Nokea
The nurse is caring for a 17-year-old married male scheduled for a hernia repair. The nurse administers meperidine hydrochloride (Demerol) 50 mg and hydroxyzine pamoate (Vistaril) 25 mg IM. Thirty minutes later the nurse discovers that the informed consent is unsigned.
Which of the following actions by the nurse is BEST?
- A. Cancel the surgery.
- B. Ask the client to sign the informed consent.
- C. Notify the physician.
- D. Ask the client's mother to sign the informed consent.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) inappropriate action, should inform physician (2) can't sign informed consent if client has been drinking alcohol or has been pre-medicated for surgery (3) correct-physician needs to be informed (4) married minor is considered emancipated; provides own consent for treatment
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An extremely agitated client is receiving haloperidol (Haldol) IM every 30 minutes while in the psychiatric emergency room.
- A. What is the most important nursing intervention for a client receiving haloperidol IM every 30 minutes?
- B. Monitor vital signs, especially blood pressure, every 30 minutes.
- C. Remain at the client’s side to provide reassurance.
- D. Tell the client the name of the medication and its effects.
- E. Monitor the anticholinergic effects of the medication.
Correct Answer: A
Rationale: Haloperidol can cause postural hypotension due to alpha-adrenergic blockade, especially during rapid neuroleptization. Monitoring vital signs, particularly blood pressure, every 30 minutes ensures client safety. Reassurance, education, and monitoring side effects are secondary to physiological stability.
The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding?
- A. Stand on 1 foot
- B. Catch a ball
- C. Skip on alternate feet
- D. Ride a bicycle
Correct Answer: A
Rationale: Stand on 1 foot. Balancing on one foot is expected by age 3, indicating gross motor delay if absent.
The nurse is to insert an indwelling catheter in a male. Which action is appropriate?
- A. Cleanse the meatus before preparing the catheter for insertion
- B. Wash hands before starting the procedure
- C. Hold the penis at a 45-degree angle during insertion of the catheter
- D. Inflate the balloon immediately before inserting the catheter
Correct Answer: B
Rationale: Washing hands before catheter insertion is critical to maintain a sterile field and prevent infection. Cleansing the meatus occurs after hand washing, a 45-degree angle is incorrect (90 degrees is typical), and the balloon is inflated post-insertion.
A client's Salem sump tube (nasogastric).
Which of the following findings would indicate to the nurse that a client's Salem sump tube (nasogastric) was functioning effectively?
- A. Fluctuation of the fluid level in the water seal chamber.
- B. Active bubbling in the suction bottle.
- C. The presence of a hissing sound from the blue lumen tube.
- D. A pressure of 25 mm Hg in the esophageal balloon.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to a Salem sump tube. (1) Salem sump tube is not a water-sealed drainage system (2) associated with a water-sealed drainage system (3) correct-'hissing' sound is indicative that air is freely exiting the airway, purpose is to provide continuous steady suction without pulling gastric mucosa (4) is relevant to a Sengstaken-Blakemore tube
The LPN/LVN has delegated basic hygienic care of several clients to a certified nursing assistant. Which action by the nurse will ensure that the clients receive the best care?
- A. Observe the nursing assistant during the performance of all care
- B. Ask the nursing assistant if there were any problems
- C. Check the nursing assistant's charting
- D. Observe the clients following administration of care by the nursing assistants
Correct Answer: D
Rationale: Observing clients post-care ensures care was performed correctly and identifies issues like skin integrity or comfort, ensuring quality. Constant observation, questioning, or charting checks are less direct.