Nokea
Select the 5 findings that require immediate follow-up
- A. Stool results
- B. Hemoglobin and Hematocrit
- C. Respiratory rate
- D. Heart rate
- E. Current medications
- F. Temperature
- G. WIC count
Correct Answer: A,B,D,E,H
Rationale: The correct choices for immediate follow-up are A, B, D, E, and H. Stool results (A) are crucial for detecting gastrointestinal issues. Hemoglobin and hematocrit (B) levels indicate blood health. Heart rate (D) reflects cardiovascular function. Current medications (E) help assess potential drug interactions. WIC count (H) is essential for monitoring infection. Respiratory rate (C) and temperature (F) are important but not as urgent.
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Which of the following findings places the client at risk if he receives alteplase?
- A. Family history of malignant hypertension
- B. Hip arthroplasty 1 week ago
- C. Chronic obstructive pulmonary disease
- D. Acute renal failure 6 months ago
Correct Answer: B
Rationale: Recent surgeries increase bleeding risks with thrombolytics.
The client is at risk for developing-----due to---
- A. mania
- B. serotonin syndrome
- C. psychosis
- D. feelings of hopelessness
- E. adverse effects of paroxetine
- F. anxiety
Correct Answer: B,E
Rationale: Increasing paroxetine while discontinuing fluoxetine can lead to serotonin syndrome.
A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take?
- A. Document the client's behavior prior to being placed in seclusion,
- B. Assess the client's behavior once every hour
- C. Offer fluids every 2 hr.
- D. Discuss with the client his inappropriate behavior prior to seclusion
Correct Answer: A
Rationale: The correct answer is A: Document the client's behavior prior to being placed in seclusion. This is important for legal and clinical reasons as it provides a clear record of the client's behavior leading up to seclusion, ensuring transparency and accountability. Assessing behavior once every hour (choice B) may not be sufficient for monitoring the client's condition in seclusion. Offering fluids every 2 hours (choice C) is important for hydration but not directly related to seclusion. Discussing inappropriate behavior with the client (choice D) may escalate the situation and is not recommended in this scenario.
Which of the following actions should the nurse plan to take?
- A. The nurse should use a filter needle to withdraw the medication.
- B. The nurse should break the neck of the ampule toward their body
- C. The nurse should use the same needle to draw up and inject the client
- D. The nurse should dispose of the ampule in the trash can.
Correct Answer: A
Rationale: The correct answer is A: The nurse should use a filter needle to withdraw the medication. This is the correct action as filter needles help prevent the introduction of particulate matter or impurities into the medication, ensuring patient safety. Using a filter needle also reduces the risk of needlestick injuries and contamination.
Choice B is incorrect as breaking the neck of the ampule towards the body increases the risk of injury due to glass shards flying towards the nurse. Choice C is incorrect as it violates safe medication administration practices by risking contamination. Choice D is incorrect as ampules should be disposed of in a sharps container, not the trash can.
After notifying the provider, the nurse should-----and then-----
- A. prepare the client for cardiac catheterization
- B. request a prescription for an increase in statin medication
- C. administer oxygen at 2 L/min via nasal cannula
- D. request a prescription for a beta-blocker
- E. check a STAT cardiac troponin
- F. administer sublingual nitroglycerin
Correct Answer: C,F
Rationale: Oxygen and nitroglycerin are initial interventions for chest pain relief.