a client being seen in the emergency department for complaints of chest pain confides in the nurse about regular use of cocaine as a recreational drug
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Nursing Elites

ATI LPN

LPN Pharmacology

1. A client being seen in the emergency department for complaints of chest pain confides in the nurse about regular use of cocaine as a recreational drug. The nurse takes which important action in delivering holistic nursing care to this client?

Correct answer: D

Rationale: In this scenario, the nurse should prioritize educating the client about the effects of cocaine on the heart and provide a referral for further help. This approach is crucial in addressing the root cause of the client's health issues and supporting them in making informed decisions about their health. Reporting the client to the police is not appropriate in this situation as the focus should be on the client's health and well-being. Simply explaining the damage without offering solutions may not effectively address the client's needs or promote holistic care. Telling the client to stop without providing support or education may not be as effective as teaching about the effects of cocaine and offering help for cessation. Therefore, educating about the effects and providing a referral for further assistance is the best course of action for holistic nursing care.

2. When preparing to administer a controlled substance, which of the following actions is required?

Correct answer: C

Rationale: When administering controlled substances, it is crucial to have a second nurse witness the disposal of the medication. This measure ensures proper handling, reduces the risk of diversion, and promotes compliance with regulations regarding controlled substances. Having a second nurse witness the disposal is a safeguard to maintain accountability and prevent any potential misuse or errors during the disposal process. Checking the client's identification bracelet and allergy status are important steps in medication administration but are not specifically required for controlled substances. Documenting the administration in the client's medical record is essential but does not specifically relate to the disposal of controlled substances.

3. A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. What should the nurse check the client for next?

Correct answer: A

Rationale: In this case, the nurse should check the client's smoking history next. Smoking is a significant risk factor for peripheral vascular disease, leading to the development of thrombophlebitis and claudication. It is important to assess this risk factor as it can significantly impact the client's vascular health and the progression of their current symptoms. Choices B, C, and D are incorrect because they are not directly related to the symptoms described by the client. Recent exposure to allergens or insect bites would typically present with different symptoms, and familial tendency toward peripheral vascular disease is not the immediate concern in this case.

4. A client with schizophrenia taking clozapine is being assessed by a nurse. Which of the following findings is the priority for the nurse to report to the provider?

Correct answer: B

Rationale: The priority finding for the nurse to report to the provider is B: Fever. Fever can be an indication of agranulocytosis, a potentially life-threatening condition associated with clozapine. Agranulocytosis is characterized by a significant decrease in white blood cells, making the client susceptible to severe infections. Prompt reporting of fever is crucial to prevent serious complications. Elevated blood pressure (Choice A), weight gain (Choice C), and dry mouth (Choice D) are important to monitor but are not as immediately concerning as fever, which could indicate a severe adverse reaction requiring urgent medical attention.

5. The healthcare provider is reinforcing instructions to a client with heart failure who is prescribed a low-sodium diet. The provider should advise the client to choose which food item?

Correct answer: B

Rationale: Fresh vegetables are a suitable choice for clients on a low-sodium diet as they are naturally low in sodium and provide essential nutrients. In contrast, canned soup, processed cheese, and pickled vegetables tend to be high in sodium, which is not recommended for individuals with heart failure and on a low-sodium diet. Fresh vegetables are also rich in fiber, vitamins, and minerals, making them a healthier option compared to the other choices provided.

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