Nokea
The nurse is observing client care activities on the unit. It would require completion of an incident report if
- A. clozapine is held for a client with schizophrenia who has a decreased absolute neutrophil count
- B. escitalopram is administered to a client with major depressive disorder who received the last dose of phenelzine yesterday
- C. isosorbide mononitrate is held for a client with chronic angina who has a blood pressure of 84/52 mm Hg
- D. warfarin is administered to a client who has a mechanical heart valve and a normal INR
Correct Answer: B
Rationale: Administering escitalopram within 24 hours of phenelzine, a monoamine oxidase inhibitor, risks serotonin syndrome, a life-threatening condition, requiring an incident report. Holding clozapine for low neutrophils, holding isosorbide for low blood pressure, and giving warfarin for a normal INR are appropriate actions.
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The nurse is caring for several clients who have ostomies. Which client will have the most wellformed drainage? The client whose colostomy is in the:
- A. ileum.
- B. ascending colon.
- C. transverse colon.
- D. descending colon.
Correct Answer: D
Rationale: The descending colon absorbs more water, producing well-formed, solid stool compared to the ileum (liquid), ascending colon (semi-liquid), or transverse colon (semi-formed).
A client has been admitted with a catheter-associated, vancomycin-resistant enterococcal bacteremia. Which interventions should the nurse implement? Select all that apply.
- A. Keep dedicated equipment for client
- B. Perform hand hygiene before exiting the room
- C. Place a 'No Visitors' sign on the client's door
- D. Wear a face mask when in the room
- E. Wear an isolation gown when providing direct care
Correct Answer: A,B,E
Rationale: Dedicated equipment, hand hygiene, and an isolation gown prevent the spread of vancomycin-resistant enterococcus. A 'No Visitors' sign is unnecessary, and a face mask is not required unless droplet precautions are indicated.
The nurse is caring for a client who had a transsphenoidal hypophysectomy and developed diabetes insipidus. Which of the following findings would the nurse expect to observe? Select all that apply.
- A. excessive thirst
- B. increased urine output
- C. increased serum osmolality
- D. decreased serum sodium level
- E. increased urine specific gravity
Correct Answer: A,B,C
Rationale: Diabetes insipidus results from antidiuretic hormone deficiency, causing excessive thirst, increased dilute urine output, and increased serum osmolality due to water loss. Serum sodium may increase, not decrease, and urine specific gravity is low due to dilute urine.
A couple from the Philippines living in the United States is expecting their first child. In providing culturally competent care, the nurse must first:
- A. review their own cultural beliefs and biases.
- B. respectfully request that the couple utilize only medically approved health care providers.
- C. realize that the clients have to learn their new country's accepted medical practices.
- D. study family dynamics to understand the male and female gender roles in the clients' culture.
Correct Answer: A
Rationale: Self-awareness of the nurse's own cultural biases is the first step in providing culturally competent care, ensuring nonjudgmental interactions. The other actions are secondary or prescriptive. Psychosocial Integrity
A client is admitted with suspected pheochromocytoma. The physiological alteration associated with pheochromocytoma is:
- A. An extreme elevation in blood pressure
- B. Petechial rash across the chest and axilla
- C. White flecks in the iris
- D. Yellow creases at the nasolabial folds
Correct Answer: A
Rationale: Pheochromocytoma causes catecholamine release, leading to extreme hypertension . Rash , iris flecks , and nasolabial creases are not associated.