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An LPN is taking care of an elderly client who experiences the effects of Sundowner's Syndrome almost every evening. Which of these interventions implemented by the nurse would be the most helpful?
- A. Place a nightlight in the client's room.
- B. Administer the PRN sedative prescribed by the attending physician.
- C. Remind the client the things and people they are seeing are not real and that they are safe.
- D. Turn on the TV or radio to a station the client enjoys.
Correct Answer: A
Rationale: A nightlight will help reorient the client to his or her surroundings in the evening and nighttime hours. It is best not to challenge the reality of a client experiencing Sundowner's Syndrome, and sedatives may make the effects of the syndrome worse. Every effort should be made to keep the client's room calm, quiet, and peaceful, so noise should be kept to a minimum.
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The nurse telephones the HCP to request a pm anxiolytic medication order for a hospitalized client having occasional anxiety. Which medication, if prescribed, should the nurse question regarding its effectiveness for prn use?
- A. Buspirone
- B. Lorazepam
- C. Clorazepate
- D. Clonazepam
Correct Answer: A
Rationale: Buspirone (BuSpar) has a 10- to 14-day delay in therapeutic onset, making it unsuitable for prn use.
The client is prescribed medications on hospital admission. Four days later the client's serum creatinine level, which was normal at admission, is now 3.7 mg/dL. The nurse should contact the HCP regarding a dosage change for which medication?
- A. Ceftriaxone
- B. Insulin glargine
- C. Diltiazem
- D. Furosemide
Correct Answer: A
Rationale: A: The nurse should contact the HCP regarding ceftriaxone (Rocephin). Ceftriaxone, a third-generation cephalosporin antibiotic, is 33% to 67% excreted in the urine unchanged. Dosage reduction or increased dosing interval is recommended in renal insufficiency because ceftriaxone is nephrotoxic and can further damage the kidneys. B: Insulin glargine (Lantus) is partially metabolized at the site of injection to active insulin metabolites and partially metabolized by the liver, the spleen, the kidney, and muscle tissue; no dose reduction is necessary unless serum glucose levels fluctuate. C: Diltiazem (Cardizem) is mostly metabolized by the liver; no dose reduction is necessary. D: Furosemide (Lasix) is 30% to 40% metabolized by the liver with some nonhepatic metabolism and renal excretion as unchanged medication; no dose reduction is necessary.
Which of the following injuries, if demonstrated by a client entering the Emergency Department, is the highest priority?
- A. open leg fracture
- B. open head injury
- C. stab wound to the chest
- D. traumatic amputation of a thumb
Correct Answer: C
Rationale: A stab wound to the chest might result in lung collapse and mediastinal shift that, if untreated, could lead to death. Treatment of an obstructed airway or a chest wound is a higher priority than hemorrhage. The principle of ABC (airway, breathing, and circulation) prioritizes care decisions.
The client has an order for an IV piggyback of Ceftriaxone 750 mg in 50 mL D5W to run over 30 minutes. What is the appropriate drip rate?
- A. 100 mL/hr
- B. 150 mL/hr
- C. 200 mL/hr
- D. 50 mL/hr
Correct Answer: A
Rationale: (50 mL / 30 min) × (60 min / 1 hr) = 100 mL/hr
Which spot is the safest place to administer an IM injection to an infant? Select the correct corresponding letter from the attached graphic.
- A. C
- B. B
- C. A
- D. D
Correct Answer: B
Rationale: The vastus lateralis muscle, highlighted by the letter B, should be used in infants as the muscle tends to be thickest in this area.