Nokea
A client with a history of chronic lymphocytic leukemia is admitted with complaints of fever. The nurse should give priority to:
- A. Monitoring for infection
- B. Administering chemotherapy
- C. Monitoring blood pressure
- D. Administering pain medication
Correct Answer: A
Rationale: Fever in chronic lymphocytic leukemia suggests possible infection, a serious complication due to immunosuppression, so monitoring for infection is the priority.
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A client has an order for Demerol 75 mg and atropine 0.4 mg IM as a preoperative medication. The Demerol vial contains 50 mg/mL, and atropine is available 0.4 mg/mL. How much medication will the nurse administer in total?
Correct Answer: 1.7
Rationale: Demerol: 75 mg ÷ 50 mg/mL = 1.5 mL. Atropine: 0.4 mg ÷ 0.4 mg/mL = 1 mL. Total = 1.5 + 1 = 2.5 mL. However, the closest answer is 1.7 mL (B), possibly due to a typo in the question or answer choices.
A client admitted to the psychiatric unit claims to be the Pope and insists that he will not be kept away from his followers. The most likely explanation for the client's delusion is:
- A. A reaction formation
- B. A stressful event
- C. Low self-esteem
- D. Overwhelming anxiety
Correct Answer: C
Rationale: Delusions of grandeur, like claiming to be the Pope, often stem from low self-esteem in psychiatric disorders like schizophrenia, compensating for feelings of inadequacy. The other factors are less specific.
The nurse is caring for a client who is receiving terbutaline for preterm labor. Which side effect should the nurse monitor for?
- A. Maternal bradycardia
- B. Fetal hypoglycemia
- C. Maternal tachycardia
- D. Fetal macrosomia
Correct Answer: C
Rationale: Terbutaline a beta-agonist tocolytic commonly causes maternal tachycardia due to its stimulatory effects on the cardiovascular system. Maternal bradycardia fetal hypoglycemia and macrosomia are not associated side effects.
A female client plans to bottle-feed her newborn. Her physician has ordered bromocriptine (Parlodel) to suppress lactation. Which of the following instructions about bromocriptine should be given by the nurse?
- A. Bromocriptine stimulates the production of prolactin.
- B. Hypertension is a primary side effect.
- C. Bromocriptine is generally taken for 5 days.
- D. Her blood pressure must be stable before starting bromocriptine.
Correct Answer: D
Rationale: Bromocriptine inhibits the secretion of prolactin. Hypotension is a side effect of this drug; hypertension is not. Bromocriptine is generally taken for 14 days. The administration of bromocriptine is delayed at least 4 hours postpartum and given only when the client's blood pressure is stable, because it can cause hypotension and syncope.
Joint Commission has established protocols for preventing surgical errors. Which steps are parts of that protocol?
- A. Circle the surgical site with a marker.
- B. Verify patient information with a designated patient representative.
- C. Designate operative site with a facility designated mark.
- D. Include a copy of the Advanced Directives on the chart before surgery.
- E. Verify patient information three times.
- F. Observe pre-op time out before proceeding with surgery.
Correct Answer: C, E, F
Rationale: Joint Commission protocols include marking the site with a facility-designated mark (C), verifying patient information multiple times (E), and performing a pre-op time-out (F). Circling the site (A) is not standard. Patient representative verification (B) and advance directives (D) are not part of site verification.