Nokea
Four clients are to receive medication. Which client should receive medication first?
- A. A client with an apical pulse of 72 receiving Lanoxin (digoxin) PO daily
- B. A client with abdominal surgery receiving Phenergan (promethazine) IM every 4 hours PRN for nausea and vomiting
- C. A client with labored respirations receiving a stat dose of IV Lasix (furosemide)
- D. A client with pneumonia receiving Polycillin (ampicillin) IVPB every 6 hours
Correct Answer: C
Rationale: A stat dose of Lasix for labored respirations indicates an urgent need to address potential pulmonary edema, prioritizing this client.
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To minimize confusion in the elderly hospitalized client, the nurse should:
- A. Provide sensory stimulation by varying the daily routine
- B. Keep the room brightly lit and the television on to provide orientation to time
- C. Encourage visitors to limit visitation to phone calls to avoid overstimulation
- D. Provide explanations in a calm, caring manner to minimize anxiety
Correct Answer: D
Rationale: Calm, clear explanations reduce anxiety and confusion in elderly clients, promoting orientation and comfort in the hospital setting.
A client in labor has an order for Demerol (meperidine) 75 mg. IM to be administered 10 minutes before delivery. The nurse should:
- A. Wait until the client is placed on the delivery table and administer the medication
- B. Question the order
- C. Give the medication IM during the delivery to prevent pain from the episiotomy
- D. Give the medication as ordered
Correct Answer: B
Rationale: Administering meperidine 10 minutes before delivery risks neonatal respiratory depression, so the nurse should question the order.
Upon entering the client's room the nurse discovers a dose of amoxicillin at the bedside. Which of the following should the nurse do?
- A. file an incident report and document the finding in the client's medical record
- B. document the finding in the client's medical record only
- C. report the incident to the nursing supervisor
- D. file an incident report but do not document the finding in the client's medical record
Correct Answer: A
Rationale: Documenting in the medical record and filing an incident report address the medication error and ensure follow-up for patient safety.
A client with a tracheostomy is exhibiting difficulty breathing, and respirations are increasingly noisy. Secretions are very thick. Which of the following initial interventions is most indicated?
- A. Increase humidification, and suction the tracheostomy tube.
- B. Notify the physician.
- C. Sit the client upright, and encourage the client to breathe deeply and cough.
- D. Gently irrigate and suction the tracheostomy tube.
Correct Answer: A
Rationale: Thick secretions causing noisy respirations and breathing difficulty indicate the need for increased humidification to thin secretions and suctioning to clear the tracheostomy tube (A). Notifying the physician (B) or encouraging coughing (C) is secondary, and irrigation (D) is not typically the initial step.
The physician has prescribed rantidine (Zantac) for a client with erosive gastritis. The nurse should administer the medication:
- A. 30 minutes before meals
- B. With each meal
- C. In a single dose at bedtime
- D. 60 minutes after meals
Correct Answer: C
Rationale: Ranitidine is most effective when taken at bedtime to suppress nocturnal acid production in erosive gastritis.