Nokea
A client has orders for placing a small-bore nasoenteric tube. Which finding in the health history would prompt the nurse to notify the prescriber before placing tube?
- A. small-bowel lesion
- B. basilar skull fracture
- C. acute coronary syndrome
- D. use of diabetic insulin pump
Correct Answer: B
Rationale: A basilar skull fracture is a contraindication for nasoenteric tube placement due to the risk of intracranial insertion. Other conditions are not absolute contraindications.
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A client with osteoarthritis has a prescription for Celebrex (celecoxib). Which instruction should be included in the discharge teaching?
- A. Take the medication with milk.
- B. Report chest pain.
- C. Remain upright after taking for 30 minutes.
- D. Allow 6 weeks for optimal effects.
Correct Answer: B
Rationale: Chest pain may indicate a cardiovascular side effect of Celebrex, requiring immediate reporting.
A client in the prenatal clinic is assessed to have a blood pressure of 180/96. The nurse should give priority to:
- A. Providing a calm environment
- B. Obtaining a diet history
- C. Administering an analgesic
- D. Assessing fetal heart tones
Correct Answer: D
Rationale: Severe hypertension (180/96) poses a risk to fetal well-being, prioritizing fetal heart tone assessment.
The nurse is preparing to administer an injection to a 6-month-old when she notices a white dot in the infant's right pupil. The nurse should:
- A. Report the finding to the physician immediately
- B. Record the finding and give the infant's injection
- C. Recognize that the finding is a variation of normal
- D. Check both eyes for the presence of the red reflex
Correct Answer: A
Rationale: A white dot in the pupil (leukocoria) may indicate retinoblastoma or cataracts, requiring immediate reporting to the physician for further evaluation.
An 18-month-old is being discharged following hypospadias repair. Which instruction should be included in the nurse's discharge teaching?
- A. The child should not play on his rocking horse.
- B. Applying warm compresses will decrease pain.
- C. Diapering should be avoided for 1-2 weeks.
- D. The child will need a special diet to promote healing.
Correct Answer: A
Rationale: Avoiding straddling activities like rocking horses prevents strain on the surgical site post-hypospadias repair.
A client is admitted complaining of chest pain. Which of the following drug orders should the nurse question?
- A. Nitroglycerin
- B. Ampicillin
- C. Propranolol
- D. Verapamil
Correct Answer: B
Rationale: Ampicillin, an antibiotic, is not indicated for chest pain, which is typically cardiac-related and treated with nitroglycerin, propranolol, or verapamil.