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The client is being treated with intravenous Vancomycin for MRSA when the nurse notes redness of the client's neck and chest. Place in ordered sequence the actions to be taken by the nurse:
- A. Call the doctor.
- B. Stop the IV infusion of Vancomycin.
- C. Administer Benadryl as ordered.
- D. Take the vital signs.
Correct Answer: B,D,C,A
Rationale: Redness suggests an allergic reaction or 'red man syndrome' from rapid vancomycin infusion. The nurse should: stop the infusion to prevent further reaction, take vital signs to assess severity, administer Benadryl if ordered, and call the doctor for further orders.
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The nurse is caring for a client with tuberculosis. Which precautions should the nurse take when providing care for this client? Select all that apply:
- A. Wear gloves when handling tissues containing sputum
- B. Wear a face mask at all times
- C. Keep the client in strict isolation
- D. When the client leaves the room for tests, have all people in contact with him wear a mask
- E. Keep the client's door open to allow fresh air into room and prevent social isolation
- F. Wash hands after direct contact with the client or contaminated articles
Correct Answer: A,B,F
Rationale: The nurse should always wear gloves when handling items contaminated with sputum or body secretions. All staff and visitors must wear face masks when coming in contact with the client in his room; masks must be discarded before leaving the client's room. Hand washing is required after direct contact with the client or contaminated articles. Strict isolation isn't required if the client adheres to special respiratory precautions. The client, not the people in contact with him, must wear a mask when leaving the room for tests. The client should be in a negative-pressure, private room, and the door should remain closed at all times to prevent the spread of infection.
When a client needs oxygen therapy, what is the highest flow rate that oxygen can be delivered via nasal cannula?
- A. 2 liters/minute
- B. 4 liters/minute
- C. 6 liters/minute
- D. 8 liters/minute
Correct Answer: C
Rationale: The maximum flow rate for a nasal cannula is 6 liters/minute to avoid drying nasal passages and discomfort. Higher rates require a mask. Reduction of Risk Potential
Marie is a 38-year-old primigravida who is admitted with a diagnosis of pregnancy induced hypertension (PIH).
Priority nursing care on the patient with PIH include:
- A. Urinary protein, 2 grams/24hous.
- B. HR 110 bpm.
- C. Urine output 335 ml/24 hours.
- D. Patellar reflex positive.
Correct Answer: C
Rationale: Low urine output (335 ml/24 hours) indicates possible renal involvement in PIH, a priority for monitoring and reporting to prevent further complications.
A client with Anemia has been prescribed liquid iron. Which would the nurse expect to be included in the teaching plan?
- A. Take the medication through a straw.
- B. Administer this drug mixed with coffee.
- C. The drug causes the urine to turn black.
- D. The drug must be stored in the refrigerator.
Correct Answer: A
Rationale: Liquid iron should be administered through a straw to prevent dental staining. Answers B, C, and D are not correct instructions for taking liquid iron, so they are incorrect.
The nurse prepares a 25-year-old woman for a cesarean section. The patient says she had major surgery several years ago and asks if she will receive a similar 'shot' before surgery. The nurse's response should be based on an understanding that the preoperative medication given before a cesarean section
- A. contains a lower overall dosage of medication than is given before general surgery.
- B. contains reduced amounts of sedatives and hypnotics than are given before general surgery.
- C. contains reduced amounts of narcotics than are given before general surgery.
- D. contains medications similar in type and dosages to those given before general surgery.
Correct Answer: C
Rationale: Preoperative medications for cesarean sections typically include reduced amounts of narcotics to minimize the risk of respiratory depression in the newborn, as narcotics cross the placental barrier. Sedatives and hypnotics are used in similar doses as in general surgery, and the overall dosage is not necessarily lower.