Nokea
A primigravida begins labor when her family is unavailable and she is alone. She is very upset that her family is not with her. Which approach can the nurse take to meet the client's needs at this time?
- A. asking whether another individual wants to be her support person
- B. assuring her that the nursing triage group will be with her at all times
- C. telling her you will try to locate her family
- D. reinforcing the woman's confidence in her own abilities to cope and maintain a sense of control
Correct Answer: A
Rationale: Allow the client to select another individual to give support. This allows her to have someone with her until her family can be with her.
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The nurse is administering a tap water enema when the client begins to complain of abdominal cramping. The nurse should:
- A. Stop the administration of the enema.
- B. Lower the height of the enema container.
- C. Clamp the enema tubing and withdraw it slowly.
- D. Advance the tubing 1-2 inches.
Correct Answer: B
Rationale: Lowering the enema container slows the flow, reducing cramping. Stopping or withdrawing the tubing is premature, and advancing may worsen discomfort.
Medication administration record
Allergies: None
Medications Time
Haloperidol: 5 mg PO, twice a day 0900, 2100
Hydrochlorothiazide: 25 mg PO, daily 0900
Omeprazole: 20 mg PO, daily 0900
Acetaminophen: 650 mg PO, PRN Every 6 hours
The nurse on the inpatient psychiatric unit is preparing to administer 9 AM medications to a client. On assessment, the client is exhibiting signs of neuroleptic malignant syndrome. Which of the following actions should the nurse take?
- A. Administer acetaminophen, hold the haloperidol and reassess in 30 minutes
- B. Administer all medications, including acetaminophen, and reassess in 30 minutes
- C. Hold the haloperidol and notify the health care provider (HCP) immediately
- D. Hold the hydroxyzine and notify the HCP immediately
Correct Answer: C
Rationale: Neuroleptic malignant syndrome is a life-threatening reaction to antipsychotics like haloperidol, requiring immediate cessation and provider notification. Acetaminophen, continuing medications, or holding hydroxyzine do not address the emergency.
The nurse is reviewing new medication prescriptions for a client who has a suspected brain tumor. The client is scheduled for a CT scan of the head with IV iodinated contrast in 24 hours. The nurse should clarify the prescription for
- A. gabapentin
- B. amlodipine
- C. metformin
- D. phenytoin
Correct Answer: C
Rationale: Metformin should be held before and after iodinated contrast due to the risk of lactic acidosis if contrast-induced kidney injury occurs. Gabapentin, amlodipine, and phenytoin are safe with contrast.
Which of the following is a common complaint of the client with end-stage renal failure?
- A. Weight loss
- B. Itching
- C. Ringing in the ears
- D. Bruising
Correct Answer: B
Rationale: Itching is common in end-stage renal failure due to uremia and phosphate accumulation. Weight loss , tinnitus , and bruising are less specific.
Laboratory Reference Ranges
Creatinine
Male: 0.6–1.3 mg/dL
(53–114.9 μmol/L)
Female: 0.5–1.2 mg/dL
(44.2–106.1 μmol/L)
The nurse is planning to assess 4 assigned clients. Which client situation is of greatest concern and warrants immediate assessment?
- A. Client scheduled for hemodialysis in an hour who has a serum creatinine level of 9.2 mg/dL (813 µmol/L) and refuses to take prescribed medications
- B. Client taking diphenhydramine for urticaria who reports difficulty urinating and increasing lower abdominal pain
- C. Client with an infected venous leg ulcer prescribed IV vancomycin who has a dressing saturated with yellow, foul-smelling drainage
- D. Client with an inguinal hernia who rates abdominal pain as 10 on a 0-10 scale and reports bloating, nausea, and vomiting
Correct Answer: D
Rationale: Severe pain (10/10) with bloating, nausea, and vomiting in an inguinal hernia suggests strangulation, a surgical emergency. High creatinine, urinary retention, and infected ulcers are urgent but less immediately life-threatening.