Nokea
The nurse is administering epoetin alfa to a client diagnosed with chronic kidney disease (CKD). For which adverse effect of this therapy should the nurse monitor the client?
- A. Anemia
- B. Hypertension
- C. Iron intoxication
- D. Bleeding tendencies
Correct Answer: B
Rationale: The client taking epoetin alfa is at risk of hypertension and seizure activity as the most serious adverse effects of therapy. This medication is used to treat anemia. The medication does not cause iron intoxication. Bleeding tendencies is not an adverse effect of this medication.
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The nurse is ready to administer a partial fill of imipenem-cilastatin (Primaxin) in the I.V. pump when a full partial fill bag of imipenem-cilastatin is found hanging at the client's bedside. Which of the following is not appropriate to do by the nurse when recognizing that the previous dose was not administered 8 hours ago to the client with pneumonia?
- A. Discard the full partial fill of imipenem-cilastatin found hanging at the client's bedside.
- B. Check the identifying information of the full partial fill of imipenem-cilastatin found hanging at the client's bedside.
- C. Follow up on the legal documentation of the client's previous administration of imipenem-cilastatin.
- D. Administer the new partial fill of imipenem-cilastatin.
Correct Answer: A
Rationale: Discarding the medication without investigation is inappropriate; the nurse should verify, document, and address the error appropriately.
Select the member of the multidisciplinary team that you would most likely collaborate with when the client is at risk for falls due to an impaired gait.
- A. The physical therapist
- B. The occupational therapist
- C. The podiatrist
- D. The nurse practitioner
Correct Answer: A
Rationale: A physical therapist specializes in assessing and improving gait and mobility, making them the most appropriate team member to collaborate with for a client at risk for falls due to impaired gait.
When you are monitoring your client who is now started on an intravenous antibiotic for an infection, you notice that the client is exhibiting signs of anaphylaxis. What is your first priority intervention?
- A. Stop the intravenous flow
- B. Slow down the intravenous flow
- C. Notify the doctor
- D. Begin CPR
Correct Answer: A
Rationale: Stopping the IV flow is the first priority to halt the administration of the allergen causing anaphylaxis, followed by other emergency interventions.
The nurse is caring for a client with a history of burns. Which of the following complications should the nurse monitor for? Select all that apply.
- A. Sepsis.
- B. Hypovolemia.
- C. Hyperkalemia.
- D. Respiratory distress.
- E. Hypoglycemia.
Correct Answer: A, B, C, D
Rationale: Burns can cause sepsis (infection), hypovolemia (fluid loss), hyperkalemia (tissue damage), and respiratory distress (inhalation injury).
A 9-year-old child is newly diagnosed with type 1 diabetes mellitus. The nurse is planning for home care with the child and the family and determines that which is an age-appropriate activity for health maintenance?
- A. Administering insulin drawn up by an adult
- B. Self-administering insulin with adult supervision
- C. Making independent decisions with regard to sliding-scale coverage of insulin
- D. Having an adult assist in the self-administration of insulin and glucose monitoring
Correct Answer: B
Rationale: School-age children have the cognitive and motor skills to draw up and administer insulin with adult supervision. Developmentally, they do not yet have the maturity to make independent decisions such as about sliding-scale coverage without adult validation. Options requiring adult to manage insulin administration and glucose monitoring suppress the maximum level of independence appropriate to the level of this child.