Nokea
The nurse has administered prescribed medications to assigned clients. Which follow-up assessment requires immediate follow-up? A client who received prescribed
- A. intravenous hydromorphone for chronic back pain and is drowsy.
- B. intravenous metoclopramide for nausea and vomiting and now has involuntary movements of the jaw.
- C. intravenous dexamethasone for chronic bronchitis reporting perineal itching.
- D. nitroglycerin infusion for chest pain and reports a headache.
Correct Answer: B
Rationale: Involuntary jaw movements after intravenous metoclopramide (B) indicate extrapyramidal symptoms, a serious adverse reaction that may progress to dystonia, requiring immediate intervention like stopping the drug or administering an antidote (e.g., diphenhydramine). Drowsiness with hydromorphone (A), perineal itching with dexamethasone (C), and headache with nitroglycerin (D) are expected side effects and less urgent.
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A client has used a condescending tone towards the nurse, subsequently angering the nurse. Which response by the nurse would be most therapeutic?
- A. That tone of voice makes me feel upset.'
- B. You make me angry when you talk like that.'
- C. Are you trying to upset me?'
- D. Why do you use that tone of voice with me?'
Correct Answer: A
Rationale: Expressing feelings using 'I' statements (A) is therapeutic, promoting open communication without blame. Blaming the client (B), assuming intent (C), or questioning their tone (D) escalates conflict and is non-therapeutic.
The nurse offers to stay late to assist the next shift because they are short-staffed. Which ethical principle is the nurse demonstrating?
- A. Non-maleficence
- B. Paternalism
- C. C. Beneficence
- D. D. Veracity
Correct Answer: C
Rationale: Staying late to assist (C) demonstrates beneficence by acting to benefit staff and clients through additional support. Non-maleficence (A), paternalism (B), and veracity (D) do not apply to this act of goodwill.
The nurse has received a telephone prescription from the primary healthcare provider (PHCP) for citalopram 10 mg PO daily. Which action is the nurse's priority while taking the telephone order?
- A. Verify that the medication is in stock
- B. Read back the prescription to the PHCP
- C. Inform the client of the new prescription
- D. Transmit the prescription to the pharmacy
Correct Answer: B
Rationale: Reading back the prescription to the PHCP (B) is the priority to ensure accuracy and prevent medication errors, a critical safety step in taking telephone orders. Verifying stock (A), informing the client (C), and transmitting to the pharmacy (D) are important but follow confirmation of the order’s correctness.
The nurse is caring for a client admitted for an exacerbation of Meniere’s disease. Which of the following nursing interventions is of the highest priority when caring for this client?
- A. Determining if the client has experienced hearing loss.
- B. Initiating fall risk measures.
- C. Ensuring adherence to a low-sodium diet.
- D. Administering prescribed anticholinergic medications.
Correct Answer: B
Rationale: Initiating fall risk measures (B) is the highest priority in Meniere’s exacerbation due to vertigo, which poses an immediate safety risk. Hearing loss assessment (A), low-sodium diet (C), and medications (D) are important but secondary to preventing falls.
The nurse is educating staff on adult basic life support. It would be appropriate to include which of the following? Select all that apply.
- A. Carotid pulse check should not take more than 20 seconds.
- B. The rate of chest compressions should be 100-120 per minute.
- C. Chest compression depth should be 2 inches on the center breastbone.
- D. Chest tube insertion should be prepared after five minutes of CPR.
- E. Early defibrillation is essential in the survival of ventricular fibrillation.
Correct Answer: B, E
Rationale: Chest compression rate of 100-120/minute (B) and early defibrillation for ventricular fibrillation (E) are correct per AHA guidelines. Pulse check is ≤10 seconds (A), depth is ~2.4 inches (C), and chest tube insertion (D) is not part of BLS.