Nokea
The nurse cares for a confused client who continues to pull at the intravenous (IV) catheter on the left forearm despite frequent instructions not to do so. What is the nurse's next action?
- A. Apply a gauze wrap and elastic stockinette around the IV site
- B. Apply a mitt on the right hand
- C. Apply a soft wrist restraint on the right wrist
- D. Apply an arm board to the left arm
Correct Answer: D
Rationale: An arm board on the left arm stabilizes the IV site, reducing pulling without restraining the client, aligning with least-restrictive interventions. Mitts or restraints on the right side do not protect the left-sided IV.
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An adult is receiving cancer chemotherapy. Metoclopramide (Reglan) is also prescribed. The client asks why she is getting Reglan. How should the nurse respond?
- A. Reglan helps to prevent bleeding that may occur as a side effect of your other medications.'
- B. Reglan helps to prevent any nausea and vomiting that may occur as a side effect of your other medications.'
- C. Reglan increases the effectiveness of the cancer chemotherapeutic agents.'
- D. Reglan helps to control pain associated with your disease.'
Correct Answer: B
Rationale: Metoclopramide is an antiemetic, prescribed to prevent nausea and vomiting, common chemotherapy side effects, improving patient comfort.
An adult client is to have a portable chest x-ray in his room. The client's wife and pregnant daughter are visiting. Which action is essential for the nurse?
- A. Ask the pregnant daughter to leave the room and have the wife assist in holding the client.
- B. Have the client wear a lead apron over his chest and abdomen.
- C. Close the door to the room securely during the x-ray.
- D. Ask the wife and daughter to leave the room.
Correct Answer: D
Rationale: Removing visitors, especially a pregnant woman, minimizes radiation exposure, the essential safety action during a chest x-ray.
The nurse is performing a developmental assessment on a 12-month-old client. Which of the following findings are expected at this age? Select all that apply.
- A. Birth weight has tripled
- B. Cruises along furniture
- C. Kicks a ball
- D. Searches for hidden objects
- E. Speaks in two word phrases
Correct Answer: A,B,D
Rationale: By 12 months, infants typically triple birth weight, cruise along furniture, and search for hidden objects (object permanence). Kicking a ball and two-word phrases are expected at 18-24 months.
Medication administration record
Allergies: No known allergies
Sliding-Scale Serum Glucose Level Regular Insulin Dose
<150 mg/dL (<8.3 mmol/L) 0 units
150-199 mg/dL (8.3-11 mmol/L) 3 units
200-249 mg/dL (11.1-13.8 mmol/L) 5 units
250-299 mg/dL (13.9-16.6 mmol/L) 7 units
≥300 mg/dL (≥16.7 mmol/L) 9 units and notify the health care provider
The nurse is caring for a client who has a prescription for 25 units of NPH insulin and sliding-scale regular insulin. The client's serum glucose level is 237 mg/dL (13.2 mmol/L). How many total units of insulin should the nurse administer to the client? Record your answer using a whole number.
Correct Answer: 29
Rationale: Assuming a sliding-scale protocol (e.g., 4 units for 201-250 mg/dL), 25 units NPH + 4 units regular = 29 units total.
The nurse in the outpatient clinic is talking with a client who was diagnosed with hypertension 6 months ago. The client’s current blood pressure is 170/94 mm Hg. Which of the following questions would be most important for the nurse to ask?
- A. Are you feeling overwhelmed at home or work?
- B. Can you describe your daily eating habits to me?
- C. Do you smoke cigarettes or use tobacco products?
- D. How often do you take your antihypertensive medications?
Correct Answer: D
Rationale: Medication adherence is the most critical factor to assess in uncontrolled hypertension (170/94 mm Hg), as non-compliance is a common cause. Stress, diet, and smoking are secondary.