Nokea
What would the nurse expect the admitting assessment to reveal in a client with glomerulonephritis?
- A. Hypertension
- B. Lassitude
- C. Fatigue
- D. Vomiting and diarrhea
Correct Answer: A
Rationale: Glomerulonephritis often causes hypertension due to fluid retention and renal dysfunction.
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The nurse administers a dose of acetaminophen to the wrong client. Which of the following actions is the most appropriate after notifying the physician?
- A. Notify her supervisor and complete an incident report.
- B. Ask the physician for an order of acetaminophen to cover the inadvertent administration.
- C. Take no further action because acetaminophen is relatively benign.
- D. Document in the client's record that an error in drug administration occurred.
Correct Answer: A
Rationale: Medication errors require notifying the supervisor and completing an incident report (A) to ensure proper follow-up and system improvements. Retroactively obtaining an order (B) is unethical, assuming acetaminophen is benign (C) is unsafe, and documenting the error in the client's record (D) is inappropriate.
The nurse calculates the amount of an antibiotic for injection to be given to an infant. The amount of medication to be administered is 1.25 mL. The nurse should:
- A. Divide the amount into two injections and administer in each vastus lateralis muscle
- B. Give the medication in one injection in the dorsogluteal muscle
- C. Divide the amount in two injections and give one in the ventrogluteal muscle and one in the vastus lateralis muscle
- D. Give the medication in one injection in the ventrogluteal muscle
Correct Answer: A
Rationale: For infants, volumes greater than 1 mL should be divided and administered in separate sites, such as each vastus lateralis, to reduce discomfort and ensure absorption.
A client is discharged home with a prescription for Coumadin (sodium warfarin). The client should be instructed to:
- A. Have a Protime done monthly
- B. Eat more fruits and vegetables
- C. Drink more liquids
- D. Avoid crowds
Correct Answer: A
Rationale: Monthly Protime tests monitor the therapeutic effect of warfarin and prevent bleeding complications.
A client with a tracheostomy is exhibiting difficulty breathing, and respirations are increasingly noisy. Secretions are very thick. Which of the following initial interventions is most indicated?
- A. Increase humidification, and suction the tracheostomy tube.
- B. Notify the physician.
- C. Sit the client upright, and encourage the client to breathe deeply and cough.
- D. Gently irrigate and suction the tracheostomy tube.
Correct Answer: A
Rationale: Thick secretions causing noisy respirations and breathing difficulty indicate the need for increased humidification to thin secretions and suctioning to clear the tracheostomy tube (A). Notifying the physician (B) or encouraging coughing (C) is secondary, and irrigation (D) is not typically the initial step.
A client is to be discharged 48 hours after a normal vaginal delivery of an infant with no laceration or episiotomy. Which of the following danger signs should the client be advised to report to her physician? Select all that apply.
- A. Temperature higher than 38°C/100.4°F
- B. Difficulty urinating
- C. Swelling, redness, or pain in one or both legs
- D. Fatigue
- E. Foul-smelling vaginal discharge
Correct Answer: A,B,C,E
Rationale: Postpartum danger signs include fever >38°C (A), difficulty urinating (B), leg swelling/redness/pain (C, indicating possible DVT), and foul-smelling discharge (E, suggesting infection). Fatigue (D) is common and not necessarily a danger sign.