Nokea
A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make?
- A. I can start the medication 30 minutes earlier.
- B. I can adjust the time and schedule for when its convenient for you.
- C. I can infuse the medication at a faster rate.
- D. I have up to 2 hours after the usual schedule time to give you this medication.
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Vancomycin is typically given at specific intervals to maintain therapeutic levels in the bloodstream.
2. Giving the medication 2 hours earlier may lead to suboptimal drug levels.
3. Answer D allows flexibility within the recommended dosing schedule.
4. Answers A, B, and C compromise the effectiveness and safety of vancomycin administration.
5. Option D ensures the medication is given within an appropriate timeframe.
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A nurse is assessing a client who is undergoing radiation therapy for breast cancer. Which of the following findings is an indication to the nurse that the client is experiencing an adverse effect of the therapy?
- A. Skin changes
- B. Hypertension
- C. Diarrhea
- D. Increased white blood cell count
Correct Answer: A
Rationale: The correct answer is A: Skin changes. This is because skin changes, such as redness, irritation, or peeling, are common adverse effects of radiation therapy. The skin over the treated area may become sensitive and may develop a sunburn-like appearance. This indicates that the radiation is affecting the skin cells. Hypertension (B), diarrhea (C), and increased white blood cell count (D) are not typically associated with adverse effects of radiation therapy for breast cancer. Hypertension may be related to stress or other factors, diarrhea could be due to other causes, and an increased white blood cell count is not a typical adverse effect of radiation therapy.
A nurse is monitoring a client following a lumbar laminectomy. The client has a drain and indwelling urinary catheter. The nurse should identify which of the following findings as an indication of a complication of the surgery?
- A. Red-tinged drainage on the dressing
- B. Cloudy urine in the catheter
- C. Clear drainage on the dressings
- D. Mild back pain at the surgical site
Correct Answer: C
Rationale: The correct answer is C: Clear drainage on the dressings. Clear drainage may indicate a cerebrospinal fluid leak, which is a serious complication following a lumbar laminectomy. Cerebrospinal fluid is a clear fluid that surrounds the brain and spinal cord, and its leakage can lead to infection and other complications. Red-tinged drainage (choice A) may be expected initially due to surgical trauma. Cloudy urine in the catheter (choice B) is more likely related to urinary tract infection. Mild back pain at the surgical site (choice D) is common after this surgery and does not necessarily indicate a complication.
A nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions should the nurse implement to decrease the clients risk for ventilator-associated pneumonia (VAP)? (Select all that apply.)
- A. Wear a protective gown when suctioning the clients airway.
- B. Monitor for oral secretions every 2 hr.
- C. Provide oral care every 2 hr.
- D. Maintain the client in a supine position.
- E. Assess the client daily for readiness of extubation.
Correct Answer: B, C, E
Rationale: Correct Answer: B, C, E
Rationale:
- Monitoring for oral secretions every 2 hr helps prevent aspiration of secretions, reducing the risk of VAP.
- Providing oral care every 2 hr reduces the bacterial load in the mouth, decreasing the risk of VAP.
- Assessing the client daily for readiness of extubation allows for timely removal of the ventilator, reducing the duration of ventilation and lowering the risk of VAP.
Incorrect Choices:
- Wearing a protective gown when suctioning the client's airway does not directly decrease the risk of VAP.
- Maintaining the client in a supine position may increase the risk of aspiration and VAP.
A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of type 1 diabetes?
- A. Ketones in the urine
- B. Weight gain
- C. Hypotension
- D. Decreased hunger
Correct Answer: A
Rationale: The correct answer is A: Ketones in the urine. In type 1 diabetes, the body cannot produce insulin, leading to high blood sugar levels and breakdown of fats for energy, resulting in ketones in the urine. Weight gain (B) is unlikely as type 1 diabetes is associated with weight loss. Hypotension (C) is not a typical manifestation. Decreased hunger (D) is more commonly seen in type 2 diabetes.
A nurse in a long-term care facility is caring for a client who has dementia. Which of the following actions should the nurse take?
- A. Encourage the client to eat independently with utensils.
- B. Provide finger food at mealtime.
- C. Feed the client only pureed foods.
- D. Offer the client fluids only between meals.
Correct Answer: B
Rationale: The correct answer is B: Provide finger food at mealtime. This option is appropriate for a client with dementia as it promotes independence and encourages self-feeding, which can help maintain their dignity and autonomy. Finger foods are easy to handle and reduce the risk of frustration or confusion that may arise from using utensils. Encouraging self-feeding also helps stimulate cognitive function and maintain motor skills.
A: Encouraging the client to eat independently with utensils may be challenging and frustrating for someone with dementia.
C: Feeding the client only pureed foods may not be necessary if the client is able to eat regular food safely.
D: Offering fluids only between meals may lead to dehydration, especially for clients who may forget to ask for fluids when needed.