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A client receives the influenza vaccine in a clinic. Within 15 minutes after the immunization, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. What should be the first action in the sequence of care for this client?
- A. Maintain the airway
- B. Administer epinephrine 1:1000 as ordered
- C. Monitor for hypotension with shock
- D. Administer diphenhydramine as ordered
Correct Answer: B
Rationale: In the scenario described, the client is experiencing symptoms of an anaphylactic reaction, a severe allergic response. The priority action in an anaphylactic reaction is to administer epinephrine. Epinephrine helps counteract the severe allergic response, improves breathing difficulties, and maintains airway and circulation. Administering epinephrine takes precedence to stabilize the client's condition. Options A, C, and D may be necessary in the management of anaphylaxis, but the immediate priority is to administer epinephrine to address the life-threatening symptoms.
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A client with an aggressive form of prostate cancer declines to discuss concerns after the provider briefly discusses treatment options and leaves the room. Which of the following statements should the nurse make?
- A. "I am available to talk if you should change your mind."
- B. "I understand you do not want to discuss it further."
- C. "You should talk to the provider if you have more questions."
- D. "I will be back later to discuss your concerns."
Correct Answer: A
Rationale: The nurse should offer support without pressuring the client. Stating, "I am available to talk if you should change your mind," acknowledges the client's decision while leaving the door open for future discussions. Choice B is incorrect as it assumes the client's decision is final without offering further support. Choice C directs the client back to the provider without addressing the nurse's availability. Choice D commits to a future discussion without considering the client's current preference.
When entering the room of an adult male, the nurse finds that the client is very anxious. Before providing care, what action should the nurse take?
- A. Divert the client's attention
- B. Call for additional help from staff
- C. Document the planned action
- D. Re-assess the client's situation
Correct Answer: D
Rationale: Re-assessing the client's situation before providing care is the most appropriate action in this scenario. By re-evaluating the client, the nurse can better understand the cause of the anxiety and tailor the care accordingly. Diverting the client's attention (Choice A) may not address the underlying issue causing anxiety. Calling for additional help (Choice B) is not the initial step required unless there is an urgent need. Documenting the planned action (Choice C) should come after reassessing the client to ensure accuracy and relevance.
When parents call the emergency room to report that a toddler has swallowed drain cleaner, the nurse instructs them to call for emergency transport to the hospital. While waiting for an ambulance, what substance should the nurse suggest the parents give the child sips of?
- A. Tea
- B. Water
- C. Milk
- D. Soda
Correct Answer: B
Rationale: The correct answer is B: Water. Giving sips of water can help dilute the drain cleaner while waiting for emergency transport, which may help reduce the potential harm caused by the ingestion. Choices A, C, and D are incorrect because tea, milk, and soda can interact with the chemicals in the drain cleaner or increase the risk of vomiting, which is not recommended in this situation.
The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the LPN/LVN administer?
- A. 0.5 ml
- B. 1 ml
- C. 1.5 ml
- D. 2 ml
Correct Answer: A
Rationale: To administer 4 mg of morphine, as prescribed, the LPN/LVN needs to calculate the correct volume based on the concentration provided (8 mg per ml). Since the desired dose is 4 mg, half of 8 mg (0.5 ml) is required to administer the correct amount. Therefore, the correct answer is 0.5 ml. Choices B, C, and D are incorrect as they would either underdose or overdose the patient.
A client is 1-day postoperative and reports a pain level of 10 on a scale of 0 to 10. After reviewing the client's medication administration record, which of the following medications should be administered?
- A. Meperidine 75 mg IM
- B. Fentanyl 50 mcg/hr transdermal patch
- C. Morphine 2 mg IV
- D. Oxycodone 10 mg PO
Correct Answer: C
Rationale: Morphine IV is the most appropriate choice for severe postoperative pain due to its rapid onset and effectiveness. Meperidine is not preferred due to its potential side effects, and fentanyl patches are typically used for chronic pain, not acute postoperative pain. Oxycodone taken orally is not ideal for providing immediate relief in this situation.