Nokea
The nurse prepares to administer medications to a client. Which of the following client data are acceptable for use as client identifiers? Select all that apply.
- A. Date of birth
- B. First and last name
- C. Health care provider
- D. Medical record number
- E. Room number
Correct Answer: A, B, D
Rationale: Date of birth (A), first and last name (B), and medical record number (D) are reliable identifiers. Health care provider (C) and room number (E) are not specific to the client.
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The nurse has reinforced teaching with a client who has rheumatoid arthritis and is receiving methotrexate. Which of the following statements by the client would require follow-up?
- A. I will avoid drinking alcoholic beverages while taking methotrexate.'
- B. I should take precautions to prevent pregnancy while taking methotrexate.'
- C. I should avoid large crowds and people who are ill while taking methotrexate.'
- D. I will avoid consuming foods high in folic acid that will decrease the effectiveness of methotrexate.'
Correct Answer: D
Rationale: Avoiding alcohol (A), preventing pregnancy (B), and avoiding crowds (C) are correct. Avoiding folic acid (D) is incorrect, as methotrexate often requires folic acid supplementation to reduce side effects.
A postoperative client is having difficulty voiding. Palpation of the bladder indicates that the bladder is full. What should the nurse do initially?
- A. Ask the physician for a catheterization order
- B. Pour water over the client's perineum
- C. Encourage the client to take deep breaths
- D. Administer pain medication
Correct Answer: B
Rationale: Pouring water over the perineum stimulates the micturition reflex, aiding voiding non-invasively. Catheterization, breathing, or pain medication are secondary.
A female client seen in the health department's STD clinic is diagnosed with chlamydia. Before the client leaves the clinic, the nurse should:
- A. Obtain the names and addresses of the client's sexual contacts.
- B. Tell the client to avoid alcohol while taking her prescription for Flagyl.
- C. Instruct the client to avoid sexual relations until the infection is resolved.
- D. Tell the client to douche after sexual intercourse.
Correct Answer: C
Rationale: Avoiding sexual relations prevents chlamydia spread until treatment is complete. Contact tracing is secondary, Flagyl is for trichomoniasis, and douching is harmful.
Laboratory reference ranges
Glucose (fasting)
70-110 mg/dL
(3.9-6.1 mmol/L)
Potassium
3.5-5 mEq/L
(3.5-5 mmol/L)
The nurse is administering prescribed medications to assigned clients. The nurse should hold and seek clarification for which scheduled administrations? Select all that apply.
- A. client with cirrhosis had 2 stools today, lactulose prescribed daily
- B. client receiving IV vancomycin; mild facial flushing noted after 30 minutes
- C. client scheduled for abdominal surgery tomorrow; vitamin E PO prescribed daily
- D. client prescribed lisinopril PO daily; serum potassium level is 5.6 mEq/L (5.6 mmol/L)
- E. client with diabetes mellitus has insulin glargine and aspart prescribed, AM glucose is 100 mg/dL (5.6 mmol/L)
Correct Answer: B, C, D
Rationale: Vancomycin flushing (B) suggests red man syndrome, vitamin E (C) increases bleeding risk pre-surgery, and hyperkalemia (D) contraindicates lisinopril. Lactulose (A) and insulin (E) are appropriate.
A woman is admitted with Hodgkin's disease. Which does the nurse expect the client to report?
- A. Swollen lymph nodes
- B. A painful rash
- C. Stomach pain
- D. Joint pain
Correct Answer: A
Rationale: Hodgkin's disease typically presents with painless swollen lymph nodes, a hallmark symptom the nurse should expect.