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A nurse is assessing a client who is taking haloperidol and is experiencing pseudoparkinsonism. Which of the following findings should the nurse document as a manifestation of pseudoparkinsonism?
- A. Serpentine limb movement
- B. Shuffling gait
- C. Nonreactive pupils
- D. Smacking lips
Correct Answer: B
Rationale: The correct answer is B: Shuffling gait. Pseudoparkinsonism is a side effect of antipsychotic medications like haloperidol, characterized by symptoms similar to Parkinson's disease. A shuffling gait, which is a slow, dragging walk with short steps and reduced arm swing, is a classic manifestation. Serpentine limb movement (A) is not associated with pseudoparkinsonism. Nonreactive pupils (C) are not a typical symptom of pseudoparkinsonism. Smacking lips (D) is a sign of tardive dyskinesia, another side effect of antipsychotic medications.
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A nurse is teaching a newly licensed nurse about medication reconciliation. The nurse should instruct the newly licensed nurse to perform medication reconciliation for which of the following?
- A. A client who has a referral for social services
- B. A client who is transdermal to radiology
- C. A client who is transferal to a stepdown unit
- D. A client who has a consultation for physical therapy
Correct Answer: C
Rationale: The correct answer is C: A client who is transferal to a stepdown unit. Medication reconciliation is crucial during transitions of care to ensure accuracy and safety. When a client is transferred to a stepdown unit, their care level changes, necessitating a review of medications to prevent errors. Choice A is not directly related to medication reconciliation. Choice B involves a procedure, not a care transition requiring medication review. Choice D pertains to therapy but does not involve a care transition.
A nurse is caring for a client who is in shock and is receiving an infusion of albumin. Which of the following findings should the nurse expect?
- A. Oxygen saturation 96%
- B. PaCO2 30 mm Hg
- C. Increase in BP
- D. Decrease in protein
Correct Answer: C
Rationale: The correct answer is C: Increase in BP. Albumin is a colloid solution that helps increase blood volume and subsequently improves blood pressure in shock patients. Increasing blood volume leads to an increase in blood pressure. Option A is incorrect because oxygen saturation is not directly affected by albumin infusion. Option B is incorrect because a low PaCO2 level is not a direct effect of albumin infusion. Option D is incorrect because albumin is a protein and its infusion would not lead to a decrease in protein levels.
A nurse is preparing to administer potassium chloride elixir 20 mEq/day PO to divide equally every 12 hr. Available is 6.7 mEq/5 mL. How many mL should the nurse administer per dose? (Round to the nearest tenth.)
Correct Answer: 7.5
Rationale: The correct answer is 7.5 mL. To determine this, first calculate the total daily dose: 20 mEq/day ÷ 2 doses/day = 10 mEq/dose. Next, find the mL per dose using the available concentration: 10 mEq ÷ 6.7 mEq/5 mL = 7.46 mL, which rounds to 7.5 mL. This ensures the patient receives the correct dose of potassium chloride elixir. Other choices are incorrect because they do not follow the correct calculation or rounding process, leading to potential under or overdosing.
A nurse is assessing for allergies with a client who is scheduled to receive the influenza vaccine. Which of the following allergies should the nurse report to the provider as a possible contraindication to receiving the vaccine?
- A. Eggs
- B. Shellfish
- C. Peanuts
- D. Milk
Correct Answer: A
Rationale: The correct answer is A: Eggs. Influenza vaccines are typically produced using eggs, so individuals with egg allergies may have an allergic reaction to the vaccine. Reporting this allergy to the provider is crucial to avoid potential adverse reactions. Shellfish, peanuts, and milk allergies are not contraindications for receiving the influenza vaccine. Summary: Eggs are the correct answer due to the vaccine production method; shellfish, peanuts, and milk allergies are not relevant in this context.
A nurse is reviewing the medical record of a client who has sinusitis and a new prescription for cefuroxime. Which of the following client information is the priority for the nurse to report to the provider?
- A. The client has a BUN of 18 mg/dL
- B. The client takes an aspirin daily
- C. The client has a history of a severe penicillin allergy
- D. The client reports a history of nausea with cefuroxime
Correct Answer: C
Rationale: The correct answer is C: The client has a history of a severe penicillin allergy. This is the priority for the nurse to report because cefuroxime belongs to the cephalosporin class of antibiotics, which has a cross-reactivity with penicillins. Individuals with a history of severe penicillin allergy are at an increased risk of also being allergic to cephalosporins like cefuroxime. This can lead to potentially life-threatening allergic reactions. Reporting this information to the provider is crucial to avoid prescribing a medication that could harm the client.
Choice A (BUN of 18 mg/dL) is not directly related to the prescription of cefuroxime for sinusitis. Choice B (client takes an aspirin daily) is important but not as critical as the potential allergic reaction to cefuroxime. Choice D (client reports a history of nausea with cefuroxime) is relevant but does not pose an