Nokea
The nurse is preparing 7:00 AM medications for a client with a urinary tract infection and a history of heart failure and type 2 diabetes. Based on the information from the medical and medication records, which prescription should the nurse question before administering?
- A. Furosemide
- B. Glipizide
- C. Levofloxacin
- D. Potassium chloride
Correct Answer: A
Rationale: Furosemide in heart failure requires careful monitoring of fluid status and electrolytes, especially early in the day, to avoid exacerbating dehydration or hypotension. Glipizide, levofloxacin, and potassium chloride are appropriate for diabetes, UTI, and potential hypokalemia, respectively.
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The practical nurse is assisting the registered nurse in caring for 4 clients in the pediatric emergency department. Which client should be seen first?
- A. Adolescent with abdominal pain, heart rate 120/min, and respirations 26/min
- B. Child with history of cystic fibrosis has new yellow sputum and cough today
- C. Crying infant with fiery redness and moist papules in the diaper region
- D. Grade-school child with swollen ecchymotic ankle after playing basketball
Correct Answer: A
Rationale: The adolescent with abdominal pain, tachycardia (heart rate 120/min), and tachypnea (respirations 26/min) may have a serious condition like appendicitis or perforation, requiring urgent evaluation. The other clients' conditions are less acute.
The nurse working on the renal unit is preparing to make rounds for the day. Which client should the nurse visit first?
- A. The client maintained on hemodialysis
- B. The client with chronic glomerulonephritis
- C. The client one hour post-renal transplant
- D. The client scheduled for an IVP
Correct Answer: C
Rationale: The client one hour post-renal transplant is at highest risk for complications, such as bleeding or graft rejection, requiring immediate assessment. Other clients are stable or less urgent.
A client is admitted with severe injuries from an auto accident. The client's vital signs are BP 120/50, pulse rate 110, and respiratory rate of 28. The initial nursing intervention would be to
- A. begin intravenous therapy
- B. initiate continuous blood pressure monitoring
- C. administer oxygen therapy
- D. institute cardiac monitoring
Correct Answer: C
Rationale: Early findings of shock reveal hypoxia with rapid heart rate and rapid respirations, and oxygen is the most critical initial intervention. The other interventions are secondary to oxygen therapy.
A client is admitted with a possible gastric ulcer. Suddenly he calls to the nurse and says, 'It hurts so bad.' The client is pale and diaphoretic. What should the nurse do initially?
- A. Call the physician
- B. Touch the abdomen
- C. Obtain a stool for guaiac
- D. Place the client in a supine position
Correct Answer: A
Rationale: Sudden severe pain with pallor and diaphoresis suggests ulcer perforation, requiring immediate physician notification for urgent intervention.
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.