Nokea
A client is being taught how to administer ear drops. Which of the following statements should the nurse identify as an indication that the client understands?
- A. I will straighten my ear canal by pulling my ear down and back.
- B. I will gently apply pressure with my finger to the front part of my ear after putting in the drops.
- C. I will insert the nozzle of the ear drop bottle snugly into my ear before squeezing the drops in.
- D. After the drops are in, I will place a cotton ball all the way into my ear canal.
Correct Answer: B
Rationale: The correct answer is B. Gently applying pressure to the front part of the ear after administering drops helps with absorption. Pulling the ear down and back is a correct technique for adults. Snugly inserting the nozzle of the ear drop bottle or placing a cotton ball all the way into the ear canal is unnecessary and can potentially cause harm or discomfort. Therefore, choices A, C, and D are incorrect.
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The client is advised to take dexamethasone (Decadron) with food or milk. What is the physiological basis for this advice?
- A. Inhibits pepsin production
- B. Stimulates hydrochloric acid production
- C. Delays stomach emptying time
- D. Reduces hydrochloric acid production
Correct Answer: B
Rationale: The correct answer is B: Stimulates hydrochloric acid production. Dexamethasone can stimulate the production of hydrochloric acid in the stomach, which may lead to irritation of the stomach lining. Taking dexamethasone with food or milk helps to neutralize or buffer the acid, reducing the risk of stomach irritation. Choice A is incorrect because dexamethasone does not inhibit pepsin production. Choice C is incorrect as dexamethasone does not slow stomach emptying time. Choice D is incorrect as dexamethasone does not reduce hydrochloric acid production.
A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the LPN/LVN to implement?
- A. Contact the healthcare provider and complete a medication variance form.
- B. Administer the Levaquin at 1300 and resume the 0900 schedule the next morning.
- C. Notify the charge nurse and complete an incident report to explain the missed dose.
- D. Give the missed dose at 1300 and change the schedule to administer daily at 1300.
Correct Answer: D
Rationale: The correct intervention is to give the missed dose at 1300 and adjust the schedule to administer daily at 1300. This approach ensures that the client receives the correct total daily dose of levofloxacin. Choice A is incorrect because contacting the healthcare provider and completing a medication variance form would not address the immediate need to administer the missed dose. Choice B is incorrect as administering the missed dose at 1300 and resuming the 0900 schedule the next morning would result in a missed dose for that day. Choice C is not the best course of action as notifying the charge nurse and completing an incident report should come after addressing the immediate need to administer the missed dose and adjusting the schedule for future doses.
A healthcare professional is preparing to admit a client suspected of having pulmonary tuberculosis. Which of the following actions should the healthcare professional plan to perform first?
- A. Implement airborne precautions.
- B. Obtain a sputum culture.
- C. Administer antituberculosis medications.
- D. Recommend a screening test for close contacts.
Correct Answer: A
Rationale: The initial priority when admitting a client suspected of having pulmonary tuberculosis is to implement airborne precautions to prevent the spread of the disease. Airborne precautions include wearing a mask and placing the client in a negative pressure room. Obtaining a sputum culture is essential for confirming the diagnosis, but ensuring infection control measures come first to protect others. Administering antituberculosis medications is important but should be initiated after implementing necessary precautions. Recommending a screening test for close contacts is relevant but is a secondary concern compared to immediate infection control measures.
The patient has been in bed for several days and needs to be ambulated. Which action will the nurse take first?
- A. Maintain a narrow base of support.
- B. Dangle the patient at the bedside.
- C. Encourage isometric exercises.
- D. Suggest a high-calcium diet.
Correct Answer: B
Rationale: The correct action the nurse should take first when a patient needs to be mobilized after being in bed for several days is to dangle the patient at the bedside. Dangling at the bedside is the initial step to assess the patient's tolerance to sitting up and moving. It helps prevent orthostatic hypotension and allows the nurse to evaluate the patient's response to upright positioning before attempting further ambulation. Maintaining a narrow base of support (Choice A) is related to assisting with ambulation but is not the first step. Encouraging isometric exercises (Choice C) and suggesting a high-calcium diet (Choice D) are not immediate actions needed to initiate mobilization in this scenario.
A healthcare professional is providing care to a client who has a tracheostomy. Which of the following actions should the professional take to prevent complications?
- A. Clean around the stoma with povidone-iodine.
- B. Maintain sterile technique when performing tracheostomy care.
- C. Use clean technique when suctioning the tracheostomy.
- D. Change tracheostomy ties weekly.
Correct Answer: B
Rationale: Maintaining sterile technique when performing tracheostomy care is essential in preventing infections and complications. Option A is incorrect because povidone-iodine may be too harsh for cleaning around the stoma and can lead to skin irritation. Option C is incorrect because suctioning a tracheostomy should be done using sterile technique to minimize the risk of introducing pathogens. Option D is incorrect as tracheostomy ties need to be changed more frequently, usually every 1-2 days, to prevent skin breakdown and infection.