Nokea
For each potential action, click to specify if the action is indicated or contraindicated for the client.
- A. Allow the client to watch TV at a high volume.
- B. Ask the client about the content of their hallucinations
- C. Instruct the client on expected hygiene practices.
- D. Assess the client for suicidal ideation.
- E. Place the client in a room near the activity room
Correct Answer: B, C, D indicated; A, E contraindicated
Rationale: Correct Answer: B, C, D indicated; A, E contraindicated
Rationale:
1. B is indicated because asking about hallucinations can help assess the client's mental state.
2. C is indicated as maintaining hygiene is important for the client's well-being.
3. D is indicated to assess and address any suicidal ideation for client safety.
4. A is contraindicated as high TV volume can worsen auditory hallucinations.
5. E is contraindicated as placing near activity room may cause overstimulation and distress.
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A nurse is assessing a client who received hydromorphone 4 mg IV 15 min ago. The client has a respiratory rate of 10/min. The nurse should prepare to administer which of the following medications?
- A. Acetylcysteine
- B. Protamine
- C. Naloxone
- D. Flumazenil
Correct Answer: C
Rationale: The correct answer is C: Naloxone. Naloxone is an opioid antagonist used to reverse the effects of opioid overdose, such as respiratory depression. In this case, the client's respiratory rate of 10/min indicates opioid overdose due to hydromorphone. Naloxone administration can help reverse the respiratory depression and restore normal breathing.
Choice A: Acetylcysteine is used for acetaminophen overdose, not opioid overdose.
Choice B: Protamine is used to reverse the effects of heparin, not opioids.
Choice D: Flumazenil is a benzodiazepine antagonist, not an opioid antagonist.
Therefore, the most appropriate choice in this scenario is Naloxone to address the opioid overdose and respiratory depression.
A nurse is providing teaching about home safety to the adult child of an older adult client who is postoperative following hip replacement surgery. Which of the following instructions should the nurse include?
- A. Encourage the client to avoid wearing shoes at home.
- B. Place a throw rug over electrical cords
- C. Mark the edges of the doorway to the house with tape.
- D. Ensure that area rugs have rubber backs.
Correct Answer: D
Rationale: The correct answer is D: Ensure that area rugs have rubber backs. This instruction helps prevent slipping and falling, which is crucial for a postoperative hip replacement patient. Rubber-backed rugs provide stability and reduce the risk of accidents. Option A is incorrect as wearing shoes at home can increase the risk of falls. Option B is incorrect as placing a throw rug over electrical cords can lead to tripping hazards. Option C is incorrect as marking doorways with tape does not address home safety concerns for a postoperative patient.
A nurse is planning care for a client who has acute appendicitis. Which of the following actions should the nurse plan to take?
- A. Place the client's head of bed flat
- B. Apply heat to the client's abdomen
- C. Keep the client on NPO status
- D. Administer a laxative to the client.
Correct Answer: C
Rationale: The correct answer is C: Keep the client on NPO status. This is essential to prevent exacerbation of appendicitis by reducing the risk of bowel obstruction or rupture. Allowing the intestine to rest helps decrease inflammation and pain. Placing the client's head of bed flat (A) can increase intra-abdominal pressure, worsening the condition. Applying heat to the abdomen (B) can mask symptoms and potentially lead to delay in diagnosis. Administering a laxative (D) is contraindicated as it can increase the risk of perforation. In summary, maintaining NPO status is crucial for managing acute appendicitis effectively.
The nurse is initiating the client's plan of care. Which of the following interventions should the nurse plan to implement? Select all that apply
- A. Provide a low-stimulation environment
- B. Maintain bed rest
- C. Give antihypertensive medication.
- D. Administer betamethasone
- E. Monitor intake and output hourly
- F. Obtain a 24-hr urine specimen
- G. Perform a vaginal examination every 12 hr
Correct Answer: A, B, C, D, E, F
Rationale: Correct Answer: A, B, C, D, E, F
Rationale:
A: Providing a low-stimulation environment promotes rest and reduces stress.
B: Maintaining bed rest may be necessary for certain conditions to prevent complications.
C: Giving antihypertensive medication helps control blood pressure.
D: Administering betamethasone can be part of the treatment plan for certain conditions.
E: Monitoring intake and output hourly helps assess fluid balance and kidney function.
F: Obtaining a 24-hr urine specimen is a common diagnostic test to assess kidney function.
Summary:
Choice G is incorrect as performing vaginal examinations every 12 hours is unnecessary and invasive.
A nurse is preparing to initiate intravenous fluids via infusion pump for a client. Which of the following actions should the nurse take?
- A. Obtain a surge protector that can accommodate the pump and several other appliances
- B. Verify that the extension cord for the pump is ungrounded
- C. Report the pump has a frayed cord and proceed with the infusion
- D. Check the expiration date on the safety inspection sticker of the pump
Correct Answer: D
Rationale: The correct answer is D: Check the expiration date on the safety inspection sticker of the pump. This is crucial for ensuring the safety and efficacy of the pump. Checking the expiration date ensures that the pump has been recently inspected and is functioning properly, reducing the risk of malfunctions.
A: Obtaining a surge protector is important for electrical safety, but it is not directly related to the specific task of initiating intravenous fluids via an infusion pump.
B: Verifying that the extension cord is ungrounded is unsafe as it increases the risk of electrical hazards.
C: Reporting a frayed cord is essential for patient safety, but proceeding with the infusion without addressing the issue is dangerous.
E, F, G: No information provided.