Nokea
Right documentation includes the name, dosage, route, and time of administration. When should you sign your initials on the medication administration record?
- A. Immediately before the dose is given
- B. Immediately after the dose has been given
- C. Immediately before the dose is given, in the medication room
- D. Within one hour after administering the medication
Correct Answer: B
Rationale: Signing immediately after administration confirms the dose was given, ensuring accurate documentation. Signing before risks errors, and waiting an hour delays accuracy.
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Ron is 4-year-old child being discharge to home after an uneventful tonsillectomy.
The nurse would suggest that the appropriate car seat for the child is
- A. the rear-facing seat.
- B. the front facing seat.
- C. the booster seat with car seat belt.
- D. the back seat.
Correct Answer: C
Rationale: A booster car seat is appropriate for a bigger child like a 4-year-old, ensuring proper restraint and safety.
The nurse is performing an assessment of the motor function in a client with a head injury. The best technique is
- A. touching the trapezius muscle or arm firmly
- B. pinching any body part
- C. shaking a limb vigorously
- D. rubbing the sternum
Correct Answer: D
Rationale: rubbing the sternum. The purpose is to assess the non-responsive client's reaction to a painful stimulus after less noxious methods have been tried.
The nurse understands that an acute attack of pancreatitis can be precipitated by heavy drinking because:
The nurse understands that an acute attack of pancreatitis can be precipitated by heavy drinking because:
- A. Alcohol promoted the formation of calculi in the cystic duct.
- B. The pancreas is stimulated to secrete more insulin than it can immediately produce.
- C. The alcohol alters the composition of enzymes so they are capable of damaging the pancreas.
- D. Alcohol increases enzyme secretion and pancreatic duct pressure and causes backflow of enzymes into the pancreas.
Correct Answer: D
Rationale: Alcohol causes enzyme backflow, leading to pancreatic autodigestion.
The physician has ordered IV replacement of potassium for a patient with severe hypokalemia.
The nurse would administer the IV potassium
- A. by rapid bolus.
- B. diluted in 100 cc over 1 hour.
- C. diluted in 10 cc over 10 minutes.
- D. IV push.
Correct Answer: B
Rationale: Potassium is diluted and infused slowly to prevent cardiac arrhythmias.
The nurse is preparing to discharge a client who is receiving Nardil (phenelzine). The nurse should tell the client to:
- A. Wear protective clothing and sunglasses outside.
- B. Avoid medications containing pseudoephedrine.
- C. Drink six to eight glasses of water a day.
- D. Avoid foods that are high in purine.
Correct Answer: B
Rationale: Drug interactions between an MAOI and pseudoephedrine can result in hypertensive crisis. Answer A refers to the client receiving antipsychotic medications such as Thorazine, so it is incorrect. Answers C and D do not apply to MAOIs, so they are incorrect.