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The nurse walks into the room of a client who has a 'do not resuscitate' order and finds the client without a pulse, respirations, or blood pressure. What is the most appropriate action?
- A. Stay in the room and notify the nursing team for assistance.
- B. Push the emergency alarm to call a code.
- C. Dial the hospital phone number for a code.
- D. Pull the curtain and leave the room.
Correct Answer: D
Rationale: For a DNR client, no resuscitation is performed. The nurse should respectfully leave the room after ensuring privacy, notifying the team as needed for post-mortem care.
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A client has a history of syphilis infection. The nurse interprets that the client has been re-infected when which characteristic is noted in a penile lesion?
- A. Papular areas and erythema
- B. Cauliflower-like appearance
- C. Induration and absence of pain
- D. Multiple vesicles, with some that have ruptured
Correct Answer: C
Rationale: The characteristic lesion of syphilis is painless and indurated. The lesion is referred to as a chancre. Scabies is characterized by erythematous, papular eruptions. Genital warts are characterized by cauliflower-like growths, or growths that are soft and fleshy. Genital herpes is accompanied by the presence of one or more vesicles that then rupture and heal.
When a client states that he is allergic to amoxicillin (Ampicillin) even though his medication administration record and armband do not indicate medication allergies, the nurse should:
- A. Administer the prescribed medication.
- B. Withhold the amoxicillin (Ampicillin).
- C. Administer another, similarly acting antibiotic.
- D. Call the family to verify the client's statement.
Correct Answer: B
Rationale: Withholding the medication is the safest action until the allergy can be verified to prevent an allergic reaction.
A family has been notified that their son is brain dead, and the physician has discussed the possibility of donating organs. The nurse should collaborate with the physician to contact which referral source that is responsible for organ recovery in the United States?
- A. Organ and Tissue Procurement Organizations.
- B. American Transplant Association.
- C. American Hospice Foundation.
- D. American Association of Critical-Care Nurses.
Correct Answer: A
Rationale: Organ and Tissue Procurement Organizations are responsible for coordinating organ recovery in the United States, as they manage the donation process and ensure compliance with regulations.
A client with a urinary tract infection is prescribed ciprofloxacin. What should the nurse include in the teaching?
- A. Take the medication with dairy products.
- B. Report tendon pain or swelling.
- C. Increase fluid intake to 1 L/day.
- D. Avoid sunlight exposure completely.
Correct Answer: B
Rationale: Ciprofloxacin can cause tendonitis or tendon rupture, so reporting tendon pain or swelling is critical.
Carbamazepine is prescribed for the management of generalized tonic-clonic seizures. The nurse instructs the client to inform the primary health care provider if which sign/symptom occurs?
- A. Nausea
- B. Dizziness
- C. Sore throat
- D. Drowsiness
Correct Answer: C
Rationale: Drowsiness, dizziness, nausea, and vomiting are frequent side effects associated with the medication. Adverse reactions include blood dyscrasias. If the client develops a fever, sore throat, mouth ulcerations, unusual bleeding or bruising, or joint pain, this may be indicative of a blood dyscrasia, and the primary health care provider should be notified.