Nokea
Your client has a doctor's order for the antihistamine medication diphenhydramine for sleep. What should you do?
- A. Question the order because Benadryl is an antihistamine and not a sleeping medication.
- B. Refuse to give the Benadryl because this medication is a stimulant.
- C. Question the order because Benadryl is contraindicated when the client has a sleep inducement disorder.
- D. Give the Benadryl because sleep inducement is an accepted off label use of this medication.
Correct Answer: D
Rationale: Diphenhydramine (Benadryl) is commonly used off-label for sleep due to its sedative effects, making it an appropriate choice if ordered for this purpose.
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The nurse is to administer a bolus starting dose of heparin to a child who is taking penicillin. What should the nurse do? Select all that apply.
- A. Check that the dose is appropriate for the child's weight.
- B. Note that the onset of the medication will be immediate.
- C. Follow the administration of the bolus of heparin with an I.V. infusion of heparin 10 units/kg/hour.
- D. Monitor partial thromboplastin time (PTT).
- E. Discontinue the penicillin until the PTT is at a therapeutic level.
Correct Answer: A,C,D
Rationale: Verifying the dose, administering a maintenance infusion, and monitoring PTT are standard for heparin therapy. Heparin's onset is immediate for I.V. but not a primary concern. Penicillin does not need discontinuation.
A nurse at the outpatient clinic receives a lithium level report of 1.0 mEq/L for a client who has been taking lithium for 2 months. The nurse should interpret this level to indicate which of the following?
- A. An error in reporting
- B. Too low to be therapeutic
- C. Too high, indicating toxicity
- D. Within the therapeutic range
Correct Answer: D
Rationale: A lithium level of 1.0 mEq/L is within the therapeutic range (0.6–1.2 mEq/L) for maintenance therapy. Levels below this are subtherapeutic, and higher levels indicate toxicity.
Which actions should the nurse implement to prevent ventilator-associated pneumonia (VAP) in the client who is intubated and on mechanical ventilation?
- A. Practice meticulous hand hygiene.
- B. Maintain the head of the bed elevation at 10 degrees.
- C. Perform suctioning of oral cavity secretions every 4 hours.
- D. Have the respiratory therapist change the ventilator circuit tubing every 4 hours.
Correct Answer: A
Rationale: Because normal upper airway defenses are bypassed, clients who are intubated with mechanical ventilation are at risk for VAP. Prevention includes effective hand washing before and after suctioning, when touching ventilator equipment, and when in contact with respiratory secretions. To prevent aspiration of colonized secretions from the oral cavity, the client will need more frequent oral cavity suctioning and at least 30 degrees head of the bed elevation. The more frequently the circuit is broken, the greater the risk for pathogen entry.
Which of the following assessment finding is expected in a client with bacterial pneumonia?
- A. Increased fremitus.
- B. Bilateral expiratory wheezing.
- C. Resonance on percussion.
- D. Vesicular breath sounds.
Correct Answer: A
Rationale: Increased fremitus is expected in bacterial pneumonia due to lung consolidation.
The nurse is evaluating the pin insertion site of a client's skeletal traction. Which of the following indicate a complication?
- A. Presence of crusts around the pin insertion site.
- B. Serous drainage on the dressing.
- C. Pin moves slightly at insertion site.
- D. Client does not feel pain at insertion site.
Correct Answer: C
Rationale: A moving pin indicates instability, a complication risking infection or poor healing. Crusts and serous drainage are normal, and lack of pain is not a complication.