Nokea
A postoperative client has three different PRN analgesics prescribed for different levels of pain. The nurse inadvertently administers a dose that is not within the prescribed parameters. What actions should the nurse take first?
- A. Assess for side effects of the medication.
- B. Document the client's responses.
- C. Complete a medication error report.
- D. Determine if the pain was relieved.
Correct Answer: A
Rationale: This is a medication error, and the first step in addressing it is to assess for any side effects of the medication on the patient. Some analgesics can cause respiratory depression, so it is crucial to monitor for vital sign changes or respiratory distress. Once the patient is stable, the next steps would include contacting the provider, documenting the response, and completing a medication error report. Choices B, C, and D are not the immediate priority when dealing with a medication error. While documenting the client's responses and completing a medication error report are important, assessing for side effects and ensuring patient safety come first.
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The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider?
- A. Oral temperature of 100.1°F
- B. Serum sodium level of 138 mEq/L (138 mmol/L)
- C. Gradually decreasing level of consciousness (LOC)
- D. Weight gain of 2 pounds (1 kg) above the admission weight
Correct Answer: C
Rationale: The priority assessment finding for the nurse to report to the healthcare provider is a gradually decreasing level of consciousness (LOC). This change in LOC could indicate fluid and electrolyte disturbances, which require immediate attention to prevent complications. While the other options such as an elevated temperature, serum sodium level, and weight gain are important to note and report, they do not indicate an urgent need for intervention compared to changes in LOC which could signify serious issues that need prompt evaluation and management.
A male client with unstable angina needs a cardiac catheterization. So the healthcare provider explains the risks and benefits of the procedure and then leaves to set up for the procedure. When the nurse presents the consent form for signature, the client hesitates and asks how the wires will keep his heart going. Which action should the nurse take?
- A. Answer the client's specific questions with a short, understandable explanation
- B. Postpone the procedure until the client understands the risks and benefits
- C. Call the client's next of kin and ask them to provide verbal consent
- D. Page the healthcare provider to return and provide additional explanation
Correct Answer: D
Rationale: The correct action for the nurse to take in this situation is to page the healthcare provider to return and provide additional explanation. It is crucial for the client to have a clear understanding of the procedure, including its risks and benefits, before signing the consent form. While the nurse can provide general information, the detailed explanation of how the procedure works and its effects should come from the healthcare provider who will perform the procedure. Postponing the procedure until the client understands is appropriate, but the immediate need is to clarify the client's concerns with the healthcare provider. Calling the client's next of kin for verbal consent is not the correct course of action as the client is present and able to provide consent after receiving adequate information.
The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?
- A. Blood pressure is 90/40 mm Hg.
- B. Urine output is 30 mL over the last hour.
- C. Oral fluid intake is 100 mL over the last 8 hours.
- D. There is prolonged skin tenting over the sternum.
Correct Answer: A
Rationale: The correct answer is A: "Blood pressure is 90/40 mm Hg." A low blood pressure reading of 90/40 mm Hg indicates that the patient may be developing hypovolemic shock due to intravascular fluid loss from the burn injury. This finding is of utmost concern as it suggests systemic hypoperfusion, requiring immediate intervention to prevent complications. Choices B, C, and D also indicate signs of dehydration and the need to increase fluid intake; however, they are not as urgent as addressing the hypotension and potential shock presented in choice A.
A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor while the patient is receiving this infusion?
- A. Lung sounds
- B. Urinary output
- C. Peripheral pulses
- D. Peripheral edema
Correct Answer: A
Rationale: The correct answer is A: Lung sounds. Hypertonic solutions like 3% NaCl can cause water retention, leading to fluid excess. Monitoring lung sounds is crucial as crackles may indicate pulmonary edema, a serious manifestation of fluid excess. While monitoring urinary output, peripheral pulses, and peripheral edema are also important when administering hypertonic solutions, they do not provide immediate clues to acute respiratory or cardiac decompensation like lung sounds.
A patient with renal failure has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. The patient arrives for outpatient hemodialysis and is unresponsive to questions and has decreased deep tendon reflexes. Which action should the dialysis nurse take first?
- A. Notify the patient's health care provider.
- B. Obtain an order to draw a potassium level.
- C. Review the magnesium level on the patient's chart.
- D. Teach the patient about the risk of magnesium-containing antacids
Correct Answer: A
Rationale: The health care provider should be notified immediately. The patient has a history and manifestations consistent with hypermagnesemia. The nurse should check the chart for a recent serum magnesium level and make sure that blood is sent to the laboratory for immediate electrolyte and chemistry determinations. Dialysis should correct the high magnesium levels. The patient needs teaching about the risks of taking magnesium-containing antacids. Monitoring of potassium levels also is important for patients with renal failure, but the patient's current symptoms are not consistent with hyperkalemia.