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The nurse is caring for a client who is experiencing status epilepticus and does not have a peripheral venous access device. Which of the following actions should the nurse take first?
- A. Administer rectal diazepam.
- B. Transport the client for a CT scan.
- C. Obtain a blood specimen for complete blood count.
- D. Check the client for neck stiffness and Brudzinski sign.
Correct Answer: A
Rationale: Rectal diazepam is a first-line treatment for status epilepticus when IV access is unavailable, as it rapidly terminates seizures to prevent brain damage.
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The nurse is teaching an adult who has a broken ankle that has been casted how to climb stairs. The nurse knows that the client understands how to climb up stairs when she does which of the following?
- A. While bearing weight on the unaffected leg, the client moves the crutches up to the next step followed by the affected leg and then the unaffected leg.
- B. While bearing weight on the unaffected leg, the client moves affected leg to the next step followed by the unaffected leg and the crutches.
- C. While bearing weight on crutches, the client moves the affected leg to the next step followed by the unaffected leg and the crutches.
- D. While bearing weight on crutches, the client moves the unaffected leg to the next step followed by the affected leg and the crutches.
Correct Answer: D
Rationale: To climb stairs, weight is borne on crutches, moving the unaffected leg first, then the affected leg and crutches, ensuring stability and safety using the stronger leg.
A nurse is preparing to administer 2 continuous IV medications concurrently via a 20-gauge IV. What is the nurse's priority action?
- A. Assess the condition of the IV site
- B. Check 2 client identifiers before administering medications
- C. Consult a medication guide for compatibility
- D. Wash hands prior to administering medications
Correct Answer: C
Rationale: Ensuring medication compatibility prevents chemical interactions or precipitation in the IV line, which could harm the client or obstruct the catheter.
A nurse has received report from the off-going shift that a client is confused and has been identified as a high risk for falls. The nurse shares this information with the unlicensed assistive personnel (UAP). Which finding by the nurse requires intervention?
- A. UAP has attached a bed alarm to the client's gown and bed
- B. UAP has been making hourly rounds on the client
- C. UAP has lowered the bed and raised all 4 side rails
- D. UAP has placed a fall risk ID bracelet on the client's wrist
Correct Answer: C
Rationale: Raising all four side rails is a restraint and can increase fall risk if the client attempts to climb over them. It also violates standards of care unless specifically prescribed.
A client diagnosed with pneumonia is experiencing shortness of breath, chest pain, and orthopnea. The chest x-ray reveals a very large right pleural effusion. Which intervention should the nurse anticipate for this client?
- A. Endotracheal intubation
- B. Paracentesis
- C. Thoracentesis
- D. Ventilation-perfusion scan
Correct Answer: C
Rationale: Thoracentesis removes fluid from the pleural space, relieving pressure on the lung and improving breathing in a large pleural effusion.
The nurse is reinforcing teaching to a client with advanced chronic obstructive pulmonary disease who was prescribed oral theophylline. Which client statement indicates that additional teaching is required?
- A. I need to avoid caffeinated products.
- B. I need to get my blood drug levels checked periodically.
- C. I need to report anorexia and sleeplessness.
- D. I take cimetidine rather than omeprazole for heartburn.
Correct Answer: D
Rationale: Cimetidine inhibits theophylline metabolism, increasing toxicity risk. Omeprazole is safer, and this statement indicates a need for further teaching.