Nokea
The nurse is caring for a client with a suspected stroke who is scheduled for a CT scan of the head. Which of the following assessments would be a priority for the nurse to make prior to the CT scan?
- A. Assess for a history of asthma
- B. Check the client’s blood glucose level
- C. Obtain a set of vital signs
- D. Verify whether the client has any allergies to contrast media
Correct Answer: D
Rationale: Allergies to contrast media are critical to assess before a CT scan to prevent anaphylaxis. Asthma, glucose, and vital signs are important but secondary to contrast safety.
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The nurse is caring for a 2-year-old who had an anaphylactic reaction to a bee sting. After the nurse reinforces teaching on applying epinephrine, which statements by the parent indicate correct understanding? Select all that apply.
- A. I will give the injection if my child has trouble breathing after a bee sting
- B. I will give the injection in the upper arm
- C. I will keep an epinephrine injection close to my child at all times
- D. I will take my child to the emergency room after giving the injection
- E. The injection can be given through clothing
Correct Answer: A,C,D,E
Rationale: Epinephrine is given for breathing difficulty, kept accessible, followed by ER visit, and can be administered through clothing. The correct site is the thigh, not the upper arm, making B incorrect.
The nurse is responsible for teaching the client regarding dietary choices to provide needed magnesium. Which food is a good source of magnesium?
- A. Apple
- B. Spinach
- C. Liver
- D. Squash
Correct Answer: B
Rationale: Spinach is a rich source of magnesium, found in green leafy vegetables, nuts, and whole grains. Apple , liver , and squash have lower magnesium content.
A 3 year-old child is treated in the emergency department after ingestion of 1 ounce of a liquid narcotic. What action should the nurse perform first?
- A. Provide the ordered humidified oxygen via mask
- B. Suction the mouth and the nose
- C. Check the mouth and radial pulse
- D. Start the ordered intravenous fluids
Correct Answer: C
Rationale: Check the mouth and radial pulse. Assessing airway, breathing, and circulation is the first step in treating toxic ingestion to stabilize the client.
The LPN is caring for all of the following women on the postpartum unit. Which situation requires further attention?
- A. A woman who gave birth four hours ago has red vaginal drainage on her perineal pad.
- B. The nurse palpates the uterine fundus 3 cm above the umbilicus in a woman who gave birth 12 hours ago.
- C. A woman who had a 20-hour labor and gave birth 8 hours ago asks the nurse not to bring her baby in for breastfeeding during the night.
- D. A woman who gave birth yesterday is sweating profusely and producing large amounts of urine.
Correct Answer: B
Rationale: A fundus 3 cm above the umbilicus 12 hours postpartum suggests uterine atony or retained clots, requiring further assessment to prevent hemorrhage. Other findings are normal or less urgent.
Medication administration record
Allergies: None
Medications Time
Gabapentin: 300 mg orally, every 8 hours 0700, 1500, and 2300
Hydrocodone/acetaminophen: (5 mg/325 mg) orally, every 4 hours Every 4 hours prn
Acetaminophen: 1,000 mg IV, every 6 hours 0600, 1200, 1800, and 2400
Phenytoin: 100 mg orally, every 12 hours 0700 and 1900
The practical nurse on the neurosurgery step-down unit is assisting the registered nurse in the care of a stable client with a closed head injury who is 1 day post-craniotomy. The practical nurse prepares to administer the 7:00 AM medications and reviews the client’s medication administration record. Which prescription prompts the practical nurse to contact the prescribing health care provider for clarification?
- A. Acetaminophen 1,000 mg IV, every 6 hours
- B. Gabapentin 300 mg orally, every 8 hours
- C. Hydrocodone/acetaminophen (5 mg/325 mg) orally, every 4 hours PRN
- D. Phenytoin 100 mg orally, every 12 hours
Correct Answer: A
Rationale: Acetaminophen 1,000 mg IV is unusual for routine post-craniotomy pain and risks overdose if combined with oral hydrocodone/acetaminophen, requiring clarification. Other medications are standard.