1. A nurse is caring for four clients. After administering morning medications, she realizes that the nifedipine prescribed for one client was
... [Show More] inadvertently administered to another client. Which of the following actions should the nurse take first?
A. Notify the client's provider.
Rationale: The nurse should notify the client's provider to inform her of the event; however, there is another action the nurse should take first.
B. Check the client's vital signs.
Rationale: The first action the nurse should take using the nursing process is to assess the client. The nurse should know that the action of nifedipine is to lower blood pressure. Immediately upon realizing the error, the nurse should check the client's vital signs (especially the client's blood pressure) to ensure that the client is not hypotensive as a result. Only after ensuring that the client is safe and has stable vital signs should the nurse take other actions.
C. Fill out an occurrence form.
Rationale: The nurse should fill out an occurrence form to report the event to hospital personnel; however, there is another action the nurse should take first.
D. Administer the medication to the correct client.
Rationale: The nurse should administer the medication to the correct client to fulfill the provider's prescription; however, there is another action the nurse should take first.
2. A nurse is reviewing a client's admission record. The nurse notes that there are prescriptions for several medications. Which of the following factors should the nurse recognize is of primary consideration when determining the schedule of administration?
A. Institutional policies regarding routine medication administration times
Rationale: The nurse should consider institutional policies regarding routine medication administration times; however, evidence-based practice indicates that the nurse should base medication administration times on another consideration.
B. Specific characteristics of the medications
Rationale: Evidence-based practice indicates that the specific characteristics of the medications be the primary consideration of scheduling administration times. The characteristics of each medication, including the indication, onset, durations of action, and potential adverse effects and interactions, primarily determine the schedule of administration. Although an institutional policy may require that all once daily medications be administered at 0800, the nurse should be aware that some classifications of medications should only be given at bedtime, or should only be given with food. Likewise, the client's preferences, as well as the availability of each medication from the pharmacy, play important but smaller roles in determining the schedule of administration.
C. Schedule of administration that the client follows at home
Rationale: The nurse should consider the schedule of administration that the client follows at home;
however, evidence-based practice indicates that the nurse should base medication administration times on another consideration.
D. Time at which the medication can be available from the pharmacy
Rationale: The nurse should consider the time at which the medication can be available from the pharmacy; however, evidence-based practice indicates that the nurse should base medication administration times on another consideration.
3. A clinic nurse is giving instructions to a mother on the proper technique of applying ophthalmic ointment to her preschool-age child who has conjunctivitis. Which of the following should the nurse include in the instructions?
A. "Warm the ointment by placing the tube in glass of hot tap water."
Rationale: Eye drops that are stored in the refrigerator should come to room temperature before instillation.
The parent should not warm the ointment by placing it in glass of hot water.
B. "Cleanse the eye with a wet cotton ball in a direction towards the inner canthus before applying the ointment."
Rationale: The parent should clean the eye in a direction from the inside canthus outward in order to prevent contamination of the lacrimal duct or the other eye.
C. "Discard the first bead of ointment before each application."
Rationale: The parent should discard the first bead of ointment from the tube because it is considered contaminated.
D. "Instruct your child to squeeze his eyes shut following application."
Rationale: Closing the eyes spreads the medication over the eyeball, but squeezing the eyelid shut can force out some of the medication.
4. A home health nurse is assessing an older adult client who reports falling a couple of times over the past week. Which of the following findings should the nurse suspect is contributing to the client's falls?
A. The client takes alprazolam.
Rationale: Alprazolam is a CNS depressant that can cause dizziness and orthostatic hypotension, which can cause the client to lose his balance and fall.
B. The client has a nonslip bath mat in his shower.
Rationale: A nonslip bath mat should reduce the risk for the client to fall.
C. The client uses a raised toilet seat.
Rationale: A raised toilet seat should reduce the risk for the client to fall.
D. The client wears fitted slippers.
Rationale: Fitted and nonslip slippers should reduce the risk for the client to fall.
5. A nurse is teaching a client who takes warfarin daily. Which of the following statements by the client indicates a need for further teaching?
