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When using an IV pump for a newly admitted client, what action should the nurse take?
- A. Grasp the IV pump cord when unplugging it from the electrical outlet.
- B. Ensure the pump is plugged into an outlet with two prongs.
- C. Hold the IV pump cord while walking the client.
- D. Check for malfunctioning pump alerts.
Correct Answer: C
Rationale: The correct action for the nurse to take when using an IV pump for a newly admitted client is to hold the IV pump cord while walking the client. This is important for ensuring the safe and secure management of the IV pump during client mobility. Option A is incorrect as grasping the IV pump cord when unplugging it can lead to electrical hazards. Option B is incorrect as ensuring the pump is plugged into an outlet with two prongs is important for electrical safety but not directly related to the nurse's action. Option D is also important but does not directly address the nurse's immediate action while using the IV pump with the client.
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A nurse is reviewing the medical record of a client who is receiving gentamicin for a wound infection. Which of the following findings should the nurse report to the provider?
- A. Blood urea nitrogen (BUN) 25 mg/dL
- B. Serum creatinine 1.5 mg/dL
- C. Serum glucose 110 mg/dL
- D. White blood cell (WBC) count 5,000/mm3
Correct Answer: A
Rationale: An elevated BUN level indicates possible nephrotoxicity, which is a side effect of gentamicin and should be reported. Elevated serum creatinine and WBC count are not specifically related to gentamicin therapy. Normal serum glucose levels are also within the expected range.
A healthcare provider is reviewing the medical records of a client with a prescription for combination oral contraceptives. Which of the following conditions is a contraindication?
- A. Hyperthyroidism
- B. Thrombophlebitis
- C. Diverticulosis
- D. Hypocalcemia
Correct Answer: B
Rationale: Thrombophlebitis is a contraindication to combination oral contraceptives due to the increased risk of thromboembolic events. Hyperthyroidism, diverticulosis, and hypocalcemia are not contraindications to combination oral contraceptives. Hyperthyroidism may affect thyroid hormone levels but does not directly contraindicate oral contraceptives. Diverticulosis is a condition related to the digestive system and does not impact the use of oral contraceptives. Hypocalcemia, a low calcium level in the blood, is not a contraindication for oral contraceptives.
A client who has a new prescription for prednisone is being discharged. Which of the following client statements indicates an understanding of the teaching?
- A. I should take this medication with food.
- B. I will need to take this medication for the rest of my life.
- C. I should avoid crowded places while taking this medication.
- D. I will take this medication until my symptoms resolve.
Correct Answer: C
Rationale: The correct answer is C. Clients taking prednisone should avoid crowded places to reduce the risk of infection due to immunosuppression. Choice A is incorrect because prednisone should be taken with food to reduce stomach upset. Choice B is incorrect as prednisone is usually prescribed for a specific duration and not for life. Choice D is incorrect because prednisone should be taken as prescribed by the healthcare provider, which may not always align with symptom resolution.
A nurse is preparing to administer a dose of vancomycin IV to a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following actions should the nurse take?
- A. Administer the medication over 15 minutes.
- B. Monitor the client's urine output every 8 hours.
- C. Check the client's creatinine level before administering the medication.
- D. Assess the client for a history of allergies to antibiotics.
Correct Answer: C
Rationale: The correct action for the nurse to take is to check the client's creatinine level before administering vancomycin. Vancomycin is known to be nephrotoxic, so assessing the client's renal function before administering the medication is crucial to prevent further kidney damage. Administering the medication over 15 minutes (Choice A) is not the priority in this scenario as renal function assessment takes precedence. Monitoring urine output (Choice B) is important for assessing renal function but checking creatinine level directly provides more accurate information. Assessing for allergies to antibiotics (Choice D) is also important but not as essential as checking the creatinine level due to the nephrotoxic nature of vancomycin.
A client reports intimate partner violence to a nurse. What is the nurse's priority action?
- A. Develop a safety plan with the client.
- B. Refer the client to a community support group.
- C. Determine if the client has any injuries.
- D. Ensure the client has access to legal services.
Correct Answer: A
Rationale: The correct answer is to develop a safety plan with the client. When a client reports intimate partner violence, the priority is ensuring their immediate safety. Developing a safety plan involves identifying safe places, emergency contacts, and strategies to protect the client from harm. Referring the client to a community support group (Choice B) can be helpful but not the immediate priority. While determining if the client has any injuries (Choice C) is important for assessing their physical well-being, the priority is to ensure their safety. Ensuring the client has access to legal services (Choice D) is crucial, but it is not the immediate priority when the client is at risk of violence.