NUR280 Questions and Answers with Complete Solutions

NUR280 Questions and Answers with Complete Solutions The nurse is examining medical orders for newly admitted patients. It is crucial for the nurse to consult with the physician if a patient: (a) has a potassium level of 4.5 mEq/L and is prescribed Kayexalate (sodium polystyrene) (b) has a Dilantin (phenytoin) level of 8 mcg/ml and is placed on seizure precautions (c) has sensitivity to Aspirin (acetylsalicylic acid) and is prescribed Tylenol (acetaminophen) (d) has sensitivity to Penicillin and is prescribed Zithromax (azithromycin) 1. A. The normal potassium range is 3.5 - 5.0 mEq/L. Administering Kayexalate in this situation may cause potassium loss, leading to hypokalemia, so the drug is not recommended. The therapeutic range for Dilantin is 10 - 20 mcg/ml; a level of 8 is subtherapeutic and increases seizure risk. Acetaminophen can be safely given to patients with ASA sensitivity. Azithromycin (Zithromax) is safe for patients with Penicillin sensitivity. The nurse should intervene if they observe a staff member: (a) obtaining a patient's consent for a procedure after administering Ativan (lorazepam) (b) positioning a patient on the affected side following surgical repair of a retinal detachment (c) handling a wet cast with bare hands (d) using a broad base of support while transferring a patient 2. A. Informed consent and decision-making should precede sedation administration. For retinal detachment, therapeutic measures include bedrest with the detachment area dependent to aid healing. Wet casts should be handled with palms to prevent damage. Transfers require a broad base of support to prevent muscle injury. In community health nursing, it is essential to convene a multidisciplinary conference for the patient who: (a) is 12 years old, has Autism, is starting a new school, and recently had a URI (b) is 16 years old, has type 1 Diabetes Mellitus, is unemployed, and has a recent Hemoglobin A1c of 13% (c) is 52 years old, has Myasthenia Gravis, recently started Mestinon (pyridostigmine), and works as a mail carrier (d) is 70 years old, has schizophrenia, lives alone, and hears non-threatening voices 3. B. An adolescent with uncontrolled Diabetes Mellitus requires multidisciplinary care involving Medicine, Nursing, Social Work, and Nutrition. The other patients' needs can be met with fewer disciplines. A nurse from the postpartum unit temporarily assigned to the medical surgical unit should be assigned to: (a) a patient who returned four hours ago from right total hip replacement surgery (b) a patient being monitored for increased intracranial pressure (c) a patient who underwent appendix removal surgery two hours ago (d) a patient who is two weeks postpartum and on mechanical ventilator for respiratory failure 4. C. Postpartum nurses typically care for mothers post-caesarean section. Assigning a postpartum nurse to a patient following abdominal surgery is appropriate. The other patients' conditions do not match the postpartum nurse's expertise. In a well-baby clinic, it is a priority for the nurse to recommend follow-up for the child who: (a) is 2 months old with a positive Babinski reflex (b) is 5 months old and unable to hold their own bottle (c) is 10 months old and displays stranger anxiety (d) is 18 months old and requires support while ambulating 5. D. A child should typically ambulate independently by 12 months. The Babinski reflex should disappear by age 2, infants usually hold their own bottle by 6 months, and stranger anxiety typically appears around 7 months. When caring for a mechanically ventilated client declared brain dead without an Advance Directive, it is appropriate to obtain organ donation consent from the: (a) client's primary care provider (b) client's nurse manager