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The nurse is preparing the client for surgery. The pre-op medication includes atropine sulfate 0.4 mg, meperidine (Demerol HCl) 50 mg, and promethazine hydrochloride (Phenergan) 25 mg IM. Which action should the nurse do first?
- A. make sure the surgical permit is signed
- B. ask the client to go to the bathroom
- C. explain the purpose of the medication to the client
- D. ask family members to exit the room
Correct Answer: A
Rationale: Ensuring the surgical permit is signed is the priority to confirm informed consent before administering preoperative medications.
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A client with schizophrenia is receiving depot injections of Haldol Deconate (haloperidol decanoate). The client should be told to return for his next injection in:
- A. 1 week
- B. 2 weeks
- C. 4 weeks
- D. 6 weeks
Correct Answer: C
Rationale: Haldol Decanoate is a long-acting depot injection typically administered every 4 weeks for maintenance therapy in schizophrenia.
The nurse is teaching circumcision care to the mother of a newborn. Which statement indicates that the mother needs further teaching?
- A. I will apply a petroleum gauze to the area with each diaper change.
- B. I will clean the area carefully with each diaper change.
- C. I can place a heat lamp to the area to speed up the healing process.
- D. I should carefully observe the area for signs of infection.
Correct Answer: C
Rationale: Using a heat lamp is incorrect and could cause burns or delay healing; the other statements reflect appropriate circumcision care.
Which of the following actions does NOT require the use of standard precautions?
- A. contact with blood
- B. contact with urine
- C. contact with sweat
- D. contact with vomit
Correct Answer: C
Rationale: Standard precautions are required for contact with blood, urine, and vomit due to potential infectious agents. Sweat is not considered a significant risk for transmission.
The nurse is preparing to pull a thin, frail client up in the bed. No one responds to the nurse's call for lifting assistance. Which is the best action by the nurse?
- A. call again and apologize to the client for the wait
- B. stand behind the bed at the client's head, and pull her up gently from her armpits
- C. since the client is small, pull her up in the bed by pulling on the draw sheet, alternating sides
- D. if the client is able to roll and bend her knees, lower the head of the bed and place it in Trendelenburg's position while helping the client bend her knees and push up
Correct Answer: C
Rationale: Using the draw sheet to pull the client up is the safest option to prevent injury to both the client and nurse when assistance is unavailable.
The nurse has an order to give 500 mL of 0.45% NS over 12 hours. The IV set has a drop factor of 10. How many gtts/min should the client receive? Fill in the blank.
Correct Answer: 7
Rationale: Rate = 500 mL ÷ 12 hr = 41.67 mL/hr. Drops/min = (41.67 mL/hr × 10 gtts/mL) ÷ 60 min = 6.94 gtts/min, rounded to 7 gtts/min.