Nokea
The nurse is preparing to administer a dose of penicillin to a client with a streptococcal infection. Which assessment is most important before administration?
- A. Allergy history
- B. Blood pressure
- C. Temperature
- D. Respiratory rate
Correct Answer: A
Rationale: Penicillin has a high risk of allergic reactions, including anaphylaxis. Assessing allergy history is critical before administration. Vital signs are monitored but are less specific to penicillin risks.
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An appropriate nursing intervention for the client with borderline personality disorder is:
- A. Observing the client for signs of depression or suicidal thinking
- B. Allowing the client to lead unit group sessions
- C. Restricting the client's activity to the assigned unit of care throughout hospitalization
- D. Allowing the client to select a primary caregiver
Correct Answer: A
Rationale: Clients with borderline personality disorder often experience mood instability and are at risk for self-harm or suicide. Observing for signs of depression or suicidal thinking is a priority nursing intervention to ensure safety. Allowing the client to lead group sessions or select a caregiver may reinforce manipulative behaviors, and restricting activity to the unit is not typically therapeutic unless specified for safety.
The nurse is caring for a client with a history of a pneumothorax who is being prepared for discharge. The nurse should teach the client to:
- A. Avoid air travel
- B. Sleep on the affected side
- C. Resume heavy lifting
- D. Restrict fluid intake
Correct Answer: A
Rationale: Air travel can cause pressure changes that risk pneumothorax recurrence. Sleeping position, lifting, and fluids are secondary, with lifting typically restricted.
The nurse is preparing to administer regular insulin by continuous IV infusion to a client with diabetic ketoacidosis. The nurse should:
- A. Mix the insulin with Dextrose 5% in water.
- B. Flush the IV tubing with the insulin solution and discard the first 50 mL.
- C. Give the insulin without diluting.
- D. Add the insulin to a solution of normal saline.
Correct Answer: D
Rationale: Regular insulin for IV infusion should be diluted in normal saline to ensure compatibility and prevent adsorption to IV tubing. Dextrose is inappropriate during DKA, and flushing with insulin wastes medication.
A child is admitted with suspected epiglottitis. Which action is not a part of the nursing care?
- A. Checking the vital signs
- B. Assessing the throat with a tongue blade
- C. Administering oxygen as needed
- D. Administering IV antibiotics
Correct Answer: B
Rationale: Assessing the throat with a tongue blade is contraindicated in suspected epiglottitis as it may trigger airway obstruction. Vital signs oxygen and antibiotics are appropriate interventions.
The nurse is caring for a client with a history of a stroke who has dysphagia. The nurse should:
- A. Offer thin liquids
- B. Position the client upright for meals
- C. Feed the client quickly
- D. Use a straw for fluids
Correct Answer: B
Rationale: Positioning upright during meals reduces aspiration risk in dysphagia post-stroke. Thickened liquids, slow feeding, and avoiding straws are also recommended.