A. "I have started taking ginger root to treat my joint stiffness."
Rationale: Ginger root can interfere with the blood clotting effect of warfarin and place the client at risk for bleeding. This statement indicates the client needs further teaching.
B. "I take this medication at the same time each day."
Rationale: The client should take warfarin at the same time each day to maintain a stable blood level.
C. "I eat a green salad every night with dinner."
Rationale: Green leafy vegetables are a good source of vitamin K, which can interfere with the clotting effects of warfarin. Clients who are taking warfarin do not need to restrict dietary vitamin K intake but rather should maintain a consistent intake of vitamin K in order to control the therapeutic effect of the medication.
D. "I had my INR checked three weeks ago."
Rationale: Clients who have been taking warfarin for more than 3 months should have their INR level checked every 2 to 4 weeks.
6. A nurse is assessing a client prior to administering a seasonal influenza vaccine. The client says he read about an influenza vaccine that is given as a nasal spray and wants to receive it. The nurse should recognize that which of the following findings is a contraindication for the client receiving the live attenuated influenza vaccine (LAIV)?
A. The client's age is 62.
Rationale: Clients must be between the ages of 2 and 49 to receive the LIAV; therefore, it is contraindicated for this client. Pregnancy and immunocompromised status are also contraindications.
B. The client smokes one pack of cigarettes a day
Rationale: Cigarette smoking is not a contraindication for receiving the LIAV.
C. The client has a history of myocardial infarction.
Rationale: A history of myocardial infarction is not a contraindication for receiving the LIAV.
D. The client has recently traveled to Europe.
Rationale: Recent travel to Europe is not a contraindication for receiving the LIAV.
7. A nurse is teaching a client about the adverse effects of cisplatin. Which of the following adverse effects should the nurse include in the teaching?
A. Tinnitus
Rationale: Tinnitus and hearing loss are adverse effects of cisplatin.
B. Constipation
Rationale: Diarrhea is an adverse effect of cisplatin.
C. Hyperkalemia
Rationale: Hypokalemia is an adverse effect of cisplatin.
D. Weight gain
Rationale: Weight gain is an adverse effect of docetaxel due to fluid retention.
8. A nurse is caring for a client who is experiencing severe nausea and vomiting after a course of chemotherapy. The nurse should monitor the client for which of the following clinical manifestations?
A. Metabolic acidosis
Rationale: Hypermetabolism, such as with fever or exercise, can cause metabolic acidosis.
B. Metabolic alkalosis
Rationale: Metabolic alkalosis can occur in clients who have excessive vomiting because of the loss of hydrochloric acid.
C. Respiratory acidosis
Rationale: Respiratory depression can cause respiratory acidosis.
D. Respiratory alkalosis
Rationale: Hyperventilation can cause respiratory alkalosis.
9. A nurse is assessing a client prior to the administration of morphine. The nurse should recognize that which of the following assessments is the priority?
A. Pupil reaction
Rationale: The nurse should assess the client's pupils because morphine can cause miosis; however, another assessment is the priority.
B. Urine output
Rationale: The nurse should assess the client's urine output because morphine can cause urinary retention; however, another assessment is the priority.
C. Bowel sounds
Rationale:
The nurse should assess the client's bowel sounds because morphine can cause constipation; however, another assessment is the priority.
D. Respiratory rate
Rationale: When using the airway, breathing, circulation approach to client care, the nurse should determine the priority assessment is respiratory rate. Morphine can cause respiratory depression. The nurse should withhold the medication and notify the prescriber if the client has a respiratory rate less than 12/min.
10. A nurse is completing a medical interview with a client who has elevated cholesterol levels and takes warfarin. The nurse should recognize that which of the following actions by the client can potentiate the effects of warfarin?
A. The client follows a low-fat diet to reduce cholesterol.
Rationale: A low-fat diet should not potentiate the action of warfarin.
B. The client drinks a glass of grapefruit juice every day.
Rationale: Grapefruit juice can interfere with the metabolism of statins.
C. The client sprinkles flax seeds on food 1 hr before taking the anticoagulant.
Rationale: Flax seed can affect the absorption of medications and should be taken 1 hr before or 2 hr after medications.
D. The client uses garlic to lower cholesterol levels.
Rationale: The nurse should recognize that garlic can potentiate the action of the warfarin.
11. A nurse is providing dietary teaching for a client who takes furosemide. The nurse should recommend which of the following foods as the best source of potassium?
A. Bananas
Rationale: The nurse should determine that bananas are the best food source to recommend because 1 cup of bananas contains 806 mg of potassium. In addition to the potassium supplements the provider might prescribe, the client should increase his daily intake of foods that have high potassium content, such as bananas, orange juice, and spinach.
B. Cooked carrots
Rationale: The nurse should recommend a different food because there is another choice that contains more potassium
C. Cheddar cheese
Rationale: The nurse should recommend a different food because there is another choice that contains more potassium
D. 2% milk
Rationale:
The nurse should recommend a different food because there is another choice that contains more potassium.
12. A nurse is teaching a client who has a new prescription for regular insulin and NPH insulin. Which of the following instructions should the nurse include in the teaching?
A. Keep the open vial of insulin at room temperature.
Rationale: The client should keep the vial in use at room temperature to minimize tissue injury and to reduce the risk for lipodystrophy.
B. Inject the insulin into a large muscle.
Rationale: The client should inject the medication into subcutaneous tissue.
C. Aspirate the medication prior to administration.
Rationale: It is not necessary for the nurse to aspirate the medication.
D. Administer the insulin in two separate injections.
Rationale: The client should mix compatible solutions, such as regular insulin and NPH insulin, to reduce the need for an additional injection and reduce the risk for lipodystrophy.
13.A A nurse is teaching a client who has iron deficiency anemia about ferrous sulfate. Which of the following instructions should the nurse include in the teaching?
A. Take the ferrous sulfate at bedtime.
Rationale: The client should take the medication at least 1 hr before bedtime to reduce the risk of stomach irritation.
B. Take the ferrous sulfate with an antacid.
Rationale: Antacids interfere with the absorption of ferrous sulfate.
C. Take the ferrous sulfate between meals.
Rationale: The client should take the medication between meals for optimal absorption.
D. Take the ferrous sulfate with yogurt.
Rationale: Dairy products interfere with the absorption of carbonyl iron; therefore, the client should not take the medication with yogurt.
14. A nurse is caring for a child who is experiencing status asthmaticus. Which of the following interventions is the priority for the nurse to take?
A. Administer a short-acting ß2 –agonist (SABA).
Rationale: When using the urgent versus non-urgent approach to client care, the nurse should determine that the priority action is to administer a nebulized high-dose SABA to relieve bronchoconstriction and improve ventilation.
B. Obtain a peak flow reading.
Rationale: Obtaining a peak flow reading is non-urgent while the client is in distress. Although a peak flow reading will assist with determining the severity of the bronchospasms and assist with management of medications to prevent further exacerbations, there is another action that is the priority.
C. Administer an inhaled glucocorticoid.
Rationale: Administering an inhaled glucocorticoid is non-urgent while the client is in distress. Although an inhaled glucocorticoid should be used for long-term therapy to prevent future exacerbations, there is another action that is the priority. The nurse should administer a systemic glucocorticoid for immediate relief of airway inflammation.
D. Determine the cause of the acute exacerbation.
Rationale: Determining the cause of the acute exacerbation is non-urgent while the client is in distress. Although the nurse should determine the trigger for the asthma exacerbation to prevent future attacks, there is another action that is the priority.
15.A A nurse is preparing to administer a unit of packed red blood cells to a client. Which of the following actions should the nurse plan to take?
A. Check the unit of blood with an assistant personal (AP).
Rationale: Two RNs or an RN and a practical nurse (PN) (in certain institutions) can check a unit of blood before it is transfused. This action is outside the scope of practice for an AP.
B. Premedicate the client with an antiemetic.
Rationale: The client might require premedication with an antipyretic, but not an antiemetic.
C. Plan to infuse the unit of blood over 6 hr.
Rationale: The unit of blood should infuse within 4 hr to reduce the risk for bacteria growth.
D. Remain with the client for the first 15 minutes of the transfusion.
Rationale: The nurse should remain with the client for [Show Less]