Nokea
The client tells the nurse she is having trouble falling asleep. What initial nursing action is least appropriate?
- A. Asking the physician for a sleeping medication
- B. Offering the client a back rub
- C. Asking the client if she is concerned about something
- D. Repositioning the client
Correct Answer: A
Rationale: Requesting sleeping medication is premature and least appropriate without exploring non-pharmacologic interventions like back rubs, addressing concerns, or repositioning, which promote sleep naturally.
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While sitting in the cafeteria, a nurse overhears two students discussing a client admitted for chemical detoxification. The nurse should:
- A. Report the incident to the teacher.
- B. Report the incident to the nursing supervisor.
- C. Confront the students with their behavior.
- D. Ignore the students' behavior.
Correct Answer: C
Rationale: Confronting the students addresses the breach of confidentiality directly and educates them. Reporting to the teacher or supervisor escalates unnecessarily, and ignoring the behavior allows the violation to persist.
Diltiazem (Cardizem) 90 mg qid is prescribed for an adult who has angina. Which statement by the client indicates a need for further instruction?
- A. I will take the pills before meals and at bedtime.
- B. I will call my physician if the pain gets worse than it has been.
- C. If my heart rate is less than 70, I will not take the pill.
- D. I will get up slowly when I stand up.
Correct Answer: C
Rationale: Diltiazem is not typically withheld based on heart rate alone unless specified; this indicates a need for clarification on administration instructions.
Which client event would be considered an adverse event and would require completion of an incident/event/irregular occurrence/variance report? Select all that apply.
- A. Administered 9.00 AM medication at 9.30 AM
- B. Developed worsening cellulitis after missing antibiotics for 1 day
- C. Has a seizure and a history of epilepsy
- D. Slides off the edge of the bed and ends up sitting on the floor
- E. Waits 4 hours to be transported for STAT diagnostic CT scan
Correct Answer: B,D,E
Rationale: Adverse events requiring an incident report include worsening cellulitis due to missed antibiotics , a fall even without injury , and a significant delay in a STAT procedure . Late medication administration is a variance but not typically an adverse event unless harm occurs, and a seizure in a known epileptic is expected unless protocol was not followed.
The doctor has prescribed imipramine (Tofranil) for an elderly client with endogenous depression. The nurse should give priority to assessing the client's:
- A. Fluid intake
- B. Cardiac status
- C. Respiratory effort
- D. Urinary output
Correct Answer: B
Rationale: Imipramine, a tricyclic antidepressant, can cause cardiac arrhythmias, especially in the elderly, making cardiac status assessment a priority.
The health care provider has told a client to take over-the-counter supplemental calcium carbonate 1000 mg/day for treatment of osteoporosis. Which instruction should the clinic nurse reinforce with the client?
- A. Monthly calcium levels will need to be drawn
- B. Stop vitamin D supplements when taking calcium
- C. Take calcium at bedtime
- D. Take calcium in divided doses with food
Correct Answer: D
Rationale: Taking calcium carbonate in divided doses with food enhances absorption and reduces GI upset. Monthly calcium levels are unnecessary, vitamin D should continue, and bedtime dosing is less effective.