Nokea
The doctor writes an order for piperacillin (Pipracil) 3 g IV q6h for an adult client.
Before administering this drug, the nurse should
- A. check for known allergies to medications.
- B. ensure that the client's respiratory rate is over 12.
- C. administer dexamethasone sodium phosphate (Decadron) 2 mg IV stat.
- D. check the client's blood pressure both sitting and standing.
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires assessment? Yes. Is there an appropriate assessment? Yes. (1) correct-assessment, piperacillin (Pipracil) is a semisynthetic broad-spectrum penicillin, should not be administered to clients with known allergies (2) assessment, not relevant for administration of this medication (3) implementation, not relevant for administration of this medication (4) assessment, not relevant for administration of this medication
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Which of the following symptoms is not indicative of autonomic dysreflexia in the client with a spinal cord injury?
- A. sudden onset of headache
- B. flushed face
- C. hypotension
- D. nasal congestion
Correct Answer: C
Rationale: Hypotension is not indicative of autonomic dysreflexia; rather, hypertension is a sign of autonomic dysreflexia.
A client with diabetes experiences Somogyi's effect. To prevent this complication, the nurse should instruct the client to:
- A. Take his insulin each day at 1400 hours
- B. Engage in physical activity daily
- C. Increase the amount of regular insulin
- D. Eat a protein and carbohydrate snack at bedtime
Correct Answer: D
Rationale: Somogyi's effect involves rebound hyperglycemia due to nighttime hypoglycemia. A bedtime snack with protein and carbohydrates prevents hypoglycemia. Options A, B, and C do not directly address this issue.
An adult is admitted with gastroenteritis. The physician has ordered prochlorperazine (Compazine) 10 mg PO tid PRN or prochlorperazine (Compazine) 5 mg suppository every 6 hours PRN and loperamide (Imodium) 2 mg PO PRN. The client has an episode of diarrhea and complains of nausea. What should the nurse administer?
- A. Prochlorperazine (Compazine) PO
- B. Loperamide (Imodium)
- C. Prochlorperazine (Compazine) PO and loperamide (Imodium)
- D. Prochlorperazine (Compazine) via suppository
Correct Answer: C
Rationale: Nausea and diarrhea warrant both prochlorperazine (anti-emetic) and loperamide (anti-diarrheal) orally, addressing both symptoms effectively.
An 85-year-old woman recovering from a fractured pelvis in a long-term care facility. The woman's activity order reads: ambulate with walker bid.
After the nurse implements the order, which of the following charting entries is BEST?
- A. Patient ambulated well with walker. States has no c/o stiffness or pain. Did not appear fatigued.'
- B. Ambulated without difficulty for 20 minutes. Vital signs remained stable. Color good.'
- C. Walked full length of hall with walker. No difficulty with balance. Using walker correctly.'
- D. Patient ambulated 60 feet independently with walker. Gait steady. Respirations 14 and unlabored.'
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) gives subjective information (2) gives judgments without objective information (3) information is not complete, contains some judgments without objective information (4) correct-gives objective information
The nurse is caring for a client with a history of cirrhosis who is receiving lactulose (Chronulac) 30 mL PO tid. Which of the following findings should the nurse report immediately?
- A. Ammonia level of 40 mcg/dL.
- B. Potassium 3.5 mEq/L.
- C. Diarrhea with 4 stools per day.
- D. Sodium 140 mEq/L.
Correct Answer: C
Rationale: Diarrhea with 4 stools per day suggests lactulose overdose, risking dehydration. Options A, B, and D are normal.