Nokea
The nurse on the inpatient memory care unit is caring for a client with Alzheimer's who exhibits wandering behavior. The 24-hour observer calls the nurse to report that the client left the unit. It would be most appropriate for the nurse to take which of the following actions?
- A. notify the family
- B. notify security along with a description of the client
- C. ask the observer in what direction the client headed
- D. ask other staff on the unit to assist in finding the client
Correct Answer: B
Rationale: Notifying security with a description ensures a rapid, coordinated response to locate the client and ensure safety.
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The nurse assesses a new order for a blood transfusion. The order is to transfuse 1 unit of packed red blood cells (contains 250 mL) in a 2-hour period. What will be the hourly rate of infusion?
- A. 50 mL/hr
- B. 62 mL/hr
- C. 125 mL/hr
- D. 137 mL/hr
Correct Answer: C
Rationale: To calculate the hourly rate: 250 mL ÷ 2 hours = 125 mL/hr, ensuring the transfusion is completed within the prescribed time.
Which one of the following symptoms is common in the client with duodenal ulcers?
- A. Vomiting shortly after eating
- B. Epigastric pain following meals
- C. Frequent bouts of diarrhea
- D. Presence of blood in the stools
Correct Answer: B
Rationale: Duodenal ulcers typically cause epigastric pain 1-3 hours after meals, relieved by food or antacids.
A client who has glaucoma is to have miotic eyedrops instilled in both eyes. The nurse knows that the purpose of the medication is to:
- A. Anesthetize the cornea
- B. Dilate the pupils
- C. Constrict the pupils
- D. Paralyze the muscles of accommodation
Correct Answer: C
Rationale: Miotics constrict the pupils, increasing aqueous humor outflow to reduce intraocular pressure in glaucoma.
The client is receiving heparin for thrombophlebitis of the left lower extremity. Which of the following drugs reverses the effects of heparin?
- A. Cyanocobalamine
- B. Protamine sulfate
- C. Streptokinase
- D. Sodium warfarin
Correct Answer: B
Rationale: Protamine sulfate neutralizes heparin's anticoagulant effect.
A client on the postpartum unit has a proctoepisiotomy. The nurse should anticipate administering which medication?
- A. Dulcolax suppository
- B. Docusate sodium (Colace)
- C. Methyergonovine maleate (Methergine)
- D. Bromocriptine sulfate (Parlodel)
Correct Answer: B
Rationale: Docusate sodium (Colace) is a stool softener, appropriate to prevent straining and promote healing after a proctoepisiotomy.