Nokea
You are going to perform gastric lavage for your adult client who was accidentally poisoned. How many mLs of irrigating solution would you instill after each suctioning?
- A. 100 mLs
- B. 250 mLs
- C. 400 mLs
- D. 500 mLs
Correct Answer: B
Rationale: Gastric lavage typically involves instilling 200-300 mL of solution (commonly 250 mL) per cycle to effectively wash out the stomach contents.
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The nurse finds a client lying on the floor next to the bed. After returning the client to bed, assessing for injury, and notifying the physician, the nurse fills out an incident report. Which of the following is the nurse's next action?
- A. Give the incident report to the nurse-manager.
- B. Place the incident report on the chart.
- C. Call the family to inform them.
- D. Omit mentioning the fall in the chart documentation.
Correct Answer: A
Rationale: The incident report should be given to the nurse-manager for review and follow-up, as it is an internal document for quality improvement, not part of the medical record.
The nurse is caring for a client with a history of peptic ulcer disease who is prescribed misoprostol (Cytotec). The nurse should instruct the client to take the medication:
- A. With meals to enhance absorption.
- B. On an empty stomach.
- C. At bedtime only.
- D. With an antacid.
Correct Answer: A
Rationale: Misoprostol should be taken with meals to reduce gastrointestinal side effects and protect the stomach lining.
Which sign/symptom indicates that a client being treated with haloperidol may be experiencing an adverse effect of this medication?
- A. Nausea
- B. Hypotension
- C. Blurred vision
- D. Excessive drooling
Correct Answer: D
Rationale: Adverse effects of antipsychotic medications such as haloperidol include marked drowsiness and lethargy; extrapyramidal symptoms, including parkinsonism effects (drooling); dystonias; akathisia; and tardive dyskinesia. The correct option is a parkinsonism effect of this medication, excessive drooling. Nausea, hypotension, and blurred vision are occasional side effects of the medication.
A client with a diagnosis of schizophrenia is prescribed risperidone (Risperdal). The nurse should monitor the client for which of the following side effects?
- A. Weight gain.
- B. Hypotension.
- C. Dry mouth.
- D. Tremors.
Correct Answer: A,D
Rationale: Risperidone can cause weight gain and extrapyramidal symptoms like tremors, which the nurse should monitor.
A worried mother confides in the nurse that she wants to change physicians because her infant is not getting better. The best response by the nurse is which of the following?
- A. This doctor has been on our staff for 20 years.'
- B. I know you are worried, but the doctor has an excellent reputation.'
- C. You always have an option to change. Tell me about your concerns.'
- D. I take my own children to this doctor.'
Correct Answer: C
Rationale: Acknowledging the mother's concerns and offering to discuss them respects her autonomy and opens a dialogue to address specific issues, potentially resolving misunderstandings or facilitating a change if needed.