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 is showing ventricular ectopy, and the HCP orders amiodarone (Cordarone) intravenously. Which interventions should the nurse implement? Select all that apply.
- A. Monitor telemetry continuously.
- B. Assess the client's respiratory status.
- C. Evaluate the client's liver function studies.
- D. Confirm the original order with another nurse.
- E. Prepare to defibrillate the client at 200 joules.
Correct Answer: A,B,C
Rationale: Telemetry monitors dysrhythmias, respiratory status tracks amiodarone’s pulmonary toxicity risk, and liver studies monitor hepatotoxicity. Order confirmation is unnecessary, and defibrillation is unrelated.
The nurse administered an IV broad-spectrum antibiotic scheduled every six (6) hours to the client with a systemic infection at 0800. At 1000, the culture and sensitivity prompted the HCP to change the IV antibiotic. When transcribing the new antibiotic order, when would the initial dose be administered?
- A. Schedule the dose for 1400.
- B. Schedule the dose for the next day.
- C. Check with the HCP to determine when to start.
- D. Administer the dose within one (1) hour of the order.
Correct Answer: D
Rationale: New antibiotic orders for active infections require prompt administration (within 1 hour) to maintain therapeutic levels, per sepsis guidelines.
You are caring for a hypertensive client with a new order for captopril (Capoten). Which information should the nurse include in client teaching?
- A. Avoid green leafy vegetables
- B. Restrict fluids to 1000 cc/day
- C. Avoid the use of salt substitutes
- D. Take the medication with meals
Correct Answer: C
Rationale: Avoid the use of salt substitutes. Captopril can cause an accumulation of potassium or hyperkalemia. Clients should avoid the use of salt substitutes, which are generally potassium-based.
The client in the intensive care department has a nasogastric tube for continuous feedings. The nurse is preparing to administer nifedipine (Procardia XL) via the N/G tube. Which procedure should the nurse follow?
- A. Crush the medication and dissolve it in water.
- B. Administer and flush the N/G tube with cranberry juice.
- C. Give the medication orally with pudding.
- D. Do not administer the medication and notify the HCP.
Correct Answer: D
Rationale: Procardia XL is extended-release and cannot be crushed or given via NG tube; HCP notification is needed for an alternative form.
The 54-year-old female client with severe menopausal symptoms is prescribed hormone replacement therapy (HRT). Which secondary health screening activity should the nurse recommend for HRT?
- A. A Pap smear every six (6) months.
- B. A yearly mammogram.
- C. A bone density test every three (3) months.
- D. A serum calcium level monthly.
Correct Answer: B
Rationale: HRT increases breast cancer risk; yearly mammograms are recommended for screening, per ACOG guidelines. Other tests are not standard.