Nokea
The nurse is preparing to administer the initial dose of an aminoglycoside antibiotic to the client diagnosed with acute diverticulitis. Which intervention should the nurse implement?
- A. Obtain a serum trough level.
- B. Ask about drug allergies.
- C. Monitor the peak level.
- D. Assess the vital signs.
Correct Answer: B
Rationale: Checking for drug allergies before administering an aminoglycoside prevents allergic reactions, a critical safety step. Trough and peak levels are monitored later, and vital signs are routine but not specific to the initial dose.
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The nurse is caring for clients on a medical unit. Which client information should be brought to the attention of the HCP immediately?
- A. A serum sodium of 128 mEq/L in a client diagnosed with obstipation.
- B. The client diagnosed with fecal impaction who had two (2) hard formed stools.
- C. A serum potassium level of 3.8 mEq/L in a client diagnosed with diarrhea.
- D. The client with diarrhea who had two (2) semiliquid stools totaling 300 mL.
Correct Answer: A
Rationale: Hyponatremia (sodium 128 mEq/L) in obstipation risks neurological complications, requiring immediate HCP attention. Formed stools, normal potassium, and moderate diarrhea are less urgent.
Which complaint is significant for the nurse to assess in the adolescent male client who uses oral tobacco?
- A. The client complains of clear to white sputum.
- B. The client has an episodic blister on the upper lip.
- C. The client complains of a nonhealing sore in the mouth.
- D. The client has bilateral ducts at the second molars.
Correct Answer: C
Rationale: A nonhealing sore in the mouth is concerning for oral cancer, a risk associated with oral tobacco use, requiring immediate assessment. Sputum, blisters, and salivary ducts are less significant.
The client with liver problems asks the nurse, 'Why are my stools clay-colored?' On which scientific rationale should the nurse base the response?
- A. There is an increase in serum ammonia level.
- B. The liver is unable to excrete bilirubin.
- C. The liver is unable to metabolize fatty foods.
- D. A damaged liver cannot detoxify vitamins.
Correct Answer: B
Rationale: Clay-colored stools result from the liver’s inability to excrete bilirubin, which gives stool its brown color. Ammonia, fat metabolism, and vitamin detoxification are unrelated.
The 20-year-old female is being admitted to the hospital with exacerbation of Crohn’s disease. The client is alert and oriented and has been taking azathioprine for disease control. Into which room should the charge nurse place the client?
- A. Private room across from the nurse’s station
- B. Room with a female who has Crohn’s disease
- C. Private room that has a private attached bathroom
- D. Room with an elderly female who is on bedrest
Correct Answer: C
Rationale: A. The client is alert and oriented; there is no need to be near the nurse’s station. B. The client is at an increased risk for infection and should have a private room rather than rooming with another female with Crohn’s disease. C. The client should be in a private room with a private bathroom due to an increased risk for infection with azathioprine (Imuran). Azathioprine suppresses cell-mediated immune responses and may cause bone marrow suppression. It is also a biohazard medication. D. The client is at an increased risk for infection and should have a private room rather than rooming with another female.
While reviewing the client’s medical records, the nurse notes the diagnosis of biliary colic. Considering this diagnosis, which additional sign will the nurse most likely find in the client’s medical record?
- A. Bloody diarrhea
- B. Heartburn and regurgitation
- C. Abdominal distention
- D. Severe abdominal pain
Correct Answer: D
Rationale: A. Diarrhea is not related to biliary colic. B. Heartburn and regurgitation are not related to biliary colic. C. Abdominal distention is not related to biliary colic. D. Biliary colic is the term used for the severe pain that is caused by a gallstone lodged in the cystic or common bile duct and/or traveling through the ducts. The presence of the stone causes the duct to spasm, causing severe abdominal pain.