57-year-old man admitted with metastatic cancer has been receiving chemotherapy for 3 months. His lab values include: RBC 3.8 million/mm³, WBC 2,000/mm³, Hgb 9.3 g/dL, platelets 50,000/mm³. Which of the following nursing diagnoses is MOST appropriate for this patient?
- A. Decreased cardiac output.
- B. Ineffective thermoregulation.
- C. Risk for injury.
- D. Ineffective airway clearance.
Correct Answer: C
Rationale: due to low platelet count, normal platelets 150,000-400,000/mm³, decrease causes problems with blood clotting
The daughter of a 70-year-old patient with cancer asks the nurse, 'Do you believe in euthanasia?' Which of the following responses by the nurse is BEST?
- A. I think that each person has to decide this issue for herself.
- B. My religion is opposed to euthanasia.
- C. What are your thoughts about euthanasia?
- D. Did you see the TV program about euthanasia last night?
Correct Answer: C
Rationale: open-ended question, allows client to verbalize
A five-year-old is scheduled for a lumbar puncture (LP). Which of the following nursing actions would BEST prepare the child for the procedure?
- A. Explain the procedure in detail.
- B. Show a video of the procedure.
- C. Do a mock run-through of the procedure.
- D. Answer all questions simply and honestly.
Correct Answer: C
Rationale: excellent method to use with a child because it incorporates actually 'feeling' many aspects of the procedure as they are explained
The nurse is caring for a client who is receiving IV fluids at 150 mL/hour. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 140/90 mmHg.
- B. Heart rate of 90 bpm.
- C. Crackles in the lung bases.
- D. Urine output of 100 mL/hour.
Correct Answer: C
Rationale: Crackles in the lung bases suggest fluid overload, a serious complication of IV fluids, potentially leading to pulmonary edema. Options A, B, and D are normal or less concerning: blood pressure 140/90 mmHg and heart rate 90 bpm are stable, and urine output 100 mL/hour is adequate.