Nokea
A 4-year-old child is admitted for a cardiac catheterization. Which of the following is most important to include as the nurse teaches this child about the cardiac catheterization?
- A. A plastic model of the heart.
- B. A catheter that will be inserted into the artery.
- C. The parents.
- D. Other children undergoing a catheterization.
Correct Answer: C
Rationale: Including the parents in teaching provides emotional support and reassurance to the child, which is critical for a 4-year-old facing a procedure. While a model or catheter explanation may be useful, parental presence is most important for the child's comfort and understanding.
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A client with a diagnosis of tuberculosis is prescribed isoniazid (INH). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild fatigue.
- B. Yellowing of the skin.
- C. Sore throat.
- D. Nausea.
Correct Answer: B
Rationale: Yellowing of the skin indicates potential hepatotoxicity, a serious side effect of isoniazid, requiring immediate reporting.
Select the opioid classification that is accurately coupled with an example of it AND a side effect or adverse reaction to it.
- A. Opioid Agonist: Dilaudid: Constipation
- B. Opioid Agonist: Naloxone: Constipation
- C. Opioid Antagonist: Dilaudid: Anaphylaxis
- D. Opioid Antagonist: OxyContin: Anaphylaxis
Correct Answer: A
Rationale: Dilaudid (hydromorphone) is an opioid agonist, and constipation is a common side effect due to opioid effects on the gastrointestinal tract.
A primiparous client at 38 weeks' gestation is admitted in early labor. The client's membranes rupture, and the nurse observes that the amniotic fluid is meconium-stained. The nurse should:
- A. Notify the physician immediately.
- B. Perform a vaginal exam to assess dilation.
- C. Encourage the client to ambulate.
- D. Administer oxygen to the client.
Correct Answer: A
Rationale: Meconium-stained amniotic fluid may indicate fetal distress, requiring immediate notification of the physician for further evaluation and management.
A client with a diagnosis of hyperthyroidism is prescribed methimazole (Tapazole). The nurse should monitor the client for which of the following side effects?
- A. Weight gain.
- B. Agranulocytosis.
- C. Hypertension.
- D. Hyperglycemia.
Correct Answer: B
Rationale: Methimazole can cause agranulocytosis, requiring monitoring of white blood cell counts.
Two days after being placed in a cast for a fracture, the client suddenly develops chest pain and dyspnea. The client is confused and has an elevated temperature. The nurse should assess the client for:
- A. Osteomyelitis.
- B. Compartment syndrome.
- C. Venous thrombosis.
- D. Fat embolism syndrome.
Correct Answer: D
Rationale: Chest pain, dyspnea, confusion, and fever suggest fat embolism syndrome, a complication of fractures, particularly within 48 hours.