Nokea
The RN charge nurse hands the LPN/LVN a syringe filled with medication that the RN has just drawn and asks the LPN/LVN to administer this to a client. How should the LPN/LVN respond?
- A. Do as requested by the charge nurse
- B. Ask the charge nurse what the medication is and then administer it
- C. Ask the charge nurse what the medication is, check the order, and then administer it
- D. Refuse to administer the medication
Correct Answer: C
Rationale: Verifying the medication and checking the order ensures safe administration, adhering to medication safety protocols. Blind administration or refusal is unsafe or uncooperative.
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Which nursing intervention is most critical during the administration of Acyclovir (Zovirax)?
- A. Limit the client's activity.
- B. Encourage a high-carbohydrate diet.
- C. Utilize an incentive spirometer to improve respiratory function.
- D. Encourage fluids.
Correct Answer: D
Rationale: Acyclovir can cause renal toxicity; encouraging fluids promotes renal perfusion and reduces risk of crystal formation in the kidneys.
The nurse is performing a neurological assessment on a client post right cerebral vascular accident (CVA). Which finding, if observed by the nurse, would warrant immediate attention?
- A. Decrease in level of consciousness
- B. Loss of bladder control
- C. Altered sensation of stimuli
- D. Emotional lability
Correct Answer: A
Rationale: Decrease in level of consciousness. A further decrease in the level of consciousness would be indicative of a further progression of the CVA.
The nurse is performing a developmental assessment on a 12-month-old client. Which of the following findings are expected at this age? Select all that apply.
- A. Birth weight has tripled
- B. Cruises along furniture
- C. Kicks a ball
- D. Searches for hidden objects
- E. Speaks in two word phrases
Correct Answer: A,B,D
Rationale: By 12 months, infants typically triple birth weight, cruise along furniture, and search for hidden objects (object permanence). Kicking a ball and two-word phrases are expected at 18-24 months.
The nurse in the outpatient clinic is talking with a client who was diagnosed with hypertension 6 months ago. The client's current blood pressure is 170/94 mm Hg. Which of the following questions would be most important for the nurse to ask?
- A. Are you feeling overwhelmed at home or work?
- B. Can you describe your daily eating habits to me?
- C. Do you smoke cigarettes or use tobacco products?
- D. How often do you take your antihypertensive medications?
Correct Answer: D
Rationale: A major disadvantage of long-term management of hypertension is poor adherence to the treatment plan. Blood pressure medications can have unpleasant adverse effects, including fatigue, dizziness, and erectile dysfunction. In addition, clients may stop taking the medications when they believe their blood pressure has returned to normal range or if medications are expensive. Abrupt discontinuation of prescribed antihypertensive medications can lead to hypertensive crisis, a life-threatening emergency characterized by severely elevated blood pressure (ie, systolic ≥180 mm Hg and/or diastolic ≥120 mm Hg). To prevent complications (eg, end organ damage), the nurse should determine if the client has been taking the medications consistently (Option 4). There may be a need for a dosage change or addition of another medication.
The nurse is caring for a client with diabetic ketoacidosis (DKA). Which of the following acid-base imbalances would the nurse expect to assess in this client?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: DKA causes metabolic acidosis due to excess ketone production from fat breakdown. Alkalosis and respiratory imbalances are not typical in DKA.