Nokea
The nurse is preparing to administer the first dose of IV antibiotic to the client. Halfway through the infusion, the nurse realizes that the antibiotic dosage is not the same as ordered by the health care provider. Which action should the nurse take first?
- A. stop the infusion
- B. fill out an incident form
- C. notify the health care provider
- D. only give part of the antibiotic to obtain the correct dose
Correct Answer: A
Rationale: Stopping the infusion is the priority to prevent harm from an incorrect dose, followed by notifying the provider and completing an incident report.
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The doctor has prescribed a diet high in vitamin B12 for a client with pernicious anemia. Which foods are good sources of B12?
- A. Meat, eggs, dairy products
- B. Peanut butter, raisins, molasses
- C. Broccoli, cauliflower, cabbage
- D. Shrimp, legumes, bran cereals
Correct Answer: A
Rationale: Vitamin B12 is found in animal products like meat, eggs, and dairy, essential for treating pernicious anemia due to impaired B12 absorption.
The nurse is preparing to discharge a client diagnosed with gout. Which statement by the client indicates understanding of dietary restrictions while managing gout?
- A. I should avoid beer, anchovies, and liver.
- B. I should avoid bananas, grapefruit, and oranges.
- C. I should avoid dairy products such as milk and ice cream.
- D. I should avoid red wine, dark chocolate, and aged cheeses.
Correct Answer: A
Rationale: Beer, anchovies, and liver are high in purines, which can exacerbate gout, making avoidance appropriate.
Which would be included in the nursing care plan of a client experiencing severe delirium tremens?
- A. Placing the client in a darkened room
- B. Keeping the closet and bathroom doors closed
- C. Administering a diuretic to decrease fluid excess
- D. Checking vital signs every 8 hours
Correct Answer: B
Rationale: Keeping closet and bathroom doors closed minimizes visual stimuli that could exacerbate hallucinations or confusion in delirium tremens, promoting a safe environment.
A client receiving high doses of hydromorphone (Dilaudid®) develops acute respiratory depression with a drop in blood pressure. Which of the following treatments is most indicated?
- A. Naloxone
- B. Naproxen
- C. Flumazenil
- D. Nortriptyline
Correct Answer: A
Rationale: Naloxone (A) reverses opioid-induced respiratory depression. Naproxen (B), flumazenil (C), and nortriptyline (D) are not appropriate.
A pregnant client is keeping a 'kick count' log during the last trimester. Which of the following may indicate fetal distress?
- A. Fewer than 5 movements within 2 hours
- B. Fewer than 5 movements within 1 hour
- C. Fewer than 10 movements within 2 hours
- D. Fewer than 10 movements within 1 hour
Correct Answer: C
Rationale: Fewer than 10 movements in 2 hours (C) suggests fetal distress, as normal is >10 movements in 2 hours. Other options (A, B, D) set incorrect thresholds.