Nokea
The nurse is caring for a group of clients on a medical surgical unit. Which client is most at risk for contracting a nosocomial infection?
- A. 51-year-old client who received a permanent pacemaker 48 hours ago
- B. 60-year-old client who had a myocardial infarction 24 hours ago
- C. 74-year-old client with stroke and an indwelling urinary catheter for 3 days
- D. 75-year-old client with dementia and dehydration who is on IV fluids
Correct Answer: C
Rationale: An indwelling urinary catheter increases the risk of catheter-associated urinary tract infections, a common nosocomial infection, especially in older adults with prolonged catheter use.
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The practical nurse is collecting data on a client receiving methotrexate to treat rheumatoid arthritis. Which finding associated with this drug is most important for the nurse to report to the registered nurse?
- A. Hair loss
- B. Nausea
- C. Petechiae
- D. Stomatitis
Correct Answer: C
Rationale: Petechiae indicate thrombocytopenia, a serious adverse effect of methotrexate, risking bleeding and requiring immediate reporting for dose adjustment or discontinuation.
The nurse is feeding a 3-month-old client with tetralogy of Fallot. During the feeding, the client becomes cyanotic and has difficulty breathing. Which action should the nurse take first?
- A. Administer oxygen via face mask to the client
- B. Administer subcutaneous morphine to the client
- C. Obtain the client's pulse oximetry reading
- D. Place the client in the knee-chest position
Correct Answer: D
Rationale: The knee-chest position increases systemic vascular resistance and reduces right-to-left shunting in tetralogy of Fallot, immediately improving oxygenation during a tet spell.
A client is receiving nitroprusside IV for the treatment of acute heart failure with pulmonary edema. What diagnostic lab value should the nurse monitor when a client is receiving this medication?
- A. Potassium level
- B. Arterial blood gasses
- C. Blood urea nitrogen
- D. Thiocyanate
Correct Answer: D
Rationale: Thiocyanate. Nitroprusside metabolism increases thiocyanate levels, which can lead to cyanide toxicity if elevated.
Four clients were involved in a major highway motor vehicle accident. Which client requires priority care?
- A. Client with blood pressure of 90/70 mm Hg and deviated trachea
- B. Client with concussion who was unconscious for 5 minutes
- C. Client with grossly swollen upper thigh and blood pressure of 80/60 mm Hg
- D. Client with pain at the thoracic spine and complete paralysis of both legs
Correct Answer: A
Rationale: A deviated trachea and hypotension suggest tension pneumothorax, a life-threatening condition requiring immediate decompression to restore breathing.
The nurse is reinforcing teaching to a client with advanced chronic obstructive pulmonary disease who was prescribed oral theophylline. Which client statement indicates that additional teaching is required?
- A. I need to avoid caffeinated products.
- B. I need to get my blood drug levels checked periodically.
- C. I need to report anorexia and sleeplessness.
- D. I take cimetidine rather than omeprazole for heartburn.
Correct Answer: D
Rationale: Cimetidine inhibits theophylline metabolism, increasing toxicity risk. Omeprazole is safer, and this statement indicates a need for further teaching.