Nokea
What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)?
- A. Bladder palpation
- B. Inspection of the mouth
- C. Blood glucose monitoring
- D. Auscultation of breath sounds
Correct Answer: B
Rationale: The correct answer is B: Inspection of the mouth. Phenytoin can cause gingival hyperplasia as a common untoward effect. By inspecting the mouth regularly, the nurse can assess for signs of this side effect such as swollen or bleeding gums. Bladder palpation (A) is not relevant to monitoring phenytoin side effects. Blood glucose monitoring (C) is not typically associated with phenytoin use. Auscultation of breath sounds (D) is not directly related to monitoring for phenytoin side effects.
You may also like to solve these questions
The nurse is making assignments for a new graduate from a practical nursing program who is orienting to the unit. Because the unit is particularly busy this day, there will be little time to provide supervision of this new employee. Which client is the best for the nurse to assign to this newly graduated practical nurse?
- A. Whose discharge has been delayed because of a postoperative infection
- B. With poorly controlled type 2 diabetes who is on a sliding scale for insulin administration
- C. Newly admitted with a head injury who requires frequent assessments
- D. Receiving IV heparin that is regulated based on protocol
Correct Answer: A
Rationale: The correct answer is A: Whose discharge has been delayed because of a postoperative infection. This assignment is the best choice for the new graduate nurse because a client whose discharge has been delayed due to a postoperative infection is likely stable and requires minimal immediate interventions. This client would benefit from the new nurse's routine care and monitoring skills, allowing the nurse to focus on completing tasks efficiently.
Option B: With poorly controlled type 2 diabetes who is on a sliding scale for insulin administration requires close monitoring and frequent adjustments in insulin dosages, which may be challenging for a new nurse without adequate supervision.
Option C: Newly admitted with a head injury who requires frequent assessments demands critical thinking skills and quick decision-making abilities, which may overwhelm a new nurse who lacks experience in handling such cases.
Option D: Receiving IV heparin that is regulated based on protocol involves complex medication management and monitoring for potential complications, which may be beyond the scope of a new nurse's comfort level without proper guidance.
A 59-year-old male client is brought to the emergency room where he is assessed to have a Glasgow Coma Scale of 3. Based on this assessment, how should the nurse characterize the client's condition?
- A. The client is experiencing increased intracranial pressure
- B. He has a good prognosis for recovery
- C. This client is conscious, but is not oriented to time and place
- D. He is in a coma, and has a very poor prognosis
Correct Answer: D
Rationale: The correct answer is D because a Glasgow Coma Scale score of 3 indicates deep unconsciousness, which is classified as a coma. A GCS score of 3 signifies the lowest possible level of consciousness and is associated with a very poor prognosis due to the severity of neurological impairment. Choices A, B, and C are incorrect. Increased intracranial pressure may be present in comatose patients but is not solely indicated by a GCS score of 3. A good prognosis is unlikely with a GCS score of 3. Being unconscious with a GCS score of 3 does not equate to being conscious but disoriented as in choice C.
An experienced nurse tells the nurse-manager that working with a new graduate is impossible because the new graduate will not listen to suggestions. The new graduate comes to the nurse-manager describing the senior nurse's attitude as challenging and offensive. What action is best for the nurse manager to take?
- A. Have both nurses meet separately with the staff mental health consultant
- B. Listen actively to both nurses and offer suggestions to solve the dilemma
- C. Ask the senior nurse to examine mentoring strategies used with the new graduate
- D. Ask the nurses to meet with the nurse-manager to identify ways of working together
Correct Answer: D
Rationale: The correct answer is D. The nurse-manager should ask the nurses to meet to identify ways of working together. This is the best action because it promotes open communication, collaboration, and conflict resolution between the two nurses. By facilitating a discussion between them, the nurse-manager can help address the underlying issues, clarify misunderstandings, and find common ground for effective teamwork. This approach encourages mutual understanding and fosters a positive working relationship.
A: Having both nurses meet separately with the staff mental health consultant does not directly address the conflict between them.
B: While listening actively and offering suggestions is important, involving both nurses in the discussion is crucial for resolving the conflict.
C: Asking the senior nurse to examine mentoring strategies does not involve the new graduate in the conversation and may not address the overall issue.
The nurse assesses a client who is receiving an infusion of 5% dextrose in water with 20 mEq of potassium chloride. The client has oliguria and a serum potassium level of 6.5 mEq/L. What action should the nurse implement first?
- A. Notify the healthcare provider of the laboratory results
- B. Decrease the rate of the IV infusion
- C. Stop the infusion
- D. Administer sodium polystyrene sulfonate (Kayexalate)
Correct Answer: C
Rationale: The correct action for the nurse to implement first is to stop the infusion (Choice C). Oliguria and a high serum potassium level indicate the client is at risk for hyperkalemia, which can be exacerbated by the potassium chloride infusion. Stopping the infusion is crucial to prevent further elevation of potassium levels and potential cardiac complications.
Choice A (Notify the healthcare provider) is not the first action as immediate intervention is needed to prevent harm. Choice B (Decrease the rate of the IV infusion) is not sufficient to address the immediate risk of hyperkalemia. Choice D (Administer sodium polystyrene sulfonate) is not appropriate as the first action and should only be considered after stabilizing the client's condition.
An angry client screams at the emergency department triage nurse, 'I've been waiting here for two hours! You and the staff are incompetent.' What is the best response for the nurse to make?
- A. The emergency department is very busy at this time.
- B. I'll let you see the doctor next because you've waited so long.
- C. I'm doing the best I can for the sickest clients first.
- D. I understand you are frustrated with the wait time.
Correct Answer: D
Rationale: The correct answer is D because it demonstrates empathy and acknowledges the client's feelings without admitting fault. By saying "I understand you are frustrated with the wait time," the nurse validates the client's emotions and shows a willingness to listen and address concerns. This response can help de-escalate the situation and build rapport.
Choice A is incorrect because it doesn't directly address the client's emotions. Choice B is incorrect as it prioritizes the client based on their anger rather than medical need. Choice C is incorrect as it may come off as dismissive of the client's feelings and lacks empathy.