Nokea
The nurse is assessing the laboratory results of a client scheduled to receive phenytoin (Dilantin). The Dilantin level, drawn 2 hours ago, is 30 mcg/mL. What is the appropriate nursing action?
- A. Administer the Dilantin as scheduled
- B. Hold the scheduled dose and notify the physician
- C. Decrease the dosage from 100 mg to 50 mg
- D. Increase the dosage to 200 mg from 100 mg
Correct Answer: B
Rationale: A Dilantin level of 30 mcg/mL is above the therapeutic range (10-20 mcg/mL), indicating toxicity risk. The nurse should hold the dose and notify the physician for further orders.
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The nurse is caring for an adolescent with a 5-year history of bulimia. A common clinical finding in the client with bulimia is:
- A. Extreme weight loss
- B. Dental caries
- C. Hair loss
- D. Decreased temperature
Correct Answer: B
Rationale: Dental caries are common in bulimia due to frequent vomiting, which exposes teeth to stomach acid, causing enamel erosion.
A client is being treated for irritable bowel syndrome (IBS). The nurse knows that the involvement of nursing, pharmacy, gastroenterology, and nutritional services is an example of which of the following approaches?
- A. continuity of care
- B. multidisciplinary
- C. managed care
- D. case management
Correct Answer: B
Rationale: A multidisciplinary approach involves multiple specialties (nursing, pharmacy, gastroenterology, nutrition) collaborating to manage IBS.
A client with primary sclerosing cholangitis has received a liver transplant. The nurse should give priority to assessing the client for complications. Which findings are associated with an acute rejection of the new liver?
- A. Increased jaundice and prolonged prothrombin time
- B. Fever and foul-smelling bile drainage
- C. Abdominal distention and clay-colored stools
- D. Increased uric acid and increased creatinine
Correct Answer: A
Rationale: Increased jaundice and prolonged prothrombin time indicate liver dysfunction, consistent with acute liver transplant rejection.
A client in restraints is assigned to a newly graduated nurse. The nurse understands that which of the following are true regarding restraints? Select all that apply.
- A. Restraints can be chemical, mechanical, or physical.
- B. Children under 9 years of age have a 30-minute time limit in restraints.
- C. Bed rails are a form of restraint if used to prevent the client from leaving the bed.
- D. Restraints must be assessed every 2 hours for proper application and continued need.
- E. Once released, the client may be placed back in restraints for up to 24 hours if needed.
- F. Active listening, diversionary techniques, and reducing stimulation are alternatives to restraints.
Correct Answer: A, C, F
Rationale: Restraints include chemical, mechanical, or physical methods; bed rails are restraints if used to restrict movement; and non-restraint alternatives like active listening are preferred. Pediatric time limits and reassessment frequency vary by policy, and reapplication requires new orders.
A pregnant client is keeping a 'kick count' log during the last trimester. Which of the following may indicate fetal distress?
- A. Fewer than 5 movements within 2 hours
- B. Fewer than 5 movements within 1 hour
- C. Fewer than 10 movements within 2 hours
- D. Fewer than 10 movements within 1 hour
Correct Answer: C
Rationale: Fewer than 10 movements in 2 hours (C) suggests fetal distress, as normal is >10 movements in 2 hours. Other options (A, B, D) set incorrect thresholds.