Nokea
As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to give the medication without first aspirating. What should the nurse do?
- A. Ask the student: 'What did you forget to do?'
- B. Stop. Tell me why aspiration is needed.
- C. Loudly state: 'You forgot to aspirate.'
- D. Walk up and whisper in the student's ear 'Stop. Aspirate. Then inject.'
Correct Answer: D
Rationale: This action is a direct threat to the client if the medication enters into the blood stream instead of the muscle. The purpose of aspiration with IM injections is to prevent the injection of the drug directly into the blood stream.
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An adult is admitted with a pneumothorax following an accident. Immediately after insertion of a chest tube, the client says to the nurse, 'Why do I have a tube in my chest and that thing hanging on the side of the bed? I don't like it.' What should the nurse include when replying to the client?
- A. Tell the client that the chest tube helps the client take bigger breaths
- B. Focus on the client's feelings
- C. Explain that the chest tube will remove air and/or fluid from the pleural cavity and allow the lung to reexpand
- D. Tell the client that the nurse will contact the physician to have it removed
Correct Answer: C
Rationale: The chest tube drains air/fluid from the pleural space, allowing lung re-expansion in pneumothorax, providing an accurate, educational response to the client's question.
A client is taking lithium for management of bipolar I disorder. The client's most recent serum lithium level is 0.8 mEq/L (0.8 mmol/L). Based on this result, what prescription does the nurse anticipate receiving from the health care provider?
- A. Continue at the current dose
- B. Decrease the dose
- C. Discontinue the medication
- D. Increase the dose
Correct Answer: D
Rationale: A lithium level of 0.8 mEq/L is low (therapeutic range: 1.0-1.5 mEq/L for acute mania). Increasing the dose is likely to achieve therapeutic levels.
Discharge medications
Aspirin: 81 mg by mouth, once daily
Clopidogrel: 75 mg by mouth, once daily
Rivaroxaban: 20 mg by mouth, once daily
Metoprolol: 25 mg by mouth, twice daily
Rosuvastatin: 20 mg by mouth, once daily
Lisinopril: 10 mg by mouth, once daily
A client with coronary artery disease and atrial fibrillation is being discharged home following coronary artery stent placement. Discharge medications are shown in the exhibit. The nurse identifies which educational topic as the highest priority to reinforce for this client?
- A. Bleeding risk
- B. Bronchospasm
- C. Muscle injury
- D. Tinnitus
Correct Answer: A
Rationale: Anticoagulants/antiplatelets for CAD/AF increase bleeding risk , the highest priority. Bronchospasm , muscle injury , and tinnitus are less relevant.
The nurse is caring for a client who has been started on sulfamethoxazole/trimethoprim for a urinary tract infection. It is most important for the nurse to follow up on which client statement?
- A. I go to the bathroom a lot more than usual
- B. It burns when I pee.
- C. My urine is cloudy
- D. There is a red rash on my abdomen.
Correct Answer: D
Rationale: A rash may indicate an allergic reaction, requiring urgent follow-up. Frequent urination , burning , and cloudy urine are UTI symptoms.
The nurse is caring for a 5-year-old client who is dehydrated and malnourished, and suspects that the client may be neglected. Which information most strongly supports the nurse's suspicion of child neglect?
- A. The parent cannot stay at the hospital due to potential job loss from absence
- B. The parent is in the process of a divorce and will soon be a single parent
- C. The parent is witnessed stealing food and drinks from the cafeteria
- D. The parent leaves the client's younger sibling to care for the client's newborn sibling
Correct Answer: D
Rationale: Leaving a young child to care for a newborn indicates inadequate supervision, supporting neglect. Job constraints , divorce , and stealing food suggest stress but not direct neglect.