Nokea
Which of the following is a commonality that is shared in terms of both restraints and urinary catheters?
- A. Both can lead to infection.
- B. Both are invasive procedures.
- C. Both are considered sentinel.
- D. Both are the last resort.
Correct Answer: A
Rationale: Both restraints and urinary catheters can lead to infections restraints through skin breakdown and catheters through urinary tract infections if not managed properly.
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A client with a diagnosis of major depressive disorder is prescribed fluoxetine (Prozac). The nurse should instruct the client that it may take how long to notice the full therapeutic effect?
- A. 1-2 days.
- B. 1-2 weeks.
- C. 3-4 weeks.
- D. 6-8 weeks.
Correct Answer: C
Rationale: Fluoxetine, an SSRI, typically takes 3-4 weeks to achieve its full therapeutic effect in treating depression.
A client with a diagnosis of Cushing's syndrome is prescribed ketoconazole. The nurse should monitor the client for which of the following side effects?
- A. Hypoglycemia.
- B. Liver toxicity.
- C. Weight gain.
- D. Hypertension.
Correct Answer: B
Rationale: Ketoconazole can cause liver toxicity, requiring regular monitoring of liver function tests.
Which statement about Respondeat Superior is accurate?
- A. Respondeat Superior does not mean that a nurse cannot be held liable.
- B. Respondeat Superior does not mean that a nurse cannot be held libel.
- C. Respondeat Superior is an ethical principle.
- D. Respondeat Superior is a law.
Correct Answer: A
Rationale: Respondeat Superior is a legal doctrine holding employers liable for employees' actions within the scope of employment, but it does not absolve nurses from personal liability for negligence.
A client who has glaucoma has been prescribed timolol (Timoptic) eyedrops. Which of the following instructions should the nurse give the client about the administration of the eyedrops?
- A. Instill the eyedrops whenever the eyes feel irritated
- B. The medication may cause some transient eye discomfort
- C. Keep the medication refrigerated between doses
- D. The need to use the eyedrops will be reevaluated after 1 month
Correct Answer: B
Rationale: Timolol eyedrops may cause transient eye discomfort, such as stinging or burning, which is a common side effect. Instilling drops only when eyes are irritated is incorrect, as timolol requires regular dosing. Refrigeration is not necessary, and reevaluation timing depends on the physician's plan, not a fixed month.
The nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions is the highest priority to prevent ventilator-associated pneumonia?
- A. Performing oral care every 4 hours.
- B. Elevating the head of the bed to 30-45 degrees.
- C. Administering prophylactic antibiotics.
- D. Suctioning the endotracheal tube every 2 hours.
Correct Answer: B
Rationale: Elevating the head of the bed to 30-45 degrees reduces the risk of aspiration, a key factor in preventing ventilator-associated pneumonia.