Nokea
The nurse is reviewing laboratory data for a client taking prescribed phenytoin. The client's phenytoin level is 12 mcg/mL (10-20 mcg/mL). Which action should the nurse take next?
- A. Evaluate the client for non-adherence
- B. Instruct the client to skip the next scheduled dose
- C. Assess the client for phenytoin toxicity
- D. Document the result as within normal limits
Correct Answer: D
Rationale: A phenytoin level of 12 mcg/mL is within the therapeutic range (10-20 mcg/mL), so the nurse should document the result as normal. Non-adherence, skipping doses, or toxicity assessment are not indicated.
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The nurse is caring for a client experiencing autonomic dysreflexia. What action should the nurse perform first?
- A. Administer sublingual nitroglycerin.
- B. Elevate the head of the bed.
- C. Obtain a residual volume reading with a bladder scan.
- D. Perform a digital examination to assess for the presence of stool.
Correct Answer: B
Rationale: Elevating the head of the bed reduces blood pressure in autonomic dysreflexia.
The following scenario applies to the next 1 items
The emergency department (ED) nurse is caring for a 15-year-old who has sustained a sports-related injury
Item 1 of 1
Triage Note Triage Vital Signs
1330: A 15-year-old female was participating in cheerleading practice and fell to the ground while in the air. Witnesses said that she hit her head and 'blacked out,' and the client reports no recall of the event. The client endorses left occipital head pain with tenderness to the affected area. Slight swelling noted. The client reports headache as a '7' (0 = no pain, 10 = worst pain). She is lethargic and oriented.
The nurse assigned to the client reviews the triage note and plans care
The nurse anticipates taking which action? Prepare the client for a computed tomography (CT) scan of the head
- A. Prepare the client for a computed tomography (CT) scan of the head
- B. Perform a Glasgow Coma Scale (GCS)
- C. Encourage by mouth (PO) fluids
- D. Assess the client's pupils
- E. Prepare the client for a lumbar puncture (LP)
Correct Answer: A,A,B,A,B
Rationale: A CT scan is indicated to assess for brain injury in a client with head trauma and loss of consciousness. GCS assessment is critical to evaluate neurological status post-head injury. Encouraging PO fluids is inappropriate until a CT scan rules out increased intracranial pressure. Pupil assessment is essential to detect neurological changes post-head trauma. Lumbar puncture is not indicated unless specific conditions like meningitis are suspected.
The nurse cares for geriatric clients. The nurse knows which of the following is the leading cause of cognitive impairment in old age?
- A. Stroke
- B. Malnutrition
- C. Alzheimer's disease
- D. Loss of cardiac reserve
Correct Answer: C
Rationale: Alzheimer's disease is the most common cause of cognitive impairment in the elderly.
The nurse is assessing a client who is postoperative following a hypophysectomy. Which of the following findings should the nurse report to the primary healthcare provider (PHCP) immediately?
- A. Client reports a decreased smell
- B. No bowel movement in two days
- C. Foul-smelling breath
- D. Hourly urine output of 125 mL
Correct Answer: D
Rationale: High urine output suggests diabetes insipidus, a serious complication post-hypophysectomy.
The nurse is performing an assessment on a client with Wernicke's aphasia. Which client finding would be consistent with this diagnosis?
- A. Loss of ability to execute or carry out skilled movements.
- B. Cannot express any words.
- C. Cannot swallow liquids.
- D. Speaks with normal fluency and prosody.
Correct Answer: D
Rationale: Wernicke's aphasia is characterized by fluent but nonsensical speech with preserved fluency and prosody.