Nokea
A client with iron-deficiency anemia is taking an oral iron supplement. The nurse should tell the client to take the medication with:
- A. Orange juice
- B. Water only
- C. Milk
- D. Apple juice
Correct Answer: A
Rationale: Orange juice, rich in vitamin C, enhances the absorption of oral iron supplements.
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The nurse is assigning staff for the day. Which client should be assigned to the nursing assistant?
- A. A 5-month-old with bronchiolitis
- B. A 10-year-old 2-day post-appendectomy
- C. A 2-year-old with periorbital cellulitis
- D. A 1-year-old with a fractured tibia
Correct Answer: B
Rationale: A stable post-appendectomy patient requires basic care, suitable for a nursing assistant.
The physician has ordered Claforan (cefotaxime) 1 g every 6 hours. The pharmacy sends the medication premixed in 100 mL of D5W with instructions to infuse the medication over 1 hour. The IV set delivers 20 drops per milliliter. The nurse should set the IV rate at:
- A. 50 drops per minute
- B. 33 drops per minute
- C. 25 drops per minute
- D. 12 drops per nursing diagnosis.
- E. 33 drops per minute
- F. The IV rate is calculated as: 100 mL over 60 minutes with 20 drops/mL = (100 × 20) ÷ 60 = 33.33 drops/min, rounded to 33 drops/min.
Correct Answer:
Rationale:
Nimotop (Nimodipine) is ordered for the client with a ruptured cerebral aneurysm. The nurse recognizes that the desired effect of this drug is to:
- A. Prevent the influx of calcium into cells
- B. Restore the client's blood pressure to a normal reading
- C. Prevent the inflammatory process
- D. Dissolve the clot that has formed
Correct Answer: A
Rationale: Nimodipine is a calcium channel blocker that prevents calcium influx into vascular smooth muscle cells, reducing vasospasm in cerebral arteries, which is critical in managing ruptured cerebral aneurysms.
The nurse is assigned to work with the parents of a retarded child. Which of the following should the nurse include in the care plan for the parents?
- A. Interpret the grieving process for the parents.
- B. Discuss the reality of institutional placement.
- C. Assist the parents in making decisions and long-term plans for the child.
- D. Perform a family assessment to assist in the planning of intervention.
Correct Answer: D
Rationale: assessment, this will help the nurse to know where the family is in regard to grieving, coping, etc.
An RN is in charge of a team on a medical/surgical unit that includes an LPN. The RN understands that which of the following is an activity that falls outside the scope of practice of an LPN?
- A. administer oral medications to a client
- B. insert a nasogastric tube
- C. care for a patient with a tracheostomy
- D. develop a nursing care plan
Correct Answer: D
Rationale: Developing a nursing care plan requires assessment and critical thinking, which are RN responsibilities. LPNs can perform the other tasks within their scope.