Nokea
A nurse is providing discharge instructions to a client who has a new prescription for haloperidol. Which of the following adverse effects should the nurse instruct the client to report to the provider?
- A. Shuffling gait
- B. Increased salivation
- C. Mild drowsiness
- D. Weight gain
Correct Answer: A
Rationale: The correct answer is A: Shuffling gait. This is a potential extrapyramidal side effect of haloperidol, a typical antipsychotic. It is important to report this to the provider as it may indicate a serious adverse reaction called tardive dyskinesia. Increased salivation (choice B) and mild drowsiness (choice C) are common side effects that may resolve on their own. Weight gain (choice D) is more commonly associated with atypical antipsychotics. Choices E, F, and G are not provided.
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Which of the following statements by a client indicates an understanding of the teaching?
- A. I should take antibiotics when I have a virus.
- B. I can visit my nephew who has chickenpox 5 days after the sores have crusted.
- C. I should avoid cleaning my cat's litter box during pregnancy.
- D. I do not need to get the flu vaccine while I am pregnant.
Correct Answer: C
Rationale: The correct answer is C: "I should avoid cleaning my cat's litter box during pregnancy." This statement shows an understanding of the teaching because cleaning a cat's litter box can expose a pregnant person to toxoplasmosis, a harmful parasite that can cause complications during pregnancy. Avoiding this task is a precautionary measure recommended to protect the health of the mother and the unborn child.
Explanation of why other choices are incorrect:
A: "I should take antibiotics when I have a virus." - Antibiotics are not effective against viruses, so this statement shows a misunderstanding of when antibiotics should be used.
B: "I can visit my nephew who has chickenpox 5 days after the sores have crusted." - Chickenpox is highly contagious, so visiting someone with active chickenpox can put the pregnant person at risk.
D: "I do not need to get the flu vaccine while I am pregnant." - The flu vaccine is recommended during pregnancy to protect both the pregnant
Which of the following clients should the nurse instruct the AP to report to the nurse?
- A. A client who has a prescription for compression stockings and did not receive them.
- B. A client who requests assistance in ambulating to the restroom.
- C. A client who ate 50% of their lunch tray.
- D. A client whose blood pressure is 88/52 mmHg.
Correct Answer: D
Rationale: The correct answer is D. A blood pressure of 88/52 mmHg is considered hypotensive and requires immediate attention. The nurse should instruct the AP to report this vital sign reading to the nurse for further assessment and intervention to prevent complications such as hypoperfusion to vital organs. Choices A, B, and C do not pose immediate life-threatening risks and can be addressed during routine care. Choice D stands out as the priority due to the potential for serious consequences if not addressed promptly.
Which of the following actions is appropriate for the nurse to take?
- A. Add medication directly to enteral feeding
- B. Dissolve the medication together
- C. Use a syringe to allow the medications to flow by gravity
- D. Flush the NG tube with 5 ml water
Correct Answer: D
Rationale: The correct answer is D: Flush the NG tube with 5 ml water. This action is appropriate because flushing the NG tube with water helps prevent clogging and ensures proper medication administration. Adding medication directly to enteral feeding (choice A) can lead to tube clogging. Dissolving medications together (choice B) can alter their effectiveness. Using a syringe to allow medications to flow by gravity (choice C) may not be sufficient for complete administration. Flushing the NG tube with water (choice D) maintains tube patency. No further choices provided.
Which of the following actions should the nurse plan to take?
- A. Place the clients head of bed flat
- B. apply heat to the client's abdomen
- C. keep the client on NPO status
- D. administer A laxative to the client
Correct Answer: C
Rationale: The correct answer is C: keep the client on NPO status. This is the correct action as it means "nothing by mouth," which is often necessary before certain medical procedures or surgeries to prevent aspiration. Choice A is incorrect as elevating the head of the bed reduces the risk of aspiration. Choice B is incorrect as heat application may not be indicated and could potentially worsen the client's condition. Choice D is incorrect as administering a laxative may not be appropriate without a proper assessment.
The nurse should identify the cardiac rhythm as which of the following?
- A. Ventricular asystole
- B. Second-degree heart block
- C. Sinus Tachycard
- D. Atrial fibrillation
Correct Answer: D
Rationale: The correct answer is D: Atrial fibrillation. In atrial fibrillation, the atria quiver instead of contracting effectively, leading to an irregular and rapid heart rate. This can be identified on an ECG by the absence of distinct P waves and irregular R-R intervals. Ventricular asystole (A) is the absence of ventricular contractions, second-degree heart block (B) is characterized by intermittent conduction block between the atria and ventricles, and sinus tachycardia (C) is a regular rapid heart rate originating from the sinus node.