Nokea
An 80-year-old client is receiving amikacin, an aminoglycoside antibiotic, IVPB every 12 hours. Which of the following data obtained
by the practical nurse is most important to report to the registered nurse before the client receives the next dose?
- A. client reports tinnitus
- B. Blood pressure 104/60 mm Hg
- C. urine output of 400 mL since last dose
Correct Answer: A
Rationale: Tinnitus may indicate ototoxicity, requiring immediate reporting. Low BP and urine output are less urgent without context of medication.
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During the interview of a prospective employee who just completed the agency orientation, which approach would be the best for the nurse manager to use to assess competence?
- A. What degree of supervision for basic care do you think you need?
- B. Let's review your skills check-list for type and level of skill
- C. Are you comfortable working independently?
- D. What client care tasks or assignments do you prefer?
Correct Answer: B
Rationale: The nurse needs to know that the employee has competence in certain tasks. One way to do this is to do mutual review of documented skills.
The nurse has received a prescription from the health care provider to administer 94 mg of methylprednisolone via IV push. The available vial contains 125 mg in 2 mL. Select the syringe containing the appropriate amount of medication to be administered.
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: C
Rationale: Calculate: 94 mg ÷ 125 mg/2 mL = 1.504 mL. Syringe 3 (typically 1.5 mL) is closest. Syringes 1, 2, and 4 are not specified but assumed incorrect volumes.
A client with hyperkalemia is to receive an infusion of $250 \mathrm{~mL}$ of $20% glucose with 20 units of regular insulin. The rationale for this therapy is:
- A. Potassium elimination is enhanced.
- B. Potassium binds with the glucose and is excreted by the kidneys.
- C. Glucose uptake by the cell drives the potassium into the cell.
- D. Insulin lowers the potassium by lowering blood glucose.
Correct Answer: C
Rationale: Insulin facilitates glucose uptake by cells, which drives potassium into cells, lowering serum potassium levels in hyperkalemia.
A client, admitted to the unit because of severe depression and suicidal threats, is placed on suicidal precautions. The nurse should be aware that the danger of the client committing suicide is greatest
- A. during the night shift when staffing is limited
- B. when the client's mood improves with an increase in energy level
- C. at the time of the client's greatest despair
- D. after a visit from the client's estranged partner
Correct Answer: B
Rationale: Suicide potential is often increased when there is an improvement in mood and energy level. At this time ambivalence is often decreased and a decision is made to commit suicide.
The health care provider (HCP) provides education to an adult client about an upcoming surgical procedure. The client states, 'I'm not clear on what is included in the low-fat diet that I'll be on after the cholecystectomy.' What action should the nurse take?
- A. Ask the client's family member to sign the consent form
- B. Inform the client that the HCP can discuss all questions after surgery
- C. Provide the client with educational materials about low-fat diet options
- D. Reinforce education about the procedure using a visual aid
Correct Answer: C
Rationale: Providing dietary education addresses the client's question directly. Family consent is inappropriate, postponing discussion delays clarification, and procedure education doesn't address diet.