Nokea
The elderly client is in a long-term care facility. If the client does not have a daily bowel movement in the morning, he requests a cathartic, bisacodyl (Dulcolax). Which action is most important for the nurse to take?
- A. Ensure the client gets a cathartic daily.
- B. Discuss the complications of a daily cathartic.
- C. Encourage the client to increase fiber in the diet.
- D. Refuse to administer the medication to the client.
Correct Answer: B
Rationale: Daily cathartics risk dependence and electrolyte imbalance; discussing complications educates and promotes safer alternatives like fiber.
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The 68-year-old client is admitted to the emergency department with complaints of slurred speech, right-sided weakness, and ataxia. The emergency department physician ordered thrombolytic therapy for the client. Which action should the nurse implement first?
- A. Administer thrombolytic therapy via protocol.
- B. Send the client for a STAT CT of the head.
- C. Arrange for admission to the intensive care department.
- D. Check to determine if the client is cross sensitive to the thrombolytic.
Correct Answer: B
Rationale: A STAT head CT rules out hemorrhagic stroke, a contraindication for thrombolytics, and is the first step per stroke guidelines.
The nurse is hanging 1,000 mL of IV fluids to run for eight (8) hours. The intravenous tubing is a microdrip. How many gtt/min should the IV rate be set?
Correct Answer: 15
Rationale: Microdrip is 60 gtt/mL. Rate: (1,000 mL / 8 hr) x (60 gtt/mL / 60 min) = 125 mL/hr x 1 gtt/min = 15.625 gtt/min, rounded to 15 gtt/min.
The client with type 2 diabetes is diagnosed with gout and prescribed allopurinol (Zyloprim). Which instruction should the nurse discuss when teaching about this medication?
- A. The client will probably develop a red rash on the body.
- B. The client should drink two (2) to three (3) liters of water a day.
- C. The client should take this medication on an empty stomach.
- D. The client will need to increase oral diabetic medications.
Correct Answer: B
Rationale: Allopurinol increases uric acid excretion, risking kidney stones; 2–3 L water daily prevents this. Rash is possible but not probable, stomach timing is flexible, and diabetes meds are unaffected.
The health care provider has written 'Morphine sulfate 2 mgs IV every 3-4 hours prn for pain' on the chart of a child weighing 22 lb. (10 kg). What is the nurse's initial action?
- A. Check with the pharmacist
- B. Hold the medication and contact the provider
- C. Administer the prescribed dose as ordered
- D. Give the dose every 6-8 hours
Correct Answer: B
Rationale: Hold the medication and contact the provider. The usual pediatric dose of morphine is 0.1 mg/kg every 3 to 4 hours. At 10 kg, this child typically should receive 1.0 mg every 3 to 4 hours.
The nurse is caring for a client who is receiving procainamide (Pronestyl) intravenously. It is important for the nurse to monitor which of the following parameters?
- A. Hourly urinary output
- B. Serum potassium levels
- C. Continuous EKG readings
- D. Neurological signs
Correct Answer: C
Rationale: Continuous EKG readings. Procainamide (Pronestyl) is used to suppress cardiac arrhythmias. When administered intravenously, it must be accompanied by continuous cardiac monitoring by ECG.