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The physician orders haloperidol 5 mg IM stat for a client and tells the nurse that the dose can be repeated in 12 hours if needed. The most likely rationale for this order is:
- A. The client will settle down more quickly if he thinks the staff is medicating him
- B. The medication will sedate the client until the physician arrives
- C. Haloperidol is a minor tranquilizer and will not oversedate the client
- D. Rapid neuroleptization is the most effective approach to care for the violent or potentially violent client
Correct Answer: D
Rationale: If the client could think logically, he would not be paranoid. In fact, he is probably suspicious of the staff, too. Newly admitted clients frequently experience high levels of anxiety, which can contribute to delusions. The goal of pharmacological intervention is to calm the client and assist with reality-based thinking, not to sedate him. Haloperidol is a neuroleptic and antipsychotic drug, not a minor tranquilizer. Haloperidol is a high-potency neuroleptic and first-line choice for rapid neuroleptization, with low potential for sedation.
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A mother brings her 3-year-old child who is unconscious but breathing to the ER with an apparent drug overdose. The mother found an empty bottle of aspirin next to her child in the bathroom. Which nursing action is the most appropriate?
- A. Put in a nasogastric tube and lavage the child's stomach.
- B. Monitor muscular status.
- C. Teach mother poison prevention techniques.
- D. Place child on respiratory assistance.
Correct Answer: A
Rationale: The immediate treatment for drug overdose is removal of the drug from the stomach by either forced emesis or gastric lavage. The child's unconscious state prohibits forced emesis. Toxic amounts of salicylates directly affect the respiratory system, which could lead to respiratory failure. The mother's anxiety is probably so high that preventive guidance will be ineffective. Respiratory assistance is not needed if the child's respiratory function is unaltered.
The nurse is preparing to administer a dose of warfarin (Coumadin). The client’s INR is 3.5. What action should the nurse take?
- A. Administer the dose as ordered.
- B. Withhold the dose and notify the physician.
- C. Double the dose to achieve therapeutic range.
- D. Administer half the dose.
Correct Answer: B
Rationale: An INR of 3.5 is above the therapeutic range (2–3 for most conditions), indicating increased bleeding risk. The nurse should withhold the dose and notify the physician for further orders. Adjusting the dose independently is unsafe.
A client is scheduled to undergo a bone marrow aspiration from the sternum. What position would the nurse assist the client into for this procedure?
- A. Dorsal recumbent
- B. Supine
- C. High Fowler's
- D. Lithotomy
Correct Answer: B
Rationale: Supine position provides access to the sternum for bone marrow aspiration. Dorsal recumbent (A) is for abdominal exams, High Fowler’s (C) is for breathing, and lithotomy (D) is for pelvic procedures.
The nurse is caring for a client with a history of a myocardial infarction. The client is receiving TPA (alteplase). The nurse should monitor the client for:
- A. Bleeding
- B. Hypertension
- C. Hypoglycemia
- D. Hyperthermia
Correct Answer: A
Rationale: TPA, a thrombolytic, increases bleeding risk by dissolving clots. Monitoring for bleeding (e.g., gums, urine) is critical. Hypertension, hypoglycemia, and hyperthermia are not primary concerns.
A client with a history of chronic migraines is admitted with complaints of photophobia. The nurse should give priority to:
- A. Providing a dark environment
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering oxygen
Correct Answer: A
Rationale: A dark environment reduces photophobia in migraines, improving comfort and reducing symptom severity.