Nursing Elites

1. At 1200, the practical nurse learns that a client's 0900 dose of an anticonvulsant was not given. The next scheduled dose is at 2100. Which action should the PN take?

• A. Administer half of the missed dose immediately
• B. Administer the missed dose as soon as possible
• C. Give the missed dose with the next scheduled dose
• D. Withhold the missed dose unless seizure activity occurs

Correct answer: B

Rationale: Administering the missed dose as soon as possible is crucial in this situation. Missing an anticonvulsant dose can lead to breakthrough seizures, which are harmful to the client. Administering the missed dose promptly helps maintain the therapeutic level of the medication and reduces the risk of seizure activity. Giving half the dose may not provide adequate protection against seizures. Delaying the dose until the next scheduled time increases the time the client is without the medication, potentially increasing the risk of seizures. Withholding the missed dose unless seizure activity occurs is not recommended, as prevention is key in managing anticonvulsant therapy.

2. Which type of isolation is required for a patient with measles?

• A. Contact isolation
• B. Airborne isolation
• C. Droplet isolation
• D. Reverse isolation

Correct answer: B

Rationale: The correct answer is B: Airborne isolation. Measles is highly contagious and can be transmitted through airborne particles, so airborne isolation is necessary to prevent its spread. Choice A, Contact isolation, is incorrect because measles is not primarily transmitted through direct contact. Choice C, Droplet isolation, is also incorrect as measles is not transmitted through large droplets but through smaller airborne particles. Choice D, Reverse isolation, is used to protect a patient from outside infections, not to prevent the spread of a contagious disease like measles.

3. In what order should the PN implement these steps to provide wound care? (Place in correct order.)

• A. Don procedure gloves
• B. Remove the dressing
• C. Apply prescribed medications to the wound
• D. All of the Above

Correct answer: D

Rationale: The correct answer is 'D - All of the Above.' The PN should first don procedure gloves to maintain aseptic technique, then remove the dressing to assess the wound, and finally apply prescribed medications to the wound. This sequence ensures that non-sterile tasks like donning gloves are done before sterile tasks like applying medications, reducing the risk of wound contamination. Choices A, B, and C are all essential steps in providing effective wound care.

4. Which electrolyte imbalance is most commonly associated with seizures?

• A. Hyponatremia
• B. Hypercalcemia
• C. Hyperkalemia
• D. Hypokalemia

Correct answer: A

Rationale: The correct answer is A: Hyponatremia. Hyponatremia, characterized by low sodium levels in the blood, can lead to cerebral edema and seizures due to water shifting into brain cells. Hypercalcemia (choice B) does not commonly cause seizures but can result in muscle weakness and cardiac arrhythmias. Hyperkalemia (choice C) may lead to muscle weakness and cardiac arrhythmias, but it is less frequently associated with seizures. Hypokalemia (choice D) is linked to muscle weakness and cardiac arrhythmias but is not typically related to seizures.

5. The nurse observes a UAP performing oral hygiene on an unconscious client who is lying in a flat side-lying position with an emesis basin on a towel under the chin. Which action should the nurse take?

• A. Stop the procedure and tell the UAP to place the client in a Fowler's position
• B. Praise the UAP for doing the oral hygiene but encourage family participation
• C. Tell the UAP to continue because the unconscious client is positioned safely
• D. Enroll the UAP in a hospital education class on conducting safe client care

Correct answer: C

Rationale: The correct answer is to tell the UAP to continue because the unconscious client is positioned safely for oral care. Placing an unconscious client in a side-lying position helps prevent aspiration, and having an emesis basin under the chin is appropriate to catch any fluids. Therefore, the nurse should acknowledge that the UAP is performing the procedure correctly. Choices A, B, and D are incorrect. Placing the client in a Fowler's position is not necessary for this procedure as the client is already positioned safely. Praise and encouragement for family participation are important aspects but not the immediate action needed in this scenario. Enrolling the UAP in a hospital education class is not warranted as the current procedure is being performed correctly.

Similar Questions