Nokea
A client is confused after receiving morphine for analgesia and repeatedly tries to pull out the intravenous (IV) line in her left arm. Which of the following actions is the best initial solution?
- A. Attempt to camouflage the IV and tie a piece of tubing to the bedrail so the client can pull on that safely.
- B. Apply wrist restraints.
- C. Apply wrist and vest restraints.
- D. Discontinue the IV line and reinsert at a more distant site.
Correct Answer: A
Rationale: Camouflaging the IV and providing a safe alternative (A) is a least-restrictive, non-invasive initial approach to prevent the client from pulling out the IV. Restraints (B, C) should be a last resort, and discontinuing the IV (D) is unnecessary.
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The nurse is caring for a client with a malignancy. The classification of the primary tumor is Tis. The nurse should plan care for a tumor:
- A. That cannot be assessed
- B. That is in situ
- C. With increasing lymph node involvement
- D. With distant metastasis
Correct Answer: B
Rationale: Tis indicates a tumor in situ, meaning it is noninvasive and confined to its original site, requiring specific care planning.
A client with AIDS is taking Zovirax (acyclovir). Which nursing intervention is most critical during the administration of acyclovir?
- A. Limit the client's activity
- B. Encourage a high-carbohydrate diet
- C. Utilize an incentive spirometer to improve respiratory function
- D. Encourage fluids
Correct Answer: D
Rationale: Acyclovir can cause nephrotoxicity, so encouraging fluids is critical to prevent kidney damage.
A client with diabetes visits the prenatal clinic at 28 weeks gestation. Which statement is true regarding insulin needs during pregnancy?
- A. Insulin requirements moderate as the pregnancy progresses.
- B. A decreased need for insulin occurs during the second trimester.
- C. Elevations in human chorionic gonadotrophin decrease the need for insulin.
- D. Fetal development depends on adequate insulin regulation.
Correct Answer: D
Rationale: Adequate insulin regulation is critical for fetal development in diabetic pregnancies.
The nurse is preparing a client for cataract surgery. The nurse is aware that the procedure will use:
- A. Mydriatics to facilitate removal
- B. Miotic medications such as Timoptic
- C. A laser to smooth and reshape the lens
- D. Silicone oil injections into the eyeball
Correct Answer: A
Rationale: Mydriatics are used to dilate the pupil, facilitating lens removal during cataract surgery.
A student in a cardiac unit is performing auscultation of a client's heart. The nurse recognizes that the student is performing pulmonic auscultation correctly when the stethoscope is placed:
- A. Between the apex and the sternum
- B. At the fifth intercostal space at the left midclavicular line
- C. At the second intercostal space, left of the sternum
- D. At the manubrium
Correct Answer: C
Rationale: The pulmonic area is auscultated at the second intercostal space, left of the sternum, where the pulmonary valve sounds are best heard.