Nokea
The nurse is caring for a client with a suspected stroke. Which assessment finding is most concerning?
- A. Mild headache
- B. Unilateral facial droop
- C. Slight dizziness
- D. Fatigue
Correct Answer: B
Rationale: Unilateral facial droop is a classic sign of stroke, indicating neurological deficit and requiring urgent evaluation. Headache (A), dizziness (C), and fatigue (D) are less specific.
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The client with a history of heart failure is prescribed spironolactone (Aldactone). The nurse should monitor for which potential side effect?
- A. Hypokalemia
- B. Hyperkalemia
- C. Hypoglycemia
- D. Hypertension
Correct Answer: B
Rationale: Spironolactone, a potassium-sparing diuretic, can cause hyperkalemia by reducing potassium excretion. Hypokalemia is caused by other diuretics, hypoglycemia is unrelated, and spironolactone lowers blood pressure.
When planning care for the passive-aggressive client, the nurse includes the following goal:
- A. Allow the client to use humor, because this may be the only way this client can express self.
- B. Allow the client to express anger by using 'I' messages, such as 'I was angry when . . .,' etc.
- C. Allow the client to have time away from therapeutic responsibilities.
- D. Allow the client to give excuses if he forgets to give staff information.
Correct Answer: B
Rationale: Ceasing to use humor and sarcasm is a more appropriate goal, because this client uses these behaviors covertly to express aggression instead of being open with anger. Use of 'I' messages demonstrates proper use of assertive behavior to express anger instead of passive-aggressive behavior. Client is expected to complete share of work in therapeutic community because he has often obstructed other's efforts by failing to do his share. Client has used conveniently forgetting or withholding information as a passive-aggressive behavior, which is not acceptable.
When preparing insulin for IV administration, the nurse identifies which kind of insulin to use?
- A. NPH
- B. Human or pork
- C. Regular
- D. Long acting
Correct Answer: C
Rationale: (A, B, D) Intermediate-acting and long-acting preparations contain materials that increase length of absorption time from the subcutaneous tissues but cause the preparation to be cloudy and unsuitable for IV use. Human insulin must be given SC. Only regular insulin can be given IV.
The client has an order for sliding scale insulin at 1900 hours and Lantus (glargine) insulin at the same hour. The nurse should:
- A. Administer the two medications together.
- B. Administer the two medications in two injections.
- C. Draw up the Lantus insulin and then the regular insulin and administer them together.
- D. Contact the doctor because these medications should not be given to the same client.
Correct Answer: B
Rationale: Lantus (glargine) is a long-acting insulin and should not be mixed with short-acting sliding scale insulin (e.g. regular insulin) due to differing pharmacokinetics. Administering them in separate injections ensures proper action profiles.
A postoperative TURP client is ordered continuous bladder irrigations. Later in the evening on the first postoperative day, he complains of increasing suprapubic pain. When assessing the client, the nurse notes diminished flow of bloody urine and several large blood clots in the drainage tubing. Which one of the following should be the initial nursing intervention?
- A. Call the physician about the problem
- B. Irrigate the Foley catheter
- C. Change the Foley catheter
- D. Administer a prescribed narcotic analgesic
Correct Answer: B
Rationale: The physician should be notified as problems arise, but in this case, the nurse can attempt to irrigate the Foley catheter first and call the physician if irrigation is unsuccessful. Notifying the physician of problems is a subsequent nursing intervention. This answer is correct. Assessing catheter patency and irrigating as prescribed are the initial priorities to maintain continuous bladder irrigation. Manual irrigation will dislodge blood clots that have blocked the catheter and prevent problems of bladder distention, pain, and possibly fresh bleeding. The Foley catheter would not be changed as an initial nursing intervention, but irrigation of the catheter should be done as ordered to dislodge clots that interfere with patency. Even though the client complains of increasing suprapubic pain, administration of a prescribed narcotic analgesic is not the initial priority. The effect of the medication may mask the symptoms of a distended bladder and lead to more serious complications.