Nokea
The nurse is assessing a client hospitalized with duodenal ulcer. Which finding should be reported to the doctor immediately?
- A. BP 82/60, pulse 120
- B. Pulse 68, respirations 24
- C. BP 110/88, pulse 56
- D. Pulse 82, respirations 16
Correct Answer: A
Rationale: A blood pressure of 82/60 and pulse of 120 indicate possible hypovolemic shock, likely due to gastrointestinal bleeding, which is a medical emergency requiring immediate reporting.
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The multidisciplinary team decides to implement behavior modification with a client. Which of the following nursing actions is of primary importance during this time?
- A. Confirm that all staff members understand and comply with the treatment plan.
- B. Establish mutually agreed upon, realistic goals.
- C. Ensure that the potent reinforcers (rewards) are important to the client.
- D. Establish a fixed interval schedule for reinforcement.
Correct Answer: A
Rationale: to implement a behavior modification plan successfully, all staff members need to be included in program development, and time must be allowed for discussion of concerns from each nursing staff member; consistency and follow-through is important to prevent or diminish the level of manipulation by the staff or client during implementation of this program
A nurse working in ICU has a client on a propofol (Diprivan) drip while on the mechanical ventilator. The nurse needs another bottle, which must be picked up in person in the hospital pharmacy. Which is the correct action by the nurse concerning this medication?
- A. ask the unit secretary to go to the pharmacy and pick it up
- B. send the unlicensed assistive personnel (UAP) to pick it up since the nurse is busy
- C. ask the client's health care provider to bring it when he or she rounds on the client
- D. ask another nurse to watch the clients while the nurse goes to the pharmacy to get the medication
Correct Answer: D
Rationale: The nurse must ensure continuous client monitoring, so asking another nurse to cover while retrieving the controlled medication is the safest action.
The nurse administers ciproflaxin to a client and then realizes that the client is allergic to the medication. What nursing action is the priority for this client?
- A. induce vomiting
- B. obtain the client's vital signs
- C. complete an incident report
- D. notify the health care provider
Correct Answer: D
Rationale: Notifying the health care provider is the priority to initiate immediate management of a potential allergic reaction, followed by monitoring and reporting.
A 35-year-old male comes into the clinic after he strains his back at work. The nurse anticipates the physician may suggest which topical anesthetic?
- A. aloe
- B. zinc oxide
- C. hydrocortisone
- D. capsaicin
Correct Answer: D
Rationale: Capsaicin is a topical analgesic used for muscle pain, such as back strain. Aloe, zinc oxide, and hydrocortisone are not anesthetics.
The nurse is caring for a client with a history of breast cancer who is receiving tamoxifen (Nolvadex). The nurse should instruct the client to report which of the following side effects?
- A. Mild nausea.
- B. Hot flashes.
- C. Vaginal bleeding.
- D. Hair thinning.
Correct Answer: C
Rationale: vaginal bleeding is a serious side effect of tamoxifen, as it may indicate endometrial cancer