Nokea
The nurse is caring for a client with bipolar disorder. The client has been manipulating some of the staff and other clients in order to get her way. Which actions by the nurse are appropriate in managing this client? Select all that apply.
- A. giving support when the client exhibits positive behaviors
- B. setting clear limits and communicating expected behaviors
- C. role playing with the client to demonstrate appropriate behaviors
- D. treating the client more like a friend in order to show respect for her as a person
- E. giving the client small gifts, such as extra dessert, in order to encourage appropriate behavior
Correct Answer: A,B,C
Rationale: Appropriate actions include reinforcing positive behaviors (A), setting clear limits (B), and role-playing (C) to promote appropriate interactions. Treating as a friend (D) or giving gifts (E) blurs boundaries and encourages manipulation.
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A client with severe anemia is to receive a unit of whole blood. In the event of a transfusion reaction, the first action by the nurse should be to:
- A. Notify the physician and the nursing supervisor
- B. Stop the transfusion and maintain an IV of normal saline
- C. Call the lab for verification of type and cross match
- D. Prepare an injection of Benadryl (diphenhydramine)
Correct Answer: B
Rationale: Stopping the transfusion and maintaining an IV of normal saline is the first action to prevent further reaction and stabilize the client.
A client with myasthenia gravis is admitted in a cholinergic crisis. Signs of of cholinergic crisis include:
- A. Decreased blood pressure and constricted pupils
- B. Increased heart rate and increased respirations
- C. Increased respirations and increased blood pressure
- D. Anoxia and absence of the cough reflex
Correct Answer: A
Rationale: Cholinergic crisis, due to excessive acetylcholinesterase inhibitors, causes symptoms like constricted pupils and decreased blood pressure from parasympathetic overstimulation.
The nurse is preparing to deliver an infusion of vancomycin through a client's peripherally inserted central catheter (PICC). Shortly after the infusion begins the IV pumps beeps, indicating a blockage. How should the nurse proceed? Select all that apply.
- A. start a peripheral IV in the opposite limb
- B. notify the PICC nurse if unable to clear the blockage
- C. use a 5 mL syringe to flush the PICC with sterile saline
- D. ask the client to raise and lower the arm or cough
- E. attempt to flush the line by aggressively pushing heparin to clear the blockage
- F. use a 10 mL syringe to gently flush the PICC with sterile saline or tPA as ordered
Correct Answer: B, D, F
Rationale: Notifying the PICC nurse, repositioning the arm, and gently flushing with a 10 mL syringe (saline or tPA as ordered) are appropriate. Aggressive flushing or small syringes risk damage, and a peripheral IV is unnecessary.
The nurse is caring for a client admitted to labor and delivery. The nurse is aware that the infant is in distress if she notes:
- A. Contractions every three minutes
- B. Absent variability
- C. Fetal heart tone accelerations with movement
- D. Fetal heart tone 120-130 bpm
Correct Answer: B
Rationale: Absent variability on the fetal monitor indicates fetal distress, suggesting compromised oxygenation.
An RN is working with an LPN to care for a group of clients. Which client would the RN most likely assign to the LPN?
- A. a client receiving blood following back surgery
- B. a client who has just returned from having a left heart catheterization
- C. a client with an arterial line who is on a nitroprusside drip to control blood pressure
- D. a client with an abdominal wound requiring dressing changes every 4 hours and PRN
Correct Answer: D
Rationale: The client requiring dressing changes is stable and within the LPN's scope of practice, whereas the other clients require advanced monitoring or interventions suitable for an RN.