Nokea
The nurse has received report on the day's assigned clients. Which of the following clients should the nurse see first?
- A. a client complaining of nausea and vomiting after eating breakfast
- B. a client complaining of itching and burning at the IV site while receiving normal saline
- C. a client who is post-op day 1 from a hernia repair with a pain level of 6 on a scale of 1-10
- D. a client who has been given the first dose of an antibiotic and complains of tingling in and around the mouth
Correct Answer: D
Rationale: Tingling around the mouth after an antibiotic suggests an allergic reaction, potentially anaphylaxis, requiring immediate assessment.
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A client with schizophrenia has been taking Clozaril (clozapine) for the past 6 months. This morning the client's temperature was elevated to 102°F. The nurse should give priority to:
- A. Placing a note in the chart for the doctor
- B. Rechecking the temperature in 4 hours
- C. Notifying the physician immediately
- D. Asking the client if he has been feeling sick
Correct Answer: C
Rationale: A fever of 102°F in a client on clozapine may indicate agranulocytosis, a life-threatening side effect, requiring immediate physician notification.
The nurse has just administered an IM injection to a client. In which of the following ways should the nurse dispose of the needle?
- A. re-cap the needle and discard it in the nearest puncture-resistant container
- B. break the needle and discard it in the nearest puncture-resistant container
- C. discard the needle in a puncture-resistant container in the central medication area
- D. discard the needle in a puncture-resistant container in the client's room
Correct Answer: D
Rationale: Needles should be disposed of immediately in a puncture-resistant container in the client’s room to minimize sharps injury risk.
A client is admitted with symptoms of vertigo and syncope. Diagnostic tests indicate left subclavian artery obstruction. What additional findings would the nurse expect?
- A. Memory loss and disorientation
- B. Numbness in the face, mouth, and tongue
- C. Radial pulse differences over 10 bpm
- D. Frontal headache with associated nausea or emesis
Correct Answer: C
Rationale: Subclavian artery obstruction can cause reduced blood flow to the arm, leading to radial pulse differences between arms, a hallmark of conditions like subclavian steal syndrome.
A client with AIDS tells the nurse that he regularly takes echinacea to boost his immune system. The nurse should tell the client that:
- A. Herbals can interfere with the action of antiviral medication
- B. Supplements have proven effective in prolonging life
- C. Herbals have been shown to decrease the viral load
- D. Supplements appear to prevent replication of the virus
Correct Answer: A
Rationale: Echinacea may interact with antiretroviral medications, potentially reducing their effectiveness.
The nurse is caring for a client who is receiving mechanical ventilation. The ventilator alarms are sounding, and the nurse notes high-pressure alarms. Which of the following actions should the nurse take FIRST?
- A. Suction the client’s airway.
- B. Notify the respiratory therapist.
- C. Check the ventilator tubing for kinks.
- D. Administer a bronchodilator.
Correct Answer: C
Rationale: checking for kinks in the tubing is the first step, as it is a common cause of high-pressure alarms