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What is the nurse's priority for a client with Guillain-Barré syndrome?
- A. Monitor respiratory function.
- B. Assess pain levels.
- C. Check skin integrity.
- D. Evaluate bowel function.
Correct Answer: A
Rationale: Monitoring respiratory function is the priority due to potential respiratory muscle weakness in Guillain-Barré syndrome.
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The home health nurse is discussing the administration of insulin glargine with a client. It would require follow-up if the client states that insulin glargine must be administered
- A. only in the abdomen.
- B. using a 6 mm and 31-gauge insulin syringe.
- C. only with a meal.
- D. after rolling the vial of insulin.
- E. within 28 days of opening the vial.
Correct Answer: A,C,D
Rationale: Insulin glargine can be administered in multiple sites, not only the abdomen; it is given regardless of meals; and it should not be rolled, as it is a clear solution.
During the preoperative interview, the nurse obtains information about the client's medication history. Which of the following is not necessary to record about the client?
- A. Current use of medications, herbs, and vitamins.
- B. Over-the-counter medication use in the last 6 weeks.
- C. Steroid use in the last year.
- D. Use of all drugs taken in the last 18 months.
Correct Answer: D
Rationale: Recording all drugs taken in the last 18 months is excessive, as many may no longer be relevant to surgical risks. Current medications, recent over-the-counter drugs, and steroid use are critical due to their potential impact on surgery.
A client with Addison's disease is admitted to the medical unit. The nurse diagnoses the client with Deficient fluid volume related to inadequate fluid intake and to fluid loss secondary to inadequate adrenal hormone secretion. As the client's oral intake increases, which of the following fluids would be most appropriate?
- A. Milk and diet soda.
- B. Water and eggnog.
- C. Bouillon and juice.
- D. Coffee and milkshakes.
Correct Answer: C
Rationale: Bouillon provides sodium, and juice offers hydration and calories, supporting fluid and electrolyte balance in Addison's disease.
On admission to same-day surgery, the nurse reviews the chart to verify the client's identification documentation. Which of the following is most important?
- A. Admitting record.
- B. Addressograph labels.
- C. Identification bracelet.
- D. Location of family.
Correct Answer: C
Rationale: The identification bracelet is the most reliable method to verify client identity, ensuring safety and preventing errors in same-day surgery.
The nurse is to administer Polycillin (ampicillin) 500 mg orally to a client with a ruptured appendix. The nurse checks the capsule in the client's medication box which is located inside of the client's room. The dosage of the medication is not labeled, but the nurse recognizes the color and shape of the capsule. The nurse should next:
- A. Administer the medication to maintain blood levels of the drug.
- B. Ask another registered nurse to verify that the capsule is ampicillin.
- C. Contact the pharmacy to bring a properly labeled medication.
- D. Adjust the unit manager to report the problem.
Correct Answer: C
Rationale: Contacting the pharmacy to bring a properly labeled medication ensures safe administration, as recognizing the capsule's color and shape is insufficient for verification. Administering without confirmation or relying on another nurse risks error, and reporting to the manager delays care. CN: Safety and infection control; CL: Synthesize