Nokea
A nurse from the float pool is giving medications on a pediatric unit and is to give medications to a 2-year-old child in room 534, bed B. The child in that room does not have an identification band. What is the best action for the nurse to take?
- A. Ask the child what his name is
- B. Give the medication to the child in room 534, bed B
- C. Refuse to give the medication
- D. Ask the adults beside the bed the name of the child in that bed
Correct Answer: C
Rationale: Refusing to give medication without proper identification ensures safety, as a 2-year-old cannot reliably confirm identity.
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The nurse in the emergency department is caring for a client who sustained blunt force head trauma and is experiencing blurry vision. The nurse should suspect the client has sustained injury to the
- A. temporal lobe
- B. occipital lobe
- C. parietal lobe
- D. frontal lobe
Correct Answer: B
Rationale: Blurry vision post-head trauma suggests injury to the occipital lobe , which processes visual information. Temporal , parietal , and frontal lobes manage other functions.
A client is scheduled for a myelogram. Which of the following medications orders should be questioned?
- A. Ampicillin (Pencipen) $250 \mathrm{mg} \mathrm{PO} \mathrm{q} 6$ hours
- B. Motrin (Ibuprofen) $400 \mathrm{mg} \mathrm{PO} \mathrm{q} 4$ hours PRN for headache
- C. Secobarbital (Seconal) $50 \mathrm{mg}$ HS PRN for sleep
- D. Propoxyphene (Darvon) $65 \mathrm{mg} \mathrm{PO} \mathrm{q} 4$ hours for pain
Correct Answer: B
Rationale: Ibuprofen (Motrin) has anticoagulant properties, increasing bleeding risk during a myelogram, a procedure involving spinal puncture. Other medications are safer.
The drug of choice for managing status epilepticus is:
- A. Carbamazepine (Tegretol)
- B. Diazepam (Valium)
- C. Clonazepam (Klonopin)
- D. Valproic acid (Depakene)
Correct Answer: B
Rationale: Diazepam is the first-line treatment for status epilepticus due to its rapid onset in stopping seizures.
The postoperative client on hydrocodone becomes hypoxic, and naloxone is administered per protocol. What is most important for the nurse to consider in the follow-up care of this client?
- A. Client's respiratory status 60 minutes later
- B. Documenting the client's hypoxic event
- C. Obtaining an order for a different analgesic
- D. Potential for drug-drug interaction now
Correct Answer: A
Rationale: After naloxone administration for opioid-induced hypoxia, monitoring respiratory status is critical as naloxone's effects are short-acting, and respiratory depression may recur. Documentation is important but secondary, changing analgesics is not immediate, and drug interactions are less urgent.
The nurse is caring for a client who is terminally ill. When the client dies, the nurse should:
- A. Pronounce the client dead and call the doctor.
- B. Contact the coroner.
- C. Tag the body prior to the funeral home notification.
- D. Request an autopsy.
Correct Answer: C
Rationale: Tagging the body ensures proper identification before transfer to the funeral home. Nurses do not pronounce death, coroner contact depends on policy, and autopsies are not routinely requested.