Nokea
A client has returned from surgery with a fine, reddened rash noted around the area where Betadine prep had been applied prior to surgery. Nursing documentation in the chart should include
- A. the time and circumstances under which the rash was noted.
- B. the explanation given to the client and family of the reason for the rash.
- C. notation on an allergy list and notification of the doctor.
- D. the need for application of corticosteroid cream to decrease inflammation.
Correct Answer: C
Rationale: suspected reaction to drugs should be reported to the doctor and noted on list of possible allergies
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A woman with chronic obstructive pulmonary disease (COPD) is admitted with an acute exacerbation. Her vital signs are: BP 162/100, pulse 78, respirations 30 and labored with wheezing. The nurse should question which of the following orders?
- A. Theophylline (Somophyllin) 0.7 mg/kg/hr IV.
- B. Tetracycline hydrochloride (Sumycin) 250 mg IM qd.
- C. Ipratropium bromide (Atrovent) inhaler 2 inhalations qid.
- D. Propranolol hydrochloride (Inderal) 40 mg PO bid.
Correct Answer: D
Rationale: Propranolol, a non-selective beta-blocker, can cause bronchoconstriction, worsening COPD. Options A, B, and C are appropriate: theophylline bronchodilates, tetracycline treats infections, and ipratropium reduces bronchospasm.
If a very active two year-old client pulls his tunneled central venous catheter out, what initial nursing action is appropriate?
- A. Obtain emergency equipment
- B. Assess heart rate, rhythm and all pulses
- C. Apply pressure to the vessel insertion site
- D. Use cold packs at the exit incision site
Correct Answer: C
Rationale: If a central venous catheter is accidentally removed, pressure should be applied to the vein entry site to prevent bleeding and complications.
A patient is admitted to the surgical unit with a diagnosis of rule out inTest inal obstruction.
- A. In which position should the nurse place the patient during insertion of a Salem sump NG tube?
- B. Head of bed elevated 30°-45°.
- C. Head of bed elevated 60°-90°.
- D. Side-lying with head elevated 15°.
- E. Lying flat with head turned to the left side.
Correct Answer: B
Rationale: Elevating the head of the bed to 60°-90° facilitates swallowing and movement of the NG tube through the gastroinTest inal tract, reducing the risk of aspiration and improving patient comfort during insertion. Other positions do not optimize swallowing or tube passage as effectively.
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who is receiving oxygen at 2 L/min via nasal cannula. Which of the following findings would be of GREATest concern to the nurse?
- A. Oxygen saturation of 90%.
- B. Respiratory rate of 20 breaths/min.
- C. Temperature of 101°F (38.3°C).
- D. Heart rate of 80 bpm.
Correct Answer: C
Rationale: A temperature of 101°F suggests infection, a serious complication in COPD that can exacerbate respiratory distress. Options A, B, and D are acceptable: oxygen saturation 90% is adequate for COPD, respiratory rate 20 is normal, and heart rate 80 bpm is normal.
A 57-year-old man admitted with metastatic cancer has been receiving chemotherapy for 3 months. His lab values include: RBC 3.8 million/mm³, WBC 3,000/mm³, Hgb 9.3 g/dL, platelets 50,000/mm³.
The nurse would expect the patient to exhibit which of the following symptoms?
- A. BP 120/70, pulse 100, respirations 16.
- B. Ankle edema and ascites.
- C. Flushed face and light stools.
- D. Nausea, anorexia, and vomiting.
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to the situation. (1) correct-increased pulse and respirations are caused by decreased oxygenation of tissues (2) no information to suggest this is provided in the question (3) will be pale due to anemia, normal RBC male 4.3-5.9 million/mm³, female 3.5-5.5 million/mm³, decreased with anemia; normal WBC 4,500-11,000/mm³, decreased (leukopenia) causes susceptibility to infection; normal Hgb - male 13.5-17.5 g/dL, female 12-16 g/dL, decreased with anemia (4) not related to information provided in the question