Nokea
A client receiving IV antibiotics for sepsis reports itching and has a rash on the chest. What is the nurse's first action?
- A. Administer an antihistamine as prescribed.
- B. Stop the infusion and notify the healthcare provider.
- C. Slow the infusion rate and monitor the client.
- D. Administer epinephrine subcutaneously.
Correct Answer: B
Rationale: The correct action for the nurse to take first when a client receiving IV antibiotics for sepsis reports itching and a rash on the chest is to stop the infusion and notify the healthcare provider. This is crucial in preventing the allergic reaction from worsening. Administering an antihistamine (choice A) may address the symptoms but does not address the primary concern of stopping the infusion. Slowing the infusion rate and monitoring the client (choice C) may not be sufficient if the reaction is severe. Administering epinephrine subcutaneously (choice D) is not the first-line intervention for this situation.
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A client with liver cirrhosis is receiving lactulose for hepatic encephalopathy. Which finding indicates the medication is effective?
- A. The client's level of consciousness improves.
- B. The client's ammonia level decreases.
- C. The client has three bowel movements daily.
- D. The client's liver enzymes return to normal.
Correct Answer: B
Rationale: The correct answer is B: "The client's ammonia level decreases." In hepatic encephalopathy, elevated ammonia levels contribute to neurological symptoms. Lactulose works by promoting the excretion of ammonia in the stool, leading to decreased serum ammonia levels. Therefore, a decrease in ammonia levels indicates that lactulose is effectively reducing ammonia buildup, improving hepatic encephalopathy symptoms. Choices A, C, and D are incorrect because improvement in level of consciousness, bowel movements, or normalization of liver enzymes may not directly reflect the effectiveness of lactulose in reducing ammonia levels and improving hepatic encephalopathy.
Why is it important for the healthcare provider to monitor blood pressure in clients receiving antipsychotic drugs?
- A. Orthostatic hypotension is a common side effect.
- B. Most antipsychotic drugs cause elevated blood pressure.
- C. This provides information on the amount of sodium allowed in the diet.
- D. It will indicate the need to institute antiparkinsonian drugs.
Correct Answer: A
Rationale: Corrected Question: Monitoring blood pressure in clients receiving antipsychotic drugs is crucial because orthostatic hypotension is a common side effect. Orthostatic hypotension can lead to a sudden drop in blood pressure upon standing, increasing the risk of falls and related injuries. Therefore, regular blood pressure monitoring helps healthcare providers detect and manage this potential side effect.
Incorrect Choices Rationale:
- Choice B is incorrect because while antipsychotic drugs can have various side effects, causing elevated blood pressure is not a common effect associated with them.
- Choice C is unrelated to blood pressure monitoring in clients receiving antipsychotic drugs. Monitoring blood pressure in this context aims to detect and manage side effects of the medication, not to assess sodium intake.
- Choice D is incorrect as monitoring blood pressure in clients receiving antipsychotic drugs is primarily aimed at detecting orthostatic hypotension, not as an indicator for instituting antiparkinsonian drugs.
The healthcare worker is wearing PPE while caring for a client. When exiting the room, which PPE should be removed first?
- A. Gloves
- B. Face shield
- C. Mask
- D. Gown
Correct Answer: A
Rationale: Gloves should be removed first as they are most likely to be contaminated. This is followed by the gown, then face shield, and mask. Correct removal sequence helps prevent contamination. Removing gloves first reduces the risk of transferring pathogens from the gloves to other PPE or surfaces. Face shield and mask should be removed last as they protect mucous membranes from exposure to contaminants. Removing PPE in the correct sequence is crucial in preventing the spread of infections.
An adolescent client with meningococcal meningitis is receiving a continuous IV infusion of penicillin G. How many mL/hour should the nurse program the infusion pump to deliver?
- A. 83
- B. 85
- C. 87
- D. 90
Correct Answer: A
Rationale: The correct answer is A: 83. The pharmacy provided the infusion at 10 million units per liter, which requires a rate of 83 mL/hour. To calculate this, multiply the dosage by the volume of the IV solution and divide by the concentration of the IV solution in million units: 10 million units per liter x 8.3 L = 83 mL/hour. Choices B, C, and D are incorrect as they do not align with the calculation based on the given information.
The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250, and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern?
- A. Diminished bowel sounds
- B. Loss of appetite
- C. A cold, pale lower leg
- D. Tachypnea
Correct Answer: C
Rationale: A cold, pale lower leg is cause for the most concern as it could indicate compromised blood circulation, potentially leading to serious complications like ischemia or thrombosis. Diminished bowel sounds, loss of appetite, and tachypnea are not directly related to the client's condition in atrial fibrillation and the heart rate discrepancy.