Nokea
A client admitted with transient ischemia attacks has returned from a cerebral arteriogram. The nurse performs an assessment and finds a newly formed hematoma in the right groin area. What is the nurse's initial action?
- A. Apply direct pressure to the site
- B. Check the pedal pulses on the right leg
- C. Notify the physician
- D. Turn the client to the prone position
Correct Answer: A
Rationale: Applying direct pressure to a hematoma at the arteriogram site controls bleeding and prevents further complications, making it the initial action.
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A client is prescribed heparin 5,000 units subcutaneously every 12 hours for deep vein thrombosis prophylaxis. The pharmacy dispenses a vial containing 10,000 units/1 ml. How many milliliter(s) of heparin should the nurse administer?
Correct Answer: 0.5 mL
Rationale: Dose: 5,000 units. Concentration: 10,000 units/mL. Volume = 5,000 ÷ 10,000 = 0.5 mL per dose.
The mother of a 9-year-old with asthma has brought an electric CD player for her son to listen to while he is receiving oxygen therapy. The nurse should:
- A. Explain that he does not need the added stimulation
- B. Allow the player, but ask him to wear earphones
- C. Tell the mother that he cannot have items from home
- D. Ask the mother to bring a battery-operated CD instead
Correct Answer: B
Rationale: Allowing the CD player with earphones provides comfort without disturbing others or interfering with oxygen therapy.
The priority nursing intervention for a client with sickle cell crisis is to
- A. administer pain medication.
- B. administer packed RBC.
- C. administer oxygen.
- D. administer IV fluids.
Correct Answer: D
Rationale: IV fluids are the priority in sickle cell crisis to reduce blood viscosity, promote perfusion, and prevent organ damage.
The nurse is caring for a client receiving TPN. The nurse understands that TPN management includes which of the following? Select all that apply.
- A. monitor daily weights and intake and output
- B. monitor serum electrolytes and glucose levels daily
- C. change IV tubing every 48 hours or per facility protocol
- D. change the IV site dressing every 24 hours or per facility protocol
- E. if TPN is unavailable, OK to give D10W or D20W until TPN becomes available
Correct Answer: A, B, C
Rationale: Monitoring weights, intake/output, electrolytes, glucose, and changing tubing per protocol are standard TPN management practices. Dressings are typically changed every 7 days or per protocol, and D10W/D20W are not suitable substitutes for TPN.
The nurse is teaching the mother regarding treatment for pedicalosis capitis. Which instruction should be given regarding the medication?
- A. Treatment is not recommended for children less than 10 years of age.
- B. Bed linens should be washed in hot water.
- C. Medication therapy will continue for 1 year.
- D. Intravenous antibiotic therapy will be ordered.
Correct Answer: B
Rationale: Washing bed linens in hot water helps eliminate lice and nits, which is a key part of treatment for pediculosis capitis.