Nokea
The nurse is preparing to ambulate a client with a diagnosis of Parkinson's disease who has recently been prescribed levodopa. Which information is most important for the nurse to assess before ambulating the client?
- A. The client's history of falls
- B. Assistive devices used by the client
- C. The client's postural (orthostatic) vital signs
- D. The degree of intention tremors exhibited by the client
Correct Answer: C
Rationale: Clients diagnosed with Parkinson's disease are at risk for postural (orthostatic) hypotension from the disease. This problem is exacerbated with the introduction of levodopa, which can also cause postural hypotension. Although knowledge of the client's risk for falls and the client's use of assistive devices are helpful, it is not the most important piece of assessment data, based on the wording of this question. Clients with Parkinson's disease generally have resting, not intention, tremors.
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A registered nurse is a preceptor for a new nurse and is observing the new nurse organize the client assignments and prioritize daily tasks. The registered nurse should intervene if the new nurse implements which action?
- A. Provides times for staff meals
- B. Gathers the supplies needed for a task
- C. Combines all tasks for clients in one list
- D. Documents task completions at the end of the day
Correct Answer: D
Rationale: The nurse should document task completion continuously throughout the day. Options 1, 2, and 3 identify accurate components of time management.
A client with a diagnosis of thrombophlebitis is being treated with prescribed heparin sodium therapy. In planning a safe environment, the nurse should ensure that which medication is available if the client develops a significant bleeding problem?
- A. Retaplase
- B. Phytonadione
- C. Protamine sulfate
- D. Fresh frozen plasma
Correct Answer: C
Rationale: Protamine sulfate is the antidote for heparin sodium. Fresh frozen plasma may be used for bleeding related to warfarin therapy. Retaplase is a thrombolytic agent used to dissolve blood clots. Phytonadione is the antidote for warfarin.
The nurse should implement which safety measures to prevent an electrical shock when using electrical equipment? Select all that apply.
- A. Use a two-prong outlet.
- B. Check the electrical cord for fraying.
- C. Keep the electrical cord away from the sink.
- D. Place the excess electrical cord under a small carpet.
- E. Grasp the electrical cord when unplugging the equipment.
- F. Disconnect the electrical cord from the wall socket when cleaning the equipment.
Correct Answer: B,C,F
Rationale: The nurse needs to implement measures to prevent an electrical shock when using electrical equipment. These measures include using a three-prong plug that is grounded, checking the electrical cord for fraying or other damage, keeping the electrical cord away from the sink or other sources of water, using electrical tape to secure the excess electrical cord to the floor where it will not be stepped on (the cord should not be placed under carpet), grasping the plug (not the electrical cord) when unplugging the equipment, and disconnecting the electrical cord from the wall socket when cleaning the equipment.
The nurse documents a written entry regarding client care in the client's medical record. When checking the entry, the nurse notices that some of the documented information was incorrect. Which action should the nurse implement at this time?
- A. Obliterate the incorrect information with a black marker.
- B. Use correction fluid to cover up the incorrect information.
- C. Erase the error completely and write in the correct information.
- D. Draw a line through the incorrect information and initial the change.
Correct Answer: D
Rationale: To correct a written error documented in a medical record, the nurse draws one line through the incorrect information and then initials the error. The information remains visible and properly labeled as incorrect. Errors are never erased, and correction fluid or black markers are never used on a legal document such as the medical record.
The nurse hangs a 1000-\mathrm{mL intravenous (IV) solution of \mathrm{D}_5W ( 5\% dextrose in water) at 9 am and sets the infusion controller device to administer 100 \mathrm{gtt} / \mathrm{min via microdrip infusion set (60 \mathrm{gtt}=1mL}) . On assessment of the IV infusion, the nurse expects that the remaining amount of solution in the IV bag at 2 \mathrm{pm will be represented at which level? Fill in the blank and round to the nearest whole number.
Correct Answer: 500
Rationale: The nurse hangs an IV solution at 9 am and sets the IV solution to infuse at 100 \mathrm{gtt} / \mathrm{min per microdrip. With a microdrip, gtt/min =\mathrm{mL} / \mathrm{hr infused. Therefore, 100 \mathrm{mL} / \mathrm{hr is being infused. A total of 500mL will be infused in the 5 elapsed hours. At 2 \mathrm{pm the nurse would expect 500mL of solution to be safely infused and 500mL to be remaining. Since this is a fill-in-the-blank question, the answer is 500 mL, which corresponds to option B for CSV formatting purposes.