Nokea
A client is receiving IV potassium. The IV pump displays an occlusion alarm. The tubing is free of occlusions, and the IV flushes easily without symptoms of infiltration. Which action should the nurse take next?
- A. Discard potassium and document administration of a partial dose
- B. Exchange the IV pump with a different one
- C. Insert a new IV catheter in a different location
- D. Remove the pump and administer medication by gravity drip
Correct Answer: B
Rationale: An occlusion alarm with patent tubing suggests a pump malfunction. Exchanging the pump (B) ensures safe delivery. Discarding (A) is unnecessary, a new catheter (C) is not indicated, and gravity drip (D) risks rapid infusion.
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While caring for a woman who delivered a healthy term infant six hours ago, the nurse notes that the fundus is soft, 2 cm above the umbilicus, and off to the left. The lochia is red. The nurse suspects that the client has which problem?
- A. Retained placental fragments
- B. Perineal laceration
- C. Urinary retention
- D. Normal involution
Correct Answer: C
Rationale: A soft, displaced fundus suggests urinary retention, causing bladder pressure on the uterus. Normal involution shows a firm, midline fundus; fragments or lacerations present differently.
The nurse is observing a staff member preparing regular insulin and NPH insulin in 1 syringe. The nurse should intervene if the staff member is observed
- A. Drawing up the NPH insulin after drawing up the regular insulin
- B. Injecting air into the regular insulin vial after injecting air into the NPH insulin vial
- C. Allowing the tip of the needle to touch the NPH insulin vial while injecting air into the vial
- D. cleaning the tops of both insulin vials with an alcohol swab prior to inserting the needle
Correct Answer: A
Rationale: When mixing regular and NPH insulin, regular (clear) insulin is drawn first to prevent contamination with NPH (cloudy) insulin, which could alter its action. Drawing NPH after regular (A) is incorrect and requires intervention. Injecting air into vials (B) follows the same order (NPH then regular), which is correct. Needle contact with the vial (C) is poor technique but less critical than incorrect insulin order.
The nurse is preparing a client for a magnetic resonance cholangiopancreatography. Which statements by the client would require the nurse to obtain further assessment data? Select all that apply.
- A. I ate lunch about 4 or 5 hours ago.
- B. I got a rash the last time I had IV contrast.
- C. I had my last period 6 weeks ago.
- D. I have a hearing aid implanted in my ear.
- E. I smoked a cigarette about an hour ago.
Correct Answer: B,C,D
Rationale: A contrast allergy rash (B) requires premedication or alternative imaging. A possible pregnancy (C) needs confirmation due to MRI risks. A hearing aid implant (D) may be MRI-incompatible. Recent eating (A) is less critical unless sedation is planned, and smoking (E) is irrelevant.
The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse would be appropriate?
- A. Schedule the therapy thirty minutes after meals
- B. Teach the child not to cough during the treatment
- C. Continue the percussion to the rib cage area
- D. Place the child in a prone position for the therapy
Correct Answer: C
Rationale: Continue the percussion to the rib cage area. Percussion should target the rib cage to mobilize secretions effectively.
The nurse is caring for a client with suspected colorectal cancer. Which of the following findings would support a diagnosis of colorectal cancer? Select all that apply.
- A. Fatigue
- B. Blood in the stool
- C. Change in bowel habits
- D. Unintentional weight loss
- E. Elevated hemoglobin level
Correct Answer: A,B,C,D
Rationale: Colorectal cancer often presents with fatigue (A) due to anemia or systemic effects, blood in the stool (B) from tumor bleeding, changes in bowel habits (C) like diarrhea or constipation, and unintentional weight loss (D) from malignancy-related cachexia. Elevated hemoglobin (E) is unlikely, as anemia is more common due to chronic blood loss.