Nokea
The nurse is preparing to administer preoperative medication of meperidine and atropine to an elderly adult who is scheduled for surgery. The client tells the nurse that he has glaucoma and wants to take his eye drops before going to the operating room. What is the best action for the nurse to take?
- A. Administer medication as ordered and encourage the client to take his eye drops
- B. Check with the physician before administering preoperative medication
- C. Administer preoperative medication as ordered and suggest the client not take his eye drops
- D. Administer the meperidine, withhold atropine, and suggest the client take his eye drops
Correct Answer: B
Rationale: Atropine, an anticholinergic, can increase intraocular pressure, exacerbating glaucoma. Checking with the physician ensures safe administration, as withholding atropine or adjusting eye drop use may be necessary.
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The nurse is giving home care to an elderly client with angina pectoris and Type 2 diabetes mellitus. Which observation is of most concern and should be reported immediately?
- A. The client reports chest discomfort yesterday while taking a walk.
- B. The nurse observes several brown spots on the client's arms and legs.
- C. The client reports an ingrown toenail that is getting more painful.
- D. The client reports shortness of breath when climbing stairs.
Correct Answer: A
Rationale: Chest discomfort in a client with angina suggests possible cardiac ischemia, requiring immediate reporting to prevent myocardial infarction. Brown spots, toenail pain, or exertional dyspnea are less urgent.
The nurse is acting as a preceptor for a student nurse in the labor and delivery unit. Which action by the student would require correction by the nurse?
- A. Removing gloves prior to removing isolation gown
- B. Using a nail brush to scrub underneath artificial nails
- C. Using alcohol-based hand sanitizer instead of washing hands when entering and exiting client room
- D. Washing hands and not wearing gloves when preparing medications in the med room
Correct Answer: B
Rationale: Artificial nails harbor bacteria, and scrubbing underneath is inadequate; they should be avoided in labor and delivery. Other actions align with infection control protocols.
Which type of accidental poisoning would the nurse expect to occur in children under age 6?
- A. Oral ingestion
- B. Topical contact
- C. Inhalation
- D. Eye splashes
Correct Answer: A
Rationale: Oral ingestion. Young children are most likely to ingest toxic substances due to their exploratory behavior.
The nurse understands that which of these body substances are modes of transmission for hepatitis B? Select all that apply.
- A. Blood
- B. Feces
- C. Semen
- D. Urine
- E. Vaginal secretions
Correct Answer: A,C,E
Rationale: Hepatitis B is transmitted via blood, semen, and vaginal secretions. Feces and urine are not significant transmission modes.
The nurse is reinforcing teaching with a client who has a prescription for sertraline for the treatment of depression. Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I can discontinue the medication as soon as I start feeling better
- B. I should avoid eating aged cheeses, cured meats, or pickled foods
- C. I should expect to feel better within 2 to 3 days after starting this medication
- D. I will report any thoughts of self-harm to my health care provider
Correct Answer: D
Rationale: Reporting self-harm thoughts is critical, as sertraline may increase suicide risk initially. Discontinuing abruptly risks relapse, food restrictions apply to MAOIs, and benefits take weeks, not days.