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A 23-year-old male client is admitted to the chemical dependency unit with a medical diagnosis of alcoholism. He reports that the last time he drank was 3 days ago, and that now he is starting to 'feel kind of shaky.' Based on the information given above, nursing care goals for this client will initially focus on:
- A. Self-concept problems
- B. Interpersonal issues
- C. Ineffective coping skills
- D. Physiological stabilization
Correct Answer: D
Rationale: Self-concept and self-esteem problems may emerge during the client's treatment, but these are not immediate concerns. Interpersonal issues may become evident during the course of the client's treatment, but these are also not immediate areas of concern. Improving individual coping skills is generally a primary focus in the treatment and nursing care of persons with substance abuse problems. However, this is still not the immediate concern in this client situation. Correction of fluid and electrolyte status and vitamin deficiencies, as well as prevention of delirium, is the immediate concern in the care of this client.
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The nurse is caring for a client who is receiving terbutaline for preterm labor. Which side effect should the nurse monitor for?
- A. Maternal bradycardia
- B. Fetal hypoglycemia
- C. Maternal tachycardia
- D. Fetal macrosomia
Correct Answer: C
Rationale: Terbutaline a beta-agonist tocolytic commonly causes maternal tachycardia due to its stimulatory effects on the cardiovascular system. Maternal bradycardia fetal hypoglycemia and macrosomia are not associated side effects.
A gravida 2 para 1 client is hospitalized with severe preeclampsia. While she receives magnesium sulfate (MgSO4) therapy, the nurse knows it is safe to repeat the dosage if:
- A. Deep tendon reflexes are absent
- B. Urine output is 20 mL/hr
- C. MgSO4 serum levels are >15 mg/dL
- D. Respirations are >16 breaths/min
Correct Answer: D
Rationale: Respirations >16 breaths/min indicate that toxic magnesium levels have not been reached, making it safe to repeat the dose.
Joint Commission has established protocols for preventing surgical errors. Which steps are parts of that protocol?
- A. Circle the surgical site with a marker.
- B. Verify patient information with a designated patient representative.
- C. Designate operative site with a facility designated mark.
- D. Include a copy of the Advanced Directives on the chart before surgery.
- E. Verify patient information three times.
- F. Observe pre-op time out before proceeding with surgery.
Correct Answer: C, E, F
Rationale: Joint Commission protocols include marking the site with a facility-designated mark (C), verifying patient information multiple times (E), and performing a pre-op time-out (F). Circling the site (A) is not standard. Patient representative verification (B) and advance directives (D) are not part of site verification.
Which diet selection by a client with a decubitus ulcer would indicate a clear understanding of the proper diet for healing of the ulcer?
- A. Tossed salad, milk, and a slice of caramel cake
- B. Vegetable soup and crackers, and a glass of iced tea
- C. Baked chicken breast, broccoli, wheat roll, and an orange
- D. Hamburger, French fries, and corn on the cob
Correct Answer: C
Rationale: Healing decubitus ulcers requires a diet high in protein, vitamins (especially C and A), and zinc. Baked chicken breast (protein), broccoli (vitamin C), wheat roll (carbohydrates), and an orange (vitamin C) provide these nutrients. Options A, B, and D lack sufficient protein or include less nutrient-dense foods (e.g., caramel cake, French fries).
A client with a history of breast cancer is receiving tamoxifen (Nolvadex). Which adverse effect should the nurse monitor for?
- A. Weight loss
- B. Endometrial hyperplasia
- C. Hypotension
- D. Hair loss
Correct Answer: B
Rationale: Tamoxifen increases the risk of endometrial hyperplasia, a serious adverse effect due to its estrogenic effects on the uterus. Weight loss (A), hypotension (C), and hair loss (D) are not typical.