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A nurse is admitting an older female client to the gynecology surgical unit. When the nurse asks the client what medication she is taking at home, the client responds that she is taking a little red pill in the morning and a white capsule at night for her blood pressure. What action by the nurse is focused on safe, effective care of this client?
- A. Consult the pharmacist regarding identification of the medications.
- B. Show pictures to the client from the Physician's Desk Reference to identify the medications.
- C. Consult the previous medical record and notify the physician regarding medications that must be ordered.
- D. Ask a family member to bring the medications from home in the original vials for proper identification and administration times.
Correct Answer: D
Rationale: Having medications brought in original vials ensures accurate identification, promoting safe administration.
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The nurse is caring for a child with sickle cell anemia who is experiencing a vaso-occlusive crisis. Which of the following interventions is the priority?
- A. Administer oxygen.
- B. Provide hydration.
- C. Apply warm compresses.
- D. Administer analgesics.
Correct Answer: B
Rationale: Hydration is the priority in vaso-occlusive crisis to reduce blood viscosity and promote circulation, preventing further sickling and complications.
The nurse is teaching a client with hypertension about dietary modifications. Which food should the nurse recommend limiting?
- A. Fresh fruits
- B. Lean proteins
- C. Canned soups
- D. Whole grains
Correct Answer: C
Rationale: Canned soups are high in sodium, which can exacerbate hypertension. Limiting sodium intake is a key dietary modification for blood pressure control.
A client with acquired immunodeficiency syndrome (AIDS) is admitted because of paranoia and visual hallucinations probably related to progressive dementia. The client continues to be restless and have hallucinations. The nurse calls the physician, and after explaining the situation, background, and assessment recommends that the physician consider writing an order to the client to have:
- A. Methylphenidate (Ritalin).
- B. Lorazepam (Ativan).
- C. Nefazodone (Serzone).
- D. Sertraline (Zoloft).
Correct Answer: B
Rationale: Lorazepam can help manage acute agitation and restlessness in a client with AIDS-related dementia.
The nurse is reviewing the client's arterial blood gas results. Which finding would indicate that the client is experiencing respiratory acidosis?
- A. pH 7.5, PcO2 of 30
- B. pH 7.3, PcO2 of 50
- C. pH 7.3, HCO3 of 19
- D. pH 7.5, HCO3 of 30
Correct Answer: B
Rationale: In respiratory acidosis, the pH is decreased and an opposite effect is seen in the PCO2 (pH decreased, PCO2 elevated). Option 1 indicates respiratory alkalosis; option 3 indicates possible metabolic acidosis; option 4 indicates possible metabolic alkalosis.
A newborn infant receives the first dose of hepatitis B vaccine within 12 hours of birth. The nurse instructs the parent regarding the immunization schedule for this vaccine and should tell the parent that the second vaccine is administered at which time periods?
- A. 3 years of age and then during the adolescent years
- B. 8 months of age and then 1 year after the initial dose
- C. 6 months of age and then 8 months after the initial dose
- D. 1 to 2 months of age and then 6 months after the initial dose
Correct Answer: D
Rationale: The vaccination schedule for an infant whose mother tests negative for hepatitis B consists of a series of 3 immunizations given at 0 months (birth), 1 to 2 months of age, and then 6 months after the initial dose. An infant whose mother tests positive receives hepatitis B immune globulin along with the first dose of the hepatitis vaccine within 12 hours of birth.