Nokea
The client who has had a kidney transplant tells the nurse he has been taking St. John's wort, an herb, for depression. Which action should the nurse take first?
- A. Praise the client for taking the initiative to treat the depression.
- B. Remain nonjudgmental about the client's alternative treatments.
- C. Refer the client to a psychologist for counseling for depression.
- D. Instruct the client to quit taking the medication immediately.
Correct Answer: D
Rationale: St. John’s wort induces CYP3A4, reducing immunosuppressant efficacy (e.g., cyclosporine), risking transplant rejection. Stopping it is the priority.
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Keflex 250 mg PO q6h is ordered for an adult. The nurse notes that the client's history indicates that she has an allergy to penicillin. What is the most appropriate initial action for the nurse?
- A. Notify the physician
- B. Observe the client carefully after giving the medication
- C. Administer the Keflex IV instead of PO
- D. Ask the client to describe the reaction that she had to penicillin
Correct Answer: D
Rationale: There is often a cross-allergy between penicillin and cephalosporins like Keflex. The nurse should first determine the type of reaction to assess if Keflex is safe.
The client is in end-stage renal disease and is receiving sodium polystyrene sulfonate (Kayexalate) via an enema. Which data indicate the medication is effective?
- A. The client has 30 mL/hr of urine output.
- B. The serum phosphorus level has decreased.
- C. The client is in normal sinus rhythm.
- D. The client's serum potassium level is 5 mEq/L.
Correct Answer: D
Rationale: Kayexalate lowers serum potassium in hyperkalemia; a level of 5 mEq/L (normal) indicates effectiveness. Urine, phosphorus, or rhythm are unrelated.
The nurse is administering a topical ointment to the client's rash on the right leg. Which intervention should the nurse implement first?
- A. Don nonsterile gloves.
- B. Cleanse the client's right leg.
- C. Check the client's armband.
- D. Wash the hands for 15 seconds.
Correct Answer: D
Rationale: Hand washing is the first step to prevent infection, per aseptic technique. Gloves, cleansing, or armband checks follow.
A young woman delivered a 7-lb, 8-oz baby boy spontaneously. Ergotrate 0.4 mg q6h for five days is ordered. A half-hour after the nurse administers the first dose, she complains of abdominal cramping. The nurse's best response is based on which understanding?
- A. Cramping indicates a serious adverse reaction.
- B. Cramping can be reduced by abdominal breathing.
- C. The medication is having the desired effect.
- D. The dosage needs to be reduced.
Correct Answer: C
Rationale: Ergotrate causes uterine contractions, leading to cramping, which is the intended effect to prevent postpartum hemorrhage.
The nurse is assessing the elderly client first thing in the morning. The client is confused and sleepy. Which intervention should the nurse implement first?
- A. Determine if the client received a sedative last night.
- B. Allow the client to continue to sleep and do not disturb.
- C. Encourage the client to ambulate in the room with assistance.
- D. Notify the health-care provider about the client's status.
Correct Answer: A
Rationale: Sedatives are a common cause of morning confusion in the elderly; determining recent administration guides next steps.