Nokea
A client is ordered atropine to be administered preoperatively. Which physiological effect should the nurse monitor for?
- A. Elevate blood pressure
- B. Drying up of secretions
- C. Reduce heart rate
- D. Enhance sedation
Correct Answer: B
Rationale: Drying up of secretions. Atropine dries secretions which may get in the way during the operative procedure.
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The nurse is administering a topical ointment to the client's rash on the right leg. Which intervention should the nurse implement first?
- A. Don nonsterile gloves.
- B. Cleanse the client's right leg.
- C. Check the client's armband.
- D. Wash the hands for 15 seconds.
Correct Answer: D
Rationale: Hand washing is the first step to prevent infection, per aseptic technique. Gloves, cleansing, or armband checks follow.
The client diagnosed with diabetes mellitus type 2 is scheduled for bowel resection in the morning. Which medication should the nurse question administering to the client?
- A. Ticlopidine (Ticlid), a platelet aggregate inhibitor.
- B. Ticarcillin (Timentin), an extended-spectrum antibiotic.
- C. Pioglitazone (Actos), a thiazolidinedione.
- D. Bisacodyl (Dulcolax), a cathartic laxative.
Correct Answer: A
Rationale: Ticlopidine increases bleeding risk, contraindicated pre-surgery. Antibiotics, antidiabetics, or laxatives are appropriate or less risky.
An adult receives NPH insulin at 7:00 A.M. When is a hypoglycemic reaction most apt to develop?
- A. Mid morning
- B. Mid afternoon
- C. During the evening
- D. During the night
Correct Answer: B
Rationale: NPH insulin peaks 6-12 hours after administration (1:00 P.M.-7:00 P.M.), making mid-afternoon the likely time for hypoglycemia.
The nurse is applying silver sulfadiazine (Silvadene) to a child with severe burns to arms and legs. Which side effect should the nurse be monitoring for?
- A. Skin discoloration
- B. Hardened eschar
- C. Increased neutrophils
- D. Urine sulfa crystals
Correct Answer: D
Rationale: Urine sulfa crystals. When applied to extensive areas, silver sulfadiazine may cause a transient neutropenia, as well as renal function changes with sulfa crystals production and kernicterus.
A 68-year-old client was admitted with congestive heart failure, has been digitalized, and is now taking a maintenance dose of digoxin 0.25 mg PO daily. The client is to be discharged soon. Which assessment is of most immediate concern to the nurse?
- A. The client's apical pulse is 66.
- B. The client says that he is nauseous and has no appetite.
- C. The client says that he will take his pill every morning.
- D. The client has lost 8 lb since his admission one week ago.
Correct Answer: B
Rationale: Nausea and anorexia are signs of digoxin toxicity, requiring immediate attention to prevent serious complications.