Nokea
Vital signs
Temperature 100.9 F (38.3 C)
Blood pressure 125/75 mm Hg
Heart rate 109/min
Respirations 15/min
SpO2 100%
The nurse is caring for a postpartum client 36 hours after a cesarean birth who was just diagnosed with postpartum endometritis. Which prescription is priority for the nurse to administer?
- A. Acetaminophen PO PRN for fever
- B. Clindamycin IV every 8 hours
- C. Lactated Ringer IV bolus once
- D. Methylergonovine PO every 4 hours
Correct Answer: B
Rationale: Postpartum endometritis requires prompt antibiotic treatment, so clindamycin IV is the priority to address the infection. Acetaminophen , fluids , and methylergonovine are supportive or unrelated.
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The nurse caring for a client with myasthenia gravis is reviewing the nursing care plan. Which is recognized as the priority nursing diagnosis?
- A. Risk for injury
- B. Acute pain
- C. Ineffective airway clearance
- D. Impaired mobility
Correct Answer: C
Rationale: Clients with myasthenia gravis have problems with the muscular activity of breathing. Answers A, B, and D are not the priority, so they are wrong.
The nurse is reviewing new medication prescriptions for a client with asthma and nasal polyps. The nurse should clarify the prescription for
- A. ibuprofen
- B. vitamin D
- C. albuterol
- D. montelukast
Correct Answer: A
Rationale: Ibuprofen should be clarified in asthma with nasal polyps due to risk of aspirin-exacerbated respiratory disease. Vitamin D , albuterol , and montelukast are safe.
Which client event would be considered an adverse event and would require completion of an incident/event/irregular occurrence/variance report? Select all that apply.
- A. Administered 9.00 AM medication at 9.30 AM
- B. Developed worsening cellulitis after missing antibiotics for 1 day
- C. Has a seizure and a history of epilepsy
- D. Slides off the edge of the bed and ends up sitting on the floor
- E. Waits 4 hours to be transported for STAT diagnostic CT scan
Correct Answer: B,D,E
Rationale: Adverse events requiring an incident report include worsening cellulitis due to missed antibiotics , a fall even without injury , and a significant delay in a STAT procedure . Late medication administration is a variance but not typically an adverse event unless harm occurs, and a seizure in a known epileptic is expected unless protocol was not followed.
The nurse is caring for a client with mild Alzheimer disease who is agitated after eating breakfast. The client states, 'I am hungry. You did not feed me.' Which of the following actions should the nurse take?
- A. Offer the client finger foods to eat.
- B. Provide the client with additional food at mealtimes.
- C. Tell the client that the client may have a snack before lunch.
- D. Ask the dietician to evaluate the client's daily calorie requirements
Correct Answer: C
Rationale: For an Alzheimer client with agitation and false hunger claims, offering a snack before lunch calms the client without overfeeding. Finger foods or extra meals may not address agitation, and a dietician evaluation is less immediate.
The nurse is caring for a client who is terminally ill. When the client dies, the nurse should:
- A. Pronounce the client dead and call the doctor.
- B. Contact the coroner.
- C. Tag the body prior to the funeral home notification.
- D. Request an autopsy.
Correct Answer: C
Rationale: Tagging the body ensures proper identification before transfer to the funeral home. Nurses do not pronounce death, coroner contact depends on policy, and autopsies are not routinely requested.