Nokea
A 38-year-old female client with a history of breast-conserving surgery, axillary node dissection, and radiation therapy reports that her arm is red, warm to touch, and slightly swollen. Which of the following actions should the nurse suggest?
- A. Apply warm compresses to the affected arm.
- B. Elevate the arm on two pillows.
- C. See the physician immediately.
- D. Schedule an appointment within 2 to 3 weeks.
Correct Answer: C
Rationale: Redness, warmth, and swelling suggest cellulitis, a serious infection in a client with a history of axillary node dissection, requiring immediate medical evaluation.
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The client is to take nothing by mouth after 4 a.m. The nurse recognizes that the client has deficient knowledge when he states that he:
- A. Ate a gelatin dessert at 3:30 a.m.
- B. Brushed his teeth at 4:00 a.m. but did not swallow.
- C. Held a cold washcloth against his lips.
- D. Smoked a cigarette at 6:00 a.m.
Correct Answer: D
Rationale: Smoking after 4 a.m. violates the nothing-by-mouth (NPO) order, as it introduces substances into the body and can affect anesthesia safety. The other actions either comply with NPO (brushing teeth without swallowing, holding a washcloth) or occurred before the cutoff (gelatin at 3:30 a.m.).
The client with a major burn injury receives total parenteral nutrition (TPN). The expected outcome is to:
- A. Correct water and electrolyte imbalances.
- B. Allow the gastrointestinal tract to rest.
- C. Provide supplemental vitamins and minerals.
- D. Ensure adequate caloric and protein intake.
Correct Answer: D
Rationale: Major burn injuries significantly increase metabolic demands, requiring high caloric and protein intake to support healing and tissue repair. TPN is primarily used to meet these nutritional needs when oral or enteral feeding is not feasible.
The following scenario applies to the next 1 items
The nurse has received prescriptions for a newborn infant in the postpartum unit.
Item 1 of 1
Orders
1958:
• phytonadione 1 mg intramuscular (IM) x 1 dose
• erythromycin ophthalmic ointment 0.5% apply from unit dose (1 cm) to both eyes
The nurse administers the prescribed medications.
The nurse should administer the phytonadione using ............ The nurse will inject the medication.............................It would be appropriate for the nurse to ...................... The nurse understands that the purpose of administering newborn erythromycin ophthalmic ointment is ............................. The nurse should apply this ointment to the ......................... Once the ointment is administered, the nurse should ..........................
- A. ¾-in, 25-gauge needle.
- B. into the middle third of the anterolateral aspect of the thigh.
- C. aspirate before injecting the medication.
- D. massage the area to promote medication absorption.
- E. prevent ophthalmia neonatorum caused by Neisseria gonorrhoeae.
- F. lower conjunctival sac.
- G. wipe the ointment from the outer eye after one minute.
Correct Answer: A,B,D,E,F
Rationale: Phytonadione is administered with a 25-gauge, ¾-in needle in the vastus lateralis; erythromycin prevents ophthalmia neonatorum and is applied to the lower conjunctival sac without wiping.
The nurse develops a plan of care for a client in the initial postoperative period following a lumbar laminectomy. Which of the following activities is contraindicated?
- A. Assisting with her daily hygiene activities.
- B. Lying flat in bed.
- C. Walking in the hall.
- D. Sitting all afternoon in her room.
Correct Answer: D
Rationale: Prolonged sitting stresses the surgical site and is contraindicated post-laminectomy.
An African-American woman had experienced severe palpitations, weakness, and shortness of breath after taking bacitracin (Bactrim). As a part of the discharge planning, the nurse should evaluate the client's knowledge about:
- A. Increased folic acid needs.
- B. Congenital enzyme deficiency.
- C. Restricted activity in hot weather.
- D. Need for blood transfusions.
Correct Answer: B
Rationale: Bactrim (sulfamethoxazole/trimethoprim) can cause hemolytic anemia in individuals with glucose-6-phosphate dehydrogenase (G6PD) deficiency, a congenital enzyme deficiency common in African-American populations. The nurse should assess the client's understanding of G6PD deficiency and how to avoid triggers like certain medications. Folic acid, activity restrictions, and transfusions are not directly related.