Nokea
The male client comes to the emergency department and reports he stepped on a rusty nail at home about two (2) hours ago. Which question would be most important for the nurse to ask during the admission assessment?
- A. What have you used to clean the puncture site?
- B. Did you bring the nail with you so we can culture it?
- C. Do you remember when you had your last tetanus shot?
- D. Are you able to put any weight on your foot?
Correct Answer: C
Rationale: Tetanus risk is high with puncture wounds; knowing the last tetanus shot guides prophylaxis, the priority per CDC guidelines.
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The client in end-stage renal disease is a Jehovah's Witness. The HCP orders erythropoietin (Epogen), a biologic response modifier, subcutaneously for anemia. Which action should the nurse take?
- A. Question this order because of the client's religion.
- B. Encourage the client to talk to his or her minister.
- C. Administer the medication subcutaneously as ordered.
- D. Obtain the informed consent prior to administering.
Correct Answer: C
Rationale: Epogen is synthetic, not blood-derived, so it’s acceptable for Jehovah’s Witnesses. Administer as ordered; questioning, minister consultation, or consent are unnecessary.
A 60-year-old client has been hospitalized for deep vein thrombosis. The client is to be discharged on warfarin (Coumadin) 5 mg PO daily. Which statement that the client makes indicates the best understanding of the medication routine?
- A. I will take aspirin for my arthritis.
- B. I love to eat spinach salads.
- C. I will get a blood test next week.
- D. I made an appointment to have my teeth pulled.
Correct Answer: C
Rationale: Warfarin requires regular INR monitoring via blood tests to ensure therapeutic anticoagulation levels.
The client is receiving thrombolytic therapy for a diagnosed myocardial infarction (MI). Which assessment data indicate the therapy is successful?
- A. The client's ST segment is becoming more depressed.
- B. The client is exhibiting reperfusion dysrhythmias.
- C. The client's cardiac isoenzyme CK-MB is not elevated.
- D. The D-dimer is negative at two (2) hours post-MI.
Correct Answer: B
Rationale: Reperfusion dysrhythmias (e.g., PVCs) indicate restored coronary flow, a sign of thrombolytic success. ST depression, normal CK-MB, or D-dimer are not specific.
Penicillin V potassium (Pen-Vee-K) 500 mg PO qid is ordered for an adult client. He reports that he took penicillin for the first time two months ago. What should the nurse do?
- A. Be sure that skin testing for a penicillin allergy has been done
- B. Observe for signs of an allergic response
- C. Withhold the penicillin
- D. Notify the physician
Correct Answer: B
Rationale: The client does not have a history of allergic response to penicillin, so there is no need to skin test or withhold the medication. However, allergic responses often occur after the first administration.
A woman is two months pregnant when her 5-year-old child develops rubella. What is most likely to be given to her?
- A. Immune serum globulin
- B. MMR
- C. RhoGam
- D. Rubella antitoxin
Correct Answer: A
Rationale: Immune serum globulin may be given to reduce the risk of rubella infection in the pregnant woman, protecting the fetus.