Nokea
The client diagnosed with a bee sting allergy is being discharged from the emergency department. Which priority discharge instruction should be taught to the client?
- A. Demonstrate how to use an EpiPen, an adrenergic agonist.
- B. Teach the client to never go outdoors in the spring and summer.
- C. Have the client buy diphenhydramine over the counter to use when stung.
- D. Discuss wearing a Medic Alert bracelet when going outside.
Correct Answer: A
Rationale: EpiPen use is critical for managing anaphylaxis in bee sting allergies. Avoiding outdoors is impractical, diphenhydramine is secondary, and bracelets are supportive.
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The nurse in the holding area of the operating room is assessing the client prior to surgery. Which information warrants immediate intervention by the nurse?
- A. The client is able to mark the correct site for the surgery.
- B. The client can only tell the nurse about the surgery in lay terms.
- C. The client is allergic to iodine and does not have an allergy bracelet.
- D. The client has signed a consent form for surgery and anesthesia.
Correct Answer: C
Rationale: Missing an allergy bracelet for iodine risks exposure during surgery, requiring immediate intervention. Site marking, lay terms, and consent are appropriate.
The nurse is assessing a client diagnosed with RA. Which assessment findings warrant immediate intervention?
- A. The client complains of joint stiffness and the knees feel warm to the touch.
- B. The client has experienced one (1)-kg weight loss and is very tired.
- C. The client requires a heating pad applied to the hips and back to sleep.
- D. The client is crying, has a flat facial affect, and refuses to speak to the nurse.
Correct Answer: D
Rationale: Crying, flat affect, and refusal to speak suggest depression or suicidal ideation, requiring immediate intervention. Stiffness, weight loss, and heating pad use are expected in RA.
The nurse caring for a client diagnosed with Multi Organ Dysfunction Syndrome (MODS) is preparing to administer morning medications. Which medication would the nurse question?
- A. Cefazolin sodium IVPB every six (6) hours.
- B. Furosemide by mouth twice daily.
- C. Metoprolol IVP every four (4) hours and prn.
- D. Acetaminophen by mouth every four (4) hours prn.
Correct Answer: C
Rationale: Metoprolol IVP every 4 hours in MODS risks hypotension in cardiovascular dysfunction. Cefazolin, furosemide, and acetaminophen are appropriate.
The nurse is caring for a client diagnosed with Systemic Inflammatory Response syndrome after an extensive abdominal surgery. Which nursing interventions could prevent the development of Multi Organ Dysfunction Syndrome (MODS)?
- A. Place the client on strict intake and output.
- B. Administer pain medication via patient-controlled analgesia.
- C. Keep the head of the bed elevated at all times.
- D. Practice therapeutic communication.
Correct Answer: A
Rationale: Strict intake and output monitoring detects early renal dysfunction, preventing MODS progression. Pain control, head elevation, and communication are less specific.
The client is experiencing an anaphylactic reaction to bee venom. Which interventions should the nurse implement? List in order of priority.
- A. Establish a patent airway.
- B. Administer epinephrine, an adrenergic agonist, IVP.
- C. Start an IV with 0.9% saline.
- D. Teach the client to carry an EpiPen when outside.
- E. Administer diphenhydramine (Benadryl), an antihistamine, IVP.
Correct Answer: A,B,C,E,D
Rationale: Priority: 1) Airway (ABCs); 2) Epinephrine (reverse anaphylaxis); 3) IV fluids (support hemodynamics); 4) Diphenhydramine (reduce histamine effects); 5) EpiPen teaching (prevention).