Nokea
A client is to be discharged with a prescription for lactulose (Cephulac). The nurse teaches the client and the client's spouse how to administer this medication. Which of the following statements would indicate that the client has understood the information?
- A. I'll take it with Maalox.'
- B. I'll mix it with apple juice.'
- C. I'll take it with a laxative.'
- D. I'll mix the crushed tablets in some gelatin.'
Correct Answer: B
Rationale: Mixing lactulose with apple juice (B) improves palatability. Maalox (A) is unrelated, additional laxatives (C) are unnecessary, and lactulose is a liquid, not a tablet (D).
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A 58-year-old client with pancreatic cancer, who has been bed-bound for 3 weeks, has just returned from having a left subclavian, long-term, tunneled catheter inserted for administration of analgesics. The nurse has not yet received radiographic results for confirmation of placement. The client becomes diaphoretic and complains of chest pain radiating to the middle of his back. Physical assessment reveals tachycardia and absent breath sounds in the left lung. The nurse should further assess the client for:
- A. An air embolus.
- B. A pneumothorax.
- C. A pulmonary embolus.
- D. A myocardial infarction.
Correct Answer: B
Rationale: Absent breath sounds, chest pain, and tachycardia post-catheter insertion suggest a pneumothorax, a known complication of subclavian catheter placement, requiring urgent assessment.
A client with acute renal failure reports shortness of breath. The nurse should:
- A. Administer oxygen.
- B. Increase fluid intake.
- C. Check lung sounds.
- D. Encourage coughing.
Correct Answer: C
Rationale: Shortness of breath may indicate fluid overload; lung sounds assess for pulmonary edema.
The nurse is preparing to administer a medication to a client with a history of Clostridium difficile infection. Which precaution is most important?
- A. Wear a face mask during administration.
- B. Use a dedicated stethoscope for the client.
- C. Administer the medication in a private room.
- D. Clean the medication cart with alcohol wipes.
Correct Answer: B
Rationale: Using a dedicated stethoscope for a client with C. difficile prevents cross-contamination, as the infection spreads via contact with contaminated surfaces. A face mask is unnecessary, a private room is ideal but not always required, and alcohol wipes are ineffective against C. difficile spores. CN: Safety and infection control; CL: Synthesize
The nurse is reviewing the postoperative orders (see chart) just written by a physician for a client with insulin-dependent diabetes who has returned to the surgery floor from the recovery. The client has pain of 5 on a scale of 1 to 10. The hand-off report from the nurse in the recovery room indicated that the vital signs have been stable for the last 30 minutes. After obtaining the client's glucose level, the nurse should do which of the following first?
- A. Administer the morphine.
- B. Contact the physician to report the glucose level and rewrite the insulin order.
- C. Administer oxygen per nasal cannula at 2 L/minute.
- D. Take the vital signs.
Correct Answer: B
Rationale: The glucose level must be assessed to determine if insulin is safe to administer, as hypoglycemia could worsen with insulin. Contacting the physician ensures appropriate insulin dosing.
A client who is taking Bufferin Arthritis Strength caplets develops prolonged bleeding from a superficial skin injury on the forearm. The nurse should tell the client to do which of the following first?
- A. Place the forearm under a running stream of lukewarm water.
- B. Pat the injury with a dry washcloth.
- C. Wrap the entire forearm from the wrist to the elbow.
- D. Apply an ice pack for 20 minutes.
Correct Answer: C
Rationale: Bufferin (aspirin) impairs platelet function, prolonging bleeding. The first action is to apply pressure by wrapping the forearm to control bleeding. Running water or patting may not provide sufficient pressure, and ice is a secondary measure after bleeding is controlled.