Nokea
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.
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The graduate nurse (GN) is reinforcing education on sitting on and standing up from a chair to a client with crutches. Which instruction by the GN would cause the supervising nurse to intervene?
- A. Hold a crutch in each hand for support when standing up from a chair
- B. Move to the edge of the chair before standing and use the unaffected leg to rise
- C. Touch the back of the unaffected leg to the chair before preparing to sit
- D. Use an armrest or seat for assistance when lowering the body into a chair
Correct Answer: A
Rationale: Holding a crutch in each hand is incorrect as crutches should be placed together on the unaffected side or against a stable surface to free the hands for support when standing. Other instructions (B, C, D) are correct for safe crutch use during sitting and standing.
A new graduate nurse is administering enoxaparin to a client. Which action indicates the need for further orientation by the nurse preceptor?
- A. Discourages the client from rubbing the injection site
- B. Ejects air bubble that is in the syringe prior to administration
- C. Inserts needle and injects medication at a 90-degree angle
- D. Selects an injection site on the left lateral side of the abdomen
Correct Answer: B
Rationale: Ejecting the air bubble in an enoxaparin syringe is incorrect, as the bubble ensures complete dose delivery and prevents leakage. Other actions (A, C, D) are correct for subcutaneous administration.
The nurse prepares equipment for insertion of a large bore nasogastric (NG) tube for a hospitalized client. Which actions should the nurse take to measure and mark the tube? Select all that apply.
- A. Fold tube in half and mark at the halfway point
- B. Extend tape measure from naris to stomach
- C. Measure from tip of nose to earlobe to xiphoid process
- D. Place a small piece of tape at the point of measurement
- E. Use rubber clamp after measuring to mark the point of measurement
Correct Answer: C,D
Rationale: To measure an NG tube, measure from nose to earlobe to xiphoid process for approximate insertion depth and mark with tape . Folding in half is inaccurate, measuring to stomach is vague, and rubber clamps are not standard.
An adult client in an acute care setting asks the nurse to show him his hospital records. The nurse's response should reflect which understanding?
- A. The client has no right to see his records without a court order.
- B. The client must have the physician's approval before he can see his records.
- C. The client has the right to see his records and to have information explained when necessary.
- D. The client must ask permission to view his records from the medical records department and must appear before a special committee.
Correct Answer: C
Rationale: HIPAA grants clients the right to access their medical records and receive explanations, ensuring transparency. Court orders, physician approval, or committees are not required.
The clinic nurse is reinforcing teaching to a client who has been prescribed transdermal scopolamine to prevent motion sickness during an upcoming vacation on a cruise ship. Which of the following statements made by the nurse are appropriate? Select all that apply.
- A. Apply the patch when the ship starts moving and not before.'
- B. Dispose of the patch out of reach of children and pets.'
- C. Ensure that the old patch is removed before applying a new one.'
- D. Place the patch on a hairless, clean, dry area behind the ear.'
- E. Wash your hands with soap and water after handling the patch.'
Correct Answer: B,C,D,E
Rationale: Appropriate scopolamine instructions include safe disposal , removing old patches , correct placement , and hand washing . Applying the patch only when moving is incorrect, as it should be applied hours before travel.