Nokea
When performing medication reconciliation for the client, which of the following actions should the nurse take?
- A. Encourage the client to make his own list after he returns to his home
- B. Include any adverse effects of the medications the client might develop
- C. Exclude nutritional supplements from the list of medications the client reports
- D. Compare new prescriptions with the fist of medications the client reports,
Correct Answer: D
Rationale: Comparing prescriptions prevents duplication and interactions.
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Which of the following actions should the nurse take?
- A. Administer dextrose 10% in water.
- B. Give 500 mL of lactated Ringers solution.
- C. Slow the TPN infusion rate.
- D. Temporarily discontinue the infusion
Correct Answer: A
Rationale: The correct answer is A: Administer dextrose 10% in water. This action is appropriate for treating hypoglycemia, which can be a potential complication of TPN (Total Parenteral Nutrition) therapy. Administering dextrose 10% in water can help raise the patient's blood sugar levels quickly and effectively. Choice B is incorrect as lactated Ringers solution does not directly address hypoglycemia. Choice C is not the best option as slowing the TPN infusion rate may further decrease the patient's blood sugar levels. Choice D is also incorrect as temporarily discontinuing the TPN infusion may exacerbate the hypoglycemia.
A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?
- A. Evaluate the client's ability to help with repositioning
- B. Reposition the client without the use of assistive devices.
- C. Raise the side rails on both sides of the client's bed during repositioning.
- D. Discuss the client's preferences for determining a repositioning schedule.
Correct Answer: A
Rationale: The correct answer is A: Evaluate the client's ability to help with repositioning. This is crucial as it assesses the client's capability and involvement in the process, promoting independence and preventing complications. Choice B is incorrect as assistive devices may be necessary for safety. Choice C is incorrect as raising side rails can limit access and may not be needed. Choice D is incorrect as discussing preferences is important but not directly related to repositioning.
A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?
- A. Polyuria
- B. Hypotension
- C. Weight loss
- D. Hematuria
Correct Answer: D
Rationale: The correct answer is D: Hematuria. In acute glomerulonephritis, there is inflammation of the glomeruli in the kidneys leading to blood in the urine. This is known as hematuria. Polyuria (choice A) is not typically seen in this condition as the kidneys are not able to effectively filter urine. Hypotension (choice B) is unlikely as fluid retention and hypertension are more common due to decreased kidney function. Weight loss (choice C) is not a common finding as the condition often leads to fluid retention. Therefore, hematuria is the most expected finding in acute glomerulonephritis.
Select the 5 findings the nurse should plan to include in the report.
- A. Client's report of lack of food in home
- B. ECG results
- C. Numerous bruises in various stages of healing
- D. Client's avoidance of eye contact
- E. Client's report of lack of access to bank accounts
- F. Client’s report of weight loss
Correct Answer: A,C,D,E,F
Rationale: These findings highlight potential abuse and neglect indicators.
Which of the following actions should the nurse include in the plan?
- A. Maintain eye contact with the newborn during feedings
- B. Minimize noise in the newborn's environment.
- C. Swaddle the newborn with his legs extended
- D. Administer naloxone to the newborn.
Correct Answer: B
Rationale: Minimizing noise and stimuli helps to reduce symptoms of neonatal abstinence syndrome.