Nokea
The unlicensed assistive personnel (UAP) reported an intake of 1,000 mL and a urinary output of 1,500 mL for a client who received a thiazide diuretic this morning. Which nursing task could the nurse delegate to the nursing assistant?
- A. Instruct the UAP to restrict the client's fluid intake.
- B. Request the UAP to insert a Foley catheter with an urometer.
- C. Tell the UAP urinary outputs are no longer needed.
- D. Ask the UAP to document fluids on the bedside I & O record.
Correct Answer: D
Rationale: Documenting I&O is within UAP scope; fluid restriction, catheter insertion, or discontinuing monitoring require nursing judgment.
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The nurse has received the morning report and has the following medications due or being requested. In which order should the nurse administer the medications? List in order of priority.
- A. Administer furosemide (Lasix), a loop diuretic, IVP daily to a client diagnosed with heart failure who is dyspneic on exertion.
- B. Administer morphine, a narcotic analgesic, IVP prn to a client diagnosed with lower back pain who is complaining of pain at a '10' on a 1-to-10 scale.
- C. Administer neostigmine (Prostigmin), a cholinesterase inhibitor, PO to a client diagnosed with myasthenia gravis.
- D. Administer lidocaine, an antidysrhythmic, IVP prn to a client in normal sinus rhythm with multifocal premature ventricular contractions.
- E. Administer vancomycin, an aminoglycoside antibiotic, to a client diagnosed with a Staphylococcus infection who has a trough level of 14 mg/dL.
Correct Answer: B,D,A,C,E
Rationale: 1) Morphine for severe pain (acute, 10/10); 2) Lidocaine for PVCs (cardiac risk); 3) Furosemide for dyspnea (respiratory distress); 4) Neostigmine for myasthenia (muscle strength); 5) Vancomycin (infection, stable trough).
A 4 year-old child is admitted with burns on his legs and lower abdomen. When assessing the child's hydration status, which of the following indicates a less than adequate fluid replacement?
- A. Decreasing hematocrit and increasing urine volume
- B. Rising hematocrit and decreasing urine volume
- C. Falling hematocrit and decreasing urine volume
- D. Stable hematocrit and increasing urine volume
Correct Answer: B
Rationale: Rising hematocrit and decreasing urine volume. A rising hematocrit indicates a decreased total blood volume, a finding consistent with dehydration.
In providing care for a client with pain from a sickle cell crisis, which one of the following medication orders for pain control should be questioned by the nurse?
- A. Demerol
- B. Morphine
- C. Methadone
- D. Codeine
Correct Answer: A
Rationale: Demerol. Meperidine is not recommended in clients with sickle cell disease. Normeperidine, a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. Clients with sickle cell disease are particularly at risk for normeperidine-induced seizures.
An adult client has pulmonary tuberculosis. He is receiving INH 300 mg PO, ethambutol 1 g PO daily, and streptomycin 1 g IM three times a week. When he comes in for a checkup, he tells the nurse that he hates getting shots and his ears ring most of the time. What advice does the nurse expect will be given to this client?
- A. Take pyridoxine daily.
- B. Expect red-colored urine and feces.
- C. Stop the medications when your cough is gone.
- D. Take streptomycin by mouth instead of by injection.
Correct Answer: B
Rationale: Streptomycin’s ototoxicity may require discontinuation, not pyridoxine (used for INH). Red urine/feces is expected with rifampin, not listed here, but monitoring is key.
The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?
- A. Blanch nail beds for color and refill
- B. Assess for post-operative arrhythmias
- C. Auscultate for pulmonary congestion
- D. Monitor equality of peripheral pulses
Correct Answer: B
Rationale: Assess for post-operative arrhythmias. The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening.