Nokea
Which of the following actions should the nurse take?
- A. Compare the current infusion with the prescription and the client's medical record.
- B. Adjust the IV infusion rate to match the information received during the shift report.
- C. Stop the infusion immediately and notify the provider.
- D. Document the discrepancy in the client's record and continue monitoring the infusion.
Correct Answer: A
Rationale: The correct answer is A. The nurse should compare the current infusion with the prescription and the client's medical record to ensure accuracy and safety. This step is crucial in preventing medication errors and ensuring that the right medication is given to the right patient at the right time. Adjusting the IV infusion rate without verifying the information can lead to potential harm (choice B). Stopping the infusion immediately and notifying the provider is not necessary unless there is a clear indication of a serious issue (choice C). Documenting the discrepancy and continuing monitoring without taking immediate action can compromise patient safety (choice D).
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A nurse is providing discharge instructions to a client who has a new prescription for haloperidol. Which of the following adverse effects should the nurse instruct the client to report to the provider?
- A. Shuffling gait
- B. Increased salivation
- C. Mild drowsiness
- D. Weight gain
Correct Answer: A
Rationale: The correct answer is A: Shuffling gait. This is a potential extrapyramidal side effect of haloperidol, a typical antipsychotic. It is important to report this to the provider as it may indicate a serious adverse reaction called tardive dyskinesia. Increased salivation (choice B) and mild drowsiness (choice C) are common side effects that may resolve on their own. Weight gain (choice D) is more commonly associated with atypical antipsychotics. Choices E, F, and G are not provided.
If the client develops a pneumothorax, which of the following assessment findings should the nurse expect?
- A. Stridor
- B. Pain on inhalation chest pain that worsens when you breathe or pleuritic pain
- C. Friction rub
- D. Bradycardia
Correct Answer: B
Rationale: The correct answer is B: Pain on inhalation chest pain that worsens when you breathe or pleuritic pain. A pneumothorax is the presence of air in the pleural space, causing lung collapse. When air enters this space, it creates pressure, leading to sharp chest pain that worsens with breathing (pleuritic pain). This occurs because the air-filled space prevents the lungs from expanding fully during inhalation, causing discomfort. Stridor (choice A) is a high-pitched sound indicating upper airway obstruction, not typically associated with a pneumothorax. Friction rub (choice C) indicates inflammation of the pleura, not specific to a pneumothorax. Bradycardia (choice D) is unlikely in pneumothorax, as it is more commonly associated with conditions affecting the heart rate.
Which of the following responses should the nurse make?
- A. I can give you information about respite care if you are interested.
- B. You should try to sleep more so you can take better care of your mother.
- C. Caring for a loved one at the end of life is very rewarding.
- D. It's important to stay strong for your mother during this time.
Correct Answer: A
Rationale: The correct answer is A because it acknowledges the caregiver's potential interest in respite care, which can provide them with much-needed rest and support. This response shows empathy and offers a helpful solution. Choice B is incorrect as it oversimplifies the situation and places undue pressure on the caregiver. Choice C is incorrect as it may invalidate the caregiver's struggles and emotions, as caregiving can be overwhelming and challenging. Choice D is incorrect as it emphasizes the importance of strength without addressing the caregiver's need for support and self-care.
The nurse is providing teaching about lithium to the client and client's adult child. Select the 3 statements the nurse should include.
- A. Blurred vision is an expected adverse effect pf this medication
- B. It will take at least a week before this medication reaches a therapeutic level.
- C. This medication can cause nausea and drowsiness.
- D. You will be placed on a low sodium diet while taking this medication.
- E. This medication can cause weight gain.
Correct Answer: B,C,E
Rationale: Blurred vision is not typical; lithium takes time to reach therapeutic levels, causes nausea/drowsiness, and often leads to weight gain. A low-sodium diet is contraindicated due to risk of toxicity.
Which statement should the nurse include in the teaching?
- A. The test should be performed after your baby is 24 hours old.
- B. Genetic screening is only necessary if there is a family history of genetic disorders.
- C. Your baby cannot eat before the genetic screening test.
- D. If the first test is abnormal, no further testing is needed.
Correct Answer: A
Rationale: The correct answer is A because it accurately states the timing for performing the genetic screening test, which should be after the baby is 24 hours old to ensure accurate results. Choice B is incorrect because genetic screening may be recommended for all newborns, not just those with a family history. Choice C is incorrect because babies can eat before the test. Choice D is incorrect as further testing may be required if the initial results are abnormal.