Nokea
At 11 AM a patient returned to the nursing unit from the postanesthesia care unit (PACU) following a hemorrhoidectomy. At noon the patient complains of pain. The physician has ordered meperidine (Demerol) 50 mg IV q 3-4 hrs. The chart indicates that the patient was given Demerol 50 mg IV at 9:15 AM.
The nurse should
- A. ask the physician if the dosage of Demerol can be increased.
- B. give the patient Demerol 25 mg IV now.
- C. have the patient wait until 1 PM before giving the Demerol.
- D. give the patient Demerol 50 mg IV now.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) no reason to call the physician (2) can't change amount of medication ordered by physician (3) medication is ordered every 3 to 4 hours, should not wait if patient needs medication after 3 hours (4) correct-give patient the medication as ordered
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A 3-year-old child who is up to date with all immunizations is seen at clinic. The child has a fever of 102°F and a pruritic rash with fluid-filled vesicles that began on the trunk. The physician says the child has varicella. The child's mother says to the nurse, 'I thought my child couldn't get this because she had all her shots.' What is the best response for the nurse to make?
- A. You child probably did not respond to the vaccine as most children do.
- B. The nurse must not have administered it correctly.
- C. It is still possible to contract the illness, but your child will most likely have a less severe case.
- D. The vaccine is only effective after the child has received two doses.
Correct Answer: C
Rationale: The varicella vaccine reduces severity but does not guarantee immunity; breakthrough cases are milder, as indicated by the child's symptoms.
The nurse is caring for a client with a history of heart failure who is receiving spironolactone (Aldactone) 25 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel tired in the afternoon.
- B. I have a dry mouth.
- C. I have muscle cramps.
- D. I take my medication with food.
Correct Answer: C
Rationale: Muscle cramps suggest hyperkalemia, a serious side effect of spironolactone, a potassium-sparing diuretic, requiring immediate evaluation to prevent arrhythmias. Options A, B, and D are less concerning: fatigue and dry mouth are nonspecific, and taking with food is acceptable.
The nurse is assigned to work with the parents of a retarded child.
- A. What should the nurse include in the care plan for the parents of a retarded child?
- B. Interpret the grieving process for the parents.
- C. Discuss the reality of institutional placement.
- D. Assist the parents in making decisions and long-term plans for the child.
- E. Perform a family assessment to assist in the planning of intervention.
Correct Answer: D
Rationale: A family assessment is essential to understand the parents’ grieving, coping, and support needs, guiding tailored interventions. Interpreting grief, discussing placement, or assisting with plans are premature without first assessing the family’s situation.
A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions?
- A. High Fowler's
- B. Supine
- C. Left lateral
- D. Low Fowler's
Correct Answer: A
Rationale: High Fowler's. This position decreases cardiac workload and facilitates breathing.
The nurse is teaching a client with a new diagnosis of gout about allopurinol (Zyloprim). Which of the following statements by the client indicates a need for further teaching?
- A. I should drink plenty of water while taking this medication.
- B. I should report a rash to my doctor.
- C. I should take this medication with food.
- D. I should stop this medication if my gout attacks stop.
Correct Answer: D
Rationale: Stopping allopurinol when gout attacks stop is incorrect, as it is used long-term to prevent uric acid buildup. Options A, B, and C are correct: water prevents kidney stones, rash may indicate hypersensitivity, and food reduces GI upset.