Nokea
You are preparing to administer a PRN medication for pain. After your assessment of the client for pain you open the narcotics cabinet with the special key. Your calculations indicate that the client will be getting 0.8 mLs of the medication and the unit dose vial is 1 mL. You discard the excess of 0.2 mLs into the sink drain and enter the client's room. After you identify the client using two unique identifiers, the client refuses the medication. You then discard the 0.8 mLs into the sink and document the client's refusal on the narcotics count record. What have you failed to do during this process?
- A. You have failed to have another nurse witness the 0.8 mLs and the 0.2 mLs of waste.
- B. You have failed to have another nurse witness the 0.8 mLs of waste.
- C. You have failed to have another nurse witness the 0.2 mLs of waste.
- D. You have failed ask another nurse to verify the calculation of the dosage.
Correct Answer: A
Rationale: Narcotic wastage (both 0.2 mL and 0.8 mL) requires a witness to ensure accountability and prevent diversion, per standard protocol.
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Select the age group that is accurately paired with the normal and recommended hours of sleep each day.
- A. The neonate: 10 to 15 hours a day
- B. The toddler: 11 to 14 hours a day
- C. The preschool child: 12 to 15 hours a day
- D. The school age child: Less than 8 hours a day
Correct Answer: B
Rationale: Toddlers (1-2 years) typically require 11-14 hours of sleep per day, including naps, which is the correct pairing.
A client at 12 weeks' gestation tells the nurse that she is a vegetarian and eats 'lots of rice.' To help meet the client's need for protein during pregnancy, the nurse suggests that the client combine the rice with which of the following?
- A. Beans.
- B. Soy milk.
- C. Yogurt.
- D. Corn.
Correct Answer: A
Rationale: Combining rice with beans provides a complete protein, meeting the increased protein needs during pregnancy.
An adolescent with type 1 diabetes mellitus is hospitalized for appendicitis. He is weak and nauseated with poor skin turgor. The nurse notes a fruity odor to the client's breath. The client uses insulin. The nurse should suspect:
- A. Diabetic ketoacidosis
- B. Hypoglycemia
- C. Hyperglycemia
- D. Insulin overdose
Correct Answer: A
Rationale: Fruity breath, weakness, nausea, and poor skin turgor in a type 1 diabetic suggest diabetic ketoacidosis, a complication of uncontrolled hyperglycemia. Hypoglycemia would present with shakiness or sweating, not fruity breath.
The nurse caring for a child diagnosed with leukemia notes that the platelet count is 20,000 mm3 (20 x 10^9/L). Based on this finding, the nurse should include which interventions in the plan of care? Select all that apply.
- A. Monitor stools for blood.
- B. Clean oral cavity with soft swabs.
- C. Provide appropriate play activities.
- D. Check the rectal temperature every 4 hours.
- E. Administer acetaminophen suppositories for fever.
Correct Answer: A,B,C
Rationale: A platelet count of 20,000 mm3 (20 x 10^9/L) places the child at risk for bleeding. The remaining options 1, 2, and 3 are accurate interventions. Taking rectal temperatures and the use of suppositories are avoided because of the risk of rectal bleeding.
A client with a history of peptic ulcer disease is admitted with hematemesis. The nurse should prioritize which of the following interventions?
- A. Administer pantoprazole intravenously.
- B. Insert a nasogastric tube.
- C. Administer vitamin K.
- D. Position the client supine.
Correct Answer: A
Rationale: Intravenous pantoprazole reduces acid production and stabilizes bleeding in peptic ulcer disease.