Nokea
The nurse observes that the client being treated with antipsychotics is unsteady while standing and walking and that the client's hands are trembling slightly. What should the nurse do?
- A. Administer a pm dose of the anticholinergic Trihexyphenidyl.
- B. Offer assistance with ambulation back to the client's room for rest.
- C. Insist that the client remain seated. Applying limb restraints if needed.
- D. Call the HCP to report that early signs of tardive dyskinesia are present.
Correct Answer: A
Rationale: The client is experiencing extrapyramidal symptoms (EPS) of pseudoparkinsonism, requiring an antiparkinsonian agent like trihexyphenidyl.
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A pregnant client asks how she can prevent getting Group B Strep. What is the LPN's best response?
- A. You should have your partner wear a condom every time you have intercourse.
- B. You cannot prevent getting Group B Strep, you can only treat it.
- C. You should be extra vigilant about hand-washing, especially in the third trimester.
- D. The Group B Strep vaccine is the only proven way to prevent the disease.
Correct Answer: B
Rationale: Group B Strep lives in the vagina, rectum, and intestines of about 25% of the female population. It is considered normal flora and is not a sexually transmitted disease. The same woman can test positive in one pregnancy and negative in another, which is why testing is done every pregnancy, usually within 5 weeks of expected delivery. If a woman tests positive for Group B Strep, she will be given antibiotics during delivery to greatly reduce the risk of complications for her and her baby.
The client seeking treatment for insomnia tells the nurse about researching complementary therapies for promoting sleep. Which are herbal remedies for promoting sleep that the client may wish to discuss with the nurse?
- A. Fennel and ginger tea
- B. Chamomile tea and hops
- C. Feverfew and peppermint
- D. Echinacea and goldenseal
Correct Answer: B
Rationale: Chamomile tea and hops are believed to relieve insomnia.
The nurse observes a colleague about to administer an IM injection to the 12-month-old. Which intervention requires the nurse to intervene?
- A. Prepares to give no more than 2 mL of fluid
- B. Plans to give the injection using a 1-inch needle
- C. Plans to give the injection in the dorsal gluteal site
- D. Plans to give the injection after applying lidocaine/prilocaine cream
Correct Answer: C
Rationale: A: No more than 2 mL of fluid should be injected into a muscle. B: The appropriate needle length for an IM injection for children ages 2 to 12 months is 1 inch and 1% inch for toddlers. C: Use of the dorsal gluteal site is not recommended due to a high risk of nerve damage. D: Use of lidocaine/prilocaine cream (EMLA) to numb the area is suggested when time allows but is not required.
The HCP prescribes 5% albumin for four clients. The nurse should consult with the HCP if 5% albumin is prescribed for which client?
- A. The client of the Catholic faith who has refractory edema
- B. The African American client experiencing hypovolemic shock
- C. The client of the Jehovah's Witnesses faith who has cerebral edema
- D. The Asian client experiencing adult respiratory distress syndrome (ARDS)
Correct Answer: C
Rationale: A: Persons of the Catholic faith usually accept blood and blood products. B: Persons of African American ethnicity usually accept blood and blood products. C: Albumin is a blood derivative obtained by fractionating pooled venous and placental human plasma. Persons of the Jehovah's Witnesses faith usually do not accept RBCs; some do not accept blood products such as albumin or plasma. D: Persons of Asian ethnicity usually accept blood and blood products.
The nurse is caring for the client with CA receiving piroxicam. Which instruction is most important for the nurse to include in the medication teaching plan?
- A. Take piroxicam with food to decrease stomach irritation.
- B. If your pain is severe, you can take another piroxicam pill.
- C. Lie down until piroxicam is effective for controlling your pain.
- D. You can take ginkgo for an energy boost when taking piroxicam.
Correct Answer: A
Rationale: A: Piroxicam (Feldene) should be taken with food and a full glass of water to prevent gastric irritation and possible bleeding. B: Piroxicam is administered in a once-daily dose, and additional doses should not be taken. C: Because of the gastric irritation and possible reflux, the client should sit upright after taking piroxicam. D: Ginkgo interacts with piroxicam, increasing the risk for bleeding.