Nokea
A nurse is evaluating a client's neurosensory system. To evaluate stereognosis, she would ask the client to close his eyes & identify which of the following items?
- A. A word she whispers 30cm from his ear
- B. A number she traces on the palm of his hand
- C. The vibration of a tuning fork she places on his foot
- D. A familiar object she places in his hand
Correct Answer: D
Rationale: The correct answer is D: A familiar object she places in his hand. Stereognosis is the ability to recognize objects by touch without visual cues. By asking the client to identify a familiar object placed in his hand with his eyes closed, the nurse is testing his ability to perceive and interpret tactile sensations. This assessment helps evaluate the client's sensory perception and integration in the neurosensory system. The other choices are incorrect because they do not specifically assess stereognosis. Choice A involves auditory perception, choice B involves tactile perception but not recognition of objects, and choice C involves vibratory perception rather than object recognition through touch.
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A client who has had a cerebrovascular accident has persistent problems w/dysphagia. The nurse caring for the client should initiate a referral w/which of the following members of the interprofessional care team? Select all.
- A. Social worker
- B. CNA
- C. Occupational therapist
- D. Speech-language pathologist
Correct Answer: C, D
Rationale: The correct answer is C and D. The occupational therapist (C) can help with improving the client's ability to eat independently by providing adaptive equipment and strategies. A speech-language pathologist (D) is crucial for assessing and treating dysphagia to prevent aspiration and improve swallowing function. The social worker (A) may address psychosocial needs but does not directly address dysphagia. The CNA (B) primarily assists with daily living activities.
A nurse is preparing to administer lactated Ringer's (LR) IV 100 mL over 15 minutes. The nurse should set the infusion pump to deliver how many mL/hr?
Correct Answer: 400
Rationale: The correct answer is 400 mL/hr. To calculate the mL/hr rate, we first convert the 15 minutes to hours (15 minutes ÷ 60 minutes = 0.25 hours). Then, we divide the total volume (100 mL) by the time in hours (100 mL ÷ 0.25 hours = 400 mL/hr). This rate ensures the safe and accurate administration of 100 mL of LR over a 15-minute period. Other choices are incorrect because they do not accurately calculate the mL/hr rate based on the given parameters.
A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy & unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on break. Which of the following actions should the nurse take?
- A. Remind the nurse that safe client care is a priority on the unit
- B. Ask others on the team whether they have observed the same behavior
- C. Report observations to the nurse manager on the unit
- D. Conclude that her coworker's fatigue is not her problem to solve
Correct Answer: C
Rationale: The correct action is to choose option C: Report observations to the nurse manager on the unit. This is the most appropriate course of action because it addresses the potential safety risk to patients due to the drowsy nurse's behavior. Reporting to the nurse manager ensures that the issue is escalated to someone in authority who can address it effectively, such as through a conversation with the drowsy nurse, adjusting their work schedule, or providing support if there are underlying issues causing the fatigue. Options A, B, and D are not as effective because reminding the nurse or asking others on the team may not lead to a resolution, and assuming the fatigue is not the nurse's problem to solve ignores the potential impact on patient safety.
A nurse is preparing to administer digoxin (Lanoxin) to a client who states, 'I don't want to take that med. I do not want one more pill.' Which of the following responses by the nurse is appropriate in this situation?
- A. Your physician prescribed it for you, so you really should take it.
- B. Well, let's just get it over with quickly then.
- C. Okay, I'll just give you your other meds.
- D. Tell me your concerns with taking this med.
Correct Answer: D
Rationale: Correct Answer: D. Tell me your concerns with taking this med.
Rationale: This response demonstrates therapeutic communication by acknowledging the client's feelings and encourages them to express their concerns. It shows empathy and respect for the client's autonomy in decision-making. By understanding the client's reasons for not wanting to take the medication, the nurse can address any misconceptions, provide education, and potentially find alternative solutions. This approach fosters trust and collaboration between the nurse and the client.
Incorrect choices:
A: This response is dismissive of the client's feelings and does not address the underlying concerns.
B: This response does not address the client's reluctance and may come off as insensitive.
C: This response avoids the issue at hand and does not promote open communication.
A nurse educator is teaching a module on pharmacokinetics to a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates an understanding of the 1st-pass effect?
- A. Some meds block normal receptor activity regulated by endogenous compounds or receptor activity caused by other meds.
- B. Some meds may have to be administered by a nonenteral route to avoid inactivation as they travel through the liver.
- C. Some meds leave the body more slowly & therefore have a greater risk of accumulation & toxicity.
- D. Some meds have a wide safety margin, so there is no need for routine serum medication level monitoring.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. The 1st-pass effect refers to the metabolism of a drug in the liver before it reaches systemic circulation.
2. Medications administered orally undergo first-pass metabolism in the liver, leading to potential inactivation.
3. Administering such meds through nonenteral routes (e.g., intravenous) bypasses the liver, avoiding inactivation.
4. Choice A discusses receptor activity, not related to the first-pass effect.
5. Choice C refers to drug elimination rate, not specific to the first-pass effect.
6. Choice D discusses safety margin and monitoring, not directly related to drug metabolism.