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NUR280 Questions and Answers (100% Correct
Answers) Already Graded A+
The nurse is reviewing medical prescriptions for newly admitted clients. It
would be a priority for the nurse to follow up with the physician if a client
with
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(a) a potassium level of 4.5mEq/L has Kayexalate (sodium polystyrene)
prescribed
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(b) a Dilantin (phenytoin) level of 8 mcg/ml is placed on seizure
precautions
(c) sensitivity to Aspirin (acetylsalicylic acid) is prescribed Tylenol
(acetaminophen)
(d) sensitivity to Penicillin is prescribed Zithromax (azithromycin) Ans: 1. A.
The normal potassium level is 3.5 - 5.0 mEq/L. Giving Kayexalate in this
situation may cause the client to lose potassium, causing hypokalemia,
therefore the drug is not indicated; the therapeutic level for Dilantin is 10
- 20 mcg/ml, a level of 8 is sub therapeutic thereby increasing the risk of
seizure activity. Acetaminophen can be safely prescribed to clients with
ASA sensitivity. Azithromycin (Zithromax) can be safely prescribed for
clients with sensitivity to Penicillin.
The nurse should intervene if the nurse notes a staff member
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(a) obtaining a clients consent prior to their operative procedure after
receiving
Ativan (lorazepam)
(b) placing a client on the affected side following surgical repair of a
retinal
detachment
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(c) handling a wet cast with the palms of the hands
(d) using a broad base of support while transferring a client Ans: 2. A.
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Informed consent, explanation and decision making must occur before
sedation is given; therapeutic interventions for retinal detachment
include bedrest with the area of detachment in a dependent position to
promote healing; the cast should be handled with the palms of the
hands while wet to prevent denting; a broad base of support is used
during transfers to prevent muscle injury.
The community health nurse is caring for the following clients. It would be
a
priority for the nurse to initiate a multidisciplinary conference for the
client who
is
(a) 12 years old with Autism who is starting a new school and recently
had a
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URI (upper respiratory tract infection)
(b) 16 years old, has type 1 Diabetes Mellitus, is unemployed and had a
recent
Hemoglobin A1c of 13%
(c) 52 years old, with Myasthenia Gravis, recently prescribed Mestinon
(pyridostigmine) and employed as a mail carrier
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(d) 70 years old, has schizophrenia, lives alone and reports hearing
non threatening voices. Ans: 3. B. An adolescent with uncontrolled
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Diabetes Mellitus would require the greatest number of disciplines
(multidisciplinary) to manage their care i.e. Medicine, Nursing, Social
Work, Nutritionist; the other choices do not require as many providers of
care to meet their needs.
The nurse from the postpartum unit has been temporarily assigned to the
medical surgical unit. It would be most appropriate to assign this nurse to
the
client who
(a) has returned from right total hip replacement surgery four hours ago
(b) is being observed for increased intracranial pressure
(c) had surgery two hours ago to remove the appendix
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(d) is two weeks post partum being maintained on a mechanical
ventilator for respiratory failure Ans: 4. C. The management of a client
following abdominal surgery is standard. The postpartum nurse routinely
cares for mothers following caesarean section; therefore it is appropriate
to assign this client; The other choices are not appropriate to assign to
this nurse.
The nurse in a well baby clinic has assessed several children today. It
would
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be a priority for the nurse to suggest follow up for the child who is
(a) 2 months old with a positive babinski reflex
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(b) 5 months old and does not hold their own bottle
(c) 10 months old who cries around strangers
(d) 18 months old who needs support while ambulating Ans: 5. D. A child
experiencing normal growth and development should be ambulating
independently by 12 months; the Babinski reflex disappears after 2 years
of age; an infant typically holds their own bottle by 6 months; stranger
anxiety usually develops at approximately 7 months
The nurse is caring for a mechanically ventilated client who was
declared brain
dead. An Advance Directive is not documented on the medical record.
It