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A client is brought to the emergency department unconscious. An empty bottle of aspirin was found in his car, and a drug overdose is suspected. Which of the following medications should the nurse have available for further emergency treatment?
- A. Vitamin K.
- B. Dextrose 50%.
- C. Activated charcoal powder.
- D. Sodium thiosulfate.
Correct Answer: C
Rationale: Activated charcoal is used to adsorb aspirin in the stomach, reducing absorption in an overdose. Vitamin K is for anticoagulant reversal, dextrose for hypoglycemia, and sodium thiosulfate for cyanide poisoning.
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The nurse should teach the client with diverticulitis to integrate which of the following into a daily routine at home?
- A. Using enemas to relieve constipation.
- B. Decreasing fluid intake to increase the formed consistency of the stool.
- C. Eating a high-fiber diet when symptomatic with diverticulitis.
- D. Refraining from straining and lifting activities.
Correct Answer: D
Rationale: Refraining from straining and lifting activities prevents increased intra-abdominal pressure, reducing the risk of diverticulitis complications. Enemas, decreased fluid, or high-fiber diets during acute symptoms can worsen the condition. CN: Physiological adaptation; CL: Synthesize
A client is admitted with a 6.5-cm thoracic aneurysm. The nurse records findings from the initial assessment in the client's chart, as shown below. At 10:30 a.m., the client complains of sharp midchest pain after having a bowel movement. What should the nurse do first?
- A. Assess the client's vital signs
- B. Administer a bolus of lactated Ringer's solution
- C. Assess the client's neurologic status
- D. Contact the physician
Correct Answer: A
Rationale: Sharp midchest pain in a client with a thoracic aneurysm suggests possible dissection or rupture, a life-threatening emergency. Assessing vital signs (e.g., hypotension, tachycardia) first provides critical data to guide action. Fluid bolus, neurologic assessment, or contacting the physician follow based on findings.
Which of the following expected outcomes would be appropriate for a client with viral hepatitis? The client will:
- A. Demonstrate a decrease in fluid retention related to ascites.
- B. Verbalize the importance of reporting bleeding gums or bloody stools.
- C. Limit use of alcohol to two to three drinks per week.
- D. Restrict activity to within the home to prevent disease transmission.
Correct Answer: B
Rationale: Reporting bleeding (B) indicates awareness of complications like coagulopathy. Ascites (A) is more relevant to cirrhosis. Alcohol (C) should be avoided entirely. Restricting activity to home (D) is unnecessary for hepatitis B or C.
The nurse anticipates that the client who has received epidural anesthesia is at decreased risk for a spinal headache because:
- A. A 17G needle is used.
- B. A subarachnoid injection is made.
- C. A noncutting needle is used.
- D. A faster onset occurs.
Correct Answer: C
Rationale: Epidural anesthesia uses a noncutting needle, reducing dural puncture risk and thus lowering the incidence of spinal headache compared to spinal anesthesia.
A client has a ureteral catheter in place after renal surgery. A priority nursing action for care of the ureteral catheter would be to:
- A. Irrigate the catheter with 30 mL of normal saline every 8 hours.
- B. Ensure that the catheter is draining freely.
- C. Clamp the catheter every 2 hours for 30 minutes.
- D. Ensure that the catheter drains at least 30 mL/hour.
Correct Answer: B
Rationale: Ensuring free drainage prevents obstruction or pressure buildup, which could harm the surgical site or kidney function.