Nokea
A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take?
- A. Monitor blood pressure every 2 hr.
- B. Attach an inline filter to the IV tubing
- C. Protect the IV bag from exposure to light.
- D. Keep calcium gluconate at the client's bedside.
Correct Answer: C
Rationale: The correct answer is C: Protect the IV bag from exposure to light. Nitroprusside is light-sensitive and can degrade when exposed to light, leading to the formation of toxic metabolites. By protecting the IV bag from light exposure, the nurse ensures the medication's stability and prevents potential harm to the client. Monitoring blood pressure every 2 hours (Choice A) is a standard practice for clients receiving nitroprusside but is not the most critical action. Attaching an inline filter to the IV tubing (Choice B) is important to prevent particulate matter from entering the client's bloodstream but is not specific to nitroprusside administration. Keeping calcium gluconate at the client's bedside (Choice D) is unrelated to nitroprusside administration and is not necessary for this situation.
You may also like to solve these questions
The nurse is initiating the client's plan of care. Which of the following interventions should the nurse plan to implement? Select all that apply
- A. Provide a low-stimulation environment
- B. Maintain bed rest
- C. Give antihypertensive medication.
- D. Administer betamethasone
- E. Monitor intake and output hourly
- F. Obtain a 24-hr urine specimen
- G. Perform a vaginal examination every 12 hr
Correct Answer: A, B, C, D, E, F
Rationale: Correct Answer: A, B, C, D, E, F
Rationale:
A: Providing a low-stimulation environment promotes rest and reduces stress.
B: Maintaining bed rest may be necessary for certain conditions to prevent complications.
C: Giving antihypertensive medication helps control blood pressure.
D: Administering betamethasone can be part of the treatment plan for certain conditions.
E: Monitoring intake and output hourly helps assess fluid balance and kidney function.
F: Obtaining a 24-hr urine specimen is a common diagnostic test to assess kidney function.
Summary:
Choice G is incorrect as performing vaginal examinations every 12 hours is unnecessary and invasive.
A charge nurse is monitoring a newly licensed nurse who is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following statements by the newly licensed nurse indicates an understanding of the procedure?
- A. I will hang a new bag of TPN and IV tubing every 24 hours.'
- B. I will obtain the client's weight every other day.'
- C. I will monitor the client's blood glucose level every 8 hours.'
- D. I will increase the rate of the TPN infusion to ensure the correct amount is given.'
Correct Answer: A
Rationale: Correct Answer: A - "I will hang a new bag of TPN and IV tubing every 24 hours."
Rationale: Changing the TPN bag and tubing every 24 hours is crucial to prevent contamination and infection. TPN is a high-risk solution that can support bacterial growth. Changing the bag and tubing decreases the risk of infection and ensures the client receives fresh and uncontaminated TPN.
Summary of Incorrect Choices:
B: Obtaining the client's weight every other day is important for adjusting the TPN formula but does not demonstrate an understanding of the procedure like changing the bag and tubing.
C: Monitoring the client's blood glucose level every 8 hours is important for assessing tolerance to TPN but does not directly relate to the procedural aspect of TPN administration.
D: Increasing the rate of TPN infusion to ensure the correct amount is given is not safe practice and can lead to complications. The rate should be prescribed by the healthcare provider and not arbitrarily increased.
A nurse enters a client's room and sees a small fire in the client's bathroom. Identify the sequence of steps the nurse should take.
- A. Transport the client to another area of the nursing unit.
- B. Activate the facility's fire alarm system
- C. Close all nearby windows and doors
- D. Use the unit's fire extinguisher to attempt to put out the fire
Correct Answer: B, A, C, D
Rationale: The correct sequence of steps for the nurse to take in case of a small fire in the client's bathroom is as follows:
1. B: Activate the facility's fire alarm system - This is the first step to alert everyone in the facility and ensure a prompt response from the fire department.
2. A: Transport the client to another area of the nursing unit - Ensures the client's safety away from the fire hazard.
3. C: Close all nearby windows and doors - Helps contain the fire and prevent it from spreading further.
4. D: Use the unit's fire extinguisher to attempt to put out the fire - Only after ensuring the client's safety and containing the fire should the nurse attempt to extinguish it.
Other choices are incorrect because:
- A: Transporting the client should only be done after activating the fire alarm system to ensure a timely response.
- C: Closing windows and doors is important but should be done after alerting others about the fire
A nurse is assessing a client who received hydromorphone 4 mg IV 15 min ago. The client has a respiratory rate of 10/min. The nurse should prepare to administer which of the following medications?
- A. Acetylcysteine
- B. Protamine
- C. Naloxone
- D. Flumazenil
Correct Answer: C
Rationale: The correct answer is C: Naloxone. Naloxone is an opioid antagonist used to reverse the effects of opioid overdose, such as respiratory depression. In this case, the client's respiratory rate of 10/min indicates opioid overdose due to hydromorphone. Naloxone administration can help reverse the respiratory depression and restore normal breathing.
Choice A: Acetylcysteine is used for acetaminophen overdose, not opioid overdose.
Choice B: Protamine is used to reverse the effects of heparin, not opioids.
Choice D: Flumazenil is a benzodiazepine antagonist, not an opioid antagonist.
Therefore, the most appropriate choice in this scenario is Naloxone to address the opioid overdose and respiratory depression.
Drag words from the choices below to fill in each blank in the following sentence. The client is at greatest risk for developing-----and-----
- A. Placental Abruption
- B. Hypoglycemia
- C. Heart failure
- D. Cervical insufficiency
- E. Seizures
Correct Answer: C,E
Rationale: The correct answer is C, Heart failure, and E, Seizures. The client is at greatest risk for developing heart failure and seizures due to complications during pregnancy. Heart failure can occur due to the increased stress on the heart from pregnancy, especially in individuals with pre-existing heart conditions. Seizures can arise from conditions like eclampsia, which is a severe form of preeclampsia characterized by high blood pressure and organ damage. Placental abruption (A) is a separation of the placenta from the uterus, not directly related to heart failure or seizures. Hypoglycemia (B) is low blood sugar levels, which may occur but is not the greatest risk in this scenario. Cervical insufficiency (D) is the inability of the cervix to stay closed during pregnancy, which is not directly linked to heart failure or seizures.