Nokea
The nurse is preparing to administer 40 mg of oral furosemide. Prior to administering the medication, the nurse should evaluate which parameters? Select all that apply.
- A. Blood pressure
- B. Blood urea nitrogen
- C. Liver enzymes
- D. Potassium
- E. White blood cell count
Correct Answer: A,D
Rationale: Furosemide can cause hypotension and hypokalemia, so blood pressure and potassium levels must be evaluated. Blood urea nitrogen reflects kidney function but is not critical before administration, and liver enzymes and white blood cell count are unrelated.
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The nurse is caring for a client with schizophrenia who is experiencing auditory hallucinations and has a new prescription for an oral antipsychotic. Which of the following actions should the nurse take?
- A. Provide music for the client
- B. Use gentle touch to calm the client
- C. Instruct the client to ignore the hallucinations
- D. Tell the client the medication will alleviate the hallucinations within a few hours
Correct Answer: C
Rationale: Instructing the client to ignore hallucinations helps them manage symptoms by redirecting focus, a practical coping strategy. Music or touch may exacerbate distress, and antipsychotics typically take days to weeks to reduce hallucinations, not hours.
Which of these clients is at greatest risk for the complications associated with osteoporosis?
- A. A 22-year-old woman with anorexia nervosa who is not having menstrual periods
- B. A 65-year-old Asian-American man who is sedentary, has a low calcium intake, and takes corticosteroids for chronic obstructive pulmonary disease
- C. A 70-year-old postmenopausal woman who has limited mobility due to rheumatoid arthritis, for which she takes corticosteroids, and who drinks a bottle of wine by herself each evening
- D. A 70-year-old woman who takes estrogen therapy, was very athletic in her youth playing tennis and golf, and takes anticonvulsant therapy as a result of a head injury suffered in an auto accident three years ago
Correct Answer: C
Rationale: The 70-year-old postmenopausal woman has multiple risk factors: age, immobility, corticosteroid use, and alcohol consumption, maximizing osteoporosis complication risk.
A client recovering from a head injury is receiving medication and nutritional feedings by nasogastric tube. The doctor has ordered medication to prevent seizure activity. The medication is supplied by the pharmacy in tablet form. Before administering the medication, the nurse should:
- A. Crush the medication and envelop it in a small amount of ice cream before giving.
- B. Help the client to sit upright while giving the tablet by mouth.
- C. Crush the tablet, mix in 100 ccs of tube feeding, and administer via NG tube.
- D. Ask the pharmacist if the medication is available in liquid form.
Correct Answer: D
Rationale: For NG tube administration, liquid medication is preferred to ensure proper delivery and absorption. Crushing tablets may alter efficacy, and oral administration is inappropriate.
A client is admitted to the ER with reported heroin intoxication. Which of the following signs is consistent with opiate use?
- A. The client's pupils are dilated.
- B. The client's speech is rapid.
- C. The client's BP is elevated.
- D. The client's pupils are constricted.
Correct Answer: D
Rationale: Opiates like heroin cause pupil constriction (miosis). Dilated pupils, rapid speech, or elevated BP are not typical.
A new nurse on the unit notes that the nurse manager seems to be highly respected by the nursing staff. The new nurse is surprised when one of the nurses states: 'The manager makes all decisions and rarely asks for our input.' The best description of the nurse manager's management style is
- A. Participative or democratic
- B. Ultraliberal or communicative
- C. Autocratic or authoritarian
- D. Laissez faire or permissive
Correct Answer: C
Rationale: Autocratic or authoritarian. The manager’s decision-making without staff input indicates an autocratic leadership style.