Nokea
When you are monitoring your client who is now started on an intravenous antibiotic for an infection, you notice that the client is exhibiting signs of anaphylaxis. What is your first priority intervention?
- A. Stop the intravenous flow
- B. Slow down the intravenous flow
- C. Notify the doctor
- D. Begin CPR
Correct Answer: A
Rationale: Stopping the IV flow is the first priority to halt the administration of the allergen causing anaphylaxis, followed by other emergency interventions.
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The mother of a 28-year-old client who is taking clozapine [Clozaril] states, 'Something is wrong. My son is drooling like a baby.' Which of the following responses by the nurse would be most helpful?
- A. I wonder if he's having an adverse reaction to the medicine.'
- B. Excess saliva is common with this drug; here's a paper cup for him to spit into.'
- C. Don't worry about it; this is only a minor inconvenience compared to its benefits.'
- D. I've seen this happen to other clients who are taking Clozaril.'
Correct Answer: B
Rationale: Excess salivation is a common side effect of clozapine. Providing a practical solution like a cup supports the client's comfort and addresses the mother's concern.
A client with diabetes is explaining to the nurse how she will care for her feet at home. Which statement indicates that the client understands proper foot care?
- A. When I injure my toe, I will plan to put iodine on it.'
- B. I should inspect my feet at least once a week.'
- C. It is okay to go barefoot in the house.'
- D. It is important to dry my feet carefully after my bath.'
Correct Answer: D
Rationale: Thorough drying prevents moisture-related infections, critical for diabetic foot care to avoid complications like ulcers.
A client asks the nurse why he was asked to complete an advance directive when he entered the hospital. The nurse's best response is which of the following?
- A. This will provide a substitute for informed discussion with the physician.'
- B. It is a legal requirement for all clients entering a hospital to be offered the chance to make an advance directive.'
- C. The physician will make the best decisions for you in an emergency.'
- D. Are you worried that extraordinary means will be taken if you are dying?'
Correct Answer: B
Rationale: It is a legal requirement in many regions for hospitals to offer patients the opportunity to complete an advance directive upon admission to ensure their wishes are documented.
A 10-year-old child is admitted with a brain tumor. Which assessment made by the nurse is most critical to report to the child's physician?
- A. Vomiting after lunch.
- B. Difficulty in recalling the day of the week.
- C. Blood pressure of 102/62 mm Hg.
- D. Incontinence of urine and difficulty voiding.
Correct Answer: B
Rationale: Difficulty recalling the day of the week suggests neurological impairment, which is critical to report in a child with a brain tumor, as it may indicate tumor progression or increased intracranial pressure.
Which of the following should be the nurse's priority assessment after an epidural anesthetic has been administered to a client in labor?
- A. Level of consciousness.
- B. Blood pressure.
- C. Cognitive function.
- D. Contraction pattern.
Correct Answer: B
Rationale: Epidurals can cause hypotension due to vasodilation, making blood pressure the priority assessment.