Nokea
A 37-year-old female client asks the nurse about contraception options, and says she would like to ask her doctor for a prescription for an oral contraception pill. Which of the following statements would indicate that oral contraception is appropriate for this client?
- A. I quit smoking last year, but I started again recently. Maybe I'll try to quit later this year.
- B. I am very diligent at taking my thyroid medications at the same time every day.
- C. I was hospitalized for deep vein thrombosis five years ago.
- D. I was recently diagnosed with breast cancer.
Correct Answer: B
Rationale: The client's statement about medication diligence shows that this client could be compliant with a daily oral contraceptive. Contraindications to oral contraception include breast cancer, a history of deep vein thrombosis, and smoking if over age 35.
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The client has an order for a 1,000 mL bag of fluids to be infused over 8 hours. What is the correct rate?
- A. 100 mL/hr
- B. 125 mL/min
- C. 125 mL/hr
- D. 80 mL/min
Correct Answer: C
Rationale: The correct calculation is 1000 / 8 which equals 125 mL/hr.
A client has chronic respiratory acidosis caused by end-stage chronic obstructive pulmonary disease (COPD). Oxygen is delivered at 1 L/min per nasal cannula. The nurse teaches the family that the reason for this is to avoid respiratory depression, based on which of the following explanations?
- A. COPD clients are stimulated to breathe by hypoxia.
- B. COPD clients depend on a low carbon dioxide level.
- C. COPD clients tend to retain hydrogen ions if they are given high doses of oxygen.
- D. COPD clients thrive on a high oxygen level.
Correct Answer: A
Rationale: COPD clients are compensating for low oxygen and high carbon dioxide levels. Hypoxia is the main stimulus to breathe in persons with chronic hypercapnia. Increasing the level of oxygen decreases the stimulus to breathe.
The 40-year-old client is receiving levothyroxine for treatment of hypothyroidism. Which serum laboratory results should lead the nurse to conclude that the client's dose is adequate?
- A. Thyroid-stimulating hormone and cortisol
- B. Thyroid-stimulating hormone and free T4
- C. Triiodothyronine (T3) and free thyroxine (T4)
- D. White blood cells, glucose, and potassium
Correct Answer: B
Rationale: A: Cortisol levels are used to evaluate adrenal and not thyroid function. B: Restoration of normal laboratory values for TSH and free T4 indicates that the dose of levothyroxine (Synthroid) is therapeutic. C: T3 is used to evaluate the effectiveness of liothyronine and propylthiouracil, used in the treatment of thyroid disorders. D: The WBC count is used to determine if the client has an infection. Evaluation of serum glucose and potassium levels is unrelated to the use of levothyroxine.
The nurse is caring for a client who has recently started using a PCA pump for pain management. Which of the following statements indicates a need for additional education.
- A. I will continue to report my pain score during assessments.
- B. I understand that there is a maximum dose in an hour that I can receive regardless of how many times I press the button.
- C. I think this new PCA pump is going to finally get rid of my back pain.
- D. I have more control of when and how much medication I receive.
Correct Answer: C
Rationale: The nurse should assess the client for reasonable versus unreasonable expectations of pain management when using a PCA pump. The patient should not expect the pain to go away completely.
The nurse has completed swaddling the 2-month-old infant, prepared supplies to cannulate the scalp vein for an IV infusion, and cleansed and shaved the hair at the site over the temporal bone. Place the remaining steps in the order that they should be performed by the nurse.
- A. Return in 60 minutes and reswaddle the infant in a mummy restraint.
- B. With an assistant holding the infant's head, insert a scalp vein needle and observe for blood return.
- C. Apply lidocaine/prilocaine cream to the site selected and unswaddle the infant after the cream application.
- D. Cleanse the shaved area with an antiseptic solution.
- E. Remove the mummy restraint after initiating the infusion and comfort the infant.
- F. Initiate the infusion and cover the infusion needle with a gauze dressing.
Correct Answer: C,A,D,B,F,E
Rationale: C: Apply lidocaine/prilocaine (EMLA) cream to the site selected and unswaddle the infant after the cream application. An anesthetic cream will numb the site and help reduce the infant's pain during insertion. The infant does not need to remain swaddled while the cream reaches its therapeutic effectiveness in about an hour. A: Return in 60 minutes and reswaddle the infant in a mummy restraint. It takes about an hour for the lidocaine/prilocaine cream to reach its therapeutic effectiveness. The infant should be reswaddled to minimize movement during insertion. D: Cleanse the shaved area with an antiseptic solution. Cleansing the area with an antiseptic solution will help prevent inadvertent introduction of microorganisms into the vascular system. B: With an assistant holding the infant's head, insert a scalp vein needle and observe for blood return. Movement of the infant's head can result in loss of the vein access or a needle-stick injury to the infant or nurse. F: Initiate the infusion and cover the infusion needle with a gauze dressing. Once the vein has been successfully cannulated, the site can be dressed and IV fluids started. E: Remove the mummy restraint after initiating the infusion and comfort the infant. The mummy restraint is no longer needed after the IV catheter has been successfully inserted into a scalp vein.