Nokea
The nurse reviews the client's laboratory report to determine the client's blood level of valproic acid (Depakene), which is 35 mcg/mL. Based on this report, what should the nurse do first?
- A. Withhold the next dose of valproic acid.
- B. Notify the physician.
- C. Give the next dose as ordered.
- D. Take the client's vital signs.
Correct Answer: B
Rationale: A valproic acid level of 35 mcg/mL is below the therapeutic range (50-100 mcg/mL), indicating a need to notify the physician for potential dose adjustment.
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The nurse is teaching a community group about violence in the family. Which statement by a group member about abusers would indicate a need for further teaching?
- A. They use fear and intimidation.
- B. They usually have poor self-esteem.
- C. They are often jealous or self-centered.
- D. They are more often from low-income families.
Correct Answer: D
Rationale: Personal characteristics of abusers include low self-esteem, immaturity, dependence, insecurity, and jealousy. The statement that abusers are more common among low-income families is inaccurate. The remaining options do describe characteristics of abusers who often use fear and intimidation to the point where their victims will do anything just to avoid further abuse.
On entering a toddler's room, the nurse finds the mother sitting about 8 feet from the child and watching television while the toddler is screaming. Which of the following is the most appropriate response by the nurse?
- A. What happened between you and your child?'
- B. Why is your child screaming?'
- C. Did something cause your child to be upset?'
- D. Have you tried to calm down your child?'
Correct Answer: C
Rationale: This response seeks to understand the situation without judgment, encouraging the mother to explain the toddler's distress.
A client with a history of peptic ulcer disease reports epigastric pain. Which action should the nurse take first?
- A. Administer an antacid.
- B. Notify the physician.
- C. Offer a light snack.
- D. Assess the pain characteristics.
Correct Answer: D
Rationale: Assessing pain characteristics provides data to determine the cause and severity, guiding further interventions.
The nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following laboratory values should the nurse monitor closely?
- A. Serum potassium.
- B. Serum sodium.
- C. Blood urea nitrogen.
- D. Blood glucose.
Correct Answer: D
Rationale: TPN contains high glucose concentrations, requiring close monitoring of blood glucose to prevent hyperglycemia.
A client with a history of chronic obstructive pulmonary disease (COPD) is prescribed prednisone. The nurse should monitor the client for which of the following adverse effects?
- A. Hyperglycemia.
- B. Hypotension.
- C. Weight loss.
- D. Bradycardia.
Correct Answer: A
Rationale: Prednisone can cause hyperglycemia, requiring blood glucose monitoring.