Nokea
A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication?
- A. I cannot give this medication as it is written. I have no idea of what you mean.
- B. Would you please clarify what you have written so I am sure I am reading it correctly?
- C. I am having difficulty reading your handwriting. It would save me time if you would be more careful.
- D. Please print in the future so I do not have to spend extra time attempting to read your writing.
Correct Answer: B
Rationale: Would you please clarify what you have written so I am sure I am reading it correctly? This is respectful and ensures patient safety.
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A 42-year-old man with metastatic lung cancer is admitted to the hospital. His orders include: do not resuscitate (DNR) and morphine 2 mg/h by continuous IV infusion. When the nurse assesses him, his BP is 86/50, respirations are 8, and he is nonresponsive. Naloxone hydrochloride (Narcan), 0.4 mg IV, is ordered STAT. In planning care for this man, it is IMPORTANT for the nurse to know that
- A. the BP and respirations will need to increase before a second dose of Narcan can be given.
- B. Narcan should not be given to the man because of his DNR status.
- C. a dose of Narcan may need to be repeated in 2-3 minutes.
- D. Narcan is effective in treating respiratory changes caused by opiates, barbiturates, and sedatives.
Correct Answer: C
Rationale: half-life of Narcan is short; may go back into respiratory depression; may need to be repeated
A 5-year old is admitted to the hospital with pneumonia. Her orders include chest physiotherapy, mist tent, and inhalation with Mucomyst (acetylcysteine). Which of the following measures should be included in her care?
- A. Telling her to breathe in through her nose and breathe out through her mouth
- B. Applying lotion to the exposed parts of her body
- C. Checking her clothing and linen frequently for dampness
- D. Obtaining a rectal temperature q 4 hours
Correct Answer: C
Rationale: Checking clothing and linen for dampness is necessary due to the mist tent, which can cause moisture buildup, leading to discomfort or skin issues.
The nurse is caring for a client who is postoperative day 1 after a cholecystectomy. Which of the following findings should the nurse report immediately?
- A. Mild pain at the incision site
- B. Temperature of 100.8°F (38.2°C)
- C. Bile-colored drainage from the T-tube
- D. Urine output of 40 mL/hour
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-cholecystectomy complication. Options A, C, and D are normal: pain is expected, bile drainage is typical, and urine output is adequate.
A client after an electroconvulsive therapy (ECT) treatment.
The nurse should report which observation to the client's physician?
- A. Headache.
- B. Disruption in short- and long-term memory.
- C. Transient confusional state.
- D. Backache.
Correct Answer: D
Rationale: Strategy: You are looking for something unexpected. (1) expected effect (2) expected effect (3) expected effect (4) correct-client undergoing ECT needs to be instructed about what s/he could experience during and after ECT; expected effects include headache, disrupted memory (short- and long-term), and general confused state; backache is not a usual effect; thorough description of the pain in relation to severity, duration, location, and what makes pain better needs to be assessed and reported to the physician
A client with end-stage renal failure is to receive a kidney transplant from her sister. Prior to surgery, the client will be scheduled for:
- A. An intravenous pyelogram
- B. Hemodialysis
- C. A voiding cystogram
- D. A renal biopsy
Correct Answer: B
Rationale: Hemodialysis is typically performed before a kidney transplant to optimize the client's electrolyte and fluid balance, ensuring a stable condition for surgery.