Nokea
The schizophrenic client has become disruptive and requires seclusion. Which staff member can institute seclusion?
- A. The security guard
- B. The registered nurse
- C. The licensed practical nurse
- D. The nursing assistant
Correct Answer: B
Rationale: An RN has the authority to initiate seclusion based on clinical judgment.
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The nurse is taking a history from a client in an outpatient clinic. The client has been taking duloxetine (Cymbalta) for fibromyalgia. Which of the following over-the-counter medications would cause the nurse some concern if the client says she is taking it?
- A. aspirin
- B. garlic supplements
- C. vitamin B6
- D. cough medicine with dextromethorphan
Correct Answer: D
Rationale: Dextromethorphan can interact with duloxetine, increasing the risk of serotonin syndrome, a potentially serious condition.
While reviewing the chart of a client with a history of hepatitis B, the nurse finds a serologic marker of HBsAg. The nurse recognizes that the client:
- A. Has chronic hepatitis B
- B. Has recovered from hepatitis B infection
- C. Has immunity to infection with hepatitis C
- D. Has no chance of spreading the infection to others
Correct Answer: A
Rationale: Presence of HBsAg indicates active hepatitis B infection, either acute or chronic, and potential infectivity.
A client receiving Vancocin (vancomycin) has a serum level of 20 mcg/mL. The nurse knows that the therapeutic range for vancomycin is:
- A. 5-10 mcg/mL
- B. 10-25 mcg/mL
- C. 25-40 mcg/mL
- D. 40-60 mcg/mL
Correct Answer: B
Rationale: The therapeutic range for vancomycin is 10-25 mcg/mL, ensuring efficacy while minimizing toxicity; a level of 20 mcg/mL is within this range.
The nurse is caring for a client with a small-bowel obstruction. A Salem sump nasogastric tube (NGT) is in place. Which finding by the nurse requires corrective action? Select all that apply.
- A. There is a sudden decrease in output.
- B. The NGT is set to low continuous suction.
- C. The NGT is set to medium intermittent suction.
- D. The patient is positioned in the semi-Fowler's position.
- E. The client dislodges the tube and the nurse replaces it, confirming placement by X-ray before use.
Correct Answer: A, C
Rationale: A sudden decrease in output may indicate blockage or displacement, requiring assessment. Medium intermittent suction is inappropriate for a Salem sump, which requires low continuous suction. Other actions are correct.
A client with adult respiratory distress syndrome has been placed on mechanical ventilation with PEEP. Which finding would indicate to the nurse that the client is experiencing the undesirable effect of an increase in airway and chest pressure?
- A. A PO2 of 88
- B. Rales on auscultation
- C. Blood pressure decrease to 90/48 from 120/70
- D. A decrease in spontaneous respirations
Correct Answer: C
Rationale: PEEP can increase intrathoracic pressure, reducing venous return and causing hypotension (e.g., BP drop to 90/48), an undesirable effect requiring intervention.