Nokea
The nurse walks into a client's room to administer the 9:00 a.m. medications and notices that the client is in an awkward position in bed. What is the nurse's first action?
- A. Ask the client his name.
- B. Check the client's name band.
- C. Straighten the client's pillow behind his back.
- D. Give the client his medications.
Correct Answer: C
Rationale: Repositioning the client first ensures comfort and safety, addressing the immediate issue of the awkward position before administering medications.
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A client with a history of bipolar disorder is prescribed lamotrigine (Lamictal). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild headache.
- B. Rash.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: A rash may indicate a serious hypersensitivity reaction to lamotrigine, such as Stevens-Johnson syndrome, requiring immediate reporting.
A client is admitted with a diagnosis of acute pancreatitis. The nurse should expect the client to report which of the following symptoms?
- A. Pain radiating to the right shoulder.
- B. Epigastric pain radiating to the back.
- C. Right lower quadrant pain.
- D. Diffuse lower abdominal pain.
Correct Answer: B
Rationale: Acute pancreatitis typically causes epigastric pain that radiates to the back due to pancreatic inflammation.
While obtaining the vital signs on a mother who delivered a healthy newborn 2 hours ago the nurse notes that the mother's temperature is 102°F. Which is the appropriate nursing action at this time?
- A. Notify the primary health care provider.
- B. Remove the blanket from the client's bed.
- C. Document the finding and recheck the temperature in 4 hours.
- D. Administer acetaminophen and recheck the temperature in 4 hours.
Correct Answer: A
Rationale: Vital signs usually return to normal within the first hour postpartum if no complications arise. A slight elevation in the temperature may be noted if the client is experiencing dehydrating effects that can occur from labor. A temperature of 102°F indicates infection, and the primary health care provider should be notified. The remaining options are inaccurate nursing interventions for a temperature of 102°F 2 hours after delivery.
The nurse administers an intradermal injection to a client. Proper technique has been used if the injection site demonstrates which of the following?
- A. No swelling.
- B. Tissue pallor.
- C. Evidence of a bleb.
- D. Erythema.
Correct Answer: C
Rationale: A bleb (small wheal) at the injection site indicates correct intradermal technique, as the medication is deposited just under the skin.
A client with a history of type 1 diabetes mellitus is prescribed insulin aspart (NovoLog). The nurse should explain that this insulin:
- A. Provides a steady basal insulin level.
- B. Is administered immediately before meals.
- C. Should be mixed with long-acting insulin.
- D. Is taken once daily at bedtime.
Correct Answer: B
Rationale: Insulin aspart is a rapid-acting insulin administered immediately before meals to control postprandial glucose.