Nokea
A client has returned to his room following an esophagoscopy. Before offering fluids, the nurse should give priority to assessing the client's:
- A. Level of consciousness
- B. Gag reflex
- C. Urinary output
- D. Movement of extremities
Correct Answer: B
Rationale: Assessing the gag reflex is critical post-esophagoscopy to ensure the client can swallow safely, as local anesthesia may impair this reflex.
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The physician orders palifermin (Kepivance) 60 mcg/kg to be administered daily. The client weighs 35 kg. The medication is supplied 5 mg/mL. How many mL would you administer?
- A. 0.42 mL
- B. 30 mL
- C. 36.5 mL
- D. 33.6 mL
Correct Answer: A
Rationale: Dose: 60 mcg/kg × 35 kg = 2100 mcg = 2.1 mg. 2.1 mg ÷ 5 mg/mL = 0.42 mL. Other options are incorrect calculations.
A 69-year-old woman has a history of heart failure. She is admitted to the emergency department with heart failure complicated by pulmonary edema.
On admission of this patient, which of the following should be assessed first?
- A. blood pressure
- B. skin breakdown
- C. serum potassium
- D. urine output
Correct Answer: A
Rationale: Blood pressure assessment is critical in pulmonary edema to guide treatment and assess cardiovascular status.
Classic symptoms of appendicitis:
Classic symptoms of appendicitis:
- A. Diffused abdominal pain occurs before nausea, fever.
- B. Pain in the right side of the abdomen, fever, elevated WBC.
- C. Pain and decreased sensation in the right leg.
- D. Distended abdomen, indigestion-like symptom.
Correct Answer: B
Rationale: Right lower quadrant pain, fever, and elevated WBC are classic appendicitis symptoms.
A woman has just started receiving external radiation therapy. When the nurse enters the client's room, she notes that the client is scrubbing the area vigorously with soap and water. When asked about her actions, the woman replies that she is trying to get rid of the ugly purple marks. What is the best action for the nurse at this time?
- A. Explain that the purple marks must stay on her because they tell the doctors where to beam the radiation
- B. Suggest that alcohol will make it easier to remove the marks
- C. Say, 'You feel the marks are ugly.'
- D. Ask her if she checked with her physician before trying to remove the purple marks
Correct Answer: A
Rationale: Radiation marks guide precise targeting; explaining their necessity prevents removal and ensures effective treatment.
Ron is 4-year-old child being discharge to home after an uneventful tonsillectomy.
The nurse would suggest that the appropriate car seat for the child is
- A. the rear-facing seat.
- B. the front facing seat.
- C. the booster seat with car seat belt.
- D. the back seat.
Correct Answer: C
Rationale: A booster car seat is appropriate for a bigger child like a 4-year-old, ensuring proper restraint and safety.