Nokea
The nurse is preparing to administer oral potassium chloride to an elderly client. Which action should the nurse take before administering the medication?
- A. Perform a fingerstick for morning glucose
- B. Assess for signs of hypocalcemia
- C. Withhold food for thirty minutes
- D. Check the creatinine level
Correct Answer: D
Rationale: Potassium chloride can worsen renal function in elderly clients. Checking the creatinine level assesses kidney function to ensure safe administration. Glucose hypocalcemia and withholding food are not directly related to potassium administration.
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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.
The nurse teaches a male client ways to reduce the risks associated with furosemide therapy. Which of the following indicates that he understands this teaching?
- A. I'll be sure to rise slowly and sit for a few minutes after lying down.'
- B. I'll be sure to walk at least 2-3 blocks every day.'
- C. I'll be sure to restrict my fluid intake to four or five glasses a day.'
- D. I'll be sure not to take any more aspirin while I am on this drug.'
Correct Answer: A
Rationale: Rising slowly prevents postural hypotension, a common side effect of furosemide that increases fall risk. The other options are not specific to furosemide therapy risks.
The nurse needs to be aware that the most common early complication of a myocardial infarction is:
- A. Diabetes mellitus
- B. Anaphylactic shock
- C. Cardiac hypertrophy
- D. Cardiac dysrhythmia
Correct Answer: D
Rationale: Myocardial infarction causes tissue damage, which may interrupt electrical impulses. Myocardial irritability results from lack of oxygenated tissue.
The physician has ordered an injection of RhoGam for a client with blood type A negative. The nurse knows that RhoGam is given at:
- A. One finger breadth below the umbilicus
- B. The deltoid
- C. Two finger breadths above the trochanter
- D. Two finger breadths below the umbilicus
Correct Answer: B
Rationale: RhoGam is administered intramuscularly, typically in the deltoid muscle, for Rh-negative mothers to prevent sensitization. The other locations are incorrect for IM injections of RhoGam.
Which toys are suited to the developmental skills of the 2-3 year old?
- A. Soap bubbles
- B. Skates
- C. Riding toys
- D. Bicycle
- E. Talking toys
Correct Answer: A, C, E
Rationale: For 2-3-year-olds, soap bubbles (A), riding toys (C), and talking toys (E) match gross motor and imaginative play skills. Skates (B) and bicycles (D) require advanced coordination.