Nokea
A child with a history of seizures begins to seize suddenly in his hospital room. The nurse would do all of the following interventions EXCEPT
- A. loosen the child's clothing and remove the pillow from his bed.
- B. administer lorazepam rectally.
- C. roll the child on his side.
- D. restrain the child's arms and legs.
Correct Answer: D
Rationale: Restraining during a seizure risks injury. Loosening clothing, removing pillows, rolling to the side, and administering lorazepam (if ordered) are appropriate to ensure safety and stop the seizure.
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A client has a chest tube in place with a three-chamber chest drainage system. The nurse notes continuous bubbling in the water seal chamber. This indicates which of the following?
- A. Pneumothorax.
- B. Suction is adequate.
- C. System air leak.
- D. The tube is positioned incorrectly.
Correct Answer: C
Rationale: Continuous bubbling in the water seal chamber indicates a system air leak (C), such as a loose connection or hole in the tubing. A pneumothorax (A) may cause intermittent bubbling, adequate suction (B) is indicated by bubbling in the suction chamber, and incorrect tube positioning (D) would not typically cause continuous bubbling.
An ICU nurse monitors a client recovering from a head injury. The client's intracranial pressure (ICP) has been between 15 and 19 mmHg throughout the shift. However, after the nurse suctions the client's endotracheal tube, the ICP jumps to 28 mmHg. It decreases a few minutes later to 20 mmHg. The best intervention by the nurse is to
- A. increase the rate of the sedative IV drip.
- B. chart the findings and continue to monitor the client.
- C. reposition the client.
- D. contact the physician.
Correct Answer: D
Rationale: A sudden ICP spike to 28 mmHg post-suctioning suggests a significant issue (e.g., impaired cerebral perfusion). The physician should be contacted for evaluation.
The nurse is caring for a 70-year-old client with hypovolemia who is receiving a blood transfusion. Assessment findings reveal crackles on chest auscultation and distended neck veins. What is the nurse's initial action?
- A. Slow the transfusion
- B. Document the finding as the only action
- C. Stop the blood transfusion and turn on the normal saline
- D. Assess the client's pupils
Correct Answer: A
Rationale: Crackles and distended neck veins suggest fluid overload from the transfusion. Slowing the transfusion reduces further overload while maintaining access. Stopping it entirely or documenting only delays intervention.
The client with a recent liver transplant asks the nurse how long he will have to take an immunosuppressant. Which response would be correct?
- A. 1 year
- B. 5 years
- C. 10 years
- D. The rest of his life
Correct Answer: D
Rationale: Lifelong immunosuppression is required post-transplant to prevent organ rejection.
The nurse has an order to give 500 mL of 0.45% NS over 12 hours. The IV set has a drop factor of 10. How many gtts/min should the client receive? Fill in the blank.
Correct Answer: 7
Rationale: Rate = 500 mL ÷ 12 hr = 41.67 mL/hr. Drops/min = (41.67 mL/hr × 10 gtts/mL) ÷ 60 min = 6.94 gtts/min, rounded to 7 gtts/min.