Nokea
The nurse administers a dose of acetaminophen to the wrong client. Which of the following actions is the most appropriate after notifying the physician?
- A. Notify her supervisor and complete an incident report.
- B. Ask the physician for an order of acetaminophen to cover the inadvertent administration.
- C. Take no further action because acetaminophen is relatively benign.
- D. Document in the client's record that an error in drug administration occurred.
Correct Answer: A
Rationale: Medication errors require notifying the supervisor and completing an incident report (A) to ensure proper follow-up and system improvements. Retroactively obtaining an order (B) is unethical, assuming acetaminophen is benign (C) is unsafe, and documenting the error in the client's record (D) is inappropriate.
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The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client?
- A. Roast beef sandwich, potato chips, pickle spear, iced tea
- B. Split pea soup, mashed potatoes, pudding, milk
- C. Tomato soup, cheese toast, Jello, coffee
- D. Hamburger, baked beans, fruit cup, iced tea
Correct Answer: B
Rationale: Soft foods like split pea soup, mashed potatoes, and pudding are easier to swallow for a client with a facial stroke, reducing the risk of aspiration.
The leukemic client is prescribed a low-bacteria diet. Which does the nurse expect to be included in this diet?
- A. Cooked spinach and sautéed celery
- B. Lettuce and alfalfa sprouts
- C. Fresh strawberries and whipped cream
- D. Raw cauliflower or broccoli
Correct Answer: A
Rationale: A low-bacteria diet includes cooked vegetables like spinach and celery to minimize infection risk, unlike raw foods (lettuce, strawberries, cauliflower) that may harbor bacteria.
After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions would be MOST appropriate?
- A. Irrigate the nasogastric tube with distilled water.
- B. Aspirate the gastric contents with a syringe.
- C. Administer an antiemetic medicine.
- D. Insert a new nasogastric tube.
Correct Answer: B
Rationale: to confirm placement, nurse should aspirate and test the pH of the aspirate, results should be 0-4
The nurse is caring for an obstetrical client in early labor. After the rupture of membranes, the nurse should give priority to:
- A. Applying an internal monitor
- B. Assessing fetal heart tones
- C. Assisting with epidural anesthesia
- D. Inserting a Foley catheter
Correct Answer: B
Rationale: Assessing fetal heart tones is critical after rupture of membranes to detect fetal distress, such as cord compression.
The nurse is preparing to administer a dose of enoxaparin (Lovenox) to a client with a pulmonary embolism. Which of the following actions by the nurse is correct?
- A. Administer the injection in the deltoid muscle.
- B. Massage the injection site after administration.
- C. Inject the medication into the abdomen, at least 2 inches from the umbilicus.
- D. Aspirate before injecting to check for blood return.
Correct Answer: C
Rationale: enoxaparin is administered subcutaneously in the abdomen, at least 2 inches from the umbilicus, without aspiration or massage