Nokea
A client comes to the nurse's station for her antipsychotic medication. The nurse notes that the client has torticollis, an arched back, and rapid movement of the eyes.
Which of the following action should the nurse take FIRST?
- A. Determine what other medications the patient is taking.
- B. Perform a neurological assessment.
- C. Administer haloperidol decanoate (Haldol D) IM stat.
- D. Administer the PRN trihexyphenidyl (Artane) IM immediately.
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each implementation. (1) assessment, demonstrating acute extrapyramidal side effects (2) assessment, no validation required (3) Haldol is antipsychotic, will exacerbate symptoms (4) correct-administer Cogentin or Artane
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The nurse is teaching a client about warfarin (Coumadin) therapy. Which of the following statements by the client indicates a need for further teaching?
- A. I will avoid contact sports while taking this medication.
- B. I will check with my doctor before taking any new medications.
- C. I will increase my intake of green leafy vegetables.
- D. I will report any unusual bleeding to my doctor.
Correct Answer: C
Rationale: green leafy vegetables are high in vitamin K, which can decrease the effectiveness of warfarin
The physician prescribes cimetidine (Tagamet) 300 mg PO qid for a 75-year-old man. The nurse instructs the client about the medication. Which of the following statements, if made by the client, would indicate that further teaching is needed?
- A. I'll take this pill with meals and before bed.
- B. I may experience mild diarrhea for a while.
- C. My stools may change color while I'm on this medication.
- D. I should call my doctor if I get an acne-like rash.
Correct Answer: C
Rationale: no change in stool color
The nurse is supervising a student nurse administer a tube feeding to a client via a Levin tube. Which of the following actions, if performed by the student nurse, indicates a proper understanding of the correct procedure?
- A. The Levin tube remains unclamped for 30 minutes after the feeding.
- B. Sterile equipment is used to administer the feeding.
- C. The amount of the feeding is varied according to the patient's tolerance.
- D. The tube feeding is given at room temperature.
Correct Answer: D
Rationale: minimizes intestinal cramping
A patient is returned to his room following an appendectomy. The nurse notices a large amount of serosanguineous drainage on the dressing. It is MOST important for the nurse to obtain an answer to which of the following questions?
- A. Were there any intraoperative complications?
- B. Has the dressing been changed?
- C. Why didn't the recovery room nurse report any drainage?
- D. Was a tissue drain placed during surgery?
Correct Answer: D
Rationale: drain is frequently placed during surgery to prevent accumulation in wound, dressing should be reinforced
The nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions is the PRIORITY?
- A. Check the ventilator settings every shift.
- B. Suction the endotracheal tube as needed.
- C. Monitor the client’s oxygen saturation.
- D. Ensure the endotracheal tube is secure.
Correct Answer: D
Rationale: Ensuring the endotracheal tube is secure is the priority to prevent accidental extubation, which could lead to respiratory failure. Options A, B, and C are important but secondary: checking settings, suctioning, and monitoring saturation follow tube security.