Nokea
The nurse is caring for a group of preoperative clients. Which client situation requires follow-up? A client, Select all that apply.
- A. stating that they took their prescribed carbamazepine with a sip of water.
- B. receiving dextrose 5% in water (D5W) and has a blood glucose of 266 mg/dL (14.77 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L].
- C. reporting that they shaved their abdomen for their scheduled appendectomy.
- D. reporting difficulty with their last surgery, stating they got 'a really high fever'.
- E. reporting burning upon urination and increased urinary frequency.
Correct Answer: B, C, D, E
Rationale: High blood glucose (B) risks surgical complications, shaving abdomen (C) increases infection risk, past surgical fever (D) suggests complications, and urinary symptoms (E) indicate possible UTI, all needing follow-up. Carbamazepine with water (A) is typically acceptable pre-op.
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The nurse is caring for a client who intentionally overdosed on amitriptyline. What action should the nurse prioritize?
- A. Obtain a 12-lead electrocardiogram
- B. Request a prescription to consult psychiatry
- C. Determine the reasoning for the overdose
- D. Establish a therapeutic relationship
Correct Answer: A
Rationale: Obtaining a 12-lead ECG (A) is the priority in amitriptyline overdose to detect life-threatening cardiac arrhythmias, common in tricyclic antidepressant toxicity. Psychiatry consult (B), overdose reasoning (C), and therapeutic rapport (D) are secondary to medical stabilization.
During a bath, the unlicensed assistive personnel (UAP) reports to the nurse that the client has malodorous discharge from the gastrostomy tube. The nurse should initially
- A. obtain a specimen for culture.
- B. assess the drainage.
- C. place a sterile dressing around the gastrostomy tube.
- D. assess the client's temperature for fever.
Correct Answer: B
Rationale: Assessing the drainage (B) is the first step to determine the cause, such as infection or tube malfunction, guiding further action. Obtaining a culture (A), applying a dressing (C), or checking for fever (D) are secondary without initial assessment data.
A registered nurse (RN) and a licensed practical/vocational nurse (LPN/VN) are working together in a psychiatric ward. Which of the following clients can the RN assign to the LPN/VN? A client
- A. taking amitriptyline who is currently grinding their jaw and grimacing
- B. with dementia who is currently confused and disoriented
- C. with bipolar disorder with a lithium level of 2.0 mEq/L [0.6-1.2 mEq/L]
- D. with a history of chronic alcoholism currently experiencing delirium tremens
Correct Answer: B
Rationale: A client with dementia who is confused (B) is stable and suitable for LPN care, focusing on safety and routine tasks. Jaw grinding on amitriptyline (A), toxic lithium level (C), and delirium tremens (D) require RN assessment due to potential toxicity or instability.
The nurse is caring for a client with a percutaneous endoscopic gastrostomy tube. Prior to administering the next tube feeding, the nurse aspirates 80 mL of gastric residual. The nurse should then
- A. notify the physician.
- B. hold the tube feeding and recheck residual volume in one hour.
- C. administer the prescribed feeding.
- D. reposition the patient in low-Fowler's position.
Correct Answer: B
Rationale: An 80 mL gastric residual (B) indicates potential delayed gastric emptying, requiring the nurse to hold the feeding and recheck in one hour to prevent aspiration. Notifying the physician (A) is premature, administering feeding (C) risks complications, and low-Fowler’s (D) is inappropriate for feeding.
The nurse is caring for a client who reports that another nurse hit them. The nurse should take which action?
- A. Inquire with the nurse if this incident occurred
- B. Assess the client for any prior episodes of abuse
- C. Determine if the client has any cognitive impairments
- D. Report the client's concern to the nursing supervisor
Correct Answer: D
Rationale: Reporting the allegation to the nursing supervisor (D) is the priority to ensure proper investigation and client safety, per facility policy. Inquiring directly (A), assessing prior abuse (B), or checking cognition (C) risks bias or delays formal action.