Nokea
A 3-year-old is admitted with croup. Which intervention should the nurse prioritize?
- A. Administer racemic epinephrine
- B. Provide a high-calorie diet
- C. Encourage oral fluids
- D. Apply a warm compress to the throat
Correct Answer: A
Rationale: Racemic epinephrine is the priority for croup to reduce airway swelling and relieve stridor, addressing the immediate respiratory distress.
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The nurse is caring for a client with a history of atrial fibrillation who is prescribed vernakalant (Brinavess). The nurse should monitor the client for which of the following side effects?
- A. Hypertension.
- B. Bradycardia.
- C. Liver toxicity.
- D. Weight gain.
Correct Answer: B
Rationale: Vernakalant can cause bradycardia, requiring close monitoring of heart rate.
The nurse is performing Leopold's maneuvers on a woman who is in her eighth month of pregnancy. The nurse is palpating the uterus as shown by the following maneuvers is the nurse performing?
- A. First maneuver.
- B. Second maneuver.
- C. Third maneuver.
- D. Fourth maneuver.
Correct Answer: C
Rationale: The third Leopold's maneuver involves palpating the lower uterus to determine the presenting part, typically performed in the eighth month to assess fetal position.
Which type of legal consent is indirectly given by the client by the very nature of their voluntary acute care hospitalization?
- A. An opt out consent
- B. An implicit consent
- C. An explicit consent
- D. No consent at all is given
Correct Answer: B
Rationale: Implicit consent is given by the client's voluntary admission to an acute care facility, implying agreement to routine treatments and procedures necessary for their care, unless explicitly refused.
A client newly diagnosed with angina pectoris has taken two sublingual nitroglycerin tablets for chest pain. The chest pain is relieved, but the client now reports a headache. The nurse interprets that this most likely represents which response?
- A. An early sign of medication tolerance
- B. An allergic reaction to the nitroglycerin
- C. An expected side effect of the medication
- D. A warning that the medication should not be used again
Correct Answer: C
Rationale: Headache is a frequent side effect of nitroglycerin, because of the vasodilating action of the medication. It usually diminishes in frequency as the client becomes accustomed to the medication and is effectively treated with acetaminophen. The other options are incorrect.
You are serving as the preceptor for a newly graduated nurse. As you observe the new nurse for their application of body mechanics principles into client care, you observe that the nurse spreads her legs apart during a transfer with a client. What should you do?
- A. Advise the nurse that the legs must be close together for stability during lifting and transfers.
- B. Advise the nurse that the legs should be one in front of the other and not spread apart during a transfer.
- C. Validate the nurse's competency in terms of the application of body mechanics principles during a transfer.
- D. Validate the nurse's competency in terms of the application of ergonomics principles during a transfer.
Correct Answer: C
Rationale: Spreading the legs apart during a transfer provides a wide base of support, which is a correct body mechanics principle , ensuring stability and reducing injury risk.