Nokea
A client in labor has an order for Demerol (meperidine) 75 mg. IM to be administered 10 minutes before delivery. The nurse should:
- A. Wait until the client is placed on the delivery table and administer the medication
- B. Question the order
- C. Give the medication IM during the delivery to prevent pain from the episiotomy
- D. Give the medication as ordered
Correct Answer: B
Rationale: Administering meperidine 10 minutes before delivery risks neonatal respiratory depression, so the nurse should question the order.
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The nurse administers a dose of acetaminophen to the wrong client. Which of the following actions is the most appropriate after notifying the physician?
- A. Notify her supervisor and complete an incident report.
- B. Ask the physician for an order of acetaminophen to cover the inadvertent administration.
- C. Take no further action because acetaminophen is relatively benign.
- D. Document in the client's record that an error in drug administration occurred.
Correct Answer: A
Rationale: Medication errors require notifying the supervisor and completing an incident report (A) to ensure proper follow-up and system improvements. Retroactively obtaining an order (B) is unethical, assuming acetaminophen is benign (C) is unsafe, and documenting the error in the client's record (D) is inappropriate.
The nurse enters the client's room and smells cigarette smoke. When confronted, the client says, 'I only smoked one cigarette because I was having a bad craving.' Which action by the nurse is most appropriate?
- A. escort the client outside to smoke
- B. call the health care provider to obtain an order for a nicotine patch
- C. remind the client that oxygen is in use and smoking is banned in the facility
- D. tell the client that if he continues to smoke in the room, he will be discharged from the hospital
Correct Answer: C
Rationale: Reminding the client of the danger of smoking near oxygen and hospital policy addresses safety and compliance immediately.
The client's intravenous (IV) line has a gauze pad wrapped around the IV catheter at the insertion site and a transparent dressing over the gauze dressing. How long after application should the nurse change the dressing?
- A. At the normal rotation time for the IV.
- B. When the transparent dressing loosens.
- C. In 48 hours.
- D. In 24 hours.
Correct Answer: B
Rationale: Transparent dressings should be changed when they loosen (B) or per facility policy (typically every 5-7 days unless soiled or loose). Fixed intervals (C, D) or IV rotation (A) do not apply directly.
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.
After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions would be MOST appropriate?
- A. Irrigate the nasogastric tube with distilled water.
- B. Aspirate the gastric contents with a syringe.
- C. Administer an antiemetic medicine.
- D. Insert a new nasogastric tube.
Correct Answer: B
Rationale: to confirm placement, nurse should aspirate and test the pH of the aspirate, results should be 0-4