Nokea
The nurse is reviewing newly prescribed medications for assigned clients. Which of the following prescribed medications should the nurse question?
- A. Levothyroxine for a client with a myxedema coma
- B. Hydrochlorothiazide for a client with hyperparathyroidism
- C. Hydrocortisone for a client with adrenal insufficiency
- D. Regular insulin for a client with diabetic ketoacidosis
Correct Answer: B
Rationale: Hydrochlorothiazide can worsen hypercalcemia in hyperparathyroidism and should be questioned.
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The nurse is educating a group of students on the measles, mumps, and rubella (MMR) vaccine. Which statement, if made by the student, would indicate effective teaching?
- A. Egg allergy is a contraindication to giving this vaccine.
- B. This is a three-series vaccine that should be started at birth.
- C. It is safe for breastfeeding women to receive the MMR vaccine.
- D. This vaccine is safe if the client is pregnant.
Correct Answer: C
Rationale: The MMR vaccine is safe for breastfeeding women but contraindicated in pregnancy and not started at birth. Egg allergy is no longer a contraindication.
The nurse is planning a staff development conference about diabetic ketoacidosis (DKA). Which of the following information should the nurse include?
- A. The goal is to lower blood glucose by 50 to 75 mg/dL/hr (2.775 to 4.165 mmol/L/hr).
- B. Dextrose 5% in water (D5W) should be available to treat symptoms of hypoglycemia.
- C. Hypovolemia caused by DKA may be treated with 3% saline.
- D. The urine output would increase once regular insulin is initiated.
Correct Answer: A, B, D
Rationale: The goal is to lower glucose gradually, D5W treats hypoglycemia, and insulin increases urine output by correcting osmotic diuresis. 3% saline is not used for hypovolemia in DKA.
The nurse is caring for a client who is recovering from surgery. Which assessment data would suggest that the client's pain is not well controlled?
- A. Tachypnea
- B. Bradycardia
- C. Nausea
- D. Mydriasis
- E. Increased blood glucose
Correct Answer: A, C, E
Rationale: Tachypnea, nausea, and increased blood glucose are signs of uncontrolled pain.
The following scenario applies to the next 6 items
The nurse in the emergency department (ED) is caring for a 64-year-old male client.
Item 1 of 6
Nurses' Notes
1742: Client arrives at the emergency department via emergency medical services (EMS). He was skiing and crashed into a post and fell to the ground. Ski patrol assessed the client, and the client was confused and had no memory of the crash. Ski patrol reports that he was wearing a helmet and had a loss of consciousness for an unknown amount of time. On assessment, the client was alert and oriented to place and time but did not recall the events leading up to hospitalization, specifically the ski crash. Client states, “My head really hurts and I'm dizzy.” Reporting aching pain rated 8/10 on the Numerical Pain Scale. Reddish contusion on the client's forehead. Pupils were 2+, equal, and sluggishly reactive to light. Glasgow Coma Scale 14. Nose is midline and symmetrical. His speech was clear and articulate. Full range of motion in all extremities observed. Clear lung fields bilaterally. Radial pulse 2+ and irregular. Normoactive bowel sounds in all quadrants. No abdominal distention or pain. Vital signs: T 97.8° F (36.6° C), P 85, RR 15, BP 124/82, pulse oximetry reading 98% on room air. The client has a medical history of essential hypertension, generalized anxiety disorder, atrial fibrillation, and chronic back pain.
Home medications
• multivitamin (MVI) 1 tablet PO daily
• fluoxetine 20 mg PO daily
• biotin 100 mcg PO daily
• pantoprazole 40 mg PO daily
• warfarin 2.5 mg PO daily
• diltiazem controlled-release 120 mg PO daily
Which of the following assessment findings require immediate follow-up?
- A. lung sounds
- B. pupil assessment
- C. abdominal assessment findings
- D. pulse, respirations, and blood pressure
- E. Glasgow coma scale
- F. speech characteristics
- G. home medications
Correct Answer: B, E, G
Rationale: Pupil sluggishness, Glasgow Coma Scale of 14, and warfarin use (increasing bleeding risk) require immediate follow-up due to potential traumatic brain injury.
The nurse is teaching a group of nursing students about the five rights of delegation. The nurse is correct to include that this involves the right
- A. intention
- B. alternative
- C. assessment
- D. task
Correct Answer: D
Rationale: The five rights of delegation include the right task, ensuring appropriate delegation.