Nokea
The nurse is transcribing the following physician's orders.
Which of the following orders warrants further clarification?
- A. Administer haloperidol (Haldol) 5 mg.
- B. Instruct client to use incentive spirometer q1h while awake.
- C. D5W 1/4 NS + KCl 20 mEq/L at 100 mL/h.
- D. CBC with differential and platelets at 8 AM.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-has no route of administration or schedule (2) clear and complete and needs no further clarification (3) clear and complete and needs no further clarification (4) clear and complete and needs no further clarification
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A six-month-old infant has had all of the required immunizations.
The nurse knows this would include which of the following?
- A. Two doses of diphtheria, tetanus, and pertussis vaccine.
- B. Measles, mumps, and rubella vaccines.
- C. A booster dose of the trivalent oral polio vaccine.
- D. Chickenpox and smallpox vaccines.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-first dose of the DPT may be given at two months, the second is given around four months (2) MMR is given at 15 months (3) polio is given at two and four months and again at 12 to 18 months (4) smallpox vaccine is no longer recommended
In addition to routine vital signs, what should the nurse assess because the client had a lumbar laminectomy?
- A. Hand grasps
- B. Foot strength
- C. Ability to swallow
- D. Abdominal muscle strength
Correct Answer: B
Rationale: Lumbar laminectomy affects lower spine nerves; assessing foot strength evaluates neurological function in the legs. Hand grasps, swallowing, and abdominal strength are unrelated.
The nurse is caring for a client with a long leg cast on his right leg. The nurse notes that the right foot is pale and cool to the touch, and the client continues to complain of pain even though an analgesic was administered 45 minutes ago. What is the FIRST action the nurse should take?
- A. Apply a heating pad to the client's right toes.
- B. Repeat the dose of the analgesic stat.
- C. Remove the cast immediately.
- D. Notify the physician immediately.
Correct Answer: D
Rationale: Pale, cool skin and persistent pain suggest compartment syndrome, requiring immediate physician notification. Options A, B, and C are unsafe.
A 12-year-old child is receiving intravenous theophylline (Aminophylline). The child presents with signs of tachycardia and irritability.
Which of the following nursing actions is MOST appropriate?
- A. Decrease external stimuli in the child's room.
- B. Administer an analgesic as ordered.
- C. Notify and advise the physician of the child's status.
- D. Document the assessments and continue to observe.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) may help the client to cope with current symptoms, but is not highest priority (2) will mask the signs of toxicity (3) correct-signs of toxicity need to be reported to the physician (4) does not take action to resolve the problem
Which of the following lab values might the nurse expect to see in a client with Addison's disease?
- A. WBC 10,000
- B. BUN 22
- C. $\mathrm{K}+3.5 \mathrm{mEq} / \mathrm{L}$
- D. $\mathrm{Na}+142 \mathrm{mEq} / \mathrm{L}$
Correct Answer: C
Rationale: Addison's disease causes hyperkalemia (elevated potassium, not 3.5 mEq/L, which is normal) and hyponatremia due to adrenal insufficiency.