Nokea
A client is admitted for an CAT scan. The nurse should question the client regarding:
- A. Pregnancy
- B. A titanium hip replacement
- C. Allergies to antibiotics
- D. Inability to move his feet
Correct Answer: A
Rationale: Pregnancy is a contraindication for a CAT scan due to radiation risks to the fetus.
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An ICU nurse monitors a client recovering from a head injury. The client's intracranial pressure (ICP) has been between 15 and 19 mmHg throughout the shift. However, after the nurse suctions the client's endotracheal tube, the ICP jumps to 28 mmHg. It decreases a few minutes later to 20 mmHg. The best intervention by the nurse is to
- A. increase the rate of the sedative IV drip.
- B. chart the findings and continue to monitor the client.
- C. reposition the client.
- D. contact the physician.
Correct Answer: D
Rationale: A sudden ICP spike to 28 mmHg post-suctioning suggests a significant issue (e.g., impaired cerebral perfusion). The physician should be contacted for evaluation.
A client with benign prostatic hypertrophy has been started on Proscar (finasteride). The nurse's discharge teaching should include:
- A. Telling the client's wife not to touch the tablets
- B. Explaining that the medication should be taken with meals
- C. Telling the client that symptoms will improve in 1-2 weeks
- D. Instructing the client to take the medication at bedtime, to prevent nocturia
Correct Answer: A
Rationale: Finasteride tablets should not be handled by pregnant women due to the risk of fetal harm. This is a critical teaching point for safety.
A burn client begins treatments with silver sulfadiazine (Silvadene) applied to the wounds. The nurse should carefully monitor for which adverse affect associated with this drug?
- A. Hypokalemia
- B. Leukopenia
- C. Hyponatremia
- D. Thrombocytopenia
Correct Answer: B
Rationale: Silver sulfadiazine can cause leukopenia as an adverse effect, requiring monitoring of white blood cell counts to detect potential bone marrow suppression.
Which one of the following infants needs a further assessment of growth?
- A. 4-month-old: birth weight 7 lb, 6 oz; current weight 14 lb, 4 oz
- B. 2-week-old: birth weight 6 lb, 10 oz; current weight 6 lb, 12 oz
- C. 6-month-old: birth weight 8 lb, 8 oz; current weight 15 lb
- D. 2-month-old: birth weight 7 lb, 2 oz; current weight 9 lb, 6 oz
Correct Answer: B
Rationale: The 2-week-old has only gained 2 oz since birth, which is inadequate (normal is 0.5-1 oz/day), indicating a need for growth assessment.
The physician has prescribed Gantrisin (sulfasoxazole) 1 g in divided doses for a client with a urinary tract infection. The nurse should administer the medication:
- A. With meals or a snack
- B. 30 minutes before meals
- C. 30 minutes after meals
- D. At bedtime
Correct Answer: A
Rationale: Gantrisin should be taken with food to reduce gastrointestinal upset, and adequate fluid intake is needed to prevent crystalluria.