Nokea
A nurse is preparing to administer 2 continuous IV medications concurrently via a 20-gauge IV. What is the nurse's priority action?
- A. Assess the condition of the IV site
- B. Check 2 client identifiers before administering medications
- C. Consult a medication guide for compatibility
- D. Wash hands prior to administering medications
Correct Answer: C
Rationale: Ensuring medication compatibility prevents chemical interactions or precipitation in the IV line, which could harm the client or obstruct the catheter.
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During the client interview for a developmentally normal 18-month-old, the parent expresses concern about the small amount of food the child consumes. What is the nurse's priority intervention?
- A. Check the child for parasitic infections
- B. Consult a pediatric nutritionist for suspected eating disorder
- C. Notify the health care provider
- D. Reinforce teaching about the toddler's nutritional needs
Correct Answer: D
Rationale: Toddlers often eat small amounts due to slower growth rates and picky eating. Educating parents about normal toddler nutrition addresses concerns and promotes appropriate feeding practices.
The nurse is assisting with the care of a client who has diabetic ketoacidosis. The nurse should recognize that it is a priority to
- A. gather supplies for an IV bolus of 0.9% sodium chloride
- B. prepare the client for an IV infusion of regular insulin
- C. request a prescription for potassium chloride
- D. obtain a urine specimen for urinalysis
Correct Answer: B
Rationale: In diabetic ketoacidosis, insulin administration is the priority to correct hyperglycemia and halt ketogenesis, addressing the underlying metabolic crisis.
The nurse is talking with a client who has urge incontinence and is receiving tolterodine. It would require immediate follow-up if the client reports
- A. straining to have a bowel movement
- B. going an entire workday without needing to urinate
- C. using over-the-counter artificial saliva products for dry mouth
- D. experiencing occasional dizziness in the morning and with position changes
Correct Answer: B
Rationale: Not urinating for an entire workday suggests urinary retention, a serious side effect of tolterodine, requiring immediate evaluation to prevent bladder damage.
The nurse is reinforcing teaching for a client who has a new prescription for levothyroxine. Which of the following information should the nurse reinforce?
- A. Discontinue the medication if you become pregnant.
- B. Take the medication at bedtime to decrease drowsiness.
- C. Notify your health care provider if you experience palpitations.
- D. Take the medication with a snack if you experience an upset stomach.
Correct Answer: C
Rationale: Palpitations may indicate levothyroxine overdose or hyperthyroidism, requiring prompt reporting to adjust the dose or evaluate thyroid function.
The family of a young man who has been declared brain dead following an accident tells the nurse that the doctors said their son would be a good organ donor. They ask the nurse if donating his organs would mean that they could not have a regular funeral. Which response by the nurse is most accurate?
- A. Donating organs does deface the body, so a closed casket is necessary.
- B. Ask the physician which organs would be donated.
- C. Organ donation involves a surgical incision but should not interfere with any type of funeral.
- D. Donating organs is a wonderful service to humanity.
Correct Answer: C
Rationale: Organ donation involves surgical incisions but allows for open-casket funerals with proper preparation, addressing the family's concern accurately.