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A nurse enters a client’s room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?
- A. Place a pillow under the client’s head.
- B. Insert a padded tongue blade into the client’s mouth.
- C. Apply a face mask for oxygen administration.
- D. Gently restrain the client’s extremities.
Correct Answer: A
Rationale: The correct action is to place a pillow under the client's head. This helps to protect the client's head from injury during the seizure. It is important to maintain a patent airway and prevent head injury. Inserting a padded tongue blade (choice B) could cause injury or obstruct the airway. Applying a face mask for oxygen (choice C) may not be necessary at this point and can be done after the seizure stops. Gently restraining the client's extremities (choice D) can cause further injury. It is crucial to prioritize safety and comfort during a seizure.
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A nurse is reviewing the laboratory test results from a client who has prerenal acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect?
- A. Hypophosphatemia
- B. Hyperkalemia
- C. Hypercalcemia
- D. Hypernatremia
Correct Answer: B
Rationale: The correct answer is B: Hyperkalemia. In prerenal AKI, decreased blood flow to the kidneys leads to reduced filtration and impaired excretion of potassium, resulting in hyperkalemia. Hypophosphatemia (A), hypercalcemia (C), and hypernatremia (D) are not typically associated with prerenal AKI. In prerenal AKI, there is usually no significant change in phosphate levels, calcium levels are typically normal or low due to volume depletion, and sodium levels may be normal or decreased due to reduced renal perfusion.
A nurse is preparing a client who is to receive chemotherapy for treatment of ovarian cancer. Which of the following actions should the nurse plan to take?
- A. Tell the client to expect dark stools following chemotherapy.
- B. Have the client swish with commercial mouthwash before therapy.
- C. Administer an antiemetic prior to the procedure.
- D. Have the client floss 4 times daily.
Correct Answer: C
Rationale: The correct answer is C: Administer an antiemetic prior to the procedure. This is important because chemotherapy often causes nausea and vomiting. Administering an antiemetic helps prevent or reduce these side effects, promoting client comfort and compliance with treatment. Choice A is incorrect because dark stools are not a common side effect of chemotherapy for ovarian cancer. Choice B is incorrect as using mouthwash before therapy may not be relevant to chemotherapy administration. Choice D is incorrect as flossing frequency is not directly related to chemotherapy treatment.
A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?
- A. Generalized urticaria.
- B. Distended jugular veins.
- C. Blood pressure 184/92 mm Hg.
- D. Bilateral flank pain.
Correct Answer: A
Rationale: The correct answer is A: Generalized urticaria. This finding indicates an allergic transfusion reaction because urticaria, or hives, is a common symptom of an allergic response. The release of histamine during the reaction causes itching and skin rash. Distended jugular veins (B) are more indicative of fluid overload or heart failure. Blood pressure of 184/92 mm Hg (C) is elevated but not specific to an allergic reaction. Bilateral flank pain (D) may suggest kidney issues or musculoskeletal problems, not necessarily related to an allergic reaction.
A nurse is reviewing the medical record of a client who reports drinking three to four glasses of wine each night and taking 3,000 mg of acetaminophen daily. Which of the following laboratory values is the priority for the nurse to assess?
- A. Creatinine
- B. Aspartate aminotransferase (AST)
- C. Amylase
- D. Antidiuretic hormone (ADH)
Correct Answer: B
Rationale: The correct answer is B: Aspartate aminotransferase (AST). The nurse should prioritize assessing AST because both alcohol consumption and acetaminophen use can lead to liver damage. Elevated AST levels indicate liver injury, making it crucial to monitor for potential hepatotoxicity in this client. Creatinine (choice A) is typically assessed to evaluate kidney function, not directly related to alcohol or acetaminophen use. Amylase (choice C) is an enzyme related to pancreas health, not specifically affected by alcohol or acetaminophen. Antidiuretic hormone (ADH - choice D) is related to fluid balance, not a priority in this scenario. By focusing on AST, the nurse can promptly identify any liver damage and intervene accordingly.
A nurse is preparing to administer clindamycin palmitate 225 mg PO every 8 hours to a client. The amount available is clindamycin palmitate oral suspension 75 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 15
Rationale: Correct Answer: 15 mL
Rationale: To calculate the mL to administer, first determine the total daily dose (675 mg). Divide this by the concentration of the oral suspension (75 mg/5 mL) to get the total mL per day (45 mL). Divide this by the number of doses per day (3) to get the mL per dose (15 mL).
Summary:
A: Incorrect, as it does not align with the correct calculation.
B-G: Irrelevant since the correct calculation method indicates 15 mL is the appropriate answer.