Nokea
A nurse is caring for 4 clients. Which prescription by the health care provider would the nurse question and seek further clarification before administering?
- A. 0.45% sodium chloride solution for a client with severe gastroenteritis who had 12 episodes of diarrhea and vomiting in the past 4 hours
- B. IV bolus of 1000 mL 0.9% sodium chloride solution for a client in anaphylaxis due to a food allergy
- C. IV bolus of 1000 mL 0.9% sodium chloride solution for a client with diabetic ketoacidosis who has a serum glucose level of 650 mg/dL (36.1 mmol/L)
- D. IV mannitol 25% solution for a client with a closed head injury who is exhibiting signs of increased intracranial pressure
Correct Answer: C
Rationale: 0.45% saline is appropriate for gastroenteritis to replace fluids. 0.9% saline bolus treats anaphylactic shock. Mannitol reduces intracranial pressure. A 1000 mL bolus for DKA is excessive; smaller boluses (e.g., 250-500 mL) are safer to avoid fluid overload.
You may also like to solve these questions
As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to give the medication without first aspirating. What should the nurse do?
- A. Ask the student: 'What did you forget to do?'
- B. Stop. Tell me why aspiration is needed.
- C. Loudly state: 'You forgot to aspirate.'
- D. Walk up and whisper in the student's ear 'Stop. Aspirate. Then inject.'
Correct Answer: D
Rationale: This action is a direct threat to the client if the medication enters into the blood stream instead of the muscle. The purpose of aspiration with IM injections is to prevent the injection of the drug directly into the blood stream.
A throat culture is ordered for an adult who has a sore throat. The nurse asks the client if he has taken any medications to treat himself. Which medication, if reported by the client, would be of greatest concern to the nurse?
- A. Aspirin
- B. A throat lozenge
- C. Acetaminophen
- D. An antibiotic
Correct Answer: D
Rationale: Antibiotics can alter throat culture results by reducing bacterial growth, potentially leading to a false negative, the greatest concern.
The nurse is caring for a postoperative client who has D5W/0.45% normal saline with 10 mEq potassium chloride infusing through a peripheral IV catheter. What are appropriate reasons for the nurse to change the site? Select all that apply.
- A. Area around the insertion site feels cool to the touch
- B. Client reports mild arm discomfort after the infusion is started
- C. Edema is observed on the dependent side of the involved arm
- D. Intraoperative peripheral IV catheter was placed in the left antecubital region
- E. Serous fluid is leaking from the site despite secure connections
Correct Answer: A,C,E
Rationale: Coolness suggests infiltration or poor circulation. Edema indicates infiltration or phlebitis. Leaking serous fluid suggests dislodgement. Mild discomfort may be normal initially, and antecubital placement is acceptable unless complications arise.
The nurse on the mental health unit is caring for assigned clients. The nurse should first check the client with
- A. obsessive-compulsive disorder who has spent the past hour counting socks
- B. major depressive disorder who has consumed no food from the past 2 meal trays
- C. posttraumatic stress disorder who reports a depressed mood and feelings of hopelessness
- D. bipolar I disorder who is experiencing an acute manic episode and reports sleeping 4 hours last night
Correct Answer: C
Rationale: Hopelessness and depressed mood in PTSD indicate suicide risk, requiring immediate assessment. OCD behavior , poor intake , and mania are less urgent but still need attention.
A client with paranoid thoughts refuses to eat because of the belief that the food is poisoned. The appropriate statement at this time for the nurse to say is
- A. Here, I will pour a little of the juice in a medicine cup to drink it to show you that it is OK.'
- B. The food has been prepared in our kitchen and is not poisoned.'
- C. Let's see if your partner could bring food from home.'
- D. If you don't eat, I will have to suggest for you to be tube fed.'
Correct Answer: C
Rationale: Reassurance is ineffective when a client is actively delusional. This option avoids both arguing with the client and agreeing with the delusional premise.