Nokea
The nurse is on a memory care unit. A client insists on leaving to go home. Which of the following should the nurse do?
- A. review the reality orientation board in the client's room
- B. take the client to the activity room to interact with others
- C. contact the client's primary health care provider for a medication order
- D. provide the client with a glass of milk and a sandwich
Correct Answer: B
Rationale: Redirecting the client to a social activity can help distract from the desire to leave and promote engagement, which is appropriate for a client with memory issues.
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The nurse is monitoring a client’s EKG strip and notes coupled premature ventricular contractions greater than 10 per minute. The nurse should expect to administer which of the following?
- A. Atropine sulfate (Atropine) IV.
- B. Isoproterenol (Isuprel) IV.
- C. Verapamil (Calan) IV.
- D. Lidocaine hydrochloride (Xylocaine) IV.
Correct Answer: D
Rationale: Lidocaine is the drug of choice for frequent premature ventricular contractions (PVC) occurring in excess of 6-10 per minute; for coupled PVCs or for a consecutive series of PVCs that may result in ventricular tachycardia
The nurse has orders for dopamine at 20 mcg/kg/min. The bag has 500 mg of dopamine in 500 mL. The client weighs 60 kg. What rate will the nurse set?
Correct Answer: 72 mL/hr
Rationale: Dose: 20 mcg/kg/min × 60 kg = 1200 mcg/min. Concentration: 500 mg/500 mL = 1 mg/mL = 1000 mcg/mL. Rate: 1200 mcg/min ÷ 1000 mcg/mL = 1.2 mL/min × 60 min/hr = 72 mL/hr.
The nurse is performing an initial assessment of a newborn Caucasian male delivered at 32 weeks gestation. The nurse can expect to find the presence of:
- A. Mongolian spots
- B. Scrotal rugae
- C. Head lag
- D. Polyhydramnios
Correct Answer: C
Rationale: Head lag is expected in a preterm newborn at 32 weeks due to underdeveloped neck muscle strength.
A client is admitted with possible appendicitis. Which finding by the nurse would be expected in assessment of this client?
- A. a positive psoas sign
- B. a positive Murphy's sign
- C. a positive Homan's sign
- D. a positive Chadwick's sign
Correct Answer: A
Rationale: A positive psoas sign (pain with leg extension) is associated with appendicitis. Murphy’s sign is for gallbladder, Homan’s for DVT, and Chadwick’s for pregnancy.
The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid:
- A. Using oil- or cream-based soaps
- B. Flossing between the teeth
- C. The intake of salt
- D. Using an electric razor
Correct Answer: B
Rationale: Flossing can cause gum bleeding, increasing infection and bleeding risks in leukemia clients with low platelet counts.