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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Which sign might the nurse see in a client with a high ammonia level?
- A. coma
- B. edema
- C. hypoxia
- D. polyuria
Correct Answer: A
Rationale: Coma might be seen in a client with a high ammonia level.
All of the following should be performed when fetal heart monitoring indicates fetal distress except:
- A. increase maternal fluids.
- B. administer oxygen.
- C. decrease maternal fluids.
- D. turn the mother.
Correct Answer: C
Rationale: Decreasing maternal fluids is the only intervention that should not be performed when fetal distress is indicated.
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.
Which of the following nursing diagnoses is most appropriate for a client with a new colostomy?
- A. Excess Fluid Volume
- B. Risk for Aspiration
- C. Disturbed Body Image
- D. Urinary Retention
Correct Answer: C
Rationale: Disturbed Body Image is the most appropriate nursing diagnosis for a client with a new colostomy, due to the adjustments that need to be made with the physical alteration of a colostomy. The other diagnoses are not applicable.
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).