Nokea
Two hours after administering iron dextran, the nurse is drawing the client's blood sample for a laboratory test. Which intervention should the nurse implement when noting that the client's blood has a brownish hue?
- A. Document the serum color.
- B. Draw blood from another site.
- C. Immediately notify the HCP.
- D. Discard the sample of blood.
Correct Answer: A
Rationale: A: The nurse should document the finding of the blood's brownish hue; iron dextran (Dexferrum) may impart a brownish hue to blood drawn within four hours after administration. B: Drawing blood from another site is unnecessary because iron dextran imparts the brown-colored serum, and the color will be unchanged even if blood is drawn at another site. C: Notifying the HCP is unnecessary because the brown-colored serum is a normal finding after iron dextran administration. D: The blood sample should not be discarded because the brown-colored serum is a normal finding after iron dextran administration and will not affect laboratory analysis.
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Which of the following actions should the LPN perform for a client with an active digoxin IV order? Select all that apply. A. Monitor ECG rhythm throughout administration., B. Administer the medication over at least 5 minutes., C. Monitor respirations during administration., D. Monitor the client's pulse for 1 minute prior to administration., E. Assess the client's blood pressure.
- A. A, D
- B. A, B, D
- C. B, C
- D. A, D, E
Correct Answer: A
Rationale: The LPN should monitor the client's heart rate and ECG with digoxin administration. Digoxin should not be given if a client's pulse is less than 60 bpm. Measuring blood pressure and respiratory rate are not indicated with digoxin administration. Administering an IV medication is outside of the LPN's scope of practice.
The nurse is storing vaccines for future use. What should the nurse do so they are properly stored? Select all that apply.
- A. Place all vaccines in a temperature-controlled refrigerator.
- B. Complete periodic checks of the expiration date on the vaccines.
- C. Place bulk supplies of vaccines in a temperature-controlled freezer.
- D. Avoid storing vaccines on the shelf in the door of the refrigerator.
- E. Do not store food or beverage in the same refrigerator or freezer as the vaccines.
Correct Answer: B,D,E,F
Rationale: A: Not all vaccines are refrigerated; some vaccines will be inactivated by refrigeration and freezing. B: Periodic checking for expiration dates is necessary to ensure that outdated vaccines are not administered. C: Not all bulk supplies should be placed in a freezer; some vaccines are inactivated by freezing. D: When refrigeration is required, a main shelf inside the refrigerator is best because a shelf in the door will have frequent temperature changes that will alter the potency of the vaccine. E: Storing food and beverage in the same unit may result in frequent opening of the unit, leading to greater chance of temperature instability and light exposure. Contamination may also result. F: Aluminum foil or packaging can be used to protect light-sensitive vaccines.
The nurse is assessing a client who has recently found out she is pregnant. Which of the following statements would be a priority for the nurse to follow up on?
- A. I am nervous about how painful labor will be.
- B. I need to review my finances and make sure I am prepared to care for a child.
- C. I hate this nausea that I've been having for a week.
- D. I am preparing myself to do this on my own because I do not have any family nearby. But I have always been very independent.
Correct Answer: D
Rationale: The nurse should follow up on the client's lack of support system. Even if there is no family in the area, there are supportive resources in the community that may help the client through the pregnancy and into motherhood. It is normal for the client to worry about labor, address financial concerns, and express displeasure from early pregnancy symptoms such as nausea.
The nurse is caring for a female client who has recently been diagnosed with cancer and will soon begin chemotherapy. Which of these statements would require additional follow-up and education?
- A. I will be most susceptible to an infection between 7 and 12 days after chemotherapy.
- B. I should try to get my annual teeth cleaning in before beginning chemotherapy.
- C. I should wait until all my hair falls out to purchase a wig.
- D. I should try to drink 8-10 glasses of water a day.
Correct Answer: C
Rationale: This client is at risk for altered body image secondary to the hair loss from chemotherapy. A wig can be helpful in coping with this, and the client should shop for a wig before his or her hair falls out so that he or she can better match his or her color and style. The remaining statements are accurate.
The HCP prescribes amoxicillin for the 8-month-old with acute otitis media that has not resolved. Which statement to the parents is correct regarding the primary purpose of amoxicillin?
- A. It will reduce the child's fever.
- B. It will reduce the child's severe ear pain.
- C. It will shrink swollen tissue in the Eustachian tube.
- D. It will treat the probable organism, Haemophilus influenzae.
Correct Answer: D
Rationale: A: As the infection is treated, the fever will be reduced, but this is not the primary reason for treatment with amoxicillin. B: Treating the ear infection will reduce the pain, but that is not the primary purpose for treatment with amoxicillin. C: Reducing inflammation of the eustachian tube will occur, but this is not the primary purpose for treatment with amoxicillin. D: Acute otitis media is frequently caused by the Haemophilus influenzae and Streptococcus pneumoniae bacteria. The primary purpose of amoxicillin (Amoxil) is to treat the infection caused by these two organisms.