Nokea
A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic?
- A. Bruising at the operative site
- B. Elevated heart rate
- C. Decreased platelet count
- D. No bowel movement for 3 days
Correct Answer: D
Rationale: No bowel movement for 3 days. With opioid analgesics, observe for respiratory depression, sedation, and constipation. Bruising is not related to the analgesic, but could be the result of corticosteroids or previously used anticoagulants. Elevated heart rate could be the result of bronchodilators. Some antibiotics can lower platelet count.
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When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula
- A. every four to six hours
- B. continuously
- C. in a bolus
- D. every hour
Correct Answer: B
Rationale: continuously. Usually gastrostomy and jejunostomy feedings are given continuously to ensure proper absorption. However, initial feedings may be given by bolus to assess the client's tolerance to formula.
The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the provider?
- A. nausea and vomiting
- B. fever of 103 degrees Fahrenheit (39.5 degrees Celsius)
- C. diffuse macular rash
- D. muscle tenderness
Correct Answer: B
Rationale: fever of 103 degrees Fahrenheit (39.5 degrees Celsius). Persistent, prolonged fever may be an indication that the antibiotics are not effective and may need to be changed.
The charge nurse is planning a room assignment for the client with meningococcal meningitis. Which room and precautions should the nurse plan for this client?
- A. A private room with droplet precautions
- B. A private room with airborne precautions
- C. A semiprivate room with a roommate who has a similar diagnosis and standard precautions
- D. A semiprivate room with a roommate who has a similar diagnosis and contact precautions
Correct Answer: B
Rationale: B: Meningococcal meningitis requires airborne precautions and a private room due to possible airborne transmission. A, C, D: These are insufficient or inappropriate.
The nurse and NA are caring for the client with hepatitis A. The nurse determines that the NA understands correct infectious precautions for this client when observing what action?
- A. Wears a mask, gown, and gloves when taking the client's vital signs
- B. Wears a gown and gloves when changing the client's incontinent briefs
- C. Wears gloves when providing urinary catheter and perineal care
- D. Wears a gown and gloves when asking the client about snack food options
Correct Answer: B
Rationale: B: Gown and gloves are required for contact precautions during incontinent brief changes due to fecal transmission risk. A: Masks are unnecessary as hepatitis A is not airborne. C: Gloves alone are insufficient; a gown is needed. D: PPE is not required for non-contact interactions.
An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next?
- A. Stay with client and observe for airway obstruction
- B. Collect pillows and pad the side rails of the bed
- C. Place an oral airway and use the body
- D. Announce a cardiac arrest, and assist with intubation
Correct Answer: A
Rationale: Stay with client and observe for airway obstruction. For the client's safety, remain at the bedside and observe respirations and level of consciousness. Prepare to clear the airway if obstructed. Do not place anything in the client's mouth. For safety, do not leave the client unattended. A cardiac arrest should only be announced if pulse or respirations are absent after the seizure.