Nokea
A client with MRSA is receiving Vanomycin (Vancocin) IV. If the client experiences 'red man' syndrome, the nurse should:
- A. Slow the infusion and monitor the blood pressure.
- B. Check the client for signs of infection.
- C. Discontinue the medication and document the action.
- D. Continue the infusion because this is a normal reaction.
Correct Answer: A
Rationale: Red man syndrome is caused by rapid vancomycin infusion, leading to histamine release. Slowing the infusion and monitoring blood pressure manage symptoms. It's not normal, and discontinuing is unnecessary.
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The nurse is caring for a client who is postoperative day 1 after a mitral valve replacement. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.8°F (38.2°C).
- B. Heart rate of 90 bpm.
- C. Chest tube drainage of 100 mL/hour.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-valve replacement due to risk of endocarditis, requiring immediate evaluation. Options B, C, and D are expected or normal: heart rate 90 bpm, drainage 100 mL/hour, and blood pressure 130/80 mmHg are stable.
The nurse is teaching a client with a new diagnosis of hypertension about lisinopril (Prinivil). Which of the following instructions should the nurse include?
- A. Take the medication at bedtime.
- B. Report a persistent dry cough.
- C. Stop the medication if blood pressure is normal.
- D. Avoid regular blood pressure checks.
Correct Answer: B
Rationale: A persistent dry cough is a common lisinopril side effect, requiring reporting. Options A, C, and D are incorrect.
The home care nurse is instructing a client recently diagnosed with tuberculosis.
- A. What is the most important instruction for a client with tuberculosis?
- B. During the first two weeks of treatment, the client should cover his mouth and nose when he coughs or sneezes.
- C. It is necessary for the client to wear a mask at all times to prevent transmission of the disease.
- D. The family should support the client to help reduce feeling of low self-esteem and isolation.
- E. The client will be required to take prescribed medication for a duration of 6-9 months.
Correct Answer: D
Rationale: Adherence to a 6-9 month medication regimen is critical to cure tuberculosis and prevent drug resistance. While respiratory precautions, family support, and masks are important, long-term medication compliance is the most essential for treatment success.
A client has returned to the floor from thyroidectomy surgery.
After a client has returned to the floor from thyroidectomy surgery, it is MOST important for the nurse to take which of the following actions?
- A. Monitor vital signs every four hours.
- B. Observe for frequent swallowing.
- C. Monitor for signs of respiratory distress every hour.
- D. Position the client in the supine position.
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Determine what assessment is being made in each answer choice. (1) assessment is not specific to this surgery (2) assessment, method used to monitor for postoperative hemorrhage in a tonsillectomy client (3) correct-assessment, after surgery, swelling can occur, which causes respiratory distress (4) implementation, head of the bed should be elevated
Four clients have signaled with their call bell for the nurse. Who should the nurse observe first?
- A. An adult who needs assistance walking to the bathroom
- B. A postoperative client who is asking for pain medication
- C. An adult who has just been given penicillin
- D. An elderly client who is in a geriatric chair
Correct Answer: C
Rationale: A client recently given penicillin is at risk for an allergic reaction, including anaphylaxis, requiring immediate observation. Bathroom assistance, pain, or chair positioning are less urgent.