Nokea
A medication nurse is supervising a newly hired nurse who is administering pyridostigmine orally to a client diagnosed with myasthenia gravis. Which instruction provided to the client indicates safe practice by the newly hired nurse regarding the administration of this medication?
- A. Take the medication with sips of water.
- B. Lie on the right side after taking the medication.
- C. Hyperextend the neck for 30 seconds before swallowing.
- D. Void within at least 10 minutes before taking the medication.
Correct Answer: A
Rationale: Myasthenia gravis can affect the client's ability to swallow. The primary assessment is to determine the client's ability to swallow. In this situation, there is no reason for the client to lie down to swallow medication or hyperextend the neck. Additionally, lying down could place the client at risk for aspiration. There is no specific reason for the client to void before taking the medication.
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Which statement about automated external defibrillators is accurate?
- A. They are not as effective as regular defibrillators.
- B. They are replacing regular defibrillators in acute care settings.
- C. Only BLS certified people in the community should use them.
- D. They can be easily used by people with no healthcare experience.
Correct Answer: D
Rationale: AEDs are designed for use by laypersons with minimal training, making them accessible for public use in emergencies.
A client at 12 weeks' gestation tells the nurse that she is a vegetarian and eats 'lots of rice.' To help meet the client's need for protein during pregnancy, the nurse suggests that the client combine the rice with which of the following?
- A. Beans.
- B. Soy milk.
- C. Yogurt.
- D. Corn.
Correct Answer: A
Rationale: Combining rice with beans provides a complete protein, meeting the increased protein needs during pregnancy.
The nurse is assessing a client with a suspected stroke. Which of the following findings is most indicative of a stroke?
- A. Sudden unilateral weakness.
- B. Gradual onset of headache.
- C. Bilateral leg pain.
- D. Chronic fatigue.
Correct Answer: A
Rationale: Sudden unilateral weakness is a classic sign of stroke due to impaired blood flow to one side of the brain.
The nurse is caring for a client with a history of hyperthyroidism who is prescribed methimazole (Tapazole). The nurse should monitor the client for which of the following adverse effects?
- A. Agranulocytosis.
- B. Hypertension.
- C. Hyperglycemia.
- D. Weight loss.
Correct Answer: A
Rationale: Methimazole can cause agranulocytosis, a serious reduction in white blood cells, requiring monitoring.
A hospice nurse is caring for a client with breast cancer and brain metastasis. The nurse is reviewing the lab report below. According to the information in the chart, what should the nurse do next?
- A. Document these results on the medical record.
- B. Report the elevated potassium level immediately.
- C. Report the elevated calcium level immediately.
- D. Refrain from reporting the results because the client is in hospice care.
Correct Answer: C
Rationale: The normal calcium level is 9.0 to 10.5 mg/dL. Hypercalcemia is commonly seen with malignant disease and metastases. The other laboratory values are normal. Hypercalcemia can be treated with fluids, furosemide (Lasix), or administration of calcitonin. Failure to treat hypercalcemia can cause muscle weakness, changes in level of consciousness, nausea, vomiting, abdominal pain, and dehydration. Although the client is on hospice care, she will still need palliative treatment. Comfort and risk reduction are components of hospice care.