Nokea
The LPN is taking care of a client with a documented allergy to Penicillin. After rounds, the PN notices that the client has an order for Cefazolin. Which of the following actions would be the least appropriate?
- A. The LPN clarifies the severity of the Penicillin allergy.
- B. The LPN discusses the order with the care team prior to administering Cefazolin.
- C. The LPN administers all ordered medications except for the Cefazolin.
- D. The LPN monitors the client after a test dose of Cefazolin is administered.
Correct Answer: C
Rationale: The LPN should clarify the order with the care team prior to determining the medication should not be given. Even though the client may have a potential reaction due to the Penicillin allergy, the therapeutic benefits of the antibiotic may outweigh the allergic reaction.
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The client has an order for an IV piggyback of Ceftriaxone 750 mg in 50 mL D5W to run over 30 minutes. What is the appropriate drip rate?
- A. 100 mL/hr
- B. 150 mL/hr
- C. 200 mL/hr
- D. 50 mL/hr
Correct Answer: A
Rationale: (50 mL / 30 min) × (60 min / 1 hr) = 100 mL/hr
The adolescent is brought to the ED with wheezing, nystagmus, ataxia, and sensorimotor neuropathy after inhaling paint thinner by “bagging.†Which nursing intervention is priority?
- A. Monitor the client's cardiac rhythm.
- B. Place the client on seizure precautions.
- C. Apply oxygen via nasal cannula at 4 liters.
- D. Notify lab to obtain a toxicology screen.
Correct Answer: C
Rationale: Applying oxygen is the priority to address wheezing and potential oxygen displacement from inhalant use.
The nurse is educating the client concerning the possible side effects of a newly prescribed traditional antipsychotic medication. Which client statement reflects a need for further education regarding the side effects of this classification of medication?
- A. I need to get up from bed slowly so I will not get dizzy.
- B. The medication can cause constipation, so I need to eat fiber.
- C. I may need a sleeping pill because insomnia is a possible side effect.
- D. I can't risk gaining weight, so I will need to add some exercise to my routine.
Correct Answer: C
Rationale: Drowsiness, not insomnia, is a common side effect of traditional antipsychotics, indicating a need for further teaching.
The initial treatment regimen of isoniazid, rifampin, and ethambutol is prescribed for the adolescent who has a positive tuberculin skin test. The client confides that she thinks she may be pregnant and asks if she should be taking these medications. Which rationale should be the basis for the nurse's response?
- A. These drugs cross the placental barrier, and treatment should be withheld until the postpartum period.
- B. The medications should be taken, but the diagnosis is an indication for termination of the pregnancy.
- C. The medications should be postponed because the risk for hepatitis is greatly increased in the intrapartum period.
- D. The medications should be taken; untreated TB represents a far greater hazard to the pregnant woman and her fetus.
Correct Answer: D
Rationale: A: The medications do not cross the placental barrier, so treatment should not be withheld. B: Administering antituberculosis medications would not be an indication for termination of pregnancy because the medications are safe during pregnancy. C: The risk of hepatitis is slightly increased with the use of antituberculosis medications in pregnant women; however, the benefits of treatment strongly outweigh postponement of treatment. D: Infants born to women with untreated TB may be of lower birth weight, but rarely would the infant acquire congenital TB. Isoniazid (Nydrazid), rifampin (Rifadin), and ethambutol (Myambutol) are all considered safe for use in pregnancy.
The client seeking treatment for insomnia tells the nurse about researching complementary therapies for promoting sleep. Which are herbal remedies for promoting sleep that the client may wish to discuss with the nurse?
- A. Fennel and ginger tea
- B. Chamomile tea and hops
- C. Feverfew and peppermint
- D. Echinacea and goldenseal
Correct Answer: B
Rationale: Chamomile tea and hops are believed to relieve insomnia.