Nokea
The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration, the nurse should:
- A. Utilize an infusion pump
- B. Check the blood glucose level
- C. Place the client in Trendelenburg position
- D. Cover the solution with foil
Correct Answer: B
Rationale: Diazoxide can cause hyperglycemia, so monitoring blood glucose levels is essential during administration.
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The nurse is caring for a Muslim client who is recovering from an automobile accident and is unable to cleanse herself after a bowel movement. Which of the following should the nurse do to show respect for the woman's cultural and religious beliefs?
- A. Use the left hand to cleanse the client's rectal area.
- B. Ask a female family member to assist the client.
- C. Wear gloves when cleansing the client's rectal area.
- D. Ask the client's husband to assist the client.
Correct Answer: B
Rationale: In Islamic culture, hygiene after defecation is important, and female clients may prefer assistance from female family members (B) to maintain modesty. The left hand (A) is traditionally used by the client, not the nurse. Gloves (C) are standard but not cultural. The husband (D) may not be appropriate due to modesty.
A client receiving Vancocin (vancomycin) has a serum level of 20 mcg/mL. The nurse knows that the therapeutic range for vancomycin is:
- A. 5-10 mcg/mL
- B. 10-25 mcg/mL
- C. 25-40 mcg/mL
- D. 40-60 mcg/mL
Correct Answer: B
Rationale: The therapeutic range for vancomycin is 10-25 mcg/mL, ensuring efficacy while minimizing toxicity; a level of 20 mcg/mL is within this range.
The nursing team includes two RNs, one LPN/LVN, and one nursing assistant. The nurse should consider the assignments appropriate if the nursing assistant is assigned to care for
- A. a client with Alzheimer’s requiring assistance with feeding.
- B. a client with osteoporosis complaining of burning on urination.
- C. a client with scleroderma receiving a tube feeding.
- D. a client with cancer who has Cheyne-Stokes respirations.
Correct Answer: A
Rationale: standard, unchanging procedure
During the assessment of a laboring client, the nurse notes that the FHT are loudest in the upper-right quadrant. The infant is most likely in which position?
- A. Right breech presentation
- B. Right occipital anterior presentation
- C. Left sacral anterior presentation
- D. Left occipital transverse presentation
Correct Answer: A
Rationale: Fetal heart tones loudest in the upper-right quadrant suggest a breech presentation, with the fetus's heart higher in the uterus.
A 57-year-old male with a history of vasculitis has purple discolorations on his legs, each approximately 0.3 cm to 1 cm in size. He asks the nurse what these discolorations are called, and the nurse correctly calls them
- A. ecchymosis.
- B. purpura.
- C. petechia.
- D. bruises.
Correct Answer: B
Rationale: Purpura are purple discolorations 0.3-1 cm, often seen in vasculitis due to small vessel bleeding. Petechiae are smaller (<0.3 cm), and ecchymosis is larger (>1 cm).