Nokea
A nurse is assisting a client who has schizophrenia prepare a relapse plan. Which of the following statements should the nurse make?
- A. Relapse is an indication that you are not taking your medications properly.
- B. You should keep your provider’s and therapist’s number with you.
- C. Taking an additional dose of medication is appropriate as soon as signs of relapse appear.
- D. You should be aware that excessive sleeping is an early sign of relapse.
Correct Answer: B
Rationale: The correct answer is B: "You should keep your provider’s and therapist’s number with you." This is the correct statement because having easy access to contact information for healthcare providers and therapists is crucial in case of a relapse. It allows the client to seek immediate help and support when needed.
Choice A is incorrect because relapse in schizophrenia can occur even with proper medication adherence. Choice C is incorrect as taking additional medication without consulting a healthcare provider can be dangerous. Choice D is incorrect as excessive sleeping may not always be a reliable early sign of relapse.
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A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client?
- A. A negative-pressure isolation room.
- B. A private room.
- C. A semi-private room with a client who has pediculosis capitis.
- D. A positive-pressure isolation room.
Correct Answer: B
Rationale: The correct answer is B: A private room. This is appropriate for a client with scabies to prevent the spread of the infestation to others. A private room allows for isolation and reduces the risk of transmission to other clients.
A: A negative-pressure isolation room is typically used for clients with airborne infections to prevent the spread of pathogens outside the room. Scabies is not transmitted through the air.
C: Placing the client in a semi-private room with a client who has pediculosis capitis (head lice) is not ideal as both conditions are caused by different parasites and may increase the risk of cross-contamination.
D: A positive-pressure isolation room is used for clients who need protection from outside pathogens, not for containing contagious conditions like scabies.
In summary, a private room is the best choice for a client with scabies to prevent transmission to others, while the other options are not appropriate due to the nature of scabies and the need for isolation.
A nurse is preparing to administer 40 mg of furosemide IV. Available is furosemide 10 mg/mL. How many mL should the nurse administer per dose?
Correct Answer: 4
Rationale: Correct Answer: A nurse should administer 4 mL of furosemide per dose. To calculate this, divide the total dose (40 mg) by the concentration (10 mg/mL). 40 mg ÷ 10 mg/mL = 4 mL. This ensures the correct dosage is administered.
Choice B: Incorrect. This choice does not follow the correct calculation method and does not provide the accurate dosage.
Choice C: Incorrect. This choice does not consider the concentration of the medication and does not provide the correct amount to administer.
Choice D: Incorrect. This choice does not involve the necessary division of the total dose by the concentration, resulting in an incorrect answer.
Choice E: Incorrect. This choice does not show a clear calculation method or consideration of the medication concentration.
Choice F: Incorrect. This choice lacks any calculation or explanation, making it an insufficient answer.
Choice G: Incorrect. This choice does not provide any reasoning or calculation to support the amount to administer, making it an inadequate
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 planning care for a client who is 1 day postoperative following spinal fusion. Which of the following actions should the nurse include?
- A. Assist the client to sit upright in a chair for 4 hours at a time.
- B. Expect clear drainage on the spinal dressing.
- C. Log roll the client every 2 hours.
- D. Perform neurological checks every 8 hours.
Correct Answer: C
Rationale: The correct answer is C: Log roll the client every 2 hours. This action is crucial for preventing complications such as pressure ulcers and maintaining spinal alignment post spinal fusion surgery. Log rolling helps to keep the spine in proper alignment and reduces the risk of injury to the surgical site. Assisting the client to sit upright for 4 hours at a time (choice A) can put excessive pressure on the surgical site and hinder the healing process. Expecting clear drainage on the spinal dressing (choice B) is not appropriate as drainage may vary and is not necessarily an indicator of infection. Performing neurological checks every 8 hours (choice D) is important but should be done more frequently in the immediate postoperative period.
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.