Nokea
While changing the client's colostomy bag and dressing, the nurse assesses that the client is ready to participate in her care by noting which of the following?
- A. The client asks what time the doctor will visit that day.
- B. The client asks about the supplies used during the dressing change.
- C. The client talks about something she read in the morning newspaper.
- D. The client complains about the way the night nurse changed the dressing.
Correct Answer: B
Rationale: The client's inquiry about the supplies used during the dressing change indicates interest and readiness to participate in her colostomy care. Other options reflect unrelated concerns or dissatisfaction, not readiness to engage in self-care. CN: Psychosocial adaptation; CL: Evaluate
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Amoxicillin trihydrate (Amoxil) 300 mg P.O. has been prescribed for a client with an oral infection. The medication is available in a liquid suspension that is available as 250 mg/5 mL. How many milliliters would the nurse administer?
Correct Answer: 6 mL
Rationale: To calculate the dose: (300 mg / 250 mg) × 5 mL = 6 mL. The nurse should administer 6 milliliters of the amoxicillin suspension to deliver the prescribed 300 mg dose.
The nurse is preparing a staff education program about medication reconciliation. Which of the following information should the nurse include? Select all that apply.
- A. Discontinued medications should be included while performing medication reconciliation.
- B. Medications taken on an as-needed basis can be excluded from this process.
- C. New medication orders should be compared with the current list.
- D. Medication reconciliation should be performed after the client has been discharged.
- E. Over-the-counter (OTC) medications should be included in the medication reconciliation.
Correct Answer: A,C,E
Rationale: Medication reconciliation includes discontinued medications, new orders, and OTC medications to ensure a complete and accurate list; it should occur at admission, transfer, and discharge, and PRN medications should not be excluded.
Which of the following client situations would require the most intensive nursing interventions for immobility?
- A. A 38-year-old woman receiving internal radiation therapy for cervical cancer.
- B. A 7-year-old boy with leukemia hospitalized for induction of high-dose chemotherapy.
- C. A 75-year-old man with metastatic prostate cancer hospitalized for a pathologic fracture of the femur.
- D. A 6-month-old undergoing surgery for placement of a central venous catheter.
Correct Answer: C
Rationale: A 75-year-old man with a pathologic femur fracture requires the most intensive nursing interventions for immobility due to pain, risk of further injury, and need for mobility aids and rehabilitation.
A client has an amylase level of 450 units/L and lipase level of 659 units/L. The client has mid-epigastric pain with nausea. What assessment helps the nurse to determine severity of the client's condition?
- A. Ranson's criteria.
- B. Vital signs.
- C. Urine output.
- D. Glasgow Coma Scale.
Correct Answer: A
Rationale: Ranson's criteria (A) assess pancreatitis severity using clinical and lab parameters like age, glucose, and white blood cell count. Vital signs (B) and urine output (C) are general but less specific. Glasgow Coma Scale (D) is for neurological assessment, not pancreatitis severity.
A client is about to undergo bone marrow aspiration of the sternum. Which of the following statements should the nurse include to provide information to the client about what the client will feel during the procedure?
- A. You may feel a warm solution being wiped over your entire front from your neck down to your navel and out to your shoulders.'
- B. You will not feel the local anesthetic being applied because it will be sprayed on.'
- C. You will feel a pulling type of discomfort for a few seconds.'
- D. After the needle is removed, you will feel a bandage being applied around your chest.'
Correct Answer: C
Rationale: During sternal bone marrow aspiration, the client may feel a brief pulling or pressure sensation as the marrow is aspirated. The antiseptic solution is not applied over such a large area, local anesthetic is injected (not sprayed), and a bandage is applied to the site, not around the chest.