Nokea
A nurse is collecting data from a client who has Tourette syndrome. The client reports taking haloperidol 0.5 mL orally three times a day at home. Which of the following components of the prescription should the nurse question?
- A. Frequency
- B. Dosage
- C. Timing of doses
- D. Route
Correct Answer: B
Rationale: The nurse should question the dosage of haloperidol as it is typically administered in milligrams (mg) and not milliliters (mL). The dosage should be expressed in a standardized unit for accuracy and to prevent medication errors. Frequency, timing of doses, and route are also important components of a prescription, but in this case, the nurse should focus on the unusual dosage form.
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What are key signs of fluid overload?
- A. Edema
- B. Hypertension
- C. Shortness of breath
- D. All of the above
Correct Answer: D
Rationale: The correct answer is 'D: All of the above.' Edema, hypertension, and shortness of breath are key signs of fluid overload, particularly common in patients with heart failure. Edema refers to the swelling caused by excess fluid trapped in the body's tissues, hypertension can be a result of fluid volume overload, and shortness of breath can occur due to fluid accumulation in the lungs. Therefore, all these signs collectively indicate fluid overload in a patient. Choices A, B, and C are incorrect individually as each alone may not necessarily indicate fluid overload, but when seen together, they strongly suggest fluid volume excess in the body.
What are the early signs of hypoglycemia in a diabetic patient?
- A. Sweating and trembling
- B. Confusion and irritability
- C. Dizziness and increased heart rate
- D. Nausea and vomiting
Correct Answer: A
Rationale: The correct answer is A: 'Sweating and trembling.' These are classic early signs of hypoglycemia in a diabetic patient. Sweating occurs due to the activation of the sympathetic nervous system in response to low blood sugar levels, while trembling is a result of the body's attempt to increase muscle activity to raise blood sugar levels. Confusion and irritability (Choice B) are more advanced signs of hypoglycemia that occur if the condition is not treated promptly. Dizziness and increased heart rate (Choice C) can also occur but are not as specific and early as sweating and trembling. Nausea and vomiting (Choice D) are more commonly associated with other conditions or severe hypoglycemia, rather than being early signs.
What advice should be given to a client experiencing constipation?
- A. Encourage the client to drink water frequently
- B. Increase dietary fiber to relieve constipation
- C. Administer a laxative to relieve discomfort
- D. Encourage the client to increase physical activity
Correct Answer: B
Rationale: The correct advice to give to a client experiencing constipation is to increase dietary fiber. Dietary fiber helps relieve constipation by promoting regular bowel movements. Encouraging the client to drink water frequently (Choice A) is also important for overall bowel health, but increasing dietary fiber is more directly related to relieving constipation. Administering a laxative (Choice C) should not be the first-line recommendation and should only be considered if dietary and lifestyle changes do not work. Encouraging the client to increase physical activity (Choice D) can be beneficial for overall health but may not directly address the issue of constipation.
What is the most important step when preparing to administer a blood transfusion?
- A. Check if the client has a fever
- B. Ensure the blood type is compatible with the client
- C. Administer the blood via IV push
- D. Ensure the blood is warmed to body temperature
Correct Answer: B
Rationale: The correct answer is B: Ensure the blood type is compatible with the client. This is the most crucial step in preparing for a blood transfusion to prevent severe transfusion reactions. Checking the client for a fever (Choice A) is important but not the most critical step. Administering blood via IV push (Choice C) is incorrect as blood transfusions are usually administered as a slow drip. Warming the blood to body temperature (Choice D) is not a standard practice and can lead to hemolysis, making it an incorrect choice.
A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?
- A. A client with pneumonia who had new onset of confusion
- B. A client with diabetes who had low blood sugar overnight
- C. A client with a leg fracture who needs pain medication
- D. A client whose urinary output was 100 mL for the past 12 hours
Correct Answer: A
Rationale: The correct answer is A. New confusion in a client with pneumonia could indicate hypoxia or a worsening condition, requiring immediate attention. Option B, a client with diabetes having low blood sugar overnight, is a concerning condition but not as urgent as potential hypoxia. Option C, a client with a leg fracture needing pain medication, and option D, a client with decreased urinary output, are important but do not take precedence over addressing a potentially critical respiratory issue.