Nokea
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.
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Which of the following is the BEST method for the nurse to use when evaluating the effectiveness of tracheal suctioning?
- A. Note subjective data, such as 'My breathing is much improved now.'
- B. Note objective findings, such as decreased respiratory rate and pulse.
- C. Consult with the respiratory therapist to determine effectiveness.
- D. Auscultate the chest for change or clearing of adventitious breath sounds.
Correct Answer: D
Rationale: to assess the effectiveness of suctioning, auscultate the client's chest to determine if the adventitious sounds are cleared and to ensure that the airway is clear of secretions.
Two new admissions to the unit. One of the new admissions is diagnosed with pneumonia, and the other new patient is diagnosed with AIDS.
Which of the following assignments is MOST appropriate?
- A. Assign both patients to one room with one nurse caring for both patients.
- B. Place both patients in the same room and assign the care to different nurses.
- C. Assign each patient to a private rooms and assign both clients to one nurse.
- D. Place each client in a private room and assign each patient to a different nurse.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) increases the potential for transmission of infection (2) keeps the clients in the same room; should not be done (3) puts them in separate rooms but same nurse is caring for them (4) correct-to prevent spread of infection, clients should have private rooms with different nurses
The nurse is discussing nutritional requirements with the parents of an 18 month-old child. Which of these statements about milk consumption is correct?
- A. May drink as much milk as desired
- B. Can have milk mixed with other foods
- C. Will benefit from fat-free cow's milk
- D. Should be limited to 3-4 cups of milk daily
Correct Answer: D
Rationale: Should be limited to 3-4 cups of milk daily. Excessive milk intake can reduce consumption of other nutrients.
A client has fludrocortisone acetate (Florinef) prescribed. What blood tests should the nurse monitor when administering this drug?
- A. Liver function tests
- B. Renal function tests
- C. Serum electrolytes
- D. Complete blood count
Correct Answer: C
Rationale: Fludrocortisone, a mineralocorticoid, affects sodium and potassium balance, requiring monitoring of serum electrolytes to detect imbalances like hypernatremia or hypokalemia.
The nurse is performing physical assessments on adolescents. What finding would the nurse anticipate concerning female growth spurts?
- A. They occur about 2 years earlier than for males.
- B. They begin about the same time for males.
- C. They begin just prior to the onset of puberty.
- D. They are characterized by an increase in height of 4 inches each year.
Correct Answer: A
Rationale: They occur about 2 years earlier than for males. Females experience a growth spurt about 2 years earlier than their male peers.