Question

A nurse is caring for a client who ingested a poison and is now experiencing a seizure. Which of the following is the priority action the nurse should take?

Answer 1

Correct Answers:

Check the patency of the client's airway

Rationale :

✔️ The priority in any emergency or acute scenario is to apply the ABC framework—Airway, Breathing, and Circulation—to identify and manage life-threatening conditions promptly. ✔️ A client experiencing a seizure is at high risk for airway obstruction due to potential tongue displacement, clenched jaw, or accumulation of secretions. ✔️ Immediate assessment of airway patency ensures oxygenation and prevents complications like respiratory arrest. ✔️ Once the airway is secured, the nurse can then proceed with positioning the client on their side to promote drainage and reduce aspiration risk.

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Answer 2

Correct Answers:

Renal stones

Rationale :

✓ Calcium supplements, especially in high doses or taken without adequate fluids, can lead to hypercalciuria, which increases the risk of renal stone (nephrolithiasis) formation. ✓ Calcium can crystallize in the kidneys and urinary tract, leading to obstruction, pain, and potential infection. ✓ Flank pain is a classic symptom of renal stones and should prompt immediate evaluation. ✓ This adverse effect is more likely in individuals with a history of kidney stones or inadequate hydration.

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Answer 3

Correct Answers:

Continue with the discussion

Rationale :

✓ Gazing at the floor may be a cultural sign of respect or attentiveness among Asian-American clients, rather than avoidance or inattention. ✓ Eye contact norms vary widely across cultures. ✓ A culturally sensitive nurse continues teaching while recognizing and respecting these differences without misinterpreting the behavior. ✓ Stopping the discussion or insisting on eye contact can appear intrusive or disrespectful.

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Answer 4

Correct Answers:

Reaches over the bed to straighten the fitted sheet

Rationale :

✔️ Reaching over the bed while changing linens is a violation of proper body mechanics. ✔️ This posture increases the risk of back strain or musculoskeletal injury, especially when caring for immobile clients. ✔️ Safe practice involves walking around the bed or repositioning oneself to maintain proper alignment. ✔️ The nurse should intervene and correct the action to protect the assistive personnel and ensure safe care.

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Answer 5

Correct Answers:

A reddened area over the sacrum

Rationale :

✓ Immobility places clients at high risk for pressure injuries, especially over bony prominences like the sacrum. ✓ A reddened area indicates stage 1 pressure ulcer, the earliest and most reversible sign of skin breakdown. ✓ Early detection is critical to prevent further tissue damage, infection, and complications. ✓ Clients who are immobile must have frequent repositioning, skin assessments, and pressure-relieving devices as part of their care plan.

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Answer 6

Correct Answers:

Bleeding gums

Rationale :

✅Gingko biloba is an herbal supplement commonly used to enhance memory but is known to inhibit platelet aggregation, increasing the risk of bleeding, especially in combination with anticoagulants or NSAIDs. ✅ Bleeding gums can be an early warning sign of this effect. ✅ Clients should be taught to report signs of unusual bleeding and may require discontinuation of the supplement before surgery or if on other anticoagulants

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Answer 7

Correct Answers:

Bradycardia

Rationale :

✓ Atenolol is a beta-1 selective adrenergic blocker that slows the heart rate and reduces cardiac output, making bradycardia a common and clinically significant adverse effect. ✓ It is used for hypertension, angina, and some arrhythmias. ✓ Nurses should assess apical pulse before administration and hold the dose if the heart rate is below 60 bpm. ✓ Clients should be taught to monitor for fatigue, dizziness, or lightheadedness, which may signal excessive bradycardia.

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Answer 8

Correct Answers:

Transcribe the order into the client's health record.
Repeat the order back to the provider
Question any part of the order that is unclear or inappropriate.
Obtain the provider's signature within 8 hr.

Rationale :

✔️ Transcribe the order into the client's health record After receiving a telephone order, it is essential to accurately document the order in the client’s medical record. This ensures that the prescription becomes part of the permanent legal and clinical record, and all members of the healthcare team can access it. Omission of transcription increases the risk of medication errors, delays, or improper care. ✔️ Repeat the order back to the provider This is a critical safety measure and a Joint Commission standard to prevent transcription errors. Repeating the order back ensures that the nurse and the provider are in agreement on the correct drug, dose, route, frequency, and any special instructions. This step is especially important over the phone, where verbal miscommunication can easily occur. ✔️ Question any part of the order that is unclear or inappropriate The nurse has a professional and legal responsibility to clarify any order that seems ambiguous, incomplete, or potentially harmful. Administering a questionable medication without clarification places the client at risk and exposes the nurse to liability. This step is aligned with safe medication practices and critical thinking in nursing. ✔️ Obtain the provider’s signature within 8 hr Telephone orders must be verified and signed by the prescribing provider within a specified time frame, often 8 to 24 hours, depending on facility policy and state law. This formalizes the order and ensures accountability. Without a signature, the order remains unofficial and noncompliant with legal standards.

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Answer 9

Correct Answers:

20

Rationale :

✓ Using ratio and proportion: Order: 12,000,000 units Available: 600,000 units/mL Formula: 12,000,000 ÷ 600,000 = 20 mL ✓ This is a large volume and should be administered with caution, using the proper technique for IM injections and selecting appropriate site (e.g., ventrogluteal).

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Answer 10

Correct Answers:

Erythrocyte sedimentation rate (ESR)

Rationale :

✓ Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) used in rheumatoid arthritis to reduce inflammation, pain, and swelling. ✓ The ESR is a laboratory marker that reflects the degree of inflammation in the body and is commonly elevated in RA. ✓ Monitoring ESR helps assess the therapeutic effectiveness of anti-inflammatory treatment. ✓ ANA and RF are diagnostic markers but do not monitor treatment response.

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QLexNursing

1 : A nurse is caring for a client who ingested a poison and is now experiencing a seizure. Which of the following is the priority action the nurse should take?

2 : A nurse is caring for a client who has osteoporosis and takes a daily calcium supplement. Which of the following adverse effects of calcium should the nurse suspect when the client reports having flank pain?

3 : A nurse is providing dietary teaching for a client who is Asian- American and is gazing at the floor during the instructions. Which of the following actions should the nurse take to demonstrate culturally sensitive nursing care?

4 : A nurse is observing an assistive personnel (AP) changing the linens on the bed of a client who is immobile. Which of the following actions by the AP should the nurse identify as an indication of the need to intervene?

5 : A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility?

6 : A nurse is teaching a client who reports taking gingko biloba to improve his memory. Which of the following adverse effects should the nurse include?

7 : A nurse is teaching a client who has hypertension and a new prescription for atenolol. Which of the following findings should the nurse include as adverse effects of this medication?

8 : A nurse is receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (Select all that apply.)

10 : A nurse is caring for an older adult client who has rheumatoid arthritis (RA) and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication?