Nokea
The nurse is administering a topical ointment to the client's rash on the right leg. Which intervention should the nurse implement first?
- A. Don nonsterile gloves.
- B. Cleanse the client's right leg.
- C. Check the client's armband.
- D. Wash the hands for 15 seconds.
Correct Answer: D
Rationale: Hand washing is the first step to prevent infection, per aseptic technique. Gloves, cleansing, or armband checks follow.
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A client is ordered atropine to be administered preoperatively. Which physiological effect should the nurse monitor for?
- A. Elevate blood pressure
- B. Drying up of secretions
- C. Reduce heart rate
- D. Enhance sedation
Correct Answer: B
Rationale: Drying up of secretions. Atropine dries secretions which may get in the way during the operative procedure.
A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Addressing which of the following should take priority in planning care?
- A. Esophagitis
- B. Leukopenia
- C. Fatigue
- D. Skin irritation
Correct Answer: B
Rationale: Leukopenia. Clients develop leukopenia due to the depressant effect of radiation therapy on bone marrow function. Infection is the most frequent cause of morbidity and death in clients with cancer.
The client diagnosed with diabetes insipidus is receiving vasopressin intranasally. Which assessment data indicate the medication is effective?
- A. The client reports being able to breathe through the nose.
- B. The client complains of being thirsty all the time.
- C. The client has a blood glucose of 99 mg/dL.
- D. The client is urinating every three (3) to four (4) hours.
Correct Answer: D
Rationale: Vasopressin reduces polyuria in diabetes insipidus; urination every 3–4 hours indicates effectiveness. Nasal breathing, thirst, or glucose are unrelated.
The client diagnosed with diabetes mellitus type 2 is scheduled for bowel resection in the morning. Which medication should the nurse question administering to the client?
- A. Ticlopidine (Ticlid), a platelet aggregate inhibitor.
- B. Ticarcillin (Timentin), an extended-spectrum antibiotic.
- C. Pioglitazone (Actos), a thiazolidinedione.
- D. Bisacodyl (Dulcolax), a cathartic laxative.
Correct Answer: A
Rationale: Ticlopidine increases bleeding risk, contraindicated pre-surgery. Antibiotics, antidiabetics, or laxatives are appropriate or less risky.
The elderly client is admitted to the emergency department from a long-term care facility. The client has multiple ecchymotic areas on the body. The client is receiving digoxin, a cardiac glycoside; Lasix, a loop diuretic; Coumadin, an anticoagulant; and Xanax, an antianxiety medication. Which order should the nurse request from the health-care provider?
- A. A STAT serum potassium level.
- B. An order to admit to the hospital for observation.
- C. An order to administer Valium intravenous push.
- D. A STAT international normalized ratio (INR).
Correct Answer: D
Rationale: Ecchymosis with Coumadin suggests bleeding risk; STAT INR assesses anticoagulation status, guiding reversal if needed. Potassium, admission, or Valium are less urgent.