Nokea
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.
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Laboratory reference ranges
INR
0.8-1.1
The nurse receives report on 4 clients. Which of the following clients should the nurse see first?
- A. Client receiving IV vancomycin who reports discomfort at the peripheral IV site
- B. Client with a pulmonary embolus receiving continuous IV heparin infusion and warfarin who has an INR of 1.9
- C. Client 1 day postoperative receiving patient-controlled analgesia with morphine who reports itching and nausea
- D. Client receiving maintenance IV 0.9% sodium chloride with labeled tubing indicating that tubing was changed 48 hours ago
Correct Answer: A
Rationale: Discomfort at an IV vancomycin site suggests possible infiltration or phlebitis, requiring immediate assessment to prevent tissue damage. INR of 1.9 is subtherapeutic but less urgent, itching/nausea are expected morphine side effects, and tubing changed 48 hours ago is within standard protocol.
The acute care clinic nurse administers a prescribed narcotic for a client with renal colic and then discharges the client without ensuring that the client has a designated driver. The client is subsequently involved in a motor vehicle accident causing injury to self and others. Which ethical principle did the nurse violate?
- A. Autonomy
- B. Nonmaleficence
- C. Paternalism
- D. Veracity
Correct Answer: B
Rationale: Nonmaleficence (do no harm) was violated by discharging the client under narcotic influence without ensuring safe transport, leading to harm. Autonomy, paternalism, and veracity are not primarily affected.
The nurse in the outpatient care facility is caring for a client with metastatic lung cancer who received chemotherapy 3 days ago. The client states, 'I have decided that I do not want to continue treatment.' Which of the following responses would be appropriate for the nurse to make?
- A. That is not an easy choice to make. I will notify your health care provider of your decision
- B. Have you considered how this decision might affect your spouse and children?
- C. I do not think it is wise to stop chemotherapy. You will become too sick to enjoy your life
- D. Have you discussed this decision with someone else that you trust?
Correct Answer: A
Rationale: Acknowledging the decision’s difficulty and notifying the provider respects autonomy and ensures follow-up. Other responses judge, guilt, or deflect the client’s choice.
Medication administration record
Allergies: None
Medications Time
Gabapentin: 300 mg orally, every 8 hours 0700, 1500, and 2300
Hydrocodone/acetaminophen: (5 mg/325 mg) orally, every 4 hours Every 4 hours prn
Acetaminophen: 1,000 mg IV, every 6 hours 0600, 1200, 1800, and 2400
Phenytoin: 100 mg orally, every 12 hours 0700 and 1900
The practical nurse on the neurosurgery step-down unit is assisting the registered nurse in the care of a stable client with a closed head injury who is 1 day post-craniotomy. The practical nurse prepares to administer the 7:00 AM medications and reviews the client’s medication administration record. Which prescription prompts the practical nurse to contact the prescribing health care provider for clarification?
- A. Acetaminophen 1,000 mg IV, every 6 hours
- B. Gabapentin 300 mg orally, every 8 hours
- C. Hydrocodone/acetaminophen (5 mg/325 mg) orally, every 4 hours PRN
- D. Phenytoin 100 mg orally, every 12 hours
Correct Answer: A
Rationale: Acetaminophen 1,000 mg IV is unusual for routine post-craniotomy pain and risks overdose if combined with oral hydrocodone/acetaminophen, requiring clarification. Other medications are standard.
The nurse is preparing the sterile field and supplies for a wet-to-damp dressing change. Which of the following actions by the nurse would require follow-up?
- A. Drop sterile gauze on the sterile field from 6 inches (15cm ) above
- B. Keeps the sterile field and sterile gloved hands within view at all times
- C. Places sterile gauze 2 inches (5 cm) inside the outer edge of the sterile drape
- D. Pours sterile saline solution from a recapped bottle opened 30 hours ago
Correct Answer: D
Rationale: Using saline from a bottle opened 30 hours ago risks contamination, as sterile solutions are typically discarded after 24 hours. Keeping the field in view and placing gauze appropriately maintain sterility.