Nokea
A client has orders for cefoxitin (Mefoxin) 2 g IV piggyback in 100 cc 5% dextrose in water. The primary IV is 5% dextrose in lactated Ringer's and is infusing by gravity.
It is MOST important for the nurse to take which of the following actions?
- A. Administer the medication slowly, at 25-25 cc/h.
- B. Change the primary IV solution.
- C. Hang the piggyback infusion bag higher than the primary infusion bag.
- D. Obtain an infusion pump prior to administration.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) antibiotic should be administered within one hour (2) unnecessary for safe infusion (3) correct-when using a gravity drip, piggyback fluid level needs to be higher than primary infusion (4) unnecessary for safe infusion
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A client who is withdrawing from alcohol says to the nurse, 'There are snakes on the wall.' Which action should the nurse take initially?
- A. Reassure the client that there are no snakes
- B. Turn the lights on brighter
- C. Tell the client that while he may see snakes, there are really no snakes
- D. Reassure the client that the snakes will not hurt him
Correct Answer: C
Rationale: Acknowledging the hallucination (delirium tremens) as perceived but clarifying reality reduces agitation without confrontation. Reassurance or lighting changes are less effective.
A client who has overdosed on a large quantity of diazepam (Valium).
Which of the following nursing actions should take priority during the first several days of this client's inpatient treatment?
- A. Complete a full psychiatric assessment.
- B. Get in touch with the client's family to involve them in treatment.
- C. Observe and record vital signs frequently, including neurological symptoms.
- D. Determine whether this client may need long-term therapy after this hospitalization.
Correct Answer: C
Rationale: Strategy: Think Maslow. (1) psychosocial, can be done after the client has been medically stabilized (2) psychosocial, can be done after the client has been medically stabilized (3) correct-physical, because of potentially life-threatening complications of depressant overdose such as respiratory failure, pulmonary edema, and seizures, nurse's priority is observation and documentation of vital signs (4) psychosocial, can be done after the client has been medically stabilized
The nurse is caring for a client who is receiving a continuous IV infusion of propofol (Diprivan) for sedation. Which of the following findings should the nurse report immediately?
- A. Respiratory rate of 12 breaths/min.
- B. Blood pressure of 100/60 mmHg.
- C. Heart rate of 80 bpm.
- D. Oxygen saturation of 90%.
Correct Answer: D
Rationale: An oxygen saturation of 90% indicates hypoxemia, a serious propofol side effect. Options A, B, and C are acceptable.
The nurse is caring for a client with a history of hemophilia.
- A. Which intervention is most important for a client with hemophilia experiencing joint pain?
- B. Administer factor replacement therapy.
- C. Apply warm compresses to the joint.
- D. Encourage active range-of-motion exercises.
- E. Administer oral analgesics.
Correct Answer: A
Rationale: Factor replacement therapy stops bleeding in hemophilia, relieving joint pain from hemarthrosis. Cold compresses are used, exercise worsens bleeding, and analgesics are supportive.
A 23-year-old man comes to the AIDS clinic for treatment of large, painful, purplish-brown open areas on his right arm and back.
The nurse should instruct the client to
- A. clean the area carefully with soap and warm water every day and cover them with a sterile dressing.
- B. soak in a warm tub twice a day and rub the areas with a washcloth before covering them.
- C. shower daily using a mild antimicrobial soap from a pump dispenser and leave the lesions uncovered.
- D. clean the lesions twice a day with a diluted solution of povidone-iodine (Betadine) and leave them open to the air.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-open Kaposi's sarcoma lesions should be cleaned and dressed daily to prevent secondary infection (2) not done because of risk of secondary skin infection (3) important to keep the skin clean to prevent secondary skin infection but should be covered due to open areas (4) treatment for herpes simplex virus abscess, not Kaposi's sarcoma