Nokea
Which of the following drug administrations should be reported as a practice error? Select all that apply.
- A. Cephalexin administered; client has history of anaphylaxis from penicillin
- B. Hydromorphone 2 mg administered; client reports pruritus
- C. Immunization for 3-month-old administered in ventrogluteal site
- D. Oral niacin (nicotinic acid) administered; client has facial flushing
- E. Warfarin administered; client at 12 weeks gestation
Correct Answer: A,E
Rationale: Cephalexin in a penicillin-allergic client risks anaphylaxis, and warfarin in pregnancy can cause fetal harm. Pruritus and flushing are expected side effects, and the ventrogluteal site is appropriate.
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A female client is admitted for a breast biopsy. She says, tearfully to the nurse, 'If this turns out to be cancer and I have to have my breast removed, my partner will never come near me.' The nurse's best response would be which of these statements?
- A. I hear you saying that you have a fear for the loss of love.'
- B. You sound concerned that your partner will reject you.'
- C. Are you wondering about the effects on your sexuality?'
- D. Are you worried that the surgery will lead to changes?'
Correct Answer: D
Rationale: This is a general lead-in type of response that encourages further discussion without focusing on an area that the nurse, but possibly not the client, feels is a problem.
The nurse is talking with the parent of an adolescent client who arrived at the emergency department after discovering that the client was involved in a motor vehicle collision. The parent asks about the clients condition. The client is unconscious and is currently receiving CPR. Which of the following responses would be appropriate for the nurse to make?
- A. I do not have any information about your child's condition, but you can see your child now.
- B. Your child is critically ill, and we are currently caring for your child's needs.
- C. The health care team is currently attempting to revive your child after your child's heart stopped.
- D. Only the health care provider is allowed to discuss your child's condition with you.
Correct Answer: C
Rationale: Honest, clear communication about the critical situation (CPR) is appropriate while maintaining sensitivity.
An 8-year-old child is admitted to the hospital with pneumonia. The child has had frequent respiratory infections. A chloride sweat test is ordered. The nurse knows that the reason for this test is to rule out which condition?
- A. Pernicious anemia
- B. Diabetes insipidus
- C. Cystic fibrosis
- D. Glomerulonephritis
Correct Answer: C
Rationale: Frequent respiratory infections and pneumonia suggest cystic fibrosis, diagnosed via chloride sweat test, which detects elevated sweat chloride levels.
Which measures will help prevent falls in the elderly clients of a long-term care facility? Select all that apply.
- A. Exercise programs
- B. Good room lighting
- C. Handrails in stairwell
- D. Smooth-soled shoes
- E. Staff hourly rounds
Correct Answer: A,B,C,E
Rationale: Exercise, lighting, handrails, and rounds reduce fall risk. Smooth-soled shoes increase slipping risk.
The nurse is teaching the parent of a 6-year-old client about sleep. Which of the following information should the nurse include? Select all that apply.
- A. Your child should sleep 9 to 12 hours every night.
- B. As your child grows, the hours of required sleep increase.
- C. Encourage active play before bedtime to promote restful sleep.
- D. Avoid giving your child large amounts of liquid after dinnertime.
- E. It is important to establish and maintain a regular bedtime routine.
Correct Answer: A,D,E
Rationale: Children aged 6 need 9-11 hours of sleep, limited liquids prevent bedwetting, and routines promote sleep. Sleep needs decrease with age, and active play close to bedtime may disrupt sleep.