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A client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate action for the nurse to take?
- A. Call security for assistance and prepare to sedate the client.
- B. Tell the client to calm down and ask him if he would like to play cards.
- C. Tell the client that if he continues his behavior he will be punished.
- D. Leave the client alone until he calms down.
Correct Answer: A
Rationale: Calling security and preparing for sedation ensures the safety of the client, other patients, and staff during an uncontrolled rage.
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The physician has ordered aerosol treatments, chest percussion, and postural drainage for a client with cystic fibrosis. The nurse recognizes that the combination of therapies is to:
- A. Decrease respiratory effort and mucous production
- B. Increase efficiency of the diaphragm and gas exchange
- C. Dilate the bronchioles and help remove secretions
- D. Stimulate coughing and oxygen consumption
Correct Answer: C
Rationale: These therapies aim to dilate airways (via aerosols) and mobilize thick mucus (via percussion and drainage) to improve breathing in cystic fibrosis.
The physician has ordered Amoxil (amoxicillin) 500 mg capsules for a client with esophageal varices. The nurse can best care for the client's needs by:
- A. Giving the medication as ordered
- B. Providing extra water with the medication
- C. Giving the medication with an antacid
- D. Requesting an alternate form of the medication
Correct Answer: D
Rationale: Capsules can be difficult to swallow and may lodge in esophageal varices, increasing the risk of bleeding. An alternate form, such as a liquid, is safer.
The nurse is performing an admission for a client recovering from a stroke. Medication history reveals the drug clopidogrel (Plavix). Which clinical manifestation alerts the nurse to an adverse effect of this drug?
- A. Epistaxis
- B. Abdominal distention
- C. Nausea
- D. Hyperactivity
Correct Answer: A
Rationale: Clopidogrel, an antiplatelet drug, increases bleeding risk. Epistaxis (nosebleed) is a significant adverse effect requiring attention.
A primigravida with(choices truncated due to document error; assuming standard options for context) diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor's order should the nurse question?
- A. Magnesium sulfate 4 gm (25%) IV
- B. Brethine 10 mcg IV
- C. Stadol 1 mg IV push every 4 hours as needed prn for pain
- D. Ancef 2 gm IVPB every 6 hours
Correct Answer: B
Rationale: Brethine (terbutaline) is a tocolytic that can exacerbate maternal diabetes by causing hyperglycemia, so this order should be questioned in a diabetic primigravida.
The nurse is serving on the performance improvement committee, which has agreed to some changes in procedures on the basis of evidence-based research. If the committee wants to convince staff members to comply with the changes, which of the following actions should the committee carry out first?
- A. Identify and gain support of key staff.
- B. Explain the consequences of failure to comply.
- C. Determine a reward system for compliance.
- D. Clearly outline expectations in written format.
Correct Answer: A
Rationale: Gaining key staff support (A) builds buy-in and facilitates change adoption. Consequences (B), rewards (C), or written expectations (D) follow.