Nokea
The nurse is reviewing new medication prescriptions for a client with an acute exacerbation of asthma. Which of the following prescriptions should the nurse clarify?
- A. Albuterol 2.5 mg via nebulizer every 4 hours
- B. Potassium chloride 20 mEq (20 mmol) IV every 24 hours
- C. Enoxaparin 40 mg subcutaneously every 24 hours
- D. Methylprednisolone sodium succinate 20 mg IV every 6 hours
Correct Answer: B
Rationale: Potassium chloride (B) is not indicated for asthma exacerbation unless hypokalemia is documented, requiring clarification. Albuterol (A), methylprednisolone (D) treat asthma, and enoxaparin (C) may prevent thrombosis in immobile patients.
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While teaching the family of a child who will take phenytoin (Dilantin) regularly for seizure control, it is most important for the nurse to teach them about which of the following actions?
- A. Maintain good oral hygiene and dental care
- B. Omit medication if the child is seizure free
- C. Administer acetaminophen to promote sleep
- D. Serve a diet that is high in iron
Correct Answer: A
Rationale: Swollen and tender gums occur often with use of phenytoin. Good oral hygiene and regular visits to the dentist should be emphasized.
The practical nurse on the mental health unit is planning care with the registered nurse. Which client should be seen first?
- A. Client with bulimia nervosa who has been in the restroom for the past hour since breakfast
- B. Client with major depressive disorder who has suicidal ideation with a plan and is on one-to-one observation
- C. Client with obsessive-compulsive disorder who refuses to attend group therapy because it interrupts handwashing ritual
- D. Client with schizophrenia who is experiencing delusions and is pacing the room and yelling at caregivers
Correct Answer: B
Rationale: Suicidal ideation with a plan (B) poses an immediate safety risk, requiring urgent assessment despite one-to-one observation. Bulimia (A) and schizophrenia (D) behaviors need monitoring but are less acute. OCD refusal (C) is a lower priority, as it does not indicate immediate harm.
The nurse is planning care for all of the following clients. Which client should be cared for first?
- A. A 60-year-old who is three days postop and needs a dressing change and ambulation
- B. A 75-year-old who had a suprapubic prostatectomy yesterday and says, 'Take that tube out of me, I have to pee.'
- C. A 90-year-old who had a total hip replacement two days ago and is to get out of bed today
- D. A 50-year-old who had an abdominal cholecystectomy yesterday and is asking for pain medication
Correct Answer: B
Rationale: The 75-year-old post-prostatectomy client's request to remove the catheter and urgency to urinate suggest potential catheter obstruction or bladder irritation, which could lead to complications like infection or bladder damage. This requires immediate assessment and intervention, taking priority over routine dressing changes, scheduled mobility, or pain management.
The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse would be appropriate?
- A. Schedule the therapy thirty minutes after meals
- B. Teach the child not to cough during the treatment
- C. Continue the percussion to the rib cage area
- D. Place the child in a prone position for the therapy
Correct Answer: C
Rationale: Continue the percussion to the rib cage area. Percussion should target the rib cage to mobilize secretions effectively.
A patient has recently been prescribed Lidocaine Hydrochloride. Which of the following symptoms may occur with over dosage?
- A. Memory loss and lack of appetite
- B. Confusion and fatigue
- C. Heightened reflexes
- D. Tinnitus and spasticity
Correct Answer: B
Rationale: Lidocaine Hydrochloride can cause fatigue and confusion if an over dosage occurs.