Nokea
A client has a prescription to have a set of arterial blood gases (ABGs) drawn, and the intended site is the radial artery. The nurse ensures that which is positive before the ABGs are drawn?
- A. Allen test
- B. Turner's sign
- C. Babinski reflex
- D. Brudzinski's sign
Correct Answer: A
Rationale: The Allen test is performed before drawing ABGs. Both the radial and ulnar arteries are occluded and then pressure on the ulnar artery is released. Observation is made in the distal circulation. If the results are positive, then the client has adequate circulation and the radial artery may be used. Turner's sign is the bluish discoloration of the flanks and is indicative of pancreatitis. The Babinski reflex is checked by stroking upward on the sole of the foot. Brudzinski's sign tests for nuchal rigidity by bending the head down toward the chest.
You may also like to solve these questions
The nurse notes that the client admitted after fainting is receiving olanzapine. Which disorder or condition should the nurse suspect the client is experiencing?
- A. Schizophrenia
- B. Dementia disorder
- C. Personality disorder
- D. Major depressive disorder
Correct Answer: A
Rationale: Olanzapine is an atypical antipsychotic medication used in the management of manifestations associated with psychotic disorders. It is the first-line treatment for schizophrenia, targeting both the positive and the negative symptoms. None of the remaining options are indicated uses for this medication.
A 4-year-old child who has been ill for 4 hours is admitted to the hospital with difficulty swallowing, a sore throat, and severe substernal retractions. The child's temperature is 104°F (40°C), and the apical pulse is 140 bpm.The white blood cell count is 16,000/mm³. Which of the following should the nurse identify as the immediate priority nursing diagnosis?
- A. Anxiety related to need for immediate and unplanned hospitalization.
- B. Risk for injury (airway obstruction) related to epiglottal edema.
- C. Impaired gas exchange related to excessive respiratory effort.
- D. Ineffective airway clearance related to aspiration.
Correct Answer: B
Rationale: The symptoms indicate epiglottitis, with a high risk of airway obstruction due to epiglottal edema, making this the priority diagnosis.
A client is suspected of having a slow gastrointestinal bleed. The nurse should evaluate the client for which sign or symptom?
- A. Increased pulse.
- B. Nausea.
- C. Tarry stools.
- D. Abdominal cramps.
Correct Answer: C
Rationale: Tarry stools are a hallmark sign of a slow gastrointestinal bleed due to digested blood.
A client's 12:00 noon blood glucose concentration was inaccurately documented as 310 instead of 130. This error was not noticed until 1:00 p.m. The nurse administered the sliding scale insulin for a blood glucose of 310 instead of 130. What should the nurse do first?
- A. Notify the physician.
- B. Assess for hypoglycemia.
- C. Consult with the clinical pharmacist.
- D. Call the charge nurse.
Correct Answer: B
Rationale: Administering insulin for a falsely high glucose level risks hypoglycemia, so assessing for symptoms (e.g., shakiness, sweating) is the priority.
Which of the following clients is at greatest risk for extravasation?
- A. The client with heart failure who is receiving Ringer's lactate
- B. The client with cancer who is receiving bendamustine
- C. The client who is receiving potassium supplementation intravenously
- D. The client who is receiving total parenteral nutrition
Correct Answer: B
Rationale: Bendamustine, a chemotherapy drug, is a vesicant, posing a high risk for extravasation, which can cause severe tissue damage if it leaks into surrounding tissues.