Nokea
The nurse is assessing the elderly client first thing in the morning. The client is confused and sleepy. Which intervention should the nurse implement first?
- A. Determine if the client received a sedative last night.
- B. Allow the client to continue to sleep and do not disturb.
- C. Encourage the client to ambulate in the room with assistance.
- D. Notify the health-care provider about the client's status.
Correct Answer: A
Rationale: Sedatives are a common cause of morning confusion in the elderly; determining recent administration guides next steps.
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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.
A woman with a 28 week pregnancy is on the way to the emergency department by ambulance with a tentative diagnosis of abruptio placenta. Which should the nurse do first when the woman arrives?
- A. administer oxygen by mask at 100%
- B. start a second IV with an 18 gauge cannula
- C. check fetal heart rate every 15 minutes
- D. insert urethral catheter with hourly urine outputs
Correct Answer: A
Rationale: administer oxygen by mask at 100%. Administering oxygen in this situation would increase the circulating oxygen in the mother's circulation to the fetus's circulation. This action will minimize complications.
An adult receives NPH insulin at 7:00 A.M. When is a hypoglycemic reaction most apt to develop?
- A. Mid morning
- B. Mid afternoon
- C. During the evening
- D. During the night
Correct Answer: B
Rationale: NPH insulin peaks 6-12 hours after administration (1:00 P.M.-7:00 P.M.), making mid-afternoon the likely time for hypoglycemia.
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.
A client with anemia has a new prescription for ferrous sulfate. In teaching the client about diet and iron supplements, the nurse should emphasize that absorption of iron is enhanced if taken with which substance?
- A. Acetaminophen
- B. Orange juice
- C. Low fat milk
- D. An antacid
Correct Answer: B
Rationale: Orange juice. Ascorbic acid enhances the absorption of iron.