Nokea
A nurse is stuck in the hand by an exposed used hypodermic needle. What immediate action should the nurse take?
- A. Look up the policy on needle sticks
- B. Contact employee health services
- C. Immediately wash the hands with vigor
- D. Notify the supervisor and risk management
Correct Answer: C
Rationale: The immediate action of vigorously washing will help remove possible contamination. Then the sequence would be to notify the supervisor, look up the policy, and contact employee health services.
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Which information should be given to a client taking Dilantin (phenytoin)?
- A. Taking the medication with meals will increase its effectiveness
- B. The medication can cause sleep disturbances
- C. More frequent dental appointments will be needed for special gum care
- D. The medication decreases the effects of oral contraceptives
Correct Answer: C
Rationale: Phenytoin can cause gingival hyperplasia, necessitating more frequent dental visits for gum care.
The nurse is caring for a client who has right-sided weakness and has been told to use a cane for walking. Which action by the client indicates that he can use a cane correctly?
- A. He holds the cane in his right hand and moves the cane with the right leg when walking.
- B. He moves the cane from hand to hand when walking.
- C. He carries the cane in his left hand and moves it at the same time he moves his right foot.
- D. He puts the cane forward and then moves the left foot forward followed by the right foot.
Correct Answer: C
Rationale: Holding the cane in the left (unaffected) hand and moving it with the right (weak) leg provides support, indicating correct use.
A woman is in the clinic complaining of urinary frequency, urgency, and pain on urination. Orders include a urine for culture and administration of sulfisoxazole (Gantrisin) and phenazopyridine (Pyridium.) Which action should the nurse take first?
- A. Obtain a clean catch urine from the client.
- B. Ask the client if she is allergic to sulfa drugs.
- C. Administer the sulfisoxazole (Gantrisin).
- D. Administer the phenazopyridine (Pyridium).
Correct Answer: B
Rationale: Checking for sulfa allergies is critical before administering sulfisoxazole, as allergies can cause severe reactions, prioritizing safety.
When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse’s actions during this intervention?
- A. The restraints/seclusion policies set forth by the institution.
- B. The patient’s competence.
- C. The patient’s voluntary/involuntary status.
- D. The patient’s nursing care plan.
Correct Answer: C
Rationale: The need for restraints is based on the patient’s behavior and safety risks, not their voluntary or involuntary admission status. Institutional policies, patient competence, and the care plan guide restraint use to ensure safety and compliance with legal and ethical standards.
The nurse is caring for a client with a history of seizures who is receiving phenytoin (Dilantin) 100 mg PO tid. Which of the following client statements would be of GREATest concern to the nurse?
- A. I brush my teeth twice a day.
- B. I take my medication with milk.
- C. I have a rash on my arms.
- D. I feel drowsy in the morning.
Correct Answer: C
Rationale: A rash may indicate a hypersensitivity reaction to phenytoin, potentially progressing to severe conditions like Stevens-Johnson syndrome, requiring immediate evaluation. Options A, B, and D are less concerning: brushing teeth is routine, milk does not affect absorption, and drowsiness is a common side effect.