Nokea
A patient refused a newly opened fentanyl patch. Which of the following actions should the nurse take?
- A. Ask another nurse to witness the disposal of the new patch
- B. Dispose of the patch in a sharps container
- C. Send the patch back to the pharmacy
- D. Document the refusal and remove the patch
Correct Answer: A
Rationale: When a patient refuses a newly opened fentanyl patch, the nurse should ask another nurse to witness the disposal of the new patch. This action ensures accountability, proper protocol, and prevents any potential diversion or misuse of the medication. Disposing of the patch in a sharps container (Choice B) is not sufficient as it does not address the need for witness accountability. Sending the patch back to the pharmacy (Choice C) may not be appropriate without proper documentation and witness. Simply documenting the refusal and removing the patch (Choice D) may lack the necessary verification of proper disposal.
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Which electrolyte imbalance is common in patients receiving diuretics?
- A. Hypokalemia
- B. Hypercalcemia
- C. Hyponatremia
- D. Hypermagnesemia
Correct Answer: A
Rationale: The correct answer is Hypokalemia. Diuretics, such as furosemide, commonly cause potassium loss in patients, leading to hypokalemia. This electrolyte imbalance should be closely monitored to prevent complications like cardiac arrhythmias. Hypercalcemia (Choice B) is not typically associated with diuretic use. Hyponatremia (Choice C) involves low sodium levels and can occur in conditions like syndrome of inappropriate antidiuretic hormone secretion (SIADH) but is not directly caused by diuretics. Hypermagnesemia (Choice D) is an excess of magnesium, usually not a common electrolyte imbalance induced by diuretics.
What is the appropriate nursing intervention for a patient experiencing a suspected stroke?
- A. Administer thrombolytics
- B. Perform a neurological assessment
- C. Perform a CT scan
- D. Administer oxygen
Correct Answer: B
Rationale: Performing a neurological assessment is the appropriate nursing intervention for a patient experiencing a suspected stroke. This assessment helps determine the severity of the stroke, identify potential deficits, and guide further interventions. Administering thrombolytics (Choice A) should only be done after a CT scan to confirm the type of stroke and rule out hemorrhagic stroke. Performing a CT scan (Choice C) is important but is typically done after stabilizing the patient. Administering oxygen (Choice D) is essential to maintain adequate oxygenation, but performing a neurological assessment takes precedence in the immediate management of a suspected stroke.
A nurse is planning care for a client who has a new prescription for a peripheral intravenous (IV) catheter. Which of the following actions should the nurse take to prevent infection?
- A. Shave the hair at the insertion site.
- B. Cleanse the site with povidone-iodine.
- C. Wear sterile gloves when changing the dressing.
- D. Change the IV site every 48 to 72 hours.
Correct Answer: D
Rationale: The correct action to prevent infection when caring for a client with a new peripheral IV catheter is to change the IV site every 48 to 72 hours. Shaving the hair at the insertion site can actually increase the risk of infection by causing microabrasions in the skin. While cleansing the site with povidone-iodine is important before insertion, it is not necessary to continue doing so once the IV is in place. Wearing sterile gloves when changing the dressing is crucial for maintaining aseptic technique but does not directly prevent infection related to the IV site itself.
A nurse is planning care for a client who has a stage 3 pressure injury. Which of the following interventions should the nurse include in the plan of care?
- A. Cleanse the wound with povidone-iodine solution daily.
- B. Irrigate the wound with hydrogen peroxide.
- C. Reposition the client every 4 hours.
- D. Use a moisture barrier ointment.
Correct Answer: D
Rationale: The correct answer is to use a moisture barrier ointment. This intervention helps protect the skin and promote healing in clients with stage 3 pressure injuries. Cleansing the wound with povidone-iodine solution daily (Choice A) can be too harsh and may delay healing by damaging the surrounding skin. Irrigating the wound with hydrogen peroxide (Choice B) is not recommended as it can be cytotoxic to healing tissue. While repositioning the client every 4 hours (Choice C) is an essential intervention in preventing pressure injuries, it is not directly related to the care of an existing stage 3 pressure injury.
A client with preeclampsia and postpartum hemorrhage is being cared for by a nurse. The nurse should recognize that which of the following medications is contraindicated?
- A. Methylergonovine
- B. Misoprostol
- C. Dinoprostone
- D. Oxytocin
Correct Answer: A
Rationale: The correct answer is A, Methylergonovine. Methylergonovine is contraindicated in clients with preeclampsia due to the risk of hypertension. Misoprostol (choice B), Dinoprostone (choice C), and Oxytocin (choice D) are appropriate medications for managing postpartum hemorrhage and are not contraindicated in clients with preeclampsia.