Nokea
The nurse is reviewing the medication administration record for a 70-year-old client. Which of the following prescribed medications places the client at increased risk for injury? Select all that apply.
- A. diphenhydramine
- B. amitriptyline
- C. simvastatin
- D. famotidine
- E. diazepam
Correct Answer: A,B,E
Rationale: Diphenhydramine (A), amitriptyline (B), and diazepam (E) cause sedation or confusion, increasing fall risk in the elderly. Simvastatin (C) and famotidine (D) do not significantly increase injury risk.
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The practical nurse is performing a physical examination with the registered nurse on a 2-year-old with cold symptoms and a fever at home of 101.7 F (38.7 C). Which interventions will enhance the child's cooperation during the examination? Select all that apply.
- A. Allow the child to play with the stethoscope
- B. Begin with the child in the parent's lap
- C. Interact with the parent in a friendly manner
- D. Play with the child using a finger puppet
- E. Start by taking the child's vital signs
Correct Answer: A,B,C,D
Rationale: Playing with the stethoscope (A), starting in the parent's lap (B), friendly interaction (C), and using a puppet (D) reduce anxiety and enhance cooperation. Vital signs (E) may distress the child if done first.
The nurse inserts a small bore nasogastric (NG) tube and prepares to initiate enteral feedings for a hospitalized client with laryngeal cancer. Which action should the nurse take first?
- A. Crush and administer medications
- B. Dilute enteral formula as prescribed
- C. Flush the tube with 30 mL of water
- D. Verify tube placement with an x-ray
Correct Answer: D
Rationale: Verifying NG tube placement with an x-ray (D) is the first step to ensure safety before feedings or medications. Other actions follow confirmation.
The nurse is caring for a client who is receiving antibiotic therapy and develops Clostridioides difficile colitis. Which of the following infection-control precautions should the nurse implement? Select all that apply.
- A. Disinfect surfaces using a diluted bleach solution
- B. Perform hand hygiene using an alcohol-based hand sanitizer
- C. Wear a face mask
- D. Wear a protective gown
- E. Wear nonsterile gloves
Correct Answer: A,D,E
Rationale: Bleach disinfection (A), gowns (D), and gloves (E) are required for C. difficile, which is spore-forming. Alcohol sanitizers (B) are ineffective against spores, and masks (C) are not routinely needed.
A client is admitted with infective endocarditis (IE). Which finding would alert the nurse to a complication of this condition?
- A. dyspnea
- B. heart murmur
- C. macular rash
- D. Hemorrhage
Correct Answer: B
Rationale: Large, soft, rapidly developing vegetations attach to the heart valves. They have a tendency to break off, causing emboli and leaving ulcerations on the valve leaflets. These emboli produce findings of cardiac murmur, fever, anorexia, malaise and neurologic sequelae of emboli.
A gravida para 1 reports that a prior pregnancy ended in loss of the baby early in the pregnancy. Which of the following instructions should be given to the client?
- A. She should refrain from sex during this pregnancy
- B. She should avoid stimulation of the breasts
- C. She should quit work until after the baby is born
- D. She should report any nausea and vomiting
Correct Answer: D
Rationale: Reporting nausea and vomiting is important, as severe symptoms could indicate complications like hyperemesis gravidarum, especially given the history of pregnancy loss.