Nokea
The nurse is preparing to administer IV Vancomycin to a client. Which of the following nursing actions should be taken first?
- A. performing a physical assessment prior to administration
- B. obtaining the most recent lab values regarding renal function
- C. reviewing peaks and troughs for the past few days
- D. ensuring the client is not allergic to the medication
Correct Answer: D
Rationale: Even before the physical assessment (which might or might not be indicated at the time of administration of Vancomycin), ensuring that the client is not allergic to the medication is the most critical action the nurse must take before administering any drug. Lab values regarding renal functioning and therapeutic ranges via peaks and troughs are also important with some medications such as Vancomycin because renal damage can occur if blood drug levels remain high over time.
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A community health nurse is asked to organize a health promotion project that plans to provide glucose screening. This activity is most beneficial within what realm?
- A. Testing that is performed by volunteers at a local department store and is open to the public
- B. At a professional health fair activity available for selected persons who have been screened as being at risk
- C. Mass-marketing vouchers for free fingersticks at a local drug store, where the pharmacist makes recommendations on the findings
- D. Testing that is performed by a nurse professional, who immediately provides education regarding the findings
Correct Answer: B
Rationale: Glucose screening is most effective for high-risk or symptomatic individuals at a health fair, ensuring targeted and meaningful results.
Which of the following statements by a client indicates adequate understanding of preparation for electroencephalography?
- A. I cannot eat or drink after midnight.'
- B. I need to wash my hair before the test.'
- C. I need to remove metal jewelry.'
- D. I cannot take aspirin before the test.'
Correct Answer: B
Rationale: The client needs to wash his hair to remove hair spray, cream, or oil that might interfere with attaching the electrodes to the scalp. Food or fluids do not need to be restricted, with the exception of caffeinated fluids. There is no restriction on metal objects. Aspirin is not a medication that needs to be held before the test (just anticonvulsants, tranquilizers, barbiturates, and other sedatives).
Which isolation procedure will be followed for secretions and blood?
- A. Respiratory
- B. Standard Precautions
- C. Contact Isolation
- D. Droplet
Correct Answer: B
Rationale: Standard precautions are taken in all situations for all clients and involve all body secretions except sweat and are designed to reduce the rate of transmission of microbes from one host to another or one source (environment such as the client's bedside table) to another.
Which enzyme is elevated in conditions of pancreatic inflammation, such as pancreatitis?
- A. Alkaline phosphatase
- B. Acid phosphatase
- C. Creatine phosphokinase
- D. Amylase
Correct Answer: D
Rationale: Amylase is elevated in conditions of pancreatic inflammation, such as pancreatitis. The other enzymes are associated with other types of tissue damage.
Which of the following might be an appropriate nursing diagnosis for an epileptic client?
- A. Dysreflexia
- B. Risk for Injury
- C. Urinary Retention
- D. Unbalanced Nutrition
Correct Answer: B
Rationale: The epileptic client is at risk for injury due to the complications of seizure activity, such as possible head trauma associated with a fall. The other choices are not related to the question.