Nokea
The nurse is preparing to administer several medications through a client's feeding tube. None of the medications are extended release. Which of the following actions should the nurse implement? Select all that apply.
- A. Combine all medications and administer together
- B. Crush each medication separately before administration
- C. Determine if the medications are available in liquid form
- D. Flush the tube before and after medication administration
- E. Mix medications with enteral feeding formula before administration
Correct Answer: B, C, D
Rationale: Crushing separately (B) prevents interactions, liquid forms (C) are preferred, and flushing (D) ensures patency. Combining all medications (A) or mixing with formula (E) can cause clogs or interactions.
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A client continually repeats phrases that others have just said. The nurse recognizes this behavior as
- A. Autistic
- B. Echopraxis
- C. Echolalia
- D. Catatonic
Correct Answer: C
Rationale: Echolalia is repeating words or phrases heard before, often seen in certain psychiatric or developmental conditions.
The nurse prepares to administer medications to a client. Which of the following client data are acceptable for use as client identifiers? Select all that apply.
- A. Date of birth
- B. First and last name
- C. Health care provider
- D. Medical record number
- E. Room number
Correct Answer: A, B, D
Rationale: Date of birth (A), first and last name (B), and medical record number (D) are reliable identifiers. Health care provider (C) and room number (E) are not specific to the client.
The most important information for the nurse to have when planning care for the client with diabetes is the client's
- A. Family medical history
- B. Blood glucose history
- C. 24-hour dietary history
- D. Medical history
Correct Answer: B
Rationale: Answer B is correct. The most objective answer is the blood glucose history. Answers A, C, and D are more subjective. This information is reported data.
A client with a pyloric obstruction is admitted to the hospital with vomiting. Which of the following blood gases would the nurse expect to see in the client with vomiting?
- A. $\mathrm{pH} 7.33, \mathrm{PCO}_2 30 \mathrm{~mm} \mathrm{Hg}$
- B. $\mathrm{pH} 7.50, \mathrm{PCO}_2 32 \mathrm{~mm} \mathrm{Hg}$
- C. $\mathrm{pH} 7.30, \mathrm{PCO}_2 50 \mathrm{~mm} \mathrm{Hg$
- D. $\mathrm{pH} 7.47, \mathrm{PCO}_2 40 \mathrm{~mm} \mathrm{Hg}$
Correct Answer: B
Rationale: Vomiting causes loss of hydrochloric acid, leading to metabolic alkalosis, indicated by a high pH (7.50) and normal to low PCO2.
The nurse is caring for a client with polycythemia vera. Which of the following actions should the nurse take? Select all that apply.
- A. Encourage increased fluid intake.
- B. Prepare the client for phlebotomy.
- C. Administer low-dose aspirin as prescribed.
- D. Teach the client to elevate the legs while sitting.
- E. Request a prescription for iron supplementation.
Correct Answer: A, B, C
Rationale: Increased fluids (A), phlebotomy (B), and aspirin (C) manage polycythemia vera by reducing blood viscosity and clotting risk. Leg elevation (D) is irrelevant, and iron supplementation (E) worsens the condition.