Nokea
All of the following individuals live at home with their families. Which of the following persons is least at risk for abuse?
- A. An 82-year-old woman who is incontinent and bosses people around
- B. An 80-year-old man who is ambulatory with help following a brain attack
- C. A 78-year-old woman who asks for help with all of her activities of daily living
- D. A 75-year-old man who wanders at night and frequently yells out
Correct Answer: B
Rationale: The ambulatory man with minimal dependency is least likely to be abused, as he retains some independence. Incontinence, high dependency, or disruptive behavior increase vulnerability.
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The nurse is preparing to administer the fourth dose of vancomycin IVPB to a client with infective endocarditis. Which intervention should the nurse anticipate?
- A. Starting a new IV line before the administration
- B. Administering an antiemetic PRN prior to the infusion
- C. Administering medication via an infusion pump over at least 30 minutes
- D. Obtaining a serum trough level 15-30 minutes before the administration of vancomycin
Correct Answer: D
Rationale: Vancomycin requires therapeutic drug monitoring to ensure efficacy and prevent toxicity. Obtaining a serum trough level 15-30 minutes before the fourth dose (D) is standard to guide dosing adjustments. A new IV line (A) is unnecessary unless the current line is compromised. Antiemetics (B) are not routinely needed. Infusion over 60 minutes (C) is typical to prevent red man syndrome, not 30 minutes.
The nurse has reinforced teaching about formula preparation with the parent of a newborn. Which of the following statements by the parent would indicate a correct understanding of the teaching? Select all that apply.
- A. I should avoid using the microwave to heat my baby's formula.
- B. I must wash the top of the concentrated formula can before opening it.
- C. If my baby is feeding poorly, I should use less water to dilute the formula.
- D. Prepared formula should be kept in the refrigerator and discarded after 24 hours.
- E. Bottled water does not need to be boiled when used to reconstitute powdered formula.
Correct Answer: A,B,D
Rationale: Microwaving (A) can cause uneven heating, risking burns, so it’s avoided. Washing the can top (B) prevents contamination. Refrigerated formula must be discarded after 24 hours (D) to prevent bacterial growth. Diluting less (C) alters nutrition, and bottled water (E) may need boiling depending on safety, indicating incorrect understanding.
A nurse prepared the 9:00 A.M. medications for his clients and then was called off the unit briefly before he was able to administer them. Who may administer the medications to the clients now?
- A. Any licensed nurse assigned to the unit and familiar with the clients
- B. A pharmacy technician certified to administer medications
- C. The nurse who prepared them
- D. The nurse manager of the unit
Correct Answer: C
Rationale: The nurse who prepared the medications must administer them to ensure accountability and familiarity with the preparation.
A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help the woman alleviate these symptoms?
- A. Drink small amounts of liquids frequently
- B. Eat the evening meal just before retiring
- C. Take sodium bicarbonate and water after each meal
- D. Sleep with head propped on several pillows
Correct Answer: D
Rationale: Sleep with head propped on several pillows. Heartburn is a burning sensation caused by regurgitation of gastric contents. It is best relieved by sleeping position, eating small meals, and not eating before bedtime.
A client is brought to the emergency room following a motor vehicle accident. When assessing the client one-half hour after admission, the nurse notes several physical changes. Which finding would require the nurse's immediate attention?
- A. increased restlessness
- B. tachycardia
- C. tracheal deviation
- D. tachypnea
Correct Answer: C
Rationale: tracheal deviation. The deviated trachea is a sign that a mediastinal shift has occurred. This is a medical emergency.