Nokea
A client is admitted complaining of chest pain. Which of the following drug orders should the nurse question?
- A. Nitroglycerin
- B. Ampicillin
- C. Propranolol
- D. Verapamil
Correct Answer: B
Rationale: Ampicillin, an antibiotic, is not indicated for chest pain, which is typically cardiac-related and treated with nitroglycerin, propranolol, or verapamil.
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The nurse is preparing to pull a thin, frail client up in the bed. No one responds to the nurse's call for lifting assistance. Which is the best action by the nurse?
- A. call again and apologize to the client for the wait
- B. stand behind the bed at the client's head, and pull her up gently from her armpits
- C. since the client is small, pull her up in the bed by pulling on the draw sheet, alternating sides
- D. if the client is able to roll and bend her knees, lower the head of the bed and place it in Trendelenburg's position while helping the client bend her knees and push up
Correct Answer: C
Rationale: Using the draw sheet to pull the client up is the safest option to prevent injury to both the client and nurse when assistance is unavailable.
The nurse is preparing the client for surgery. The pre-op medication includes atropine sulfate 0.4 mg, meperidine (Demerol HCl) 50 mg, and promethazine hydrochloride (Phenergan) 25 mg IM. Which action should the nurse do first?
- A. make sure the surgical permit is signed
- B. ask the client to go to the bathroom
- C. explain the purpose of the medication to the client
- D. ask family members to exit the room
Correct Answer: A
Rationale: Ensuring the surgical permit is signed is the priority to confirm informed consent before administering preoperative medications.
A 4-year-old male is admitted to the unit with nephrotic syndrome. He is extremely edematous. To decrease the discomfort associated with scrotal edema, the nurse should:
- A. Apply ice to the scrotum
- B. Elevate the scrotum on a small pillow
- C. Apply heat to the abdominal area
- D. Administer an analgesic
Correct Answer: B
Rationale: Elevating the scrotum reduces edema by promoting fluid drainage, decreasing discomfort.
The nurse is caring for a client with cancer who is exhibiting signs and symptoms that death is near. The client's daughter says that she does not want her mother to receive morphine because it will hasten her death. What response by the nurse is most appropriate?
- A. We always give morphine to clients at the end-of-life stage.
- B. We can give oxygen instead of morphine to help with breathing and distress.
- C. Morphine will reduce anxiety and reduce the sensation of air hunger in your mother.
- D. We will wait until the very end to give the morphine and use nonpharmacologic measures instead.
Correct Answer: C
Rationale: Morphine alleviates air hunger and anxiety in end-of-life care, improving comfort without necessarily hastening death, addressing the daughter’s concerns therapeutically.
The nurse is caring for a client whose native language is Korean; he speaks only a few words of English. The health care provider has determined that the client needs to undergo a coronary artery bypass graft. Which is the appropriate action by the nurse?
- A. ask the client's spouse to give consent for the procedure before explaining it to the client
- B. ask the client's spouse to translate for the health care provider and explain the procedure to the client
- C. communicate with the client by showing pictures of the intended surgery while a family member translates
- D. request a licensed translator to interpret for the health care provider and client during the conversation
Correct Answer: D
Rationale: A licensed translator ensures accurate communication and informed consent, adhering to ethical and legal standards.