Nokea
As a general guide for emergency management of acute alcohol intoxication, it is important for the nurse initially to obtain data regarding which of the following?
- A. What and how much the client drinks, according to family and friends
- B. The blood alcohol level of the client
- C. The blood pressure level of the client
- D. The blood glucose level of the client
Correct Answer: B
Rationale: Blood alcohol levels are generally obtained to determine the level of intoxication. The amount of alcohol consumed determines how much medication the client needs for detoxification and treatment. Reports of alcohol consumption are notoriously inaccurate.
You may also like to solve these questions
The clinic nurse reinforces teaching to a client with systemic lupus erythematosus. Which instructions will the nurse include? Select all that apply.
- A. Avoid annual influenza vaccination
- B. Avoid situations that cause physical and emotional stress
- C. Avoid sun exposure and ultraviolet light when possible
- D. Notify the health care provider if you have fever
- E. Use antibiotic soap to cleanse skin rashes
Correct Answer: B,C,D
Rationale: Stress, sun exposure, and infections can exacerbate lupus. Influenza vaccination is recommended, and antibiotic soap is unnecessary.
The nurse is preparing to flush a client's central venous catheter. Which size syringe is best for the nurse to choose?
- A. 1 mL
- B. 3 mL
- C. 10 mL
- D. 30 mL
Correct Answer: C
Rationale: A 10 mL syringe is recommended to avoid excessive pressure that could damage the catheter.
The nurse is discussing prostatectomies with a group of men. One man asks which kind of prostatectomy is done for someone who has benign prostatic hyperplasia (BPH). What answer should the nurse give?
- A. Transurethral resection prostatectomy
- B. Suprapubic prostatectomy
- C. Retropubic prostatectomy
- D. Perineal prostatectomy
Correct Answer: A
Rationale: Transurethral resection prostatectomy (TURP) is the most common procedure for BPH, removing prostate tissue via the urethra, minimally invasive compared to open approaches.
The nurse is caring for a 2 month-old infant with a congenital heart defect. Which of the following is a priority nursing action?
- A. Provide small feedings every 3 hours
- B. Maintain intravenous fluids
- C. Add strained cereal to the diet
- D. Change to reduced calorie formula
Correct Answer: A
Rationale: Infants with congenital heart defects are at increased risk for developing congestive heart failure. Infants with congestive heart failure have an increased metabolic rate and require additional calories to grow. At the same time, however, rest and conservation of energy for eating is important. Feedings should be smaller and every 3 hours rather than the usual 4 hour schedule.
Following a stroke, an elderly client develops ptosis. When assessing the client, the nurse will note:
- A. Drooping of the eyelid on the affected side
- B. Inverted eyelid margins
- C. Eversion of eyelid margins
- D. Granulomatous inflammation of the eyelids
Correct Answer: A
Rationale: Ptosis or drooping of the eyelid can occur as the result of a stroke or Bell's palsy. Answer B refers to entropion, and answer C refers to ectropion, so they are incorrect. Answer D refers to chalazion, so it's incorrect. Answers B, C, and D are incorrect because they do not relate to ptosis.