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A nurse is reviewing the medication administration record of a client.
Which of the following prescriptions should the nurse clarify?
- A. Digoxen 250 PO daily
- B. Metoprolol 50 mg PO twice daily
- C. Furosemide 40 mg IV once daily
- D. Acetaminophen 650 mg PO every 6 hours PRN pain
Correct Answer: A
Rationale: The correct answer is A. Digoxin is commonly prescribed in mcg, not mg. Therefore, the nurse should clarify the dosage unit. Metoprolol (B) is a typical dose and frequency for oral administration. Furosemide (C) is a standard dose and route for IV administration. Acetaminophen (D) is a common dose and frequency for pain management. The other choices are not problematic.
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A nurse is obtaining the temperature of a newborn.
Which of the following sites should the nurse use?
- A. Axillary
- B. Rectal
- C. Oral
- D. Tympanic
Correct Answer: B
Rationale: The nurse should use the rectal site for temperature measurement as it provides the most accurate core body temperature reading. Rectal temperature closely reflects internal body temperature, making it the preferred site for assessing critically ill patients or infants who cannot cooperate for oral measurements. Axillary, oral, and tympanic sites may not accurately represent core body temperature due to external factors affecting the readings. Rectal temperature is the gold standard for accurate temperature measurement in certain clinical situations.
The nurse is continuing to care for the client.
Diagnostic Results Day 1,
1000:
Appearance cloudy (clear) Color
yellow (yellow)
pH 5.9 (4,6 to 8)
Protein 3+ (negative)
Specific gravity 1.013 (1.005 to 1.03) Leukocyte esterase
negative (negative)
Nitrites negative (negative) Ketones
negative (negative) Crystals negative
(negative) Casts negative (negative)
Glucose trace (negative) WBC 5 (0
to 4)
WBC casts none (none)
RBC 1 (less than or equal to 2) RBC
casts none (none)
Day 1, 1030:
CBC:
Nurses' Notes
Day 1, 0900:
Client is at 31 weeks of gestation and presents with a severe headache unrelieved by
acetaminophen. Client also reports urinary frequency and decreased fetal movement.
Client is a G3 P2 with one preterm birth.
Day 1, 0930:
Client reports a constant and throbbing headache and rates it as a 6 on a scale of 0 to 10. Denies
visual disturbances. +3 pitting edema in bilateral lower extremities, Patellar reflex 4+ without
the presence of clonus. Client reports occasional nighttime leg cramps. Reports three fetal
movements within the last 30 min. External fetal monitor applied with a baseline FHR 140/min
with occasional accelerations and moderate variability. No uterine contractions noted
The client is at greatest risk for developing -----and-------
- A. Placental abruption
- B. Hypoglycemia
- C. Heart failure
- D. Cervical Insufficiency
- E. Seizures
Correct Answer: A,E
Rationale: The correct answer is A (Placental abruption) and E (Seizures) because they are common complications during pregnancy. Placental abruption poses a risk of severe bleeding and fetal distress, leading to adverse outcomes. Seizures, specifically eclampsia, can occur due to uncontrolled hypertension in pregnancy, putting both the mother and baby at risk. Hypoglycemia (B), heart failure (C), and cervical insufficiency (D) are potential complications but are not the greatest risks compared to placental abruption and seizures in this context.
A nurse is caring for a client who is postoperative following total hip arthroplasty.
Which of the following actions should the nurse take to prevent dislocation of the prosthesis?
- A. Raise the head of the client's bed to a high-fowlers position.
- B. Elevate the clients effected leg on a pillow when in bed.
- C. Position the clients knees slightly higher than the hips when up in a chair
- D. Keep an abduction pillow between the client's legs.
Correct Answer: D
Rationale: The correct answer is D: Keep an abduction pillow between the client's legs. This helps maintain proper alignment and prevents excessive internal rotation of the hip, reducing the risk of dislocation. Elevating the affected leg on a pillow (B) may not provide adequate support. Raising the head of the bed to a high-fowlers position (A) and positioning the knees higher than the hips (C) do not directly address hip alignment.
A nurse is caring for a 75-year-old client who is admitted to the medical-surgical unit
Nurses' Notes
Today
0700:
Received change of shift report. Client is 2 days postoperative following a hysterectomy and
they have not yet ambulated with physical therapy due to significant postoperative pain. Per
change of shift report, pain medications have been adjusted and pain has improved. Client
currently reports pain level as 2 on a scale of 0 to 10.
0900:
Ambulating in hallway with the assistance of physical therapy.
1000:
Return to bed with siderails up x 2, but not wearing sequential compression devices because they
"hurt too much." Applied antiembolism stockings.
1400:
Client notified nurse that right leg is warm and painful. Assessment reveals unilateral right lower
extremity swelling and warmth below the knee. Provider notified.
Laboratory Results
Today
1430:
WBC count 10,500/mm³ (5,000 to 10,000/mm³)
Hgb 11.1 g/dL (12 to 16 g/dL)
Hct 34% (37% to 47%6)
Platelet count 250,000/mm³ (150,000 to 400,000/mm³)
Coagulation studies:
PT 11.5 seconds (11 to 12.5 seconds)
INR 0.9 (0.8 to 1.1)
History and Physical
3 days ago:
Past medical history: Type 2 diabetes mellitus, hypertension
Surgical history: Cesarean birth x 2 as a young adult
Social history: Has smoked 1 pack of cigarettes per day for 4 years, drinks socially, does not
exercise.
Weight: 121,3 kg (267.4 lb)
Vital Signs
Today
0800
Temperature 37° C (98.6" F)
Heart rate 97/min
Respiratory rate 18/min
BP 138/78 mm Hg
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing.
- A. Request a prescription for IV furosemide
- B. Implement rest. ice, elevation, compression (RICE)
- C. Check for pedal pulses and sans of ischemia
- D. Cellulitis
- E. Heart failure
- F. Muscle Strain
Correct Answer: C
Rationale: Unilateral swelling and warmth suggest deep vein thrombosis (DVT), requiring assessment for ischemia.
A nurse is caring for a client who speaks a different language than the nurse and is using an interpreter.
Which action should the nurse take when working with the interpreter?
- A. Speak in a normal voice at a natural pace.
- B. Use medical jargon to ensure accuracy.
- C. Speak directly to the interpreter instead of the client.
- D. Ask the client to respond only with 'yes' or 'no' answers.
Correct Answer: A
Rationale: The correct answer is A: Speak in a normal voice at a natural pace. This is important because speaking clearly and at a natural pace allows the interpreter to accurately convey the message without missing any information. Using a normal voice also helps maintain a respectful and professional tone during communication.
Choice B is incorrect because using medical jargon may confuse the interpreter and lead to miscommunication. Choice C is incorrect as the nurse should always address the client directly to establish trust and rapport. Choice D is incorrect as it restricts the client's ability to express themselves fully.