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The nurse is preparing to administer acetaminophen (Tylenol) to a client diagnosed with a stroke who is complaining of a headache. Which intervention should the nurse implement first?
- A. Administer the medication in pudding.
- B. Check the client's armband.
- C. Crush the tablet and dissolve in juice.
- D. Have the client sip some water.
Correct Answer: B
Rationale: Checking the armband (B) ensures patient safety before medication administration. Pudding (A), crushing (C), or sipping water (D) follow identity confirmation.
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The nurse is preparing a client diagnosed with rule-out meningitis for a lumbar puncture. Which interventions should the nurse implement? Select all that apply.
- A. Obtain an informed consent from the client or significant other.
- B. Have the client empty the bladder prior to the procedure.
- C. Place the client in a side-lying position with the back arched.
- D. Instruct the client to breathe rapidly and deeply during the procedure.
- E. Explain to the client what to expect during the procedure.
Correct Answer: A,B,C,E
Rationale: Informed consent (A) is required, emptying the bladder (B) ensures comfort, side-lying with back arched (C) facilitates needle insertion, and explaining the procedure (E) reduces anxiety. Rapid breathing (D) is not advised.
The client is diagnosed with Huntington's chorea. Which interventions should the nurse implement with the family? Select all that apply.
- A. Refer to the Huntington's Chorea Foundation.
- B. Explain the need for the client to wear football padding.
- C. Discuss how to cope with the client's messiness.
- D. Provide three (3) meals a day and no between-meal snacks.
- E. Teach the family how to perform chest percussion.
Correct Answer: A,C
Rationale: Referring to the Huntington’s Disease Society (A) provides support and resources. Discussing coping with messiness (C) addresses chorea-related coordination issues. Football padding (B) is inappropriate, meal restrictions (D) are unnecessary, and chest percussion (E) is unrelated.
Which intervention is most appropriate for a client with a cerebral aneurysm at risk for rupture?
- A. Encourage deep coughing exercises.
- B. Maintain a quiet, dimly lit environment.
- C. Administer high-dose corticosteroids.
- D. Promote early ambulation.
Correct Answer: B
Rationale: A quiet, dimly lit environment reduces stimuli that could increase intracranial pressure and risk aneurysm rupture.
The client is prescribed a loading dose of phenytoin of 15 mg/kg IV for seizure activity, then 100 mg IV tid. The client weighs 198 lb. What dose in mg should the nurse administer for the loading dose of phenytoin?
- A. 1350 mg IV
Correct Answer: 1350
Rationale: 198 lb = 90 kg; (198 ÷ 2.2 = 90 kg; 90 x 15 = 1350) The nurse should administer 1350 mg phenytoin (Dilantin).
When the client is observed wandering about the facility, the nurse modifies the client's care plan to provide for safety. Which nursing intervention is most appropriate at this time?
- A. Keep the client confined to the room.
- B. Attach an identity tag to the client's clothes.
- C. Lock all the outside doors in the facility.
- D. Make sure the client knows the location of the facility.
Correct Answer: B
Rationale: An identity tag helps ensure the client can be identified and returned safely if they wander, promoting safety without restricting freedom.