Nokea
While terminating the therapeutic nurse-client relationship, which action should be avoided?
- A. raise a new issue with the client
- B. review accomplishments of the relationship
- C. refer the client to a community support group
- D. allow the client to express his feelings about ending the relationship
Correct Answer: A
Rationale: Raising a new issue at termination can disrupt closure and hinder the client’s ability to process the end of the relationship.
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The nurse is preparing to administer the first dose of IV antibiotic to the client. Halfway through the infusion, the nurse realizes that the antibiotic dosage is not the same as ordered by the health care provider. Which action should the nurse take first?
- A. stop the infusion
- B. fill out an incident form
- C. notify the health care provider
- D. only give part of the antibiotic to obtain the correct dose
Correct Answer: A
Rationale: Stopping the infusion is the priority to prevent harm from an incorrect dose, followed by notifying the provider and completing an incident report.
The nurse is assessing the laboratory results of a client scheduled to receive phenytoin (Dilantin). The Dilantin level, drawn 2 hours ago, is 30 mcg/mL. What is the appropriate nursing action?
- A. Administer the Dilantin as scheduled
- B. Hold the scheduled dose and notify the physician
- C. Decrease the dosage from 100 mg to 50 mg
- D. Increase the dosage to 200 mg from 100 mg
Correct Answer: B
Rationale: A Dilantin level of 30 mcg/mL is above the therapeutic range (10-20 mcg/mL), indicating toxicity risk. The nurse should hold the dose and notify the physician for further orders.
A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when:
- A. Her contractions are 2 minutes apart.
- B. She has back pain and a bloody discharge.
- C. She experiences abdominal pain and frequent urination.
- D. Her contractions are 5 minutes apart.
Correct Answer: D
Rationale: Contractions 5 minutes apart indicate the onset of active labor, prompting further evaluation.
The nurse is assessing a client following the removal of a pituitary tumor. The nurse notes that the urinary output has increased and that the urine is very dilute. The nurse should give priority to:
- A. Notifying the doctor immediately
- B. Documenting the finding in the chart
- C. Decreasing the rate of IV fluids
- D. Administering vasopressive medication
Correct Answer: A
Rationale: Increased dilute urine suggests diabetes insipidus, a complication of pituitary surgery, requiring immediate physician notification for evaluation and treatment.
The nurse is caring for a client with suspected AIDS dementia complex. The first sign of dementia in the client with AIDS is:
- A. Changes in gait
- B. Loss of concentration
- C. Problems with speech
- D. Seizures
Correct Answer: B
Rationale: Loss of concentration is an early cognitive change in AIDS dementia complex.