Nokea
A nurse is preparing to administer medications to a female client. Which of the following medications is included in the Medication Administration Record?
- A. Furosemide 40 mg PO daily
- B. Potassium chloride 10 mEq/L PO twice daily
- C. Lisinopril 10 mg PO daily
- D. NPH insulin 26 units SUBQ daily
- E. Atorvastatin 20 mg PO daily
Correct Answer: A
Rationale: The question tests medication record accuracy, with furosemide 40 mg PO daily listed as an option. It's a diuretic for heart failure (per Exhibit 4), matching the client's diagnosis, and is correctly formatted for administration. Potassium chloride addresses diuretic-induced losses, lisinopril manages hypertension, and NPH insulin treats diabetes, all plausible, but furosemide ties directly to the heart failure noted. Its inclusion ensures fluid overload is addressed, a primary concern, aligning with MAR standards right drug, dose, route, and frequency. This choice confirms the nurse's role in verifying orders, making it the appropriate medication to recognize.
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A nurse is caring for a client who has deep-vein thrombosis. Which of the following interventions should the nurse plan to take?
- A. Place the client's bed in reverse Trendelenburg position.
- B. Massage the affected extremity every 4 hr.
- C. Apply cold compresses to the affected extremity.
- D. Measure the calf of the affected extremity each shift.
- E. Elevate the leg.
- F. Apply warm compresses.
- G. Administer heparin.
Correct Answer: D
Rationale: Measuring the calf monitors for swelling (worsening DVT); massage and cold can dislodge clots, and reverse Trendelenburg isn't specific.
A nurse is contributing to the plan of care for a client who has HIV. Which of the following interventions should the nurse plan to include?
- A. Provide a diet of pureed foods.
- B. Encourage fluids with meals.
- C. Offer small, frequent meals.
- D. Suggest fresh fruits and vegetables.
Correct Answer: C
Rationale: Clients with HIV often experience nutritional challenges due to symptoms like nausea, fatigue, or opportunistic infections, necessitating a tailored dietary plan. Option A, pureed foods, is suited for swallowing difficulties, not a general HIV need, so it's inappropriate. Option B, encouraging fluids with meals, may dilute gastric juices and worsen digestion or appetite, countering nutritional goals. Option C is correct small, frequent meals help maintain energy, combat weight loss, and accommodate reduced appetite or early satiety common in HIV, supporting immune function and medication tolerance. Option D, fresh fruits and vegetables, sounds healthy but risks infection (e.g., from unwashed produce) in immunocompromised clients, requiring caution or cooking instead. Small, frequent meals align with evidence-based HIV care, optimizing calorie intake and nutrient absorption without overwhelming the digestive system, making it the most effective and safe intervention for this population.
A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care?
- A. Advise the client about increased dry mouth.
- B. Monitor the client for weight loss.
- C. Inform the client of the adverse effect of diarrhea.
- D. Check the client for increased hypopigmentation under the patch.
- E. Monitor for hypertension.
- F. Advise about insomnia.
- G. Check for tachycardia.
Correct Answer: A
Rationale: Dry mouth is a common side effect of clonidine; diarrhea and hypopigmentation aren't typical.
A nurse is reinforcing teaching about the care of a client who has tinea corporis with a newly licensed nurse. Which of the following should the nurse include in the teaching?
- A. Place on airborne precautions.
- B. Avoid direct contact.
- C. Isolate for 24 hr. after lesions appear.
- D. Administer a broad-spectrum antibiotic.
Correct Answer: B
Rationale: Avoiding direct contact prevents the spread of tinea corporis, a fungal infection. Airborne precautions and antibiotics are inappropriate, and isolation isn't required beyond contact precautions.
A nurse is assisting with the transfer of a client from a medical-surgical unit to an intensive care unit following a change in status. Which of the following information should the nurse include in the transfer documentation?
- A. Number of family members who have visited
- B. Primary health problem
- C. Admission vital signs from 1 week ago
- D. Scheduled times for dressing changes
- E. Current medication prescriptions
Correct Answer: B
Rationale: Transfer documentation ensures continuity of care, focusing on critical, current data for the receiving team. The primary health problem is essential it summarizes why the client's status changed (e.g., respiratory failure, sepsis), guiding ICU interventions. Number of family members who visited is irrelevant to clinical management; it's a social detail, not a priority. Admission vital signs from a week ago are outdated current vitals matter more, especially with a status change. Scheduled dressing changes are useful but secondary to understanding the underlying condition driving the transfer. Identifying the primary issue provides context for the client's deterioration, aligns with handoff standards like SBAR (Situation, Background, Assessment, Recommendation), and ensures the ICU team addresses the root cause immediately. This focus on relevance enhances patient safety, reduces miscommunication, and supports rapid response in a critical setting, making it the most vital piece of transfer information.