Nokea
A client is admitted to a medical unit with the diagnosis of gastritis and chronic heavy alcohol abuse. What should the nurse administer to prevent the development of Wernicke's syndrome?
- A. Lorazepam (Ativan)
- B. Famotidine (Pepcid)
- C. Thiamine (Vitamin B1)
- D. Atenolol (Tenormin)
Correct Answer: C
Rationale: Thiamine supplementation is critical in preventing Wernicke's syndrome, especially in clients with chronic alcohol use. Wernicke's syndrome is a neurological disorder caused by thiamine deficiency. Lorazepam is a benzodiazepine used for anxiety and not for preventing Wernicke's syndrome. Famotidine is an H2 blocker used to reduce stomach acid production but does not prevent Wernicke's syndrome. Atenolol is a beta-blocker used for hypertension and angina, not for preventing Wernicke's syndrome.
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What information is most important for the nurse to provide to an adolescent female prescribed azithromycin for lower lobe pneumonia and recurrent chlamydia?
- A. Ensure the partner is screened for chlamydia
- B. Report any signs of liver dysfunction immediately
- C. Avoid consuming grapefruit juice while on this medication
- D. Use two forms of contraception while taking this drug
Correct Answer: D
Rationale: The most important information for the nurse to provide to an adolescent female prescribed azithromycin for lower lobe pneumonia and recurrent chlamydia is to use two forms of contraception while taking this drug. Azithromycin can reduce the effectiveness of hormonal contraceptives, increasing the risk of pregnancy. It is crucial to convey this information to prevent unintended pregnancies. Option A is incorrect as the partner should be screened for chlamydia, not HIV, in this case. Option B is not the most important information to provide as liver dysfunction is a rare side effect of azithromycin. Option C is irrelevant as grapefruit juice does not interact with azithromycin. Therefore, the priority information to convey is the importance of using dual contraception to prevent pregnancy.
After a motor vehicle collision, a client is admitted to the medical unit with acute adrenal insufficiency (Addisonian crisis). Which prescription should the nurse implement?
- A. Determine serum glucose levels
- B. Withhold potassium additives to IV fluids
- C. Give IV corticosteroid replacement
- D. Prepare to initiate IV vasopressors
Correct Answer: C
Rationale: In a client with acute adrenal insufficiency (Addisonian crisis) following a motor vehicle collision, the priority intervention is to administer IV corticosteroid replacement. This is crucial to manage the crisis by replacing the deficient cortisol. Determining serum glucose levels (Choice A) may be important but is not the immediate priority in this situation. Withholding potassium additives to IV fluids (Choice B) is not indicated and may exacerbate electrolyte imbalances. Initiating IV vasopressors (Choice D) is not the primary treatment for acute adrenal insufficiency and should be reserved for managing hypotension that is unresponsive to corticosteroid therapy.
A group of nurses implemented a pilot study to evaluate a proposed evidence-based change to providing client care. Evaluation indicates successful outcomes, and the nurses want to integrate the change throughout the facility. Which action should be taken? (Select all that apply)
- A. Invite data review by the quality improvement department
- B. Submit a sentinel event report to the research committee
- C. Propose clinical practice guidelines to the nursing committee
- D. Arrange in-service training through the educational department
Correct Answer: A
Rationale: Inviting data review by the quality improvement department is crucial to ensure the quality and efficacy of the proposed evidence-based change. This step allows for a comprehensive analysis of the data collected during the pilot study. Proposing clinical practice guidelines to the nursing committee is also essential for integrating the successful change into routine practice. In-service training through the educational department will help educate staff and ensure they are proficient in implementing the new practices. Submitting a sentinel event report to the research committee is not necessary in this scenario as the outcomes were successful, and there were no adverse events that would warrant such a report. Choices B, C, and D are not as relevant in this context compared to inviting data review by the quality improvement department, which is a crucial step in ensuring the success of the proposed change.
A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client's plan of care?
- A. Observe for bleeding side effects related to heparin therapy.
- B. Assess blood pressure and heart rate at least every 4 hours.
- C. Measure calf girth to evaluate edema in the affected leg.
- D. Encourage mobilization to prevent pulmonary embolism.
Correct Answer: A
Rationale: The correct answer is to 'Observe for bleeding side effects related to heparin therapy.' This is the most crucial intervention for a client with deep vein thrombosis (DVT) on a heparin protocol. Heparin, being an anticoagulant, increases the risk of bleeding as a side effect. Therefore, close monitoring for signs of bleeding, such as bruising, petechiae, or blood in stool or urine, is essential to prevent severe complications. While assessing blood pressure and heart rate (Choice B) is important, it is not as critical as monitoring for bleeding. Measuring calf girth (Choice C) may help evaluate edema but is not as vital as observing for bleeding complications. Encouraging mobilization (Choice D) is beneficial for preventing complications like pulmonary embolism, but in this scenario, monitoring for bleeding takes precedence due to the immediate risk associated with anticoagulant therapy.
Which techniques should be used to administer an intradermal (ID) injection for a Mantoux test to screen for tuberculosis (TB)? Select all that apply.
- A. Observe for an intradermal bleed after the antigen is injected
- B. Select an ID site using the volar surface of the forearm
- C. Use a 26 or 27-gauge needle with a length of 1/4 to 5/8 inches on a 1 ml calibrated syringe
- D. Ensure that the needle is inserted into the skin with the bevel up
Correct Answer: A
Rationale: Observing for an intradermal bleed after the antigen is injected is a proper technique for an ID injection. This is important to confirm the correct placement of the injection. Choice B is correct because the recommended site for an ID injection for a Mantoux test is the volar surface of the forearm. Choice C is incorrect because the standard needle size for an ID injection is usually 26 or 27 gauge with a length of 1/4 to 5/8 inches, not 25 gauge with a length of 1/2 inch. Choice D is incorrect because the needle should be inserted into the skin with the bevel facing up, not down.