Nokea
A mother who is Mexican brings her 2-month-old son to the emergency department with a high fever and possible sepsis. A lumbar puncture is ordered, but the mother will not sign the consent until the father arrives to give permission. The nurse should:
- A. Report this to the social worker
- B. Call Child Protective Services
- C. Wait until the father arrives
- D. Inform the physician that the mother has refused to have the procedure
Correct Answer: C
Rationale: Respecting cultural norms, where the father may be the decision-maker, the nurse should wait for the father to arrive for consent, especially in a non-immediate life-threatening situation. Reporting to social services or claiming refusal is premature without further assessment.
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The nurse is evaluating the laboratory results of a client who was recently admitted to the hospital. Which one of the following results indicates the presence of inflammation?
- A. Decreased sedimentation rate
- B. Thrombocytopenia
- C. Leukocytosis
- D. Erythrocytosis
Correct Answer: C
Rationale: Leukocytosis, an elevated white blood cell count, indicates inflammation or infection. Decreased sedimentation rate, thrombocytopenia, and erythrocytosis are not specific to inflammation.
A client with a history of heart failure is prescribed carvedilol (Coreg). The nurse should instruct the client to:
- A. Monitor blood pressure regularly.
- B. Take the medication with meals.
- C. Avoid potassium-rich foods.
- D. Stop the medication if dizziness occurs.
Correct Answer: A
Rationale: Carvedilol can cause hypotension, requiring regular blood pressure monitoring.
The nurse is working on a birthing unit that has several unlicensed assistive personnel (UAP). The nurse determines that the UAP understands the type of information to report to the nurse when the UAP reports which of the following about one of the clients?
- A. An episode of nausea after administration of an epidural anesthetic.
- B. Contractions 3 minutes apart and lasting 40 seconds.
- C. Scream of spontaneous rupture of the membranes.
- D. Sleeping after administration of I.V. nalbuphine (Nubain).
Correct Answer: A,C
Rationale: Nausea after an epidural and spontaneous rupture of membranes are significant events requiring nurse assessment due to potential complications. Contractions and sleeping are expected findings.
When you are monitoring your client who is now started on an intravenous antibiotic for an infection, you notice that the client is exhibiting signs of anaphylaxis. What is your first priority intervention?
- A. Stop the intravenous flow
- B. Slow down the intravenous flow
- C. Notify the doctor
- D. Begin CPR
Correct Answer: A
Rationale: Stopping the IV flow is the first priority to halt the administration of the allergen causing anaphylaxis, followed by other emergency interventions.
The nurse is caring for a client with a history of atrial fibrillation who is prescribed dronedarone (Multaq). The nurse should monitor the client for which of the following side effects?
- A. Hypertension.
- B. Bradycardia.
- C. Liver toxicity.
- D. Weight gain.
Correct Answer: C
Rationale: Dronedarone can cause liver toxicity, requiring regular monitoring of liver function tests.