Nokea
A nurse who fails to check a client's armband before administering his medications is:
- A. Negligent.
- B. Following standard procedure.
- C. Acting within their scope of practice.
- D. Exercising professional judgment.
Correct Answer: A
Rationale: Failing to check a client's armband before administering medications is negligent, as it violates patient safety protocols for verifying identity.
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The nurse is working on a birthing unit that has several unlicensed assistive personnel (UAP). The nurse determines that the UAP understands the type of information to report to the nurse when the UAP reports which of the following about one of the clients?
- A. An episode of nausea after administration of an epidural anesthetic.
- B. Contractions 3 minutes apart and lasting 40 seconds.
- C. Scream of spontaneous rupture of the membranes.
- D. Sleeping after administration of I.V. nalbuphine (Nubain).
Correct Answer: A,C
Rationale: Nausea after an epidural and spontaneous rupture of membranes are significant events requiring nurse assessment due to potential complications. Contractions and sleeping are expected findings.
A newborn diagnosed with respiratory distress syndrome (RDS) is prescribed surfactant replacement therapy. The nurse evaluates the infant 1 hour after the therapy and determines that the infant's condition has improved somewhat. Which finding indicates improvement?
- A. An audible respiratory grunt
- B. Slight increase in the respiratory rate
- C. Arterial blood pH increases to ≥ 7.35
- D. Fine inspiratory crackles heard over both lungs
Correct Answer: C
Rationale: RDS causes hypoperfusion with hypoxemia that results in tissue hypoxia and metabolic acidosis. If the arterial blood pH increases to ≥ 7.35, the metabolic acidosis is resolving and the newborn's condition is improving. Within a few hours, respiratory distress becomes more obvious in RDS. The respiratory rate continues to increase (to 80 to 120 breaths/min), so a gradual increase in rate does not mean that the condition is improving. Also, an audible respiratory grunt and fine inspiratory crackles heard over both lungs are not signs the condition is improving.
A client with a history of asthma reports increased wheezing. Which medication should the nurse prepare to administer?
- A. Prednisone.
- B. Albuterol.
- C. Montelukast.
- D. Cromolyn sodium.
Correct Answer: B
Rationale: Albuterol, a short-acting beta-agonist, is the first-line treatment for acute asthma exacerbations to relieve bronchospasm.
A client with a history of Addison's disease is prescribed hydrocortisone. Which instruction should the nurse include?
- A. Take it on an empty stomach
- B. Double the dose during stress
- C. Stop it if weight gain occurs
- D. Take it at bedtime only
Correct Answer: B
Rationale: Doubling hydrocortisone during stress (e.g., illness) prevents adrenal crisis in Addison's disease, mimicking the body's natural cortisol response.
A client who is recovering from transurethral resection of the prostate (TURP) experiences urinary incontinence. He tells the nurse that he has decreased his fluid intake because of the incontinence. What would be the nurse's best response to the client?
- A. Yes, limiting your fluids can decrease your incontinence.'
- B. Limiting your fluids will cause kidney stones.'
- C. I think eight glasses of water a day and urinate every 2 hours.'
- D. If your incontinence continues, we will reinsert your catheter.'
Correct Answer: C
Rationale: Encouraging adequate fluid intake (eight glasses) and scheduled voiding (every 2 hours) helps manage incontinence and maintain urinary health post-TURP.