Nokea
A client on a mechanical ventilator begins to fight the ventilator. Which medication will be ordered for the client?
- A. Sublimaze (fentanyl)
- B. Pavulon (pancuronium bromide)
- C. Versed (midazolam)
- D. Atarax (hydroxyzine)
Correct Answer: B
Rationale: Pancuronium bromide, a neuromuscular blocker, paralyzes muscles to prevent fighting the ventilator, ensuring effective ventilation. Sedatives like midazolam or fentanyl are secondary.
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A client tells the nurse that she takes St. John's wort (hypericum perforatum) three times a day for mild depression. The nurse should tell the client that:
- A. St. John's wort seldom relieves depression.
- B. She should avoid eating aged cheese.
- C. Skin reactions increase with the use of sunscreen.
- D. The herbal is safe to use with other antidepressants.
Correct Answer: C
Rationale: St. John's wort increases photosensitivity, so sunscreen use may paradoxically increase skin reactions; clients should be cautioned about sun exposure.
Which of the following findings would be abnormal in a postpartal woman?
- A. Chills shortly after delivery
- B. Pulse rate of 60 bpm in morning on first postdelivery day
- C. Urinary output of 3000 mL on the second day after delivery
- D. An oral temperature of 101°F (38.3°C) on the third day after delivery
Correct Answer: D
Rationale: Frequently the mother experiences a shaking chill immediately after delivery, which is related to a nervous response or to vasomotor changes. If not followed by a fever, it is clinically innocuous. The pulse rate during the immediate postpartal period may be low but presents no cause for alarm. The body attempts to adapt to the decreased pressures intra-abdominally as well as from the reduction of blood flow to the vascular bed. Urinary output increases during the early postpartal period (12-24 hours) owing to diuresis. The kidneys must eliminate an estimated 2000-3000 mL of extracellular fluid associated with a normal pregnancy. A temperature of 100.4°F (38°C) may occur after delivery as a result of exertion and dehydration of labor. However, any temperature greater than 100.4°F needs further investigation to identify any infectious process.
The client is receiving chemotherapy for breast cancer. Which instruction should the nurse include to prevent infection?
- A. Avoid crowds and people with colds.'
- B. Take your temperature twice a week.'
- C. Eat only well-cooked meats.'
- D. Use a soft toothbrush for oral care.'
Correct Answer: A
Rationale: Chemotherapy causes immunosuppression, increasing infection risk. Avoiding crowds and sick individuals reduces exposure to pathogens. The other measures are helpful but less effective at preventing infection.
A client with a history of a kidney transplant is being discharged. The nurse should teach the client to:
- A. Monitor for signs of infection
- B. Eat a high-sodium diet
- C. Limit physical activity
- D. Take antibiotics daily
Correct Answer: A
Rationale: Immunosuppression post-kidney transplant increases infection risk, requiring vigilant monitoring. High-sodium diets, activity limits, and daily antibiotics are not standard.
A client presented herself to the mental health center, describing the following symptoms: a weight loss of 20 lb in the past 2 months, difficulty concentrating, repeated absences from work due to 'fatigue,' and not wanting to get dressed in the morning. She leaves her recorded message on her telephone and has lost interest in answering the phone or doorbell. The nurse's assessment of her behavior would most likely be:
- A. Deep depression
- B. Psychotic depression
- C. Severe anxiety
- D. Severe depression
Correct Answer: D
Rationale: Although the client was able to bring herself to the mental health center, the extent of her weight loss and the interference of symptoms with activities of daily living indicate that she is severely depressed.