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- A nurse is caring for four clients. After administering morning medications, she realizes that the nifedipine prescribed for one client was 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.
- 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;
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.
- 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.
- 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.
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.
- 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.
- 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:
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.
- 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.
- 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.
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.
- 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 the first 15 to 30 minutes of the transfusion to monitor for a transfusion reaction, which occurs often during the first 50 mL of the transfusion.
- A nurse is providing discharge teaching for a client who has a new prescription for warfarin. Which of the following instructions should the nurse include in the teaching?
A. Mild nosebleeds are common during initial treatment.
Rationale:
Rationale: The nurse should remain with the client for 15 to 30 min after the start of the transfusion to monitor for a reaction, which usually occurs during the first 50 mL of the transfusion.
B. Infuse the transfusion at a rate of 200 mL/hr.
Rationale: The transfusion should infuse in 2 to 4 hr to prevent fluid overload.
C. Check the client's vital signs every hour during the transfusion.
Rationale: The nurse should check the client's vital signs every 15 min at the start of the transfusion, then every 1 hr to monitor for a transfusion reaction.
D. Flush the blood tubing with dextrose 5% in water.
Rationale: The nurse should flush the blood tubing with 0.9% sodium chloride to prevent hemolysis of the blood.
- A nurse is assessing a client who is receiving a unit of packed red blood cells. Which of the following findings is a manifestation of acute hemolytic reaction?
A. Client report of low back pain
Rationale: Manifestations of an acute hemolytic reaction include apprehension, tachypnea, hypotension, chest pain, and lower back pain.
B. Client report of tinnitus
Rationale: Tinnitus is a manifestation of ototoxicity and is an adverse effect of aminoglycoside antibiotics.
C. A productive cough
Rationale: A cough is a manifestation of circulatory overload.
D. Distended neck veins
Rationale: Distended neck veins are a manifestation of circulatory overload.
- A nurse is educating a group of clients about the contraindications of warfarin therapy. Which of the following statements should the nurse include in the teaching?
A. "Clients who have glaucoma should not take warfarin."
Rationale: Liver disease is a contraindication for warfarin therapy.
B. "Clients who have rheumatoid arthritis should not take warfarin."
Rationale: Thrombocytopenia is a contraindication for warfarin therapy.
C. "Clients who are pregnant should not take warfarin."
Peptic ulcer disease is a contraindication for warfarin therapy
- A nurse is caring for a client who is receiving a transfusion of packed red blood cells and suspects that the client is experiencing a hemolytic reaction. Which of the following interventions is the priority?
A. Collect a urine specimen.
Rationale: The client is at risk for hemoglobinuria and acute kidney injury due to hemolysis; however, another action is the priority.
B. Administer 0.9% sodium chloride through the IV line.
Rationale: The client is at risk for hypotension and shock due to hemolysis, so it is important to keep an IV open to administer fluids and medications; however, another action is the priority.
C. Stop the transfusion.
Rationale: The greatest risk to the client is injury due to further hemolysis; therefore, the priority action is to stop the transfusion. When suspecting a hemolytic reaction, the priority action by the nurse is to immediately stop the transfusion to prevent further hemolysis.
D. Notify the blood bank.
Rationale: The client is at risk for hypotension and shock due to hemolysis, and the nurse must notify the blood bank to determine the cause of the hemolytic reaction; however, another action is the priority.
- A nurse is preparing to administer phenytoin IV to a client who has a seizure disorder. Which of the following actions should the nurse plan to take?
A. Administer the medication at 100 mg/min.
Rationale: The nurse should administer phenytoin IV slowly, not faster than 50 mg/min, to reduce the risk of hypotension.
B. Administer a saline solution after injection.
Rationale: The nurse should flush the injection site with a saline solution after the injection of phenytoin to reduce and prevent venous irritation.
C. Hold the injection if seizure activity is present.
Rationale: The nurse should administer phenytoin to prevent and to abort seizure activity.
D. Dilute the medication with dextrose 5% in water.
Rationale: The nurse should dilute phenytoin in 0.9% sodium chloride solution to prevent precipitation of the medication.
