Nokea
When performing blood pressure measurements to assess for orthostatic hypotension, which action should the nurse implement first?
- A. Record the client's pulse rate and rhythm.
- B. Assist the client to stand at the bedside.
- C. Apply the blood pressure cuff securely.
- D. Position the client supine for a few minutes.
Correct Answer: D
Rationale: Supine position provides baseline for orthostatic assessment.
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After a seven-day treatment with an IV antibiotic, the healthcare provider discharges a client from the hospital and writes a prescription for an oral antibiotic. While providing discharge instructions, the nurse notes that the dosage for the oral antibiotic is significantly higher than the IV antibiotic. Which resource should the nurse use first in resolving the situation?
- A. Medication reference guide.
- B. Nursing unit charge nurse.
- C. Healthcare provider.
- D. Hospital pharmacist.
Correct Answer: C
Rationale: Prescriber clarifies dosage discrepancies.
The nurse retrieves hydromorphone '4 mg/mL' from the electronic medication system, for a patient who is receiving hydromorphone 3 mg IM every 6 hours PRN for severe pain. How many mL should the nurse administer to the patient? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)
Correct Answer: 0.8
Rationale: 3 mg ÷ 4 mg/mL = 0.75 mL, rounded to 0.8 mL.
The nurse has removed a barbiturate capsule from the unit dose wrapper to administer to a client. The client decides to watch a television program and requests not to take the medication. Which action should the nurse implement?
- A. Explain that since the medication is a controlled substance, it must be taken.
- B. Credit the medication back and put it in the client's medication box.
- C. Keep the medication and see if the client will want to take it later.
- D. Have another nurse witness the disposal of the medication into the disposal container.
Correct Answer: D
Rationale: Witnessed disposal prevents misuse of controlled substances.
When a home health nurse is administering a 10-day prescription for intermittent infusions of daptomycin to a client with Staphylococcus aureus cellulitis, the client inquires why the pharmacy delivered only a few of the premixed bags and not all of the doses. Which response should the nurse provide to the client?
- A. The medication is in short supply at the local pharmacy.
- B. The antibiotic has a limited shelf life after reconstitution.
- C. The healthcare provider should be notified of the discrepancy.
- D. The instructions may change over the course of therapy.
Correct Answer: B
Rationale: Daptomycin has short stability post-reconstitution.
An unlicensed assistive personnel (UAP) assigned to feed a client with meningococcal infection, for whom droplet precautions have been implemented, requests a change in assignment, reporting they have not yet been fitted for an N95 respirator mask. Which action should the nurse take?
- A. Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before providing personal care.
- B. Instruct the UAP that a standard face mask is sufficient for the provision of care for the assigned client.
- C. Before changing assignments, determine which staff members have fitted particulate filter masks.
- D. Send the UAP to be fitted for a particulate filter mask immediately to be able to provide care to this client.
Correct Answer: B
Rationale: Standard mask suffices for droplet precautions.