Nokea
The nurse administers ciproflaxin to a client and then realizes that the client is allergic to the medication. What nursing action is the priority for this client?
- A. induce vomiting
- B. obtain the client's vital signs
- C. complete an incident report
- D. notify the health care provider
Correct Answer: D
Rationale: Notifying the health care provider is the priority to initiate immediate management of a potential allergic reaction, followed by monitoring and reporting.
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Twenty micrograms (g) are equal to how many milligrams? Record your answer using a decimal number.
Correct Answer: 0.02
Rationale: 1 mg = 1,000 g, so 20 /1,000 = 0.02 mg.
The client is having electroconvulsive therapy for treatment of severe depression. Prior to the ECT the nurse should:
- A. Apply a tourniquet to the client's arm.
- B. Administer an anticonvulsant medication.
- C. Ask the client if he is allergic to shell fish.
- D. Apply a blood pressure cuff to the arm.
Correct Answer: D
Rationale: Applying a blood pressure cuff allows monitoring of vital signs during ECT, which is a standard safety measure.
A client with a T5 spinal cord injury suddenly begins sweating profusely in the face and neck. Vital signs reveal sudden bradycardia and significant increase in blood pressure. Which is the priority nursing action?
- A. administer nitrate or nifedipine
- B. check the client for fecal impaction
- C. check the client for bladder distention
- D. place the bed in high Fowler's position
Correct Answer: C
Rationale: These symptoms indicate autonomic dysreflexia, often triggered by bladder distention in spinal cord injuries above T6. Checking and relieving bladder distention is the priority.
The nurse is conducting a physical examination of a client's abdomen. Place the examination techniques listed below (Roman numerals) in the correct sequence, from first to last.
- A. Percussion
- B. Palpation
- C. Inspection
- D. Auscultation
Correct Answer: C,D,A,B
Rationale: Abdominal exam sequence: Inspection (III) first, then auscultation (IV) before percussion (I) and palpation (II) to avoid altering bowel sounds.
The nurse must administer in one syringe a combined dose of two different insulins from two vials. Place the steps (Roman numerals) in the correct order.
- A. Cleanse tops of vials.
- B. Inject air into vial 1.
- C. Withdraw medication from vial 1.
- D. Change needles.
- E. Withdraw medication from vial 2.
- F. Inject air into vial 2.
Correct Answer: A,B,F,C,E
Rationale: The correct order is: Cleanse vials (I), inject air into vial 1 (II), inject air into vial 2 (VI), withdraw from vial 1 (III), withdraw from vial 2 (V). Changing needles (IV) is not standard.