Nokea
The client in end-stage renal disease is a Jehovah's Witness. The HCP orders erythropoietin (Epogen), a biologic response modifier, subcutaneously for anemia. Which action should the nurse take?
- A. Question this order because of the client's religion.
- B. Encourage the client to talk to his or her minister.
- C. Administer the medication subcutaneously as ordered.
- D. Obtain the informed consent prior to administering.
Correct Answer: C
Rationale: Epogen is synthetic, not blood-derived, so it’s acceptable for Jehovah’s Witnesses. Administer as ordered; questioning, minister consultation, or consent are unnecessary.
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Penicillin V potassium (Pen-Vee-K) 500 mg PO qid is ordered for an adult client. He reports that he took penicillin for the first time two months ago. What should the nurse do?
- A. Be sure that skin testing for a penicillin allergy has been done
- B. Observe for signs of an allergic response
- C. Withhold the penicillin
- D. Notify the physician
Correct Answer: B
Rationale: The client does not have a history of allergic response to penicillin, so there is no need to skin test or withhold the medication. However, allergic responses often occur after the first administration.
A young adult, 20 years old, who is hospitalized for the first time with schizophrenia, is receiving chlorpromazine (Thorazine) 75 mg PO tid. The client is to go home for a weekend pass. Which statement that the client makes indicates a need for nursing intervention?
- A. I won't drink any alcohol this weekend.
- B. It will be good to taste home-cooked food again.
- C. We plan to go dancing.
- D. I'm looking forward to a relaxing weekend at the beach.
Correct Answer: C
Rationale: Chlorpromazine causes orthostatic hypotension and photosensitivity. Dancing may exacerbate hypotension, requiring caution and education.
The 54-year-old female client with severe menopausal symptoms is prescribed hormone replacement therapy (HRT). Which secondary health screening activity should the nurse recommend for HRT?
- A. A Pap smear every six (6) months.
- B. A yearly mammogram.
- C. A bone density test every three (3) months.
- D. A serum calcium level monthly.
Correct Answer: B
Rationale: HRT increases breast cancer risk; yearly mammograms are recommended for screening, per ACOG guidelines. Other tests are not standard.
The male client comes to the emergency department and reports he stepped on a rusty nail at home about two (2) hours ago. Which question would be most important for the nurse to ask during the admission assessment?
- A. What have you used to clean the puncture site?
- B. Did you bring the nail with you so we can culture it?
- C. Do you remember when you had your last tetanus shot?
- D. Are you able to put any weight on your foot?
Correct Answer: C
Rationale: Tetanus risk is high with puncture wounds; knowing the last tetanus shot guides prophylaxis, the priority per CDC guidelines.
The client complains of leg cramps at night. Which medication should the nurse anticipate the HCP ordering to help relieve the leg cramps?
- A. Quinine, an antimalarial.
- B. Soma, a muscle relaxant.
- C. Ambien, a sedative-hypnotic.
- D. Darvon, an opioid analgesic.
Correct Answer: A
Rationale: Quinine is historically used for nocturnal leg cramps, though off-label due to risks. Muscle relaxants, sedatives, or opioids are less specific.