Nokea
The charge nurse is observing the new graduate administering a fentanyl (Duragesic) patch to a client diagnosed with cancer. Which action by the new graduate requires intervention by the charge nurse?
- A. The new graduate documents the date and time on the patch.
- B. The new graduate removes the patch 24 hours after it is placed on the client.
- C. The new graduate rotates the application site on the client's body.
- D. The new graduate checks the client's name band and date of birth.
Correct Answer: B
Rationale: Fentanyl patches last 72 hours; removing at 24 hours is incorrect and requires intervention. Dating, rotating sites, and ID checks are correct.
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An adult client had an abdominal hysterectomy this morning. Meperidine HCl (Demerol) 75 mg IM q3-4h PRN for pain is ordered. At 9:00 P.M., she complains of lower abdominal pain. She was last medicated at 5:45 P.M. What is the most appropriate initial action for the nurse to take?
- A. Offer her a bed pan and a back rub
- B. Reposition her
- C. Administer meperidine HCl 75 mg IM
- D. Encourage her to perform relaxation and breathing exercises
Correct Answer: C
Rationale: The last dose was over 3 hours ago, within the PRN order. Administering meperidine is appropriate for pain relief.
While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse's best response?
- A. As you urinate more, you will need less medication to control fluid.'
- B. You will have to take this medication for about a year.'
- C. The medication must be continued so the fluid problem is controlled.'
- D. Please talk to your health care provider about medications and treatments.'
Correct Answer: C
Rationale: The medication must be continued so the fluid problem is controlled.' This is the most therapeutic response and gives the client accurate information.
Keflex 250 mg PO q6h is ordered for an adult. The nurse notes that the client's history indicates that she has an allergy to penicillin. What is the most appropriate initial action for the nurse?
- A. Notify the physician
- B. Observe the client carefully after giving the medication
- C. Administer the Keflex IV instead of PO
- D. Ask the client to describe the reaction that she had to penicillin
Correct Answer: D
Rationale: There is often a cross-allergy between penicillin and cephalosporins like Keflex. The nurse should first determine the type of reaction to assess if Keflex is safe.
A woman with a 28 week pregnancy is on the way to the emergency department by ambulance with a tentative diagnosis of abruptio placenta. Which should the nurse do first when the woman arrives?
- A. administer oxygen by mask at 100%
- B. start a second IV with an 18 gauge cannula
- C. check fetal heart rate every 15 minutes
- D. insert urethral catheter with hourly urine outputs
Correct Answer: A
Rationale: administer oxygen by mask at 100%. Administering oxygen in this situation would increase the circulating oxygen in the mother's circulation to the fetus's circulation. This action will minimize complications.
To which client would the nurse question administering the osmotic diuretic mannitol (Osmitrol)?
- A. The client with 4+ pitting pedal edema.
- B. The client with decorticate posturing.
- C. The client with widening pulse pressure.
- D. The client with a positive doll's eye test.
Correct Answer: C
Rationale: Widening pulse pressure suggests increased intracranial pressure, a contraindication for mannitol due to potential brain herniation. Edema or neurological signs are indications